Hapatitis overview


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  • HAV is found in the stool (feces) of persons with hepatitis A.  HAV is usually spread from person to person by putting something in the mouth (even though it may look clean) that has been contaminated with the stool of a person with hepatitis A.  PERSONS AT RISK OF INFECTION Sex contacts of infected persons Household contacts of infected persons Persons traveling to countries where hepatitis A is common Men who have sex with men Injecting and non-injecting drug users An estimated 42, 000 new infections occurred in 2005
  • The incidence of hepatitis A began to decline after the introduction of licensed hepatitis A vaccine in 1995 and the issuance in 1996 of the first public health recommendations for the use of vaccine to prevent transmission of HAV. The greatest declines have occurred since 1999 when recommendations were made for childhood vaccinations. Disparities in rates among racial/ethnic populations also decreased after the introduction of hepatitis A vaccine.
  • Hepatitis A vaccine is the key component in the overall strategy to prevent HAV infection in the United States.
  • Transmission of HBV generally Occurs when blood from an infected person enters the body of a person who is not infected. -HBV is spread through having sex with an infected person without using a condom, by sharing drugs, needles, or "works" when "shooting" drugs, through needle sticks or sharps exposures on the job, or from an infected mother to her baby during birth. Main risk factors Persons with multiple sex partners or diagnosis of a sexually transmitted disease Men who have sex with men Injection drug users Sex contacts of infected persons and household contacts of chronically infected persons An estimated 51, 000 new infections occurred in 2005. 1.25 million are chronically infected and 5000 deaths occurred in 2005.
  • Since 1990 progress has been made in reducing racial/ethnic disparities in hepatitis B rates. Before 1990 Asians/Pacific Islanders had disproportionately higher rates of hepatitis B. Although the rates among African Americans have declined, they remain more than two-fold higher than other racial/ethnic populations as indicated here in green.
  • Incidence has declined substantially among African Americans > 19 years, but the incidence remains nearly 3 times higher than other racial and ethnic populations.
  • Soon after hepatitis B vaccine was licensed in 19982, ACIP recommended vaccination for adults at increased risk for HBV Infection. However, the recommendations were not widely implemented, and coverage among adults at risk for HBV infection remained low.
  • Setting based recommendations are new. These recommendations are intended to reduce barriers to vaccinating at risk populations
  • HCV transmission cccurs when blood from an infected person enters the body of a person who is not infected.  HCV is spread through sharing needles or "works" when "shooting" drugs, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth. Needle sharing from injection drug use is the greatest risk for HCV Injection drug use, even once many years ago, is a risk As many as 90% of IDUs are infected with HCV within 5 years of injecting
  • The incidence of hepatitis C has declined steadily since the peaking in 1980s. This decline is primarily the result of decrease in cases among IDUs; the reasons are probably related to risk-reduction practices in this population, including declines in needle-sharing behaviors. Progress has been made in reducing disparities in race/ethnicity-specific rates; in 2005 the incidence of acute hepatitis C was similar across all racial/ethnic populations.
  • Anti-HCV prevalence was significantly higher in men than in women, with the peak prevalence occurred among persons aged 40-49 years. Lastly, prevalence was also higher in African Americans.
  • The majority of coinfected people are IDUs. HCV is acquired relatively soon after individuals begin injecting drugs. Within 5 years of beginning to inject, 50% to 80% of IDUs are infected with HCV. As a result, many IDUs who become infected with HIV are already infected with HCV. It is estimated that 50% to 90% of IDUs with HIV also have HCV infection.
  • With overlapping risk factors for transmission of viral hepatitis and HIV infections and limited public health resources, integrating services makes good public health sense.
  • Many opportunities exist to prevent HIV and viral hepatitis infections in public health settings, such as HIV counseling and testing sites, sexually transmitted disease clinics, substance abuse treatment programs, jails and prisons. When examine closely in study of adults with acute hep B 61% reported a history of incarceration, drug treatment, or STD treatment but they were not vaccinated in these settings despite recommendations.
  • We fund 52 HCV Coordinators to: Collaborate with public health programs (e.g., STD, HIV, immunization, correctional health, substance abuse treatment, syringe exchange) and medical organizations to integrate viral hepatitis prevention services into their venues
  • Hapatitis overview

    1. 1. Viral Hepatitis Prevention: Overview & Integration Projects Hope King, MSPH Division of Viral Hepatitis A Consultation to Address HIV/AIDS Among African American Women June 20-21, 2007 Atlanta, GA
    2. 2. Outline of presentation <ul><li>Overview of viral hepatitis </li></ul><ul><li>Hepatitis A </li></ul><ul><li>Hepatitis B </li></ul><ul><li>Hepatitis C </li></ul><ul><li>Viral Hepatitis and HIV </li></ul><ul><li>Review CDC projects relating to integration </li></ul>
    3. 3. Hepatitis A Virus Infection Transmission Main risk factors Symptomatic Infectious period Chronic infection Mortality # of new infections Fecal-oral Sex and household contacts of infected persons, Travelers endemic countries, MSM, IDU, and NIDU 30% <6 years; 70% > 6 years of age 2 weeks, starting prior to jaundice No 0.4% (acute liver failure) 42, 000 in 2005
    4. 4. Incidence of Hepatitis A, by Race and Ethnicity, US, 1990-2005
    5. 5. Recommendations for Hepatitis A Prevention <ul><li>Vaccine is the primary prevention tool </li></ul><ul><li>2006: Universal infant vaccination </li></ul><ul><li>1996 Adults at increased risk of infection or its adverse consequences: </li></ul><ul><ul><ul><ul><li>Travelers to HAV endemic countries, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Men who have sex with men (MSM), </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Illegal drug users, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Persons with chronic liver disease, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Persons with clotting factor disorders </li></ul></ul></ul></ul>
    6. 6. Hepatitis B Virus Infection Transmission Main risk factors Symptomatic Chronic infection Mortality # of new infections # of chronic infections # of annual deaths Percutaneous, mucosal Multiple sex partners, MSM, IDU, sexual and household contacts; perinatal exposure ~0% <5 years ; 30%-50% >5 years; 90% <1 year; 5% >5 years; 0.5%-1% (acute fatality); 15-25% (chronic liver disease) 51,000 in 2005 1.25 million in 2005 3,000-5,000 in 2005
    7. 7. Incidence of Acute Hepatitis B, by Race and Ethnicity, United States, 1990-2005
    8. 8. Hepatitis B Incidence ≥ 19 Years By Race/Ethnicity: United States, 1990-2004 Asian/Pacific Islander AI/AN Black Hispanic White
    9. 9. <ul><li>Prevent perinatal HBV transmission </li></ul><ul><li>Universal infant vaccination </li></ul><ul><li>Catch-up vaccination of all children and adolescents <19 years </li></ul><ul><li>Vaccination of adults in high risk groups </li></ul>Advisory Committee on Immunization Practices Strategy to Eliminate HBV Transmission
    10. 10. Rationale for New Recommendations <ul><li>Since 1982, ACIP has recommended HepB vaccination for adults at risk for HBV infection </li></ul><ul><li>However, recommendations have not been effectively implemented </li></ul><ul><li>A substantial burden of new infections continues to occur among adults </li></ul>
    11. 11. <ul><li>HepB vaccine recommended for: </li></ul><ul><li>all unvaccinated adults at risk </li></ul><ul><li>all adults seeking protection (acknowledgment of specific risk factor not required) </li></ul><ul><li>Vaccination strategies for </li></ul><ul><li>Settings w/high proportion of at risk adults </li></ul>Hepatitis B Vaccine Recommendations for Adults
    12. 12. Settings where hepatitis B vaccination is recommended for all clients: <ul><ul><li>STD treatment facilities </li></ul></ul><ul><ul><li>HIV testing and treatment facilities </li></ul></ul><ul><ul><li>Substance abuse treatment facilities </li></ul></ul><ul><ul><li>Correctional facilities </li></ul></ul><ul><ul><li>Health care providers serving IDU </li></ul></ul><ul><ul><li>Health care providers serving MSM </li></ul></ul><ul><ul><li>Others including hemodialysis, adult institutions </li></ul></ul>Draft MMWR Adult Hepatitis B Vaccination Recommendations 11/17/2006 Advisory Committee on Immunization Practices
    13. 13. Hepatitis C Virus Infection Transmission Main risk factor Symptomatic Chronic infection Immunity Mortality # of new infections # of chronic infections # of annual deaths Percutaneous IDU <25% 85% in adults No protective antibody response identified 1%-5% (chronic liver disease) 20,000 in 2005 3.2 million in 2005 8,000-10,000 in 2005
    14. 14. Incidence of Acute Hepatitis C, by Race and Ethnicity, US, 1992-2005 *Acute hepatitis C was reported as acute hepatitis Non-A Non B until 1995
    15. 15. Prevalence of Anti-HCV, United States, 1999-2002 (NHANES) Armstrong et al. AASLD 2004. Overall prevalence: 1.6% (4.1 million) Born ~1945-1965
    16. 16. Hepatitis C Prevention Strategy <ul><li>Prevent new infections </li></ul><ul><ul><li>Risk-reduction education and awareness </li></ul></ul><ul><ul><li>Review and update infection control practices </li></ul></ul><ul><ul><li>Screen and test donors </li></ul></ul><ul><ul><li>Virus inactivation of plasma-derived products </li></ul></ul><ul><li>Reduce risk of liver disease in persons with chronic infection </li></ul><ul><ul><li>Identify and test persons at risk for HCV infection </li></ul></ul><ul><ul><li>Counseling, medical evaluation, management of infected persons </li></ul></ul>
    17. 17. HIV and HCV <ul><li>Both HIV and HCV are blood-borne </li></ul><ul><li>Affects many of same populations (primarily IDU) </li></ul><ul><li>200,000 co-infected in US </li></ul><ul><li>HCV is 10 times more infectious than HIV by blood contact </li></ul><ul><li>Most co-infected IDUs likely infected with HCV years before HIV </li></ul>
    18. 18. DVH Integration Efforts and Projects
    19. 19. Integrating Viral Hepatitis Why ??
    20. 20. Reasons to Combine Viral Hepatitis with Existing Prevention Programs <ul><li>Overlapping transmission risk factors </li></ul><ul><li>Maximize use of existing PH infrastructure </li></ul><ul><li>Opportunity to strengthen health messages </li></ul><ul><li>Good public health sense </li></ul>
    21. 21. Prior Opportunities For Vaccination Among Patients With Acute Hepatitis B, 2001-2004 Source: Sentinel Counties Study of Viral Hepatitis (n=760) % Prior Opportunity for Vaccination 61% Any of the above 22% History of drug treatment 39% History of STD treatment 40% History of incarceration
    22. 22. Integrating Viral Hepatitis How ??
    23. 23. NYC Hepatitis C Coordinators (48 states, 4 cities) Project Officer I DC Phil. Chicago 10 6 9 7 2 8 5 1 4 3 Project Officer II
    24. 24. Hepatitis C Coordinators <ul><li>48 states, 4 cities </li></ul><ul><li>Funded through NCID ELC Program through FY 2007; expected transition to new DVH Program in FY 2008: Scope Adult Viral Hepatitis Prevention Coordinator </li></ul><ul><li>Current Recipient Activities: </li></ul><ul><ul><li>Ensure training - health care professionals </li></ul></ul><ul><ul><li>Encourage HCV testing </li></ul></ul><ul><ul><li>ID resources for HepA and HepB vaccines </li></ul></ul><ul><ul><li>ID sources for medical referral of HCV-positive </li></ul></ul><ul><ul><li>Develop a viral hepatitis prevention plan </li></ul></ul><ul><ul><li>Evaluate and monitor viral hepatitis prevention efforts </li></ul></ul>
    25. 25. Integration of Viral Hepatitis Prevention into HIV/STD Program Announcements <ul><li>2004 HIV Program Announcement </li></ul><ul><li>Encourages collaboration/coordination w/hepatitis prevention programs to support local efforts to integrate viral hepatitis services </li></ul><ul><li>HIV funds may be used for HCV testing (not HepA and HepB); based on CPG recommendation </li></ul><ul><li>2005 STD Program Announcement </li></ul><ul><li>Encourages collaboration/integration w/ HIV and hepatitis prevention programs to serve groups at risk for or infected with all of these diseases </li></ul><ul><ul><li>provide HIV testing, hepatitis A and B vaccination, and STD screening in high prevalence settings </li></ul></ul><ul><ul><li>integrate HIV, hepatitis and STD prevention messages </li></ul></ul><ul><li>2007 HIV Program Announcement-African Americans </li></ul><ul><li>HIV funds may be used for HCV testing </li></ul>
    26. 26. Public Health Reports Supplement Volume 122; Supplement 2, 2007: Integrating Viral Hepatitis Prevention Into Public Health Settings <ul><li>Table of Contents: 20 articles on </li></ul><ul><li>State and local integration practices </li></ul><ul><li>Hepatitis vaccination for high risk adults </li></ul><ul><li>Hepatitis C: counseling, testing, and providing clinical care </li></ul><ul><li>A community response to hepatitis C </li></ul><ul><li>Current and future directions </li></ul><ul><li>http://www.publichealthreports.org </li></ul>
    27. 27. Thank You!! [email_address] 404-718-8528