Transcript Hepatitis C: An Overview: USA Public Health Response

The National Hepatitis C Institute Presents:
Hepatitis C
An Overview: USA Public Health Response
November 16, 2009
1998 Congressional Quote:
Senator Christopher Shays,
During The Congressional Hearing
Titled:
“HCV Silent Epidemic
Mute Public Health Response”
“HCV virus, poses a daunting challenge to public health. Chronic
infection can linger without symptoms for more than 20 years,
then produce profound health consequences, including liver
failure and cancer. There is no preventative vaccine or
generally effective treatment.”
2
World Health Organization
According to the World Health Organization…
"The Only Means Of Protection From The HCV Virus Are The
Implementation of Universal Precautions (Standard Guidelines For
Medial And Dental Procedures)
Mode Of Transmission:
 Primarily By Direct Contact With Human Blood
Major Causes Of Infection Worldwide:
 The Use Of Unscreened Blood For Transfusions
 Re-use Of Needles And Syringes That Have Not Been Adequately
Sterilized
3
Scientific Community Statement:
“You Cannot Contract HCV
Unless You were Exposed
To Infected Blood”
4
Global Prevalence
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Global Disease Burden
Estimated
170Chronically
Million Infected…
– 130 Million
– 1 In 3 Woman And 1 In 2 Men Will Develop
Cirrhosis And/Or Liver Cancer
– Responsible For 50-76% Of ALL Liver Cancer
Cases
– Responsible For 2/3 Of ALL Liver Transplants In
The Developed World
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Global Message: 1 in 12
Understanding Viral Hepatitis
HCV is spread when blood from a person infected with the HCV Virus
enters the body of someone who is not infected.
Today, Most Infections Occur From:
•Sharing Needles Or Other Equipment To Inject Drugs
•Before 1992, Blood Transfusions And Organ Transplants
•Sharing Needles, Syringes, Or Other Equipment To Inject Drugs
•Needlestick Injuries In Healthcare Settings
•Born To An Infected Mother
Hepatitis A is spread when the virus
is taken in by mouth from contact with
objects, food, or drinks contaminated by
the feces (or stool) of an infected
person.
Transmission:
•Person to person contact
•Contaminated food or water
Less Commonly:
•Sharing Personal Care Items Such As Razors Or Toothbrushes
•Having Sexual Contact With A Person Infected
Hepatitis B is spread when blood, semen, or other body fluid
enters the body of a person who is not infected. People can
become infected with the virus during activities such as
•Birth
•Sex with an infected partner
•Sharing needles, syringes, or other drug -injection equipment
•Sharing razors or toothbrushes with an infected person
•Exposure to blood from needlesticks or other sharp instruments
According To The WHO- HCV Is Just As, If Not More Contagious,
Than HBV And Many Times More Infectious Than HIV
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HCV Overview
HCV Is A Systemic Infection- Not Just A Liver Disease
Cognitive Impairment
Nervous System Damage
Visual Impairment
Dermatological Damage
Nephrological Damage
Rheumatological Damage
Blood Borne Virus
Majority Asymptomatic
Cases
5x More Prevalent Than
HIV/AIDS Globally
Complicated Progressive
Disease Process
Diverse Population
Mode Of Transmission Not
Fully Understood
Emphasis On Behavior
Driven Transmission
2000- American Association for the Study of Liver Disease
“In Ten Years” HCV will be a major burden on
Healthcare System increasing:
60%: Incidences Of Cirrhosis
68%: Incidences Hepatocellular
Carcinoma
279%: Incidences Hepatic
Decompensation
528%: Need For Transplantation
223%: Liver Death Rate
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The US Public Health Response
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Health & Human Service
Public Health Services
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Core Function of Public Health
Assessment and Surveillance: The foundation for
public health activities is an assessment and
surveillance capacity that identifies problems, provides
data to assist in decisions about appropriate actions,
and monitors progress
Policy Development: Is the means by which problem
identification, technical knowledge of possible solutions,
and societal values join to set a course of action
Assurance Of Access To The Benefits Of Public
Health: Assurance of the availability of the benefits of
public health to all citizens reflects a primary reason for
the existence of public health activities
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USA Disease Prevalence & Burden
•
An Under-Estimated 4 Million People Are Infected But These Figures
Exclude The Institutionalized Populations Like The US Military And
Prisons, Or The Estimated 12 Million Illegal Immigrants
•
40-60% Of Chronic Liver Disease In The US Is Related To Chronic
HCV Infection
•
Chronic HCV Is The Leading Cause Of Adult Liver Transplantation
•
Possible Greater Than 30,000 Deaths Yearly Associated With Chronic
Liver Disease Related To Chronic HCV *
•
Approximately 75%–85% Of People Who Become Infected With HCV
Virus Develop Chronic Infection
*Consensus Statement. 1998 National Institutes of Health (NIH) state; An estimated 8,000 to 10,000 deaths each
year result from HCV-associated chronic liver disease… without effective treatment… that number could
triple in the next 10 to 20 years)
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Congressional Quote:
Still True Today…
Senator Christopher Shays,
During The Congressional Hearing
Titled:
“HCV Silent Epidemic
Mute Public Health Response
“Since 1989 when the HCV virus, was first unmasked,
Federal public health agencies have often pondered,
but never implemented, a comprehensive response to
this insidious infectious agent.”
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Research & Prevention
Federally Funded
Domestic Programs
14
Domestic Funding FY 2005-2009
15
Actual Funding FY 2008
16
Actual Research Funding 2008
NIH
Total Spending
HCV
Other
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Congressional Committee On Reform
National Institutes of Health
The Findings…
The Federal Response to the HCV
Epidemic Lacked Energy and
Focus
•
“It is noteworthy that the National
Institute on Drug Abuse [NIDA] spent
the most NIH resources and continues
to spend the most resources on HCV
research, which may reflect an
institutional bias within HHS that HCV
is a disease of injection drug users.
This bias may have worked against
early recognition of HCV as a broader
public health threat.”
Total National Institutes of Health- NIDA HCV
Funding $18,281,932
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CDC Plan For Prevention
The National Hepatitis C
Prevention Strategy
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CDC Position On HCV
A.
With The Transfusion Risk Reduced Substantially As A
Result Of Improved Screening, The Major Risk Factor,
Today Is IV Drug Use.
B.
Virtually All Transmission Of HCV Is Associated With
Identifiable Risk Factors.
C.
This Is A Disease Largely Under Control
D.
By Focusing On Marginal Populations Who Have High
Risk Behaviors (E.G. Sex, IV Drug Abuse) HCV Infections
Will Be Greatly Reduced
E.
By Tracking Acute Disease, We Can Gauge Prevention
Strategies
F.
States Only Need To Report Acute Disease
NHANES Was Utilized To Develop Prevalence Data
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Mode of Transmission
CDC Changes Public Health Message:
 Old Statement:
Any percutaneous exposure can put you at risk.
 New Statement:
Contact with the blood of an infected person,
primarily through sharing contaminated needles to
inject drugs.
http://www.cdc.gov/hepatitis/
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Who Should be Tested - CDC
•
Current Or Former Injection Drug User, Even If You Injected Only One
Time Or Many Years Ago.
•
Treated For A Blood Clotting Problem
Before 1987.
•
Received A Blood Transfusion Or
Organ Transplant Before July 1992.
•
Long-term Hemodialysis Treatment.
•
Abnormal Liver Tests Or Liver Disease.
•
Work In Healthcare Or Public Safety
And Were Exposed To Blood Through
A Needle Stick Or Other Sharp Object
Injury.
•
Those Who Are Infected With HIV.
BreakdownHCV Infection Among
USA Citizens
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Major Causes of Transmission
CDC Says….
HCV is spread when blood from a person infected with the HCV virus enters the body of
someone who is not infected. Today, most people become infected with the HCV virus
by sharing needles or other equipment to inject drugs. Before 1992, when widespread
screening of the blood supply began in the United States, HCV was also commonly spread
through blood transfusions and organ transplants.
Transmission Activities:
–
–
–
Sharing needles, syringes, or other
equipment to inject drugs
Needlestick injuries in healthcare settings
Born to a mother who has HCV
Less Common Transmission
–
Sharing personal care items that may have
come in contact with another person’s
blood, such as razors or toothbrushes
–
Sexual contact with a person
infected with the HCV virus
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CDC Message About
Sexual Transmission Is Confusing
CDC Says…
Risk factors include:
•
“Having
sexual contact with a person infected with the
HCV virus”
NIH Says…
•
“Sexual transmission of HCV between monogamous partners appears to be
uncommon… Spread of HCV to a spouse or partner in stable, monogamous
relationships occurs in less than 1 percent of partners per year.
•
For these reasons, changes in sexual practices are not recommended for
monogamous patients…People with multiple sex partners should be advised to
follow safe sex practices, which should protect against HCV as well as hepatitis B,
HIV, and other sexually transmitted diseases.”
VHA Says…
•
“If you have had multiple sex partners”
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Poster Campaigns –
Add to Confusion
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Scientist Say: Sexual Transmission
Is Not a Risk Factor
•
FY 2008- No evidence of a HCV epidemic in HIV negative gay men
Dr Turner et al. Data from attendees at a London GUM clinic suggest that
there is no increase in HCV infections amongst HIV negative gay men.
•
FY 2007- Injection Behavior, Not Sexual Contact, Accounts for
Couples' HCV Risk NEW YORK (Reuters Health) - Injection behavior,
rather than sexual contact, accounts for the clustering of HCV virus
(HCV) infection in heterosexual couples, according to a report in the June 1st
issue of The Journal of Infectious Diseases.
•
FY 2004 No Evidence of Sexual Transmission of HCV among
Monogamous Couples: Results of a 10-Year Prospective Study The risk
of sexual transmission of HCV virus (HCV) infection was evaluated among
895 monogamous heterosexual partners of HCV chronically infected
individuals in a long-term prospective study, which provided a follow-up
period of 8,060 person-years.
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We Need To Adhere
To The Scientific
Facts
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Scientist Say:
#1 Source of Transmission
“Supplies of free needles and bleach disinfection kits
have been distributed in many cities to control disease
transmission among injection drug users.”
However, the transmission of disease to health care
workers and between injection drug users in
industrialized countries is only a fraction of the total
transmission from contaminated needles and syringes
worldwide.”
Kane, A. et al (Transmission of Hepatitis B, HCV and Human Immunodeficiency Viruses
Through Unsafe Injections in the Developing World: Model Based Regional Estimates) Bulletin
of the WHO (1999)
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U.S. Expert Say:
Syringe Reuse A Widespread Problem
Jodie Sinnema, Edmonton Journal Oct. 28, 2008
"Injection safety was often thought of as a developing
world problem and we kind of took it for granted
in the U.S. and other developed countries," said
Joseph Perz, who works at the Centers for Disease
Control and Prevention in Atlanta. "But as a result of
accumulating evidence from outbreaks and
surveys, we are taking a firmer stand on the need
for education and firmer standards.“
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Other Known Modes of Transmission
Needleless Injection
– Vaccinator Systems
Body Modification
– Tattoo/Piercing
Medically Acquired
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Needleless Jet Injectors
FINDING OF FACT:
HCV is a result of receiving
immunizations in service by
means of a multi-use jet gun
injector.
CONCLUSION OF LAW:
HCV was incurred in service.
38 U.S.C.A. § 1131 (West 2002);
38 C.F.R. § 3.102, 3.303 (2005).
http://www.hcvets.com
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The Latest Jet Injection Science
The MUNJIs or “Jetguns” are known by the trade names:
Ped–O–Jet®, Med–E–Jet®, Hypospray®, DermoJet®
Global ALERT!
Recent 2008 FDA Study Show 8.2%
Contamination For Newer "Improved" Model
Called A “PCNFI”... Researchers Stopped
The Test And Rejected The Device....
PATH, 1455 NW Leary Way, Seattle, WA 98107, USA. [email protected]
Vaccine. 2008 Mar 4;26(10):1344-52. Epub 2008 Jan 18.Preventing contamination between
injections with multiple-use nozzle needle-free injectors: a safety trial.
Kelly K, Loskutov A, Zehrung D, et al.
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Body Modification
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Evaluation of Body Modifications
Implants
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Largest Single
Contributor To HCV Epidemic
Scientist Say:
•
"Commercial Tattooing as a Potentially Important Source of
HCV Infection."
HALEY, ROBERT W., and R. PAUL FISCHER.
Medicine 80.2 (March 2001): 134.
– "Most importantly, we found that commercially acquired tattoos
accounted for more than twice as many HCV infections as
injection-drug use, "Haley said. "This means that it may have been
the largest single contributor to the nationwide epidemic of this
form of hepatitis.“ http://www.seattlepi.com/health/67805_hepc25.shtml
•
American Association for the Study of Liver Diseases
Dhalla S, et al
– "Strong Association Between Tattoos and HCV Virus Infection:
A Multicenter Study of 3,871 Patients" AASLD Meeting 2007;
Abstract 136 presented Nov. 5.
– Conclusion: “The HCV infected population was 3 times more likely
to have a tattoo.”
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Tattoos & Piercings Are Mainstream
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Underestimated Magnitude of Transmission
1998 Acute HCV Case Definition
Tested All Elevated ALT Levels For Acute Or Chronic HCV
•
98.9% Acute Had ALT Levels= >2.5 Uln
•
18% Chronically Infected Had ALT Levels= >2.5 Uln
– Investigate 20% Of Every 1000 Cases
• 5% of Chronic Infection Reported Cases
Investigated for Acute Infection
Source Of Infections: Equipment And Or Injection Environments
Facilities Did Not Met Public Health Safety Standards
Change: Efficient And More Specific CriterionDistinguish Acute From Chronic Infection
2004 Case Definition- Limits Set For Alt
– Threshold >7 Times Upper Limits Of Normal
• 4% of Chronic Infection Reported Cases
Investigated for Acute Infection
Reason For Modification:
Obtain 22% Increase Acute Case Identification
Facilitate Surveillance Less Cases Investigated
Balance Resources Follow-up To Positive Persons
Assess Risk Factors For HCV Transmission
Ensure Outbreaks Are Identified
Provide Information For Monitoring
Support Trends In The Incidence Of HCV
2007 Case Definition Modification
ALT levels > 400 IU/L
Men Normal High 30-60 IU/L
Women Normal High 19-38 IU/L
Public Health took years to discover the outbreaks and
many more months to isolate the source. The incidents
occurred at Multiple Veterans Affairs Medical Centers, Public and Private
Medical Centers, Cardiology Clinics, Endoscopy and Ambulatory Surgery
Clinics, Hematology and Oncology Clinics, Pain Remediation Clinic and Private
Physician's Office, Nuclear Imaging Centers and Urology Clinic, Nursing Homes
and Assisted-living Facility.
CSTE Position Statements 2000 ID-#7 COMMITTEE:
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Medical Exposures: Significant Outbreaks
Fremont, Nebraska (2002)
Norman, Oklahoma (2002)
New York City, New York (2001) (2007)
Long Island, New York (2007)
Laurinburg, North Carolina (2008)
Las Vegas, Nevada (2008)
Denver, Colorado (2009)
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Also Carry High Risk
“Enormous numbers of additional
injections are given outside the
Health sector, in markets, by
traditional and unlicensed
practitioners with the “family
syringe”, and by dentists.
Other parenteral exposures, such as
scarification, skin piercing,
circumcision, tattooing and
acupuncture also carry high risk of
transmission of bloodborne
pathogens, and are not included in
these estimates.”
Kane, A. et al (Transmission of Hepatitis B, HCV and Human Immunodeficiency Viruses Through Unsafe
Injections in the Developing World: Model Based Regional Estimates) Bulletin of the WHO (1999)
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HCV Surveillance
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Washington State: One of 50 States
Population: 6,549,224
State Department Of Health &
37 Health Districts
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Surveillance Is Non-Existent
Washington State: Reportable Cases
Chronic HCV Surveillance Report
10/10/ 2009
2008 2007 2006
1501
6835 5088 5945
2005
5420
The Gauge to Measure
Preventive Strategies is Flawed
2004
5242
Note: Most cases of HCV are asymptomatic and very seldom
diagnosed in acute stages
CDC USA Stats- Reportable Cases
Source: Summary of Notifiable Diseases
United States, 2006, Morbidity and Mortality
Weekly Report, <med> Vol. 55, No. 53, March 21,
2008. http://www.cdc.gov/mmwr/PDF/wk/mm5553.pdf
Table 175
HCV/Non-A, non-B \6 (1,000)
1980 1990 1995 2000 2005
(\2) 2.6
4.6
3,197
652
2006
766
*2007 *2008
845
878
*2009
1,474
\6 includes some persons positive for antibody to HCV Virus
*Data from MMWR Weekly October 16, 2009 / 58(40);11281140 Notifiable Diseases/ Deaths
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5840md.htm
2005-2009 (Oct 10)
WA State Reportable Cases 24,789
CDC Reportable Cases 4,615
National Notifiable Diseases Surveillance System
http://www.cdc.gov/ncphi/disss/nndss/casedef/index.
htm
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Washington State HCV Surveillance
Overview:
•
HCV Surveillance began in 2000
– Surveillance Limitations–
• Lack of funding affects reporting
• Lack of a well developed educational campaign to providers
• Lack of general population testing by targeted campaigns
– The targeted federal government educational campaign does not
include the 653,000 veterans, or approximately 1 out of 11
Washington State residents, that served in the US military.
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Common Age Of Diagnosis
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WA State HCV Reports- Deaths
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WA State HCV ReportsScreening Evaluations
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WA State HCV ReportsRace/Ethnicity
Diagnoses thru March 2009
Confirmed plus probable cases
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Is Integration The Solution?
The Goal Of HIV Case Management
• HIV Access Primary Medical Care
• Medications
• Identify And Remove Barriers
• Medical Care
• Ensure Adherence
• Prescribed Treatment Plan
Why Integration Will Not And Has Not Worked:
•
Modes Of Transmission
(HCV Is More Diverse And Is Not An STD)
•
•
•
•
Case Verse Medical Management
Risk Not Medical Assessment
Marginal Verses General Population
Lacks Responsibility!
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HIV/AIDS Programs in USA
HAP Prevention Overview:
Purpose: Reduce The Spread
•HIV Counseling & Testing
•Behavioral Interventions
•Educational Activities
•Prevention Activities
•Partner Counseling
•Referral Services
•Behavioral Intervention
Surveillance:
•Monitoring Progression In Each State
•Planning Prevention Efforts
•Guides Allocation Of Resources
•Treatment
•Care
•Other Supportive Services
Care and Treatment:
Assist HIV-infected/Affected Clients
•Supportive Services
•Primary Medical Care
•HIV Medication Assistance
•Insurance Assistance
•Home Health, & Housing.
•Dental
The National Center for HIV/AIDS, Viral
Hepatitis, STD, and TB Prevention
(NCHHSTP) is interested in what can be done
to build a more comprehensive approach to
address health disparities in infectious
diseases and to design and establish a strong
framework to integrate all of NCHHSTP’s
prevention activities.
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2002 CDC Foundation Forms
National Viral Hepatitis Roundtable
National Viral Hepatitis Roundtable (NVHR) - is transferred to
-Task Force for Child Survival and Development in 2005 –
Changed name to Task Force for Global Health in 2008 – (funding
comes from global HIV/AIDS programs and CDC)
NASTAD - Created
by CDC in 1992 –
liaison between CDC
and state health
departments to
oversee HIV/AIDS
funding and
distribution.
HIV/AIDS, STD and
Needle exchange
programs
National HCV
Advocacy Council
NVHR
Hepatitis B &
Immunization
groups
HCV Support
Project/HCV Advocate
HCV Appropriations
Partnership
Created by Roche & Schering-Plough Pharmaceuticals in (1998)- the groups above
were seeded by the pharmaceutical industry to look like grassroots
organizations in partnership with the CDC Foundation (Our public health
partner) and Universities (heavily funded by private research dollars supplied
by the drug companies). The Proposed Federal Bill “HCV Epidemic and
Control Act” was created by these participants.
Substance Abuse
Programs and
Funding
Created groups
from Same
Funding Streams
Hepatitis Education
Project
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The Network
•
1995- The US Congress Approved
The Creation Of A Non-profit
Connected/Created By The CDC
•
Pharmaceutical Industry
Largest Contributor
•
1998- The Non-profit and Schering
Plough Partnered To Educate
•
2002-03- The Foundation Creates The
National Viral Hepatitis Roundtable
(NVHR) As A Non-profit
•
2005- The NVHR Is Moved To Another
Non-profit Within The CDC Foundation
That Was Created By The United
Nations. NVHR Drops Its Non-profit
Status To Lobby USA Congress
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UNAIDS DefinitionStigma
Discrimination
Definition of Stigma:
•
“…a ‘process of devaluation’ of people either living with or associated
with HIV and AIDS…
•
Discrimination follows stigma and is the unfair and unjust treatment of
an individual based on his or her real or perceived HIV status.”
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Conclusion:
•
The data suggests that the public health response may be the
direct result of a system in disarray – seemingly captured by
special interest with political agendas that have influenced the
response to the epidemic. This approach has created disparities
in access to health care and created “social labels” that have
fostered discrimination, responsible for the reduction in quality of
life.
•
Public health privatization policies and pharmaceutical driven
coalitions are agents driving legislation, underscoring the need to
evaluate programs at this level. These industry coalitions and
their “for profit” and “non-profit” counterparts, fight for government
funding thru regulation by fomenting scientific uncertainty that
work against broader public health threats.
•
The enduring legacy and indifference for governments,
nonprofits, advocates, political parties or economic elites, has
grave and global consequences.
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Contact Information:
Kitty Candelaria- Executive
Director,National Hepatitis C Institute
Phone: 360-692-0795
Email: [email protected]
Patricia Lupole- Nat'l Director,
Hepatitis Movement For Awareness
Phone: 540-255-3459
Email: [email protected]
Bill Remak, B.Sc. MT, B. Public
Health, SGNA; Chairman,
National Association of Hepatitis
Task Forces, Chairman, CA
Hepatitis C Task Force, Board of
Directors, Fair Foundation
Phone: 707 773-4922
Email: [email protected]
Harry Hooks- Director,
HCVets.com Educational Website
& Support Forum
Phone: 856-340-0269
Email: [email protected]
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