Hepatitis and Liver Cancer A National Strategy for Prevention and Control of Hepatitis B and C (2010) / Chapter Skim
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5 Viral Hepatitis Services
5 Viral Hepatitis Services
Pages 147-208
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From page 147... ...
infections cause substantial morbidity and mortality despite being preventable and treatable. Deficiencies in the implementation of established guidelines for the prevention, diagnosis, and medical management of chronic HBV and HCV infections perpetuate personal and economic burdens.
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From page 148... ...
CuRRENT STATuS Health services related to viral hepatitis prevention, screening, and medical management are both limited and fragmented among entities at the federal, state, and local levels. Numerous federal agencies administer or fund some viral hepatitis–related services, including the Centers for Disease Control and Prevention (CDC)
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From page 149... ...
Community Health Facilities • 5-9. The Health Resources and Services Administration should pro vide adequate resources to federally funded community health facili ties for provision of comprehensive viral-hepatitis services.
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conducts surveillance and special studies to determine the epi demiology and disease burden associated with acute and chronic infections and liver disease associated with hepatitis viruses; 2. conducts epidemiologic and laboratory studies, including outbreak investigations, to determine risk factors for transmission of infec tions with hepatitis viruses, define the natural history and patho genesis of these infections, and determine their health impact; 3.
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From page 151... ...
Several HRSA programs provide some direct services for viral hepatitis, including the Bureau of Primary Health Care, the and eliminate transmission of hepatitis B virus infection, the pre vention and control of hepatitis C virus infection through counsel ing and testing and the prevention of transmission of bloodborne virus infections, including hepatitis viruses, through improved medical practices to reduce the frequency of unsafe injections and the improvement of the safety of blood transfusions; 6. provides the leadership and coordination required to integrate viral hepatitis prevention and control activities into other prevention programs conducted by CDC, other Federal agencies and health care providers; 7.
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From page 152... ...
Many people in HRSA-funded programs are foreign-born, including people from countries that have a high prevalence of hepatitis B or have behavior risk factors for HBV and HCV infection. CMS, also a part of DHHS, provides health insurance through Medicare and Medicaid programs.
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From page 153... ...
For example, the Jade Ribbon Campaign targets Asians and Pacific Islanders to reduce the TABLE 5‑1 Summary of Adult Viral Hepatitis Prevention Coordinators Survey Percentage of Jurisdictions Percentage of Jurisdictions Jurisdiction Plan's Program with Plans That Included with Plan Components That Components Component Have Been Acted On Public education 96.6% 83.9% Surveillance 90.6% 64.5% Training for health-service, 87.5% 90.3% human-service providers Advocacy, community 84.4% Not reported planning Counseling, testing, 81.3% 83.9% referral Vaccination 78.1% 90.3% Medical management 62.5% 25.8% NOTES: All 55 adult viral hepatitis prevention coordinators completed the survey; 23 of the 55 jurisdictions do not have a viral hepatitis plan.
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From page 154... ...
The lack of an accountable entity to lead a coordinated national effort has led to missed opportunities for prevention and identification of and treatment for chronic HBV and HCV infections. COmPOnEnTs Of VIrAL HEPATITIs sErVICEs The committee has identified five core functions for comprehensive viral hepatitis services -- (1)
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From page 155... ...
Risk-factor screening is the process of deter R mining whether a person is at risk for being chronically infected or becoming infected with HBV or HCV. Risk factors include being born in a country where the disease is prevalent, and behavior such as illicit-drug use and having multiple sexual partners.
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From page 156... ...
, and institutionalized and incarcerated persons BOX 5‑4 Summary of CDC At‑Risk Populations for Hepatitis B Virus Infection • ersons born in geographic regions that have HBsAg prevalence of P at least 2% • Infants born to infected mothers • Household contacts of persons who have chronic HBV infection • Sex partners of infected persons • Injection-drug users • exually active persons who are not in long-term, mutually monoga S mous relationships (for example, more than one sex partner during previous 6 months) • Men who have sex with men • ealth-care and public-safety workers at risk for occupational expo H sure to blood or blood-contaminated body fluids • Residents and staff of facilities for developmentally disabled persons • Persons who have chronic liver disease • Hemodialysis patients • ravelers to countries that have intermediate or high prevalence of T HBV infection SOURCE: Mast et al., 2005, 2006.
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From page 157... ...
This approach may facilitate increased vaccination rates. All persons found to have risk factors for HBV infection should receive counseling about prevention.
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Additional studies have also found that questioning patients about exposures to known risk factors for hepatitis C is predictive of HCV infection in US veterans (Zuniga et al., 2006)
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. CDC recommends that all patients be evaluated for risk factors for HCV infection (Alter et al., 2004)
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Hepatitis B Virus Laboratory Testing Serologic markers can be used to identify the different phases of HBV infection (Box 5-6)
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. Laboratory testing of adult Asian and Pacific Islanders for HBV infection (10% prevalence of chronic HBV infection)
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. That suggests that foreign-born persons from countries that have chronic HBV rates of 2% or greater should be screened for HBV infection.
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. A 2008 study in Italy found that laboratory testing (followed by appropriate medical management)
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Not done Not done Antibody probably true HCV RNA positive; need to distinguish past from current infection Positive Negative Not done False positive anti-HCV None Positive Positive Not done Past or current HCV HCV RNA; if RNA infection positive, evaluate for liver disease Positive Positive Negative Probable past HCV Repeat HCV RNA to rule infection with recoverya out active infectiona
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From page 165... ...
Positive Positive or not done Positive Current acute or chronic Evaluate for chronic HCV infection infection and liver disease Positive Indeterminate Not done Not known; possible Test for HCV RNA or false-positive anti-HCV or repeat anti-HCV testing recovery from past HCV infection Positive Indeterminate Positive Current acute or chronic Evaluate for chronic HCV infection infection and liver disease Positive Indeterminate Negative Probably not currently Repeat HCV RNA or infected;a possible false- repeat anti-HCV testing positive anti-HCV or recovery from past HCV infection aA single negative HCV-RNA result cannot determine infection status, inasmuch as a person might have intermittent viremia. Abbreviations: anti-HCV, antibody to HCV; EIA, enzyme immunoassay; CIA, enhanced chemiluminescence immunoassay; RIBA, recombinant immunoblot assay; RNA, ribonucleic acid; s/co ratio, signal-to-cutoff ratio.
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From page 166... ...
For the purposes of this report, the committee specifies that the goals of medical management of chronically infected people are to decrease the risk of developing cirrhosis, to prevent hepatic decompensation, to decrease the risk of hepatocellular carcinoma in people chronically infected with HBV or HCV, and to effect secondary prevention of virus transmission. The AASLD guidelines include recommendations for selection of patients who have chronic hepatitis B or hepatitis C for referral to specialists and for treatment with medications (Ghany et al., 2009; Lok and McMahon, 2009)
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The initial laboratory evaluation should include a full liver panel, CBC, and HCV genotype tests. Patients found to have signs or symptoms of liver disease or a low platelet count (below 100,000)
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. Chronic HCV infection has been found to be an important cause of liver-related death in Alaska Natives (Wise et al., 2008)
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. Medication costs were the largest proportion of the chronic HBV infection and compensated cirrhosis states and hospitalization costs made up the largest proportion of the other health states.
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for people who have chronic hepatitis B or hepatitis C and who do not have access to private health insurance and care is an important gap in control of chronic viral hepatitis. The committee believes that people who are living with chronic HBV or HCV infection should receive the health-care services outlined in Box 5-3.
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. The current fragmentation of viral hepatitis services involving vaccination, risk-factor screening, laboratory testing, and medical management is a major obstacle to the effective delivery of needed services and makes compliance more difficult.
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Given its tremendous purchasing power, the federal government is well positioned to be the leader in the development and enforcement of guidelines to ensure that the people for whom it provides health care have access to risk-factor screening, serologic testing for HBV and HCV, and appropriate medical management. recommendation 5‑1.
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From page 173... ...
It is unknown whether the model programs developed for Asians and Pacific Islanders could be adapted for some of those populations or whether new culturally tailored programs would need to be created. The key to eliminating HBV transmission is identification of people who are living with chronic HBV infection.
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From page 174... ...
For example, culture-specific stigmas may be attached to a diagnosis of chronic hepatitis B In China, there is discrimination against people who are chronically infected with HBV, and such people reportedly have been expelled from schools, fired from jobs, and shunned by other community members despite the recent passage of national antidiscrimination laws (China Digital Times, 2009)
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From page 175... ...
The Centers for Disease Control and Prevention, in conjunction with other federal agencies and state agencies, should provide resources for the expansion of community‑based programs that provide hepatitis B screening, testing, and vaccination services that target foreign‑born populations. Illicit‑Drug Users Preventing bloodborne infectious diseases, particularly hepatitis C, in illicit-drug users is an important public-health challenge.
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HBV infection rates in both IDUs and NIDUs are high. Seroincidence in IDUs has been reported to be 10–12% per year (Hagan et al., 1999; Ruan et al., 2007)
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It is plausible for drug treatment to reduce the risk of HCV infection inasmuch as it reduces the frequency of injection, and some IDUs stop injecting altogether. One limitation of drug-treatment programs is that only a relatively small proportion of IDUs (about one-sixth)
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(p = 0.01) Maher et al., Sydney, Cohort Being in treatment during 2006 Australia the follow-up period had no effect on HCV seroconversion (OR = 0.83, 95% CI 0.51-1.35)
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A case-control study showed that use of a SEP in Tacoma, Washington, was associated with an 88% lower risk of HCV infection and an 82% lower risk of HBV infection (Hagan et al., 1995)
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recommendation 5‑4. federal and state governments should expand services to reduce the harm caused by chronic hepatitis B and hepati‑
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As mentioned above, studies have shown that the first few years after onset of injectiondrug use constitute a high-risk period in which the rate of HCV infection can exceed 40%. Preventing the transition from non-injection-drug use to injection-drug use will probably avert many HCV infections.
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From page 182... ...
This gap has a two-fold effect in that chronically infected women do not receive the appropriate medical management and referral and perinatal transmission continues to occur. CDC estimates that only 50% of HBsAg-positive pregnant women are identified for case management (CDC, 2005)
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, account for over two-thirds of births to mothers who have chronic HBV infection. CDC-funded perinatal HBV prevention coordinators are responsible for educating HBsAg-positive mothers and for referring them for appropriate medical management.
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Correctional settings Incarcerated populations have higher rates of both HBV infection and HCV infection than the general population. Correctional facilities present a unique opportunity to bring viral hepatitis services to at-risk populations.
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From page 185... ...
Correctional systems are constitutionally required to provide necessary health care to inmates that is consistent with the community standard of care. Screening of all incarcerated people for risk factors can identify those for whom blood tests for infection are indicated, and the high prevalence of HCV infection in prisons justifies such screening so that appropriate treatment can be provided to inmates whose blood tests are positive.
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From page 186... ...
Community Health facilities There is a great deal of variation in the types of viral hepatitis services available within the United States. Several states -- including Florida, California, Massachusetts, and Texas -- have attempted to introduce some hepatitis services into publicly funded settings because of a lack of adequate federal funding for hepatitis B and hepatitis C services.
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. The committee did not find published information on viral-hepatitis services in community health facilities, but several studies have looked at the quality of care for other chronic conditions and for preventive services,
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On the basis of those findings, the committee offers the following recommendation to expand the provision of viral hepatitis services: recommendation 5‑9. The Health resources and services Administra‑ tion should provide adequate resources to federally funded community health facilities for provision of comprehensive viral‑hepatitis services.
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Some progress has been made in the integration of viral hepatitis services into health-care settings, such as STD or HIV clinics, that serve highrisk populations. A study by Gilbert et al.
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A study of risk factors for hepatitis C and laboratory testing of people who sought care at an STD clinic found that 4.9% of the 3,367 attendees who were tested for HCV infection were positive (Gunn et al., 2003)
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Programs that use mobile health-care vans have been successful in providing HIV prevention and testing services to at-risk people who might not seek health-care services in other settings. Street outreach programs have been successful in reaching marginalized populations in HIV/AIDS prevention programs (Valentine and Wright-De Aguero, 1996)
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From page 192... ...
Hence, innovative approaches of this type should be considered for hard-to-reach populations. recommendation Integration of viral hepatitis services into venues such as STD-HIV clinics, shelters, and mobile health units, is likely to have long-term benefits because most of the people who use these types of clinics engage in high-risk behaviors or are in high-risk settings.
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2007. Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: A comprehensive approach.
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2009a. Eliminating the threat of chronic hepatitis B in the Asian and Pacific Islander community: A call to action.
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1999. Health care need and utilization: A preliminary comparison of injection drug users, other illicit drug users, and nonusers.
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2007. A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users.
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2010. Attribution of HCV seroconversion risk in young injection drug users in five U.S.
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2007. Does integrating viral hepatitis ser vices into a public STD clinic attract injection drug users for care?
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2004. Hepatitis B virus infection and vaccination among young injection and non-injection drug users: Missed opportuni ties to prevent infection.
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2008. Hepatitis B virus infection and immunization status in a new generation of injection drug users in San Francisco.
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2008. STD, HIV/AIDS, and hepatitis services in Illinois county jails.
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2001. Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infec tion.
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1999. Do needle exchange programmes increase the spread of HIV among injection drug users?
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2006. Client satisfaction with rapid HIV testing: Comparison between an urban sexually transmitted disease clinic and a community-based testing center.
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2002. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment.
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2008. Recommendations for identification and public health management of persons with chronic hepatitis b virus infection.
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2007. Integrating viral hepatitis prevention into STD clinics in Illinois (excluding Chicago)
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