An Update of a Hepatitis C Strategic Plan for Action Hepatitis Prevention, Education, Treatment & Support Network  Honolul...
Hepatitis B & C - The “Silent Epidemics” of the Homeless even in a Paradise
Clouds gathering… <ul><li>“Despite over 20 years of knowledge, millions of dollars thrown into prevention and the distribu...
1 MMWR Recomm Rep. 2003;52(RR-1):1-36.  2 Edlin. Hepatology. 2002;36(5 Suppl 1):210-9.  3 NHSDA Report. 2003.  4 Khalili a...
Sirens to Wail <ul><li>60 Second Hepatitis C PSA from New Orleans </li></ul>
Adults who are at the most risk for infection with Hepatitis C  <ul><li>Homeless substance abusers </li></ul><ul><li>Injec...
Risk Factors for Transmission of Hepatitis Viruses and HIV in the USA Proportion of Infections  Slide by Countny East, APR...
Groups of High Rates  Transmission of Hepatitis C Virus in the USA Proportion of Infections  Slide by Ken Akinaka, MRA, Ja...
Other Groups with High Rates  Transmission of Hepatitis C Virus in the USA Proportion of Infections  Slide by Ken Akinaka,...
The number of homeless is growing because of the exploding real estate market, the high costs of rent, and in Hawai`i beca...
Each day at least 800,000 persons are homeless in the USA. That includes 200,000 children. On any given night, almost 300,...
Hepatitis B, Hepatitis C, Human Immunodeficiency Viral Infections and Tuberculosis In A Homeless Veteran Population   RAMS...
Domiciliary for the Homeless <ul><li>Rehabilitation program </li></ul><ul><li>Homelessness of any duration </li></ul><ul><...
Cheung et al, J Clin Gastroenterol, 2002
Cheung et al, J Clin Gastroenterol, 2002
Cheung et al, J Clin Gastroenterol, 2002
Cheung et al, J Clin Gastroenterol, 2002
Cheung et al, J Clin Gastroenterol, 2002
What most people still do not know:   The delay in signs and symptoms of HIV or chronic Hep infections can result in peopl...
The face of the Hepatitis C (HCV)  epidemic is also changing! <ul><li>The new infections are estimated at 25,000 (CDC) to ...
Other High risk groups that may continue to be a “Reservoir” of HCV infection unless they are tested, become aware of thei...
The face of the HIV pandemic is changing, and it is younger. <ul><li>25% of persons living with HIV in the world are 15 -2...
What youth are the most at the most risk for HIV infection?  <ul><li>Street youth (40% of homeless youth identify themselv...
Contributing factors to risk: What is it about teens and young  adults that makes them so vulnerable  to contract HIV or H...
Developmental stages in adolescence <ul><li>Early teens (10 – 13) </li></ul><ul><li>Sex drive begins </li></ul><ul><li>Pee...
Some quick numbers… <ul><li>17% of 7 th  and 8 th  grade students report that they have had sexual intercourse. </li></ul>...
Late adolescence developmental stage (17 – 21+) <ul><li>Maturation complete </li></ul><ul><li>Close friendships formed. </...
Teen behavior and their risks to acquire HIV or Hepatitis B or C: <ul><li>Have multiple sex partners. </li></ul><ul><li>Re...
Challenges that predispose teens & adults to  disregard  HIV or Hepatitis risk <ul><li>The fear of HIV or Hepatitis has be...
Almost 50% of Students Have Had Sex Before Leaving High School 1 <ul><li>54% of HBV infections in U.S. attributed to sexua...
Exposure   Sero-conversion Asymptomatic Symptomatic AIDS Death 0 - 3 mos   3 - 6 mos   8 - 10 years   2-3 years   8 mos – ...
STDs and Teens <ul><li>It is believed that at least 25% of sexually active American teens have contracted an STD. That’s 3...
A word on gay teens <ul><li>There are nearly 1 million gay teens in the U.S. </li></ul><ul><li>There is a lack of informat...
Traces of Blood – A Hepatitis C Video <ul><li>Training Video for Staff and Injection Drug Users </li></ul>
E Ho'omalu Kakoa I Ka Po'e  Nele A Hune &quot;Lets Shelter & Protect Those  Who Are In Need&quot; <ul><li>Save-A-Life Free...
Free Save-A-Life Safety Kit Campaign <ul><li>In May 2006, we informed a person with Hep B & a person with Hep C at the new...
Can Razor Blades Transmit Hepatitis B?  <ul><li>“ Determination of Hepatitis B Virus at Used Razor Blade by PCR” </li></ul...
Hepatitis C – contamination of toothbrushes: myth or reality? <ul><li>30 patients with chronic hepatitis C had their saliv...
HCV may survive on environmental surfaces at room temp. at least 16 hrs. up to 4 days!   <ul><li>This re-emphsizes the imp...
Get The Facts <ul><li>Video by Diana Slyvestre, MD, and Patients who have Hepatitis C at Oasis Clinic in Oakland, CA </li>...
Hawai`i has the highest rate of Liver Cancer in the USA because of our high rates Hep B & C. Immigration from Pacific Isla...
Here are the rates of hepatitis B in these other Pacific Island countries as reported by the World Health Organization. <u...
The homeless are one of the highest at-risk groups that will continue spreading chronic viral hepatitis B and/or C unless ...
Many Homeless want to receive treatment for their Hepatitis C! <ul><li>Hepatitis C treatment study in 2005 by Alan D.  Tic...
These efforts will save lives,  limit the spread of disease , and in the long run be cost-effective!   <ul><li>Earlier tes...
Chronic liver disease due to hepatitis C causes between 10,000 and 12,000 deaths per year! <ul><li>It is the leading indic...
A number of Homeless drink Alcohol.   Should they be treated  for their HCV? “Alcohol use and treatment of hepatitis C vir...
Free Hepatitis B or C Tests for the Homeless & other at risk Groups <ul><li>We now give a Free T-Shirt to those who test a...
Where can they be tested for HCV if you do not have Health Insurance? <ul><li>Very limited resources in the USA </li></ul>...
Another Important Health Concern! The Homeless as well as many otherwise Healthy People Need to Be Protected from Hepatiti...
Reminder - Persons With HIV &/or Hepatitis C need to be Protected Against HBV <ul><li>HBV can survive at room temperature ...
Persons Without Identifiable Risk Factors May Also Wish to Be Protected Against HAV <ul><li>Possible settings for hepatiti...
TWINRIX—Over 98% Effective After a 3-dose Series Complete TWINRIX safety summary to follow. Slide from Twinrix, June. 2005...
Are You at Risk for Vaccine-Preventable Hepatitis (VPH)? Page 2 <ul><li>I come from Asia or the Pacific Islands </li></ul>...
60,000 Adults Die Each Year From Vaccine-Preventable Diseases <ul><li>Medical visits are often missed opportunities to pro...
Vaccinate Adults at Risk for  Vaccine-Preventable Hepatitis (VPH) It’s Needed! <ul><li>Vaccine-preventable hepatitis (VPH)...
Vaccinate Adults at Risk for  Vaccine-Preventable Hepatitis (VPH)  It’s Recommended 1. CDC.  MMWR  1998;47(RR19)., 2. CDC....
Vaccinate Adults at Risk for  Vaccine-Preventable Hepatitis (VPH) It’s Reimbursed <ul><li>Vaccination routinely reimbursed...
 
Merck will provide free vaccines to adults who are uninsured & unable to afford vaccines! <ul><li>Starting the third quart...
Please Remind people: “It’s not who you are but  what you do  that puts you at risk for HIV or Hepatitis B or C.” Slide by...
We need to help save lives before it is too late! <ul><li>HCV is often “CURABLE” if people do not wait until they feel ill...
Many of the homeless will eventually find stable housing  and become productive  citizens again! <ul><li>However, chronic ...
 
2006
Resources <ul><li>Viral Hepatitis </li></ul><ul><li>www.cdc.gov/hepatitis </li></ul><ul><li>www.hcvadvocate.org </li></ul>...
Hepatitis and the Homeless: “The Coming Storm” Ken Akinaka, MRA In association with Alan D. Tice, M.D. Hepatitis Preventio...
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An Update of a Hepatitis C Strategic Plan for Action

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  • RG- I tried to use only chronic infection numbers (as opposed to anti HCV Ab) where these were available. Otherwise, I estimated 74% chronic infection. As children clear the virus at higher rates, I lowered the NHANES rate for Ab (0.3%) according to reported rates for chronic infection (0,1%). PEDS est is 240,000 via NIH stats from NIH HCV Meeting – This is the Anti-HCV number – chronic infections estimated at 68-100,000 (Jonas paper from the NIH meeting) I think this covers most of the populations you wanted. I did not find numbers for patients did not complete treatment. Let me know if you have alternate preferred sources for numbers. Austin. We need to tune of the prison numbers: Is the 255,000 the number of infected today? See my change in header: I would like this information to be be also intorduced step wise with the slide show NHANES 2) NEW ESTIMATE Then each sub group Neeed to add vets to this slides alsoe Could split to two slides
  • This variability in the relative efficiency of transmission results in the same risk factor causing a different proportion of infections among persons with HBV, HCV and HIV infection. For example, in the United States illegal Injection drug use accounts for approximately 60% of new HCV infections, 31% of new HIV infections and only 14% of new HBV infections. Conversely, men who have sex with men account for only 1% of new HCV infections and 15% of HBV infections, but nearly half of new HIV infections. Interestingly, a similar proportion of persons with acute HCV and HIV have no identified risk factor at 10 and 9 percent respectively.
  • This variability in the relative efficiency of transmission results in the same risk factor causing a different proportion of infections among persons with HBV, HCV and HIV infection. For example, in the United States illegal Injection drug use accounts for approximately 60% of new HCV infections, 31% of new HIV infections and only 14% of new HBV infections. Conversely, men who have sex with men account for only 1% of new HCV infections and 15% of HBV infections, but nearly half of new HIV infections. Interestingly, a similar proportion of persons with acute HCV and HIV have no identified risk factor at 10 and 9 percent respectively.
  • This variability in the relative efficiency of transmission results in the same risk factor causing a different proportion of infections among persons with HBV, HCV and HIV infection. For example, in the United States illegal Injection drug use accounts for approximately 60% of new HCV infections, 31% of new HIV infections and only 14% of new HBV infections. Conversely, men who have sex with men account for only 1% of new HCV infections and 15% of HBV infections, but nearly half of new HIV infections. Interestingly, a similar proportion of persons with acute HCV and HIV have no identified risk factor at 10 and 9 percent respectively.
  • Slide 59. Almost 50% of Students Have Had Sex Before Leaving High School 1 Almost half of students have had sex before leaving high school. 1 And, as we discussed before, VPH is often transmitted through sexual activity: Up to 14% of HAV cases in the U.S. are attributed to sexual/household contact 54% of HBV infections in the U.S. are attributed to sexual contact Like HIV, hepatitis B is spread by infected blood and body fluids, but can be 100 times more infectious than HIV. 1. CDC. Youth risk behavior surveillance—US 2001. MMWR 2002;51(SS04):1–64. 2. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004. 3. CDC. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR 2003;52(RR-01):1–36.
  • Slide 61. Otherwise Healthy Patients—Persons Who Wish to Be Protected
  • Slide 63. Persons Without Identifiable Risk Factors May Wish to Be Protected Against HBV Likewise, persons may wish to be protected against hepatitis B. Reasons a person may wish to be protected include: Nearly one-third or persons infected with acute HBV have no identifiable risk factors HBV can survive at room temperature on environmental surfaces for at least one month 50% of infected adults are asymptomatic and can spread HBV without knowing it HBV is the leading cause of liver cancer in the U.S., second only to tobacco among known human carcinogens Chronic HBV infection causes up to 80% of all liver cancer. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004.
  • Slide 62. Persons Without Identifiable Risk Factors May Wish to Be Protected Against HAV Anyone who wishes to be protected against hepatitis A should be vaccinated. Nearly half of persons infected with HAV have no identifiable risk factors, so it’s easy to see why someone might wish to be protected. In addition to the definitive risk factors established by the CDC, the following settings have also been associated with HAV transmission: Restaurants (through infected foodhandlers or contiminated food or water) Daycare (due to poor hygiene among young children and diaper-changing activities among staff) Healthcare institutions Schools Outdoor concerts/camping events 1. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004. 2. CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(RR-12):1–37. 3. CDC. Multistate outbreak of hepatitis A among young adult concert attendees—United States, 2003. MMWR 2003;52(35).844.
  • Slide 67. TWINRIX—Over 98% Effective After a 3-dose Series Here’s another chart that depicts the results of worldwide clinical trials with TWINRIX. One month after completion of a 3-dose series of TWINRIX, seroconversion for antibodies against HAV was elicited in 99.9% of vacinees, and protective antibodies against HBV were detected in 98.5%. In other words, TWINRIX elicited an effective immune response in over 98% of people after a 3-dose series. Complete TWINRIX safety summary to follow. TWINRIX prescribing information.
  • Slide 81. Are You at Risk for Vaccine-Preventable Hepatitis (VPH)?—Page 2 Screening questionnaire for vaccine-preventable hepatitis, continued. Adapted from CDC Adult Vaccination Screening Form. Accessed at www.cdc.gov/nip/recs/adult_vac_scrn_hcp.pdf on 2/11/04. (Data on file, TWR404, GlaxoSmithKline.)
  • Slide 86. 60,000 Adults Die Each Year From Vaccine-Preventable Diseases Adult vaccine-preventable disease causes significant morbidity and mortality, causing 60,000 deaths each year in the U.S. Medical visits are great opportunities to protect adults at risk from vaccine-preventable diseases. Use underlying conditions, diagnosis codes, and age to identify patients who need to be immunized. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004.
  • Slide 87. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH)— It’s Needed Vaccine-preventable hepatitis is a significant public health problem in the U.S., causing 5,100 deaths per year. Additionally, HBV is the leading cause of liver cancer in the country, second only to tobacco among known human carcinogens. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004.
  • Slide 88. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH)— It’s Recommended Experts recommend vaccination of adults at high risk for VPH. This chart outlines CDC’s recommendations for immunization of persons with chronic liver disease, hepatitis C, sexually transmitted diseases, and HIV. 1. CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(RR19):1–39. 2. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. MMWR 1991;40(RR-13):1–19. 3. CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(RR-12):1–37. 4. CDC. Guidelines for preventing opportunistic infections among HIV-infected persons —2002 . MMWR 2002;51(RR08):1–46.
  • Slide 89. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH)— It’s Reimbursed Vaccination is routinely reimbursed for adults at high risk, such as persons with chronic liver disease, hepatitis C, sexually transmitted diseases, and HIV. Data on file, TWR1602, GlaxoSmithKline.
  • An Update of a Hepatitis C Strategic Plan for Action

    1. 1. An Update of a Hepatitis C Strategic Plan for Action Hepatitis Prevention, Education, Treatment & Support Network Honolulu, HI (808) 221-6204 Fax (808) 738-5797 [email_address] Hepatitis and the Homeless: The Coming Storm
    2. 2. Hepatitis B & C - The “Silent Epidemics” of the Homeless even in a Paradise
    3. 3. Clouds gathering… <ul><li>“Despite over 20 years of knowledge, millions of dollars thrown into prevention and the distribution of countless condoms, many people in the U.S. are contracting HIV and Hepatitis at an alarming rate.” </li></ul><ul><li>WHY? </li></ul>Slide modified from Countny East, APRN, 12/2004
    4. 4. 1 MMWR Recomm Rep. 2003;52(RR-1):1-36. 2 Edlin. Hepatology. 2002;36(5 Suppl 1):210-9. 3 NHSDA Report. 2003. 4 Khalili and Behm. Clin Inf Dis. 2000;31:154-61. 5 Labreque and Sandt. In Hepatitic C: Choices. 2002. 6 Alter et al. N Engl J Med. 1999;341(8):556-562. 7 Nyamathi et al. J Gen Intern Med. 2002;17(2):134-43. 8 Br ä u et al. Am J Gastroenterol. 2002;97(8):2071-8. 9 Jonas. Hepatology. 2002;36(5 Suppl 1):S173-8 . Incarcerated, ~310,000 (15%) 1 ; Ever incarcerated, ~1,400,000 Injection drug users ~300,000 (80-90%) 2,3 HIV-infected ~300,000 (30%) 4 Alcoholics ~240,000 (11-36%) 5 Living below poverty level ~940,000 (2.4%) 6 Children (6-19 years) ~100,000 (0.1%) 9 Homeless ~175,000 (22%) 7 Estimated US HCV Prevalence including Select Populations: 5 Million United States (Gish et al, J Clin Gastro Hep, 2005) Veterans ~280,000 (8%) 8
    5. 5. Sirens to Wail <ul><li>60 Second Hepatitis C PSA from New Orleans </li></ul>
    6. 6. Adults who are at the most risk for infection with Hepatitis C <ul><li>Homeless substance abusers </li></ul><ul><li>Injection Drug Users </li></ul><ul><li>Prisoners sharing injection drug using equipment or tattooing needles or ink </li></ul><ul><li>People who snort drugs may be at risk </li></ul><ul><li>Those with multiple sex partners and a history of sexually transmitted diseases </li></ul><ul><li>Hemophiliacs </li></ul><ul><li>Healthcare workers including EMT and others </li></ul><ul><li>Military and others in other parts of the world who may exposed to blood </li></ul>Slide by Ken Akinaka, MRA 10/2005
    7. 7. Risk Factors for Transmission of Hepatitis Viruses and HIV in the USA Proportion of Infections Slide by Countny East, APRN, 12/2004 Transfusion No Identified Risk Occupational Heterosexual partners MSM Injection drug use Risk Factor rare 30% 5-7% (past) 40% 15% 14% HBV Past 7- 20% 10% <<1% 20% 1% 60% HCV 9% Past 2% <<1% 10% 47% 31% HIV
    8. 8. Groups of High Rates Transmission of Hepatitis C Virus in the USA Proportion of Infections Slide by Ken Akinaka, MRA, Jan. 2005 Residential SA Tx (Day Top, NY) Co-infected with HIV (CDC, USA) Homeless with Mental Illness & Substance Abuse (St. Louis, MI) Research indicates >2 xs Nat. Avg. 30% 30% 25% HCV Veterans (UW-SPH, USA) Higher with Vietnam era Veterans LOCAL RESEARCH IS NEEDED WITH THESE HIGH RISK GROUPS TO TARGET PREVENTION, TESTING, & TREATMENT EFFORTS!
    9. 9. Other Groups with High Rates Transmission of Hepatitis C Virus in the USA Proportion of Infections Slide by Ken Akinaka, MRA, Jan. 2005 On Methadone Maintenance Treatment Inmates In USA 85 to 95% 25 - 30% HCV
    10. 10. The number of homeless is growing because of the exploding real estate market, the high costs of rent, and in Hawai`i because of the consistent pleasant weather and environment. <ul><li>In fiscal year 2004, emergency shelters in Chicago served 13,108 unduplicated clients, up from 11,050 in fiscal year 2003 1 . </li></ul>1. http://www.chicagohomeless.org/factsfigures/causesandfacts.htm#shelter
    11. 11. Each day at least 800,000 persons are homeless in the USA. That includes 200,000 children. On any given night, almost 300,000 veterans experience homelessness nationwide, a number far greater than the roughly 58,000 U.S. soldiers who died during the Vietnam War.  <ul><li>As many as 18,000 veterans are estimated to experience homelessness every night in the six counties of the Chicago metropolitan area. </li></ul><ul><li>Over the course of a year, between 2.3 and 3.5 million people experience homelessness nationwide and approximately 166,000 people experience homelessness in the Chicago Metropolitan area. </li></ul>
    12. 12. Hepatitis B, Hepatitis C, Human Immunodeficiency Viral Infections and Tuberculosis In A Homeless Veteran Population RAMSEY CHI-MAN CHEUNG, M.D. Chief of Hepatology Veterans Affairs, Palo Alto, CA Cheung et al, J Clin Gastroenterol, 2002
    13. 13. Domiciliary for the Homeless <ul><li>Rehabilitation program </li></ul><ul><li>Homelessness of any duration </li></ul><ul><li>Ability for self-care </li></ul><ul><li>Monthly income < $1,200 </li></ul><ul><li>Willingness and ability to return to work </li></ul>Cheung et al, J Clin Gastroenterol, 2002
    14. 14. Cheung et al, J Clin Gastroenterol, 2002
    15. 15. Cheung et al, J Clin Gastroenterol, 2002
    16. 16. Cheung et al, J Clin Gastroenterol, 2002
    17. 17. Cheung et al, J Clin Gastroenterol, 2002
    18. 18. Cheung et al, J Clin Gastroenterol, 2002
    19. 19. What most people still do not know: The delay in signs and symptoms of HIV or chronic Hep infections can result in people who don’t feel sick and who disregard that possibility of spreading HIV or Hep infection. Slide by Countny East, APRN, & Ken Akinaka, MRA 12/2004
    20. 20. The face of the Hepatitis C (HCV) epidemic is also changing! <ul><li>The new infections are estimated at 25,000 (CDC) to 40,000 (HRSA) per year. </li></ul><ul><li>Injection drug use and experimental injection drug use appear to be the greatest source of the spread of new infections. </li></ul><ul><li>44% of the Homeless with mental illness and substance abuse may have already been infected with hepatitis B and/or C. </li></ul>Slide by Ken Akinaka, MRA 10/2005
    21. 21. Other High risk groups that may continue to be a “Reservoir” of HCV infection unless they are tested, become aware of their infection, and are treated: <ul><li>5.4% to 8% of Veterans appear to have been infected. </li></ul><ul><li>Prisoners and people who have been incarcerated in the past appears to be about 15%. In many prisons it is 25% to 30%. </li></ul><ul><li>It has been estimated that over 300,000 people may have HCV that had a blood transfusion before our blood supply was required to be tested for HCV in July 1992. </li></ul><ul><li>Many of them still do not know it yet! </li></ul>Slide by Ken Akinaka, MRA 10/2005
    22. 22. The face of the HIV pandemic is changing, and it is younger. <ul><li>25% of persons living with HIV in the world are 15 -24 years old. </li></ul><ul><li>½ of all new infections of HIV occur in 15 to 24 year olds. </li></ul><ul><li>51% of the new infections occur in women and girls. </li></ul>Slide by Countny East, APRN, 12/2004
    23. 23. What youth are the most at the most risk for HIV infection? <ul><li>Street youth (40% of homeless youth identify themselves as being gay or lesbian.) </li></ul><ul><li>Runaways </li></ul><ul><li>Teens having “survival sex” </li></ul><ul><li>Those with a history of sexual abuse </li></ul><ul><li>Teens with psychiatric diagnoses, such as mood disorder, substance abuse, and depression. </li></ul><ul><li>Teens lacking resources – housing, safety </li></ul><ul><li>Teens with older partners </li></ul>Slide by Countny East, APRN, 12/2004
    24. 24. Contributing factors to risk: What is it about teens and young adults that makes them so vulnerable to contract HIV or Hep B or C? Slide by Countny East, APRN, 12/2004
    25. 25. Developmental stages in adolescence <ul><li>Early teens (10 – 13) </li></ul><ul><li>Sex drive begins </li></ul><ul><li>Peer pressure, separation from parents </li></ul><ul><li>Poor future orientation. </li></ul><ul><li>Sexual interest usually exceeds activity </li></ul><ul><li>Mid Teens (14 – 16) </li></ul><ul><li>Sex drive surges </li></ul><ul><li>Peak conflict with parents </li></ul><ul><li>Peer group sets standards. </li></ul><ul><li>Increasing sexual behavior and experimentation. </li></ul>Slide by Countny East, APRN, 12/2004
    26. 26. Some quick numbers… <ul><li>17% of 7 th and 8 th grade students report that they have had sexual intercourse. </li></ul><ul><li>By the time teens turn 18, 56% of girls and 73% of boys report having had intercourse. </li></ul>Slide by Countny East, APRN, 12/2004
    27. 27. Late adolescence developmental stage (17 – 21+) <ul><li>Maturation complete </li></ul><ul><li>Close friendships formed. </li></ul><ul><li>Intimacy. </li></ul><ul><li>Focus on role in society. </li></ul><ul><li>Future oriented. </li></ul><ul><li>Refinement of values. </li></ul><ul><li>Sexual orientation consolidates. </li></ul>Slide by Countny East, APRN, 12/2004
    28. 28. Teen behavior and their risks to acquire HIV or Hepatitis B or C: <ul><li>Have multiple sex partners. </li></ul><ul><li>Relationships are short-lived. </li></ul><ul><li>Teens fall “in-and-out of love” and it can be dangerous. </li></ul><ul><li>Teens tend to be “serially monogamous”…for a very short period of time! </li></ul><ul><li>Some experiment with using Injectable drugs </li></ul><ul><li>Some have Tattoos (or in Hawai`i Tatau or Polynesian Tattoos) or body piecing that is not done with new Needles or that uses shared ink. </li></ul>Slide by Countny East, APRN, 12/2004
    29. 29. Challenges that predispose teens & adults to disregard HIV or Hepatitis risk <ul><li>The fear of HIV or Hepatitis has been lost. </li></ul><ul><li>HIV & Hepatitis command less urgency that it once did, feeding the perception that HIV is no longer a threat. </li></ul><ul><li>Infallibility, “HIV or Hep can’t happen to me.” </li></ul><ul><li>A belief by teens and others that HIV can be cured. </li></ul><ul><li>HIV medications are portrayed as being easy to take. </li></ul><ul><li>Sexual risky behavior is back in vogue. </li></ul>Slide by Countny East, APRN, 12/2004
    30. 30. Almost 50% of Students Have Had Sex Before Leaving High School 1 <ul><li>54% of HBV infections in U.S. attributed to sexual contact 2 </li></ul><ul><li>Like HIV, HBV is spread by infected blood and body fluids, but can be 100 times more infectious than HIV 3 </li></ul>1. CDC. MMWR 2002;51(SS04):1–64., 2. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004., 3. CDC. MMWR 2003;52(RR-01).
    31. 31. Exposure Sero-conversion Asymptomatic Symptomatic AIDS Death 0 - 3 mos 3 - 6 mos 8 - 10 years 2-3 years 8 mos – 2 years Why is it so important to get teens’ attention? Every hour 2 adolescents in the United States are infected with HIV, and most never know they are at risk. The Natural History of HIV infection Slide by Countny East, APRN, 12/2004
    32. 32. STDs and Teens <ul><li>It is believed that at least 25% of sexually active American teens have contracted an STD. That’s 3 million teens a year. </li></ul><ul><li>Bottom line, if teens are getting STDs, they either aren’t consistently using condoms or they aren’t using them right! </li></ul>Slide by Countny East, APRN, 12/2004
    33. 33. A word on gay teens <ul><li>There are nearly 1 million gay teens in the U.S. </li></ul><ul><li>There is a lack of information about safe-sex practices for gay teens. </li></ul><ul><li>Sex education ignores gay youth…it renders them “invisible”. </li></ul><ul><li>Experience emotional isolation. </li></ul><ul><li>Experience widespread harassment. </li></ul><ul><li>High suicide and dropout rates. </li></ul>Slide by Countny East, APRN, 12/2004
    34. 34. Traces of Blood – A Hepatitis C Video <ul><li>Training Video for Staff and Injection Drug Users </li></ul>
    35. 35. E Ho'omalu Kakoa I Ka Po'e Nele A Hune &quot;Lets Shelter & Protect Those Who Are In Need&quot; <ul><li>Save-A-Life Free Safety </li></ul><ul><li>Kits Campaign </li></ul><ul><li>Razors & Shaving Cream </li></ul><ul><li>Tooth Brushes & Tooth Paste </li></ul><ul><li>Nail Clippers </li></ul><ul><li>Toe Nail Clippers </li></ul><ul><li>Nail Files </li></ul><ul><li>Band-Aids </li></ul><ul><li>Antiseptic or Alcohol Wipes </li></ul><ul><li>Soap &/or Anti-Bacterial Hand Gel </li></ul><ul><li>Condoms </li></ul>
    36. 36. Free Save-A-Life Safety Kit Campaign <ul><li>In May 2006, we informed a person with Hep B & a person with Hep C at the new 300 people Kakoa`ako Homeless Shelter that they were positive. </li></ul><ul><li>They both stated that they had been sharing razors. </li></ul><ul><li>In June 2006, we started our new free Save-A-Life Safety Kit Campaign! </li></ul>
    37. 37. Can Razor Blades Transmit Hepatitis B? <ul><li>“ Determination of Hepatitis B Virus at Used Razor Blade by PCR” </li></ul><ul><li>78 used razor blades were purchased from different barber’s shops in Turkey. </li></ul><ul><li>HBV DNA was detected in 6 (7.7%) razor blade samples. </li></ul><ul><li>CONCULSION : Reuse of razor blade that carry HBV will infect other people. Hence any HBV control & prevention program should educate barbers (and others) about the importance of contagious diseases, proper sterilization tech., and avoiding reuse and sharing of contaminated equipment and supplies like razor blade. </li></ul><ul><li>ICAAC, Reported by Jules Levin, Sept. 27-30, 2006, San Francisco, CA. </li></ul>
    38. 38. Hepatitis C – contamination of toothbrushes: myth or reality? <ul><li>30 patients with chronic hepatitis C had their saliva and rinsing water tested. </li></ul><ul><li>40% of the toothbrush rinsing water specimens tested HCV-RNA-positive. </li></ul><ul><li>CONCULSION : Study demonstrates a contamination with HCV-RNA of considerable portion toothbrushes used by hepatitis C patients </li></ul><ul><li>Journal of Viral Hepatitis, Volume 13, No. 9, Sept. 2006, pp. 571-573(3) </li></ul>
    39. 39. HCV may survive on environmental surfaces at room temp. at least 16 hrs. up to 4 days! <ul><li>This re-emphsizes the importance of: </li></ul><ul><li>Cleaning and disinfection procedures, </li></ul><ul><li>Safe therapeutic injection practices, and </li></ul><ul><li>Harm reduction counseling and services for injection drug users. </li></ul>
    40. 40. Get The Facts <ul><li>Video by Diana Slyvestre, MD, and Patients who have Hepatitis C at Oasis Clinic in Oakland, CA </li></ul>
    41. 41. Hawai`i has the highest rate of Liver Cancer in the USA because of our high rates Hep B & C. Immigration from Pacific Island and Asian countries, which have extremely high rates of chronic hepatitis B is why we have the second highest rate of Hep B in the USA.
    42. 42. Here are the rates of hepatitis B in these other Pacific Island countries as reported by the World Health Organization. <ul><li>Population HBsAg+ % Infected with </li></ul><ul><li>Hepatitis B </li></ul><ul><li>American Samoa 50,923 3,565 7% </li></ul><ul><li>China 1,299,180,000 155,901,600 12% </li></ul><ul><li>Fiji 883,000 97,130 11% </li></ul><ul><li>Kiribati 72,000 22,320 31% </li></ul><ul><li>S. Korea 46,403,000 5,568,360 12% </li></ul><ul><li>Marshall Islands 190,000 22,800 12% </li></ul><ul><li>Micronesia, FSM 190,000 22,800 12% to 15% </li></ul><ul><li>New Zealand 3,662,000 29,296 0.8% (10% of Maori) </li></ul><ul><li>Palau 16,386 1,966 12% to 15% </li></ul><ul><li>Papua New Guinea 4,845,000 969,000 20% to 25% </li></ul><ul><li>Philippines 77,473,000 7,747,300 10% </li></ul><ul><li>Samoa (Western) 190,000 15,200 8% to 10% </li></ul><ul><li>Tonga 92,000 18,400 20% </li></ul><ul><li>Vietnam 82,427,000 9,891,240 12% </li></ul>
    43. 43. The homeless are one of the highest at-risk groups that will continue spreading chronic viral hepatitis B and/or C unless we can start to effectively test & treat them for these hidden epidemics and vaccinate them for Hepatitis B. <ul><li>Most states do not have any special case management program to help the homeless populations that are infected with chronic hepatitis and that are at risk of spreading these infections to others. </li></ul>
    44. 44. Many Homeless want to receive treatment for their Hepatitis C! <ul><li>Hepatitis C treatment study in 2005 by Alan D. Tice, MD, 32 of 150 methadone patients that thought they had active hepatitis C volunteered to be treated with pegylated interferon and ribavirin. </li></ul><ul><li>An important new finding was that of those who were interested in treatment for their hepatitis C, 40% were homeless! </li></ul>
    45. 45. These efforts will save lives, limit the spread of disease , and in the long run be cost-effective! <ul><li>Earlier testing and more housing, medical benefits, support, and case management are needed for effective treatment. </li></ul><ul><li>Medical Costs of Cirrhosis or End Stage Liver Disease related complications (even before a Liver Transplants is needed) is very costly to our Healthcare Systems. </li></ul><ul><li>Liver Transplants cost $250,000 to $350,000 apiece with about $10,000 of anti-rejection medications per year. </li></ul>
    46. 46. Chronic liver disease due to hepatitis C causes between 10,000 and 12,000 deaths per year! <ul><li>It is the leading indication for liver transplantation each year in the United States. </li></ul><ul><li>By the year 2010, the number of deaths from hepatitis C is expected to rise to 38,000 each year. </li></ul><ul><li>It is also now the primary reason for death from HIV. </li></ul>
    47. 47. A number of Homeless drink Alcohol. Should they be treated for their HCV? “Alcohol use and treatment of hepatitis C virus: results of a national multicenter study” <ul><li>A total of 4061 subjects were enrolled. </li></ul><ul><li>The aim of study was to determine the impact of alcohol use on HCV tx outcomes. </li></ul><ul><li>Recent alcohol use was associated with increased higher HCV tx discontinuation and lower SVR. </li></ul><ul><li>However, patients who use alcohol and completed HCV tx had a response comparable to that of nondrinkers. </li></ul><ul><li>CONCULSIONS : Patients with a history of alcohol use should not be excluded from HCV tx. Instead, additional support should be provided to ensure their ability to complete HCV tx. </li></ul><ul><li>Gastroenterology. 2006 May;130(6):1912-4. Dept. of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas. PMID: 16697724 [PubMed – in process] </li></ul>
    48. 48. Free Hepatitis B or C Tests for the Homeless & other at risk Groups <ul><li>We now give a Free T-Shirt to those who test at: </li></ul><ul><li>Health Fairs </li></ul><ul><li>Community & Organizational Talks </li></ul><ul><li>Free for Homeless or people with risk factors who cannot afford special low cost tests </li></ul><ul><li>$15 for HBV </li></ul><ul><li>$25 for HCV </li></ul><ul><li>$35 for Both Tests </li></ul>
    49. 49. Where can they be tested for HCV if you do not have Health Insurance? <ul><li>Very limited resources in the USA </li></ul><ul><li>Home Access Hepatitis C test Kits for $59.95 at http://www.homeaccess.com/02/ </li></ul><ul><li>Through the State Department of Health in Hawai`i if you have been an injection drug user </li></ul><ul><li>Check with your local Health Dept. if you do not have Health Insurance or cannot be tested by your physician or a local Community Health Clinic </li></ul>Slide by Ken Akinaka, MRA 10/2005
    50. 50. Another Important Health Concern! The Homeless as well as many otherwise Healthy People Need to Be Protected from Hepatitis A & B and need to be vaccinated!
    51. 51. Reminder - Persons With HIV &/or Hepatitis C need to be Protected Against HBV <ul><li>HBV can survive at room temperature on environmental surfaces for at least one month </li></ul><ul><li>50% of infected adults are asymptomatic and can spread HBV without knowing it </li></ul><ul><li>HBV is the leading cause of liver cancer in the U.S. 1 </li></ul><ul><ul><li>2nd only to tobacco among known human carcinogens 1 </li></ul></ul>Nearly one-third of persons infected with acute hepatitis B have no identifiable risk factors. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004. Slide from Twinrix, June. 2005
    52. 52. Persons Without Identifiable Risk Factors May Also Wish to Be Protected Against HAV <ul><li>Possible settings for hepatitis A transmission include: </li></ul><ul><ul><li>Restaurants—infected food handlers or contaminated food/water 2 </li></ul></ul><ul><ul><li>Daycare—poor hygiene among young children and diaper-changing activities among staff 2 </li></ul></ul><ul><ul><li>Healthcare institutions 2 </li></ul></ul><ul><ul><li>Schools 2 </li></ul></ul><ul><ul><li>Outdoor concerts/camping events 3 (and Homeless settings) </li></ul></ul>1. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8 th ed. 2004., 2. CDC. MMWR. 1999;48(RR12)., 3. CDC. MMWR .2003;52(35). Nearly half (45%) of persons infected with hepatitis A have no identifiable risk factors. 1
    53. 53. TWINRIX—Over 98% Effective After a 3-dose Series Complete TWINRIX safety summary to follow. Slide from Twinrix, June. 2005 *Anti-HAV titer  assay cut-off: 20 mIU/mL or 33 mIU/mL. † Anti-HBsAg titer  10 mIU/mL. Sera from 1,551 healthy adult volunteers in 11 clinical trials were analyzed 1 month after each of the 3 doses on a 0-, 1-, and 6-month schedule. 98.5 99.9 3 78.2 98.8 2 30.8 93.8 1 % Seroprotection for HBV † % Seroconversion for HAV * TWINRIX
    54. 54. Are You at Risk for Vaccine-Preventable Hepatitis (VPH)? Page 2 <ul><li>I come from Asia or the Pacific Islands </li></ul><ul><li>I take street drugs </li></ul><ul><li>I am a man who has sex with men </li></ul><ul><li>I have a blood-clotting disease with clotting factor infusions </li></ul><ul><li>I had more than one sex partner during the last 6 months </li></ul><ul><li>I have sex with or live with a person with hepatitis B </li></ul><ul><li>I provide direct services to people with developmental disabilities </li></ul>Adapted from CDC Adult Vaccination Screening Form. Accessed at www.cdc.gov/nip/recs/adult_vac_scrn_hcp.pdf on 2/11/04. (Data on file, TWR404, GlaxoSmithKline.)
    55. 55. 60,000 Adults Die Each Year From Vaccine-Preventable Diseases <ul><li>Medical visits are often missed opportunities to provide needed immunizations </li></ul><ul><li>Add adult vaccination to your practice </li></ul><ul><ul><li>Identify adults at risk through pre-existing conditions and/or diagnosis codes </li></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Disease State </li></ul></ul></ul>CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004.
    56. 56. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH) It’s Needed! <ul><li>Vaccine-preventable hepatitis (VPH) is a significant public health problem in the U.S. </li></ul><ul><ul><li>VPH causes 5,100 deaths per year </li></ul></ul><ul><ul><li>HBV is the leading cause of liver cancer in the U.S. </li></ul></ul><ul><ul><ul><li>2nd only to tobacco among known human carcinogens </li></ul></ul></ul>CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases . 8th ed. 2004.
    57. 57. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH) It’s Recommended 1. CDC. MMWR 1998;47(RR19)., 2. CDC. MMWR 1991;40(RR13)., 3. CDC. MMWR 1999;48(RR12)., 4. CDC. MMWR 2002;51(RR08). Centers for Disease Control and Prevention Recommendations <ul><li>Susceptible HIV pts 4 </li></ul><ul><li>Susceptible HIV pts with chronic HCV 4 </li></ul>HIV-Positive <ul><li>Persons with STDs 2 </li></ul><ul><li>Multiple sex partners 2 </li></ul><ul><li>HBV partner 2 </li></ul><ul><li>MSM 2 </li></ul><ul><li>MSM 3 </li></ul>Sexually at Risk <ul><li>Susceptible HCV Pts 2 </li></ul><ul><li>All CLD Pts 1 </li></ul>Chronic Liver Disease/HCV HBV Vaccine Recommended HAV Vaccine Recommended Risk Group
    58. 58. Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH) It’s Reimbursed <ul><li>Vaccination routinely reimbursed for patients at risk </li></ul><ul><ul><li>Persons with chronic liver disease/hepatitis C </li></ul></ul><ul><ul><li>Persons with sexually transmitted diseases </li></ul></ul><ul><ul><ul><li>Chlamydia, Gonorrhea, Herpes, HPV, Syphilis, etc. </li></ul></ul></ul><ul><ul><li>Men who have sex with men </li></ul></ul><ul><ul><li>HIV-positive persons </li></ul></ul>Data on file, TWR1602, GlaxoSmithKline.
    59. 60. Merck will provide free vaccines to adults who are uninsured & unable to afford vaccines! <ul><li>Starting the third quarter of 2006, Merck vaccines will become available through their new Patient Assistance Program. </li></ul><ul><li>All of Merck Vaccines are available in this program including Hep A, Hep B and Pneumococcal vaccines that are recommend for people with chronic viral Hepatitis. </li></ul><ul><li>Uninsured people with incomes less than $19,600 are eligible (twice the Federal poverty level). </li></ul><ul><li>Forms can be faxed to the patient’s physician’s office with a processing goal of less than ten minutes – so that qualifying patients can receive Merck vaccine during that visit! </li></ul><ul><li>May 26, 2006, News Release Media Contacts: Maggie Kohn </li></ul><ul><li>(908) 423-5655 & Mary Elizabeth Blake (215) 652-5558 </li></ul>
    60. 61. Please Remind people: “It’s not who you are but what you do that puts you at risk for HIV or Hepatitis B or C.” Slide by Countny East, APRN, 12/2004
    61. 62. We need to help save lives before it is too late! <ul><li>HCV is often “CURABLE” if people do not wait until they feel ill to be tested and treated. Most people will not feel ill until it may be too late to be treated. </li></ul><ul><li>Many homeless and substance abusers, who have been treated for Hepatitis C, are now helping to educate others in ways that outreach workers, who are not infected with Hepatitis C, cannot do! </li></ul><ul><li>We can help stop the spread of Hepatitis C, save lives, and reduce the “Reservoir” of these viruses by educating the homeless and other at risk groups, vaccinating them for HAV and HBV, and treating them before it is too late! </li></ul>
    62. 63. Many of the homeless will eventually find stable housing and become productive citizens again! <ul><li>However, chronic viral hepatitis B & C will continue to be “silent epidemics” that will infect and eventually kill many of them unless they are tested and treated. </li></ul>
    63. 65. 2006
    64. 66. Resources <ul><li>Viral Hepatitis </li></ul><ul><li>www.cdc.gov/hepatitis </li></ul><ul><li>www.hcvadvocate.org </li></ul><ul><li>www.hepcproject.org </li></ul><ul><li>www.immunize.org </li></ul><ul><li>www.hepb.org </li></ul>
    65. 67. Hepatitis and the Homeless: “The Coming Storm” Ken Akinaka, MRA In association with Alan D. Tice, M.D. Hepatitis Prevention, Education, Treatment & Support Network and www.IDLinks.com Honolulu, HI (808) 221-6204 Fax (808) 738-5797 KenAkinaka@aol.com
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