Download - John W. Ward. M.D
John W. Ward. M.D. Director, Division of Viral HepatitisNational Center for HIV/AIDS, Viral
Hepatitis,STD, and TB
Centers for Disease Control and Prevention
Division of Viral Hepatitis Update NASTAD March 31, 2008
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Reported Acute Hepatitis C United States, 1992-2005
Remarkable Prevention Successes
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•Acute infections- ~100,000
•HAV: 32,000
•HBV: 46,000
•HCV: 19,000, increase in 2006
• Chronic infection- 4.0-4.5 million
• Chronic HBV: 800,000-1.4 M
• Chronic HCV: 3.2 M
• Most unaware of infection; few treated
•Of HIV +: 9% HIV/HBV; 33% HIV/HCV
Challenges To Reduce High Burden of
Infection and Disease
Strategic Imperativesfor Viral Hepatitis Prevention
• Protect vulnerable populations from infection
• Prevent disease from chronic hepatitis B and hepatitis C
• Build surveillance systems to guide prevention
• Strengthen prevention capacity – Program development– Policy development
– Program collaboration and service integration
Protect Vulnerable Populations from Infection
Improve Hepatitis B Vaccine Coverage for Adults at Risk
• $20M awarded in FY ’07 supplement
• 51 project areas• 1,157 settings (e.g., HIV, STD)• 53,288 doses ordered, 1st qtr ‘08 • 50% of projected; start-up lag• Order vaccine through 6/08 !• Cross-Center implementation
plan • Plans to sustain funding in FY 08
Protect All Infants from Perinatal HBV
• Despite >85% decline;– 900 exposed infants
develop chronic HBV– 100-150 infants die
later of liver disease
• All states receive funds for case mgmt
• Conduct evaluation to optimize prevention– Exposed infants– HBV infected mothers – Three programs (Fl,
MN, NYC) funded in 2007
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Perinatal Chronic HBV Infections
Prevention of Healthcare Associated Hepatitis B and Hepatitis C
• HCV Outbreak Among Endoscopy Patients Nevada, 2007
– Increase in reports of acute hepatitis C
– Epidemiologic and laboratory investigation
• At least 6 HCV infected persons
• CDC lab confirmed relatedness for 4 patients
• Improper re-use of syringes and multi-dose vials
– 40,000 patients notified for HIV,HBV, HCV testing
– Investigation and response in progress
CENTERS FOR DISEASE CONTROL AND PREVENTION
Prevention of Healthcare Associated Hepatitis B and Hepatitis C
• 16 outbreaks since 1998
– 13 States
– HBV
•6 outbreaks
•104 patients
– HCV
•10 outbreaks
•271 patients
• Settings
– Hemodialysis
– Residential care facility
– Imaging
– Surgical outpatient
• Prevention Needs
– Surveillance
– Outbreak response
– Training and education
– Local program development
CENTERS FOR DISEASE CONTROL AND PREVENTION
Prevent Disease from Chronic Hepatitis B and Hepatitis C
Test and Refer for Care Persons with Chronic Viral Hepatitis
• Publish testing guidelines for chronic HBV
• Expand target populations– MSM, IDU– Born in countries >2% prevalence
• Recommend prevention management
• Integrate HBV and HCV screening in HIV testing initiative – 18 0f 23 project funded for co-infection
screening
In the United States, HCV Testing Routinely Recommended Based on Increased Risk for
Infection
• Ever injected illegal drugs
• Received clotting factors made before 1987
• Received blood/organs before July 1992
• Ever on chronic hemodialysis
• Evidence of liver disease
MMWR 1998;47 (No. RR-19)
Considerations Regarding for HCV testing
•2002 NHANES follow-up study:
–101 of 199 anti-HCV+ persons (51%) were unaware of their infection
–Of those aware of their infection, only 7% had been tested because of a risk factor
•Highest prevalence of anti-HCV:
– Persons born between 1945-1964
–69% of anti-HCV positive persons identified in this birth cohort (NHANES)
CENTERS FOR DISEASE CONTROL AND PREVENTION
Evaluate Screening and Care for
Chronic Viral Hepatitis
• Improve screening strategies• Evaluate rapid HCV tests
– Laboratory proficiency– Integration with HIV testing
•Study alternatives to HCV screening– Age based or birth cohort
• Gather data on health care access and outcome
Build Surveillance Systems to Guide Prevention
Current and Emerging Issues in Viral Hepatitis
Surveillance
• Suboptimal data quality
• Inadequate ability to identify emerging trends
• Insensitivity of current surveillance to detect cases
• No recent evaluation of the surveillance system
• Large burden of disease
• Difficulty identifying newly reported cases
• Suboptimal data quality
• No evaluation of the surveillance system has been conducted
Acute Disease Chronic Infection
CENTERS FOR DISEASE CONTROL AND PREVENTION
States Reporting Chronic Hepatitis B and C Virus Infections via NNDSS, 2007
Reports to CDC
Reportable but reports not sent to CDC
Chronic HBV Infection Chronic HCV Infection
Not reportable
Build Surveillance Systems to Guide Prevention
• Promote state based chronic viral hepatitis surveillance and registries– Develop performance standards for national
reporting
– Improve surveillance for HIV/HCV co-infection
– Monitor HCV-related cancer, deaths and other indicators of care access
– Prepare systems to monitor anti-viral resistance
• Support acute surveillance to identify outbreaks and vaccine failures
Build Prevention Capacity
Build Prevention Capacity Adult Viral Hepatitis Prevention Coordinators
Regions 1, 3, 4, and 8
Regions 1, 2, 6, 7, & 10
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(49 states and 6 Cities: NYC, Philadelphia, Chicago, Houston, and Los Angeles and District of Columbia)
Opportunities for Program Collaboration
and Service Integration
•Integrated surveillance and data efforts
– Integrated surveillance reports
– Standards for sharing of data
– Address confidentiality issues
•Integrated training efforts
– Integrated and comprehensive guidelines
– Training centers with integrated curricula
•Integrated funding
– Collaboration on program announcements
– Program management
Division of Viral HepatitisStrategic Work Plan
• Organized by pathogen
• Goals and objectives– Primary prevention research– Primary prevention activities– Secondary prevention research– Secondary prevention activities– Public health surveillance– Global
• Projects mapped to goals and objectives
• Publication scheduled for FY 08
Institute of Medicine Review
• Examine the current and future health burden of chronic viral hepatitis and associated disease
• Assess the effectiveness of current prevention strategies and programs
• Assess surveillance, research, and program needs
• Recommend priorities to guide surveillance, research, and program development
• Target start date: Summer 2008
Domestic HIV 67.7%
TB 14.2%
STD 16.3%
Total: $963.1 million
Domestic HIV, Viral Hepatitis, STD and TB Prevention
Appropriated Funds, FY 2006
Hepatitis 1.8%TB 14.2%Hepatitis 1.8%