Hepatitis and Liver Cancer A National Strategy for Prevention and Control of Hepatitis B and C (2010) / Chapter Skim
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2 Surveillance
2 Surveillance
Pages 41-78
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From page 41... ...
This chapter describes how surveillance data are used or could be used to determine the focus and scope of viral hepatitis prevention and control efforts. The committee reviewed the weaknesses of the current surveillance system for hepatitis B and hepatitis C, including the timeliness, accuracy, and completeness of data collection, analysis, and dissemination.
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From page 42... ...
Although the cooperative agreements do not include funds for viral-hepatitis surveillance, the coordinators are good sources of information about surveillance activities being conducted in each jurisdiction. CDC's Division of Viral Hepatitis (DVH)
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From page 43... ...
The recommendations for surveillance based on the committee's findings focus on the development of a model designed to improve the quality and accuracy of information by developing systems to collect, analyze, and disseminate data on acute and chronic HBV and HCV infections. The recommendations call for a two-part system: core surveillance activities, building the capacity of state and local health departments to conduct standard disease surveillance on newly diagnosed acute and chronic HBV and HCV infections, and targeted surveillance to obtain data on specific populations that are not represented fully in the collection of core surveillance data.
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From page 44... ...
All states report the cases to CDC. Chronic HBV infections are reportable in all but six states and chronic HCV infections are reportable in all but seven states (CSTE, 2009)
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From page 45... ...
If surveillance data are not available or understate the disease burden, legislators and public-health officials will not allocate sufficient resources to mount an appropriate public-health response. Information on disease burden is only one factor that guides policymakers in allocating public-health resources.
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From page 46... ...
DISEASE-SPECIFIC ISSuES RELATED TO vIRAL-HEPATITIS SuRvEILLANCE Many of the difficulties that surveillance systems face in identifying and tracking cases of hepatitis B and hepatitis C are related to the complexity of the infections and their associated progression (see Figures 2-1 and 2-2)
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From page 47... ...
About 90% of acute HBV infections in children under 5 years of age and 70% of HBV infections in adults are asymptomatic (McMahon et al., 1985) ; 75–95% of acute HCV infections are asymptomatic (Chen and Morgan, 2006; Guerrant et al., 2001)
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From page 48... ...
. In addition, some persons with chronic HBV infection can experience sudden increases in alanine aminotransferase (ALT)
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From page 49... ...
. Because auxiliary test results are not systematically reported to health departments, surveillance staff must actively follow up with health-care providers to obtain them and other clinical indicators of acute disease.
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From page 50... ...
HCV seroconversion may be missed, and there is no IgM-based assay that reliably distinguishes acute hepatitis C from chronic hepatitis C, unlike the situation with hepatitis A virus or HBV infection. Relatively low HCV ribonucleic acid (RNA)
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From page 51... ...
CDC's Guidelines for Viral Hepatitis Surveillance and Case Management recommend that only positive HBsAg-test results be reported, but this test alone is inadequate to distinguish acute from chronic infection. Automated systems attached to electronic medical records may help to address surveillance for chronic HBV cases in the future, but in the meantime many diagnoses of chronic HBV infection probably will not be correctly captured and classified as confirmed cases (CDC, 2005a)
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From page 52... ...
HEPATITIS AND LIVER CANCER BOX 2-4 CDC Chronic Hepatitis B Case Definition Clinical description Persons with chronic HBV infection may have no evidence of liver dis ease or may have a spectrum of disease ranging from chronic hepa titis to cirrhosis or liver cancer. Persons with chronic infection may be asymptomatic.
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From page 53... ...
for anti-HCV, or by nucleic acid testing for HCV RNA. In some cases, an EIA with a high signal-to-cutoff ratio predictive of a true positive will be used in the place of a confirmatory RIBA.
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From page 54... ...
The CDC-recommended case definition of nonacute HCV infection also poses some problems in interpreting the collected data. Although it is assumed that the majority of nonacute hepatitis C cases represent chronic infections, this case definition also includes acute cases that do not meet the confirmed acute case classification (CDC, 2005a)
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From page 55... ...
. BOX 2-6 CDC Perinatal Hepatitis B Virus Infection Case Definition Clinical description Perinatal hepatitis B in the newborn may range from asymptomatic to fulminant hepatitis.
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From page 56... ...
Finding ways to ensure that patients receive comprehensive and culturally appropriate care and referrals not only would increase the likelihood of improving their health outcomes but is likely to affect surveillance-data collection favorably. Finally, because of the chronic nature of viral hepatitis, it is important that surveillance staff communicate well between jurisdictions.
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From page 57... ...
The guidance for HIV/AIDS surveillance is a three-volume set containing more than 500 pages of detailed instructions, standards, and guidelines. In contrast, CDC's cooperative agreements with state and territorial health departments for viral hepatitis do not include surveillance activities.
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From page 58... ...
However, without funding and staffing for surveillance and identification of new cases of HBV, ring vaccination is not a public-health activity that is typically supported by most health departments. CDC has funded seven enhanced projects through the Viral Hepatitis Surveillance Emerging Infections Programs (EIPs)
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From page 59... ...
The CDC programs include the Immunization Services Division (related to perinatal hepatitis B) , the Epidemiology and Laboratory Capacity for Infectious Diseases program (acute hepatitis B)
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From page 60... ...
The goal of the project was to develop computer-based transmission of public-health surveillance data between states and CDC. By 1989, all 50 states were participating in the reporting system for certain acute infectious diseases, and the system was renamed the National Electronic Telecommunications System for Surveillance (NETSS)
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From page 61... ...
. Capturing Data on At-Risk Populations As discussed previously, current surveillance systems do not adequately capture cases of acute and chronic HBV and HCV infections.
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From page 62... ...
For example, NHANES, the study most commonly used to estimate the disease burden of chronic HBV and HCV infections, excludes or underrepresents populations that are most at risk for HBV and HCV infections. Those populations include homeless persons, institutionalized and incarcerated persons, and persons of Asian and Pacific Island descent.
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From page 63... ...
In 2007, the Massachusetts Department of Public Health piloted the use of STD disease intervention specialists (DISs) to follow up on cases of HCV infection in people 15–25 years old.
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From page 64... ...
. According to the guidelines, the evaluation should "involve an assessment of system attributes, including simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability." The lack of sensitivity of state hepatitis-surveillance systems is well documented for acute cases, and many states do not perform surveillance for chronic HBV or chronic HCV infections.
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From page 65... ...
. CDC is able to oversee its national effort through separate cooperative agreements with each state and territory for specific core HIV surveillance activities (CDC, 2007)
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From page 66... ...
The HIV/AIDS surveillance evaluation framework promotes continuous improvement in the quality of data through technical guidance, measurement of performance, reporting of assessment results to state and local health departments, and adjustments in guidance, training, or technical assistance according to assessment results. The cooperative agreement and the associated funding have allowed the development of the national HIV surveillance system.
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From page 67... ...
Cooperative agreements should require reporting of standardized viral-hepatitis surveillance data within 3 years of implementation. The agreements should include funding for states to hire staff to process laboratory results, enter data, and follow up cases of acute and chronic HBV and HCV infections.
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From page 68... ...
The case definition for acute HBV and HCV infection should be revised to remove the need for symptoms for classification as a confirmed case. Classification as a suspected case of acute HCV infection should be used to encourage active followup of likely recent infections (for example, in adolescents and young adults)
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From page 69... ...
. Other studies have found a similar benefit of improving surveillance for infectious diseases via automatic notification with electronic medical records (Allen and Ferson, 2000; Hopkins, 2005)
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From page 70... ...
An effective surveillance system should identify most of the diagnosed cases of both acute and chronic HBV and HCV infections. Identification of infected people by health departments should be the first step in getting them into appropriate care.
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From page 71... ...
For example, • rends in acute HBV and HCV infections should be interpreted T with caution because of systematically missing cases that represent the burden of disease in particular risk groups. • iscussions of data on acute HBV and HCV infections should D reflect the issue of the large number of chronic infections to ensure appropriate understanding of the scope of the problem.
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From page 72... ...
• easuring the vaccination status of acute HBV infection cases and M identifying missed opportunities for vaccination. • nsuring that viral hepatitis is addressed and integrated with ap E propriate projects for the National HIV Behavioral Surveillance System.
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From page 73... ...
2008a. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic -- Nevada, 2007.
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From page 74... ...
2007. Estimating the future health burden of chronic hepatitis C and human immunodeficiency virus infections in the United States.
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From page 75... ...
2006. Surveillance programs for chronic viral hepatitis in three health departments.
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2008. Automated identification of acute hepatitis b using electronic medical record data to facilitate public health surveillance.
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From page 77... ...
. Viral hepatitis surveillance survey.
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From page 78... ...
2005. Electronic laboratory reporting for the infectious diseases physician and clinical microbiologist.
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