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

0

4

8

12

16

1980 '85 1990 '95 2000 '05

Year

Cas

es/1

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Reported Hepatitis A, 1980-2006 Reported Acute Hepatitis B, 1985-2006

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0.5

1

1.5

2

2.5

19

92

19

93

19

94

19

95

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96

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97

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98

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20

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02

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03

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04

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06

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Report

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ases p

er

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Reported Acute Hepatitis C United States, 1992-2005

Remarkable Prevention Successes

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2

4

6

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14

Year

Cases p

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100,0

00

popula

tion

•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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1000

2000

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HBV

infec

tions

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%