Transcript Prevention of hepatitis C virus infection

Prevention of Hepatitis C Virus Infection:
Achievement through Integration into
Established Prevention Programs
Harold S. Margolis, M.D.
Division of Viral Hepatitis
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA
Reasons to Combine
Viral Hepatitis, HIV/AIDS and STD Prevention
• Major public health problems
• Routes of transmission overlap substantially
• Effective prevention tools
– Immunization, risk and harm reduction, treatment
• Well established prevention programs
– STD, HIV/AIDS, drug treatment and prevention,
corrections health
• Lack of integrated prevention activities leads to
transmission of viral hepatitis
Hepatitis C: the tipping point for a new
direction in prevention
Disease Burden from Bloodborne Viral
Infections, United States
Outcome
HBV
HCV
HIV
Chronic infections
1.2
(million)
2.7
(million)
0.8
(million)
New infections /yr
120,000
35,000
40,000
5,000
8,000
18,000
Deaths /yr
Risk Factors for Transmission of
Hepatitis Viruses and HIV, United States
Proportion of Infections (%)
Risk Factor
HBV
HCV
HIV
Injection drug use
14
60
31
MSM
Heterosexual partners
15
1
47
40
20
10
Transfusion
Rare
Past
Past
7- 20
2
Occupational
5-7
<<1
<<1
10
9
Unknown
(past)
30
Routes of Transmission and
Opportunities for Prevention
of Infection with
Hepatitis Viruses and HIV
Overlap Substantially
Integration of Viral Hepatitis Prevention:
Relative Disease Burden in Various Settings
Setting
HBV
HCV
HIV
STD clinic
+++
+
+++
HIV/AIDS C&T sites
+++
+++
+++
Drug Treatment
+++
++++
+++
Corrections
+++
++++
+++
Prevention Activities
• Primary (Identify person at risk of infection) = Prevent
HCV Acquisition
- high risk activities - IDU, high risk sex
- nosocomial, transfusions and transplant, occupational
• Secondary (Identify infected persons) = Reduce Risk
of Transmission to Others
- Test, counsel - harm reduction
• Tertiary (identify infected persons) = Reduce Risk of
Chronic Liver Disease
– Test, counsel -
medical management
Injecting Drug Use and HCV Infection
•
•
•
•
•
Highly efficient mode of transmission
Rapidly acquired after initiation
Four times more common than HIV
Prevalence 50-90% after 5 years
Predominant risk factor in low prevalence
countries
Risk of Bloodborne Virus Infections
Injection Drug Users
Baltimore 1983–1988
Seroprevalence (%)
100
HCV
80
HBV
60
40
HIV
20
0
0
6
12
18
24
30
36
42
48
54
Duration of Injecting (months)
Garfein RS. Am J Public Health. 1996;86:655.
60
66
72
Injecting Drug Use and HCV Infection
• Low endemic countries
– Major risk factor for infection
•
Moderate/High endemic countries
– sentinel event for emergence of injecting drug use
– 50% of persons with acute hepatitis C (Italy, Russia)
– 40% of HCV-positive persons <40 yrs old vs. 0% >40
(Italy)
– 2/3 of HCV-positive commercial blood donors (Egypt)
Injecting Drug Use and HCV Infection
• Acquisition of HCV infection (not HIV)
among injection drug users should become
the ‘Indicator’ of effective prevention
programs
• Prevention of HCV infection (and viral
hepatitis A and B) should be included in all
substance abuse programs
Transmission of Viral Hepatitis by
Unsafe Injections and Medical Practices
Post-transfusion Hepatitis
• In developing countries, most transfused units not tested
for HBV or HCV
•
Related donors often used – perception that less likely to
be infected
•
Inappropriate use of blood and blood products – single
unit transfusions common
•
Lack of organized transfusion services
•
Paid donors continue to be used in many countries
Health-Care Related HCV
Transmission
•
Unsafe injection practices
•
Contaminated equipment
– inadequate sterilization of reusable needles and
syringes
– sharing of disposable needles and syringes
– high frequency of injections
– contamination of multi-dose vials
– lack of ‘universal precautions’
– inadequate cleaning and disinfection
• in health care settings
• alternative medicine practices, rituals
Prevention Activities
• Primary (Identify person at risk of infection) = Prevent
HCV Acquisition
- high risk activities - IDU, high risk sex
- nosocomial, transfusions and transplant, occupational
• Secondary (Identify infected persons) = Reduce Risk
of Transmission to Others
- Test, counsel - harm reduction
• Tertiary (identify infected persons) = Reduce Risk of
Chronic Liver Disease
– Test, counsel -
medical management
Reasons to Identify Persons with
Chronic HCV Infection
•
Counsel to prevent disease transmission
•
Medical management
– household contacts
– sexual contacts
– drug use contacts
– evaluate for chronic liver disease
– treatment if indicated
– substance abuse treatment (alcohol, drugs) if
appropriate
– immunization (HB, HA, influenza, pneumo)
National Hepatitis C Prevention
Strategy
Prevent new HCV infections
Detect persons with HCV infection
- prevention of transmission to others medical
management for chronic liver disease
• Evaluate effectiveness of activities
• Conduct surveillance and research
Implementation Components
National Hepatitis C Prevention Strategy
• Communication of information on hepatitis C
State-based prevention programs
• Surveillance
• Epidemiology and laboratory investigations
Development of State and Local
Hepatitis Prevention Programs
Viral Hepatitis Prevention at the
State/Local Level – A Model
• STD Programs
• Immunization
(Hepatitis B
Coordinator)
Laboratory
Medical Services
Surveillance
Hepatitis C
Coordinator
•Corrections
•HIV/AIDS
Prevention
•Drug Treatment
Patient
Support/
Advocacy
Groups
State Hepatitis
Prevention Plan
Development of State and Local
Hepatitis C / Viral Hepatitis Prevention
Programs
•
•
•
•
•
•
•
•
Identify stakeholders
Choose a planning process (consensus meeting,
consultants, internal)
Adopt or modify CDC’s recommendations
Identify elements of implementation framework
Write a plan
Secure resources to implement plan
Implement program
Evaluate and modify program
Stakeholders in Hepatitis Prevention
•
•
•
•
•
•
•
•
•
•
•
Communicable disease prevention programs (surveillance)
Immunization program
HIV/AIDS prevention programs (CBOs)
STD programs
Substance abuse/mental health programs
Corrections
Programs for high-risk youth
Public and private laboratories
Public health nursing
NGOs
Clinical care – primary and specialty care
Viral Hepatitis Integration Projects (VHIPs)
•
•
Evaluate feasibility of integrating viral hepatitis
prevention -- immunization, testing, counseling,
medical referral -Into existing programs for:
 HIV/AIDS counseling and testing
 STD clinics
 Drug treatment/prevention
•
 Corrections health
Develop materials for use by other programs
CDC State-Based Hepatitis C Prevention
Programs
MA
NYC
RI
DC
Demonstration Project
11/01
Coordinator
Challenges
•
Funding and/or referral sources for: lab tests, vaccines,
medical care
•
Incorporation of viral hepatitis prevention messages into
“client-centered” counseling
•
Staff of other programs (HIV/AIDS, STD, drug
treatment, corrections) may not see viral hepatitis
prevention as part of their job
•
Funding of prevention services flows through separate
programs (hepatitis, HIV/AIDS, STD,
immunization,corrections)
Next Steps
•
VHIPs
– Full evaluation of testing and counseling component of each
project
– Evaluate effectiveness of referral for medical evaluation
– New projects for minority populations
•
State Programs
– HCV testing and counseling in all HIV/AIDS, STD, drug treatment
and correction health programs
– Hepatitis B vaccine for all HIV/AIDS, STD, drug treatment and
corrections health programs
Funding
Hepatitis C Prevention Activities
•
FY 98: ~$ 2.0 million
•
FY 99: ~$6 million
• FY 2000: ~$13 million
•
FY 2001: ~ $17 million
•
FY 2002: ~$21 million
•
FY 2003: President’s Budget = ??