Harold S. Margolis, M.D. Division of Viral Hepatitis National Center for Infectious Diseases

1. 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

2. 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

3. Outcome HBV HCV HIV Chronic infections 1.2 (million) 2.7 (million) 0.8 (million) New infections /yr 120,000 35,000 40,000 Deaths /yr 5,000 8,000 18,000 Disease Burden from Bloodborne Viral Infections, United States

4. HBV HCV HIV Injection drug use 14 60 31 MSM 15 1 47 Heterosexual partners 40 20 10 Transfusion Rare Past 7- 20 Past 2 Occupational 5-7 (past) <<1 <<1 Unknown 30 10 9 Risk Factors for Transmission of Hepatitis Viruses and HIV, United States Proportion of Infections (%) Risk Factor

5. Routes of Transmission andOpportunities for Prevention of Infection with Hepatitis Viruses and HIV Overlap Substantially

6. Integration of Viral Hepatitis Prevention: Relative Disease Burden in Various Settings

7. 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

8. 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

9. 100 80 60 40 20 0 0 6 12 18 24 30 36 42 48 54 60 66 72 Risk of Bloodborne Virus Infections Injection Drug UsersBaltimore 1983–1988 HCV HBV Seroprevalence(%) HIV Duration of Injecting (months) Garfein RS. Am J Public Health. 1996;86:655.

10. 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)

11. 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

12. Transmission of Viral Hepatitis by Unsafe Injections and Medical Practices

13. 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

14. Health-Care Related HCV Transmission • Unsafe injection practices • inadequate sterilization of reusable needles and syringes • sharing of disposable needles and syringes • high frequency of injections • contamination of multi-dose vials • Contaminated equipment • lack of ‘universal precautions’ • inadequate cleaning and disinfection • in health care settings • alternative medicine practices, rituals

15. 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

16. Reasons to Identify Persons with Chronic HCV Infection • Counsel to prevent disease transmission • household contacts • sexual contacts • drug use contacts • Medical management • evaluate for chronic liver disease • treatment if indicated • substance abuse treatment (alcohol, drugs) if appropriate • immunization (HB, HA, influenza, pneumo)

17. 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

18. Implementation Components National Hepatitis C Prevention Strategy • Communication of information on hepatitis C • State-based prevention programs • Surveillance • Epidemiology and laboratory investigations

19. Development of State and Local Hepatitis Prevention Programs

20. STD Programs • Immunization (Hepatitis B Coordinator) Laboratory Medical Services Surveillance Hepatitis C Coordinator Patient Support/ Advocacy Groups • Corrections • HIV/AIDS • Prevention • Drug Treatment State Hepatitis Prevention Plan Viral Hepatitis Prevention at the State/Local Level – A Model

21. 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

22. 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

23. 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

24. CDC State-Based Hepatitis C Prevention Programs MA NYC RI DC Demonstration Project Coordinator 11/01

25. 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)

26. 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

27. FundingHepatitis 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 = ??