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John W. Ward. M.D.

John W. Ward. M.D.






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  • There are other elements to the national strategy. CDC doesn’t have the lead in every element (SAMHSA, NIH), civil society and local government (needle exchanges)
  • This slight highlights some of the specific issues that have had an impact on our current viral hepatitis surveillance activities…..
  • Part of these increases have been due to an increasing number of state health departments reporting cases of chronic viral hepatitis infections to the CDC via NNDSS. These two maps show the states that are currently reporting chronic hepatitis B and chronic hepatitis C infections to the CDC. The red states are those that are currently reporting to CDC. The grey states are those for which chronic viral hepatitis is reportable in the state but who do not yet report these to the CDC and the blue states are those where these infections are not yet reportable so do not currently have data to send to the CDC. As you can see in the map on the left currently 39 states report chronic hepatitis B infections. Slightly fewer, 36 states, are currently reporting chronic hepatitis C infections to the CDC. You’ll note that there are still some large states for whom we do not get this data. The large volume of reports of chronic viral hepatitis infections and the lack of financial resources to adequately conduct surveillance for these chronic infections most likely plays a role in this lack of reporting.

John W. Ward. M.D. John W. Ward. M.D. Presentation Transcript

  • John W. Ward. M.D. Director, Division of Viral Hepatitis National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Centers for Disease Control and Prevention Division of Viral Hepatitis Update NASTAD March 31, 2008
  • Reported Hepatitis A, 1980-2006 Reported Acute Hepatitis B, 1985-2006 Reported Acute Hepatitis C United States, 1992-2005 Remarkable Prevention Successes
  • Challenges To Reduce High Burden of Infection and Disease
    • 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
  • Strategic Imperatives for 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, 1 st 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
    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
  • 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
  • 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)
  • 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
  • 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 10 6 9 7 2 8 5 1 4 3 (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 Hepatitis Strategic 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%