A National Strategy for the Elimination of Hepatitis B and C Phase Two Report (2017) / Chapter Skim
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4 Essential Interventions
4 Essential Interventions
Pages 75-112
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From page 75... ...
PREVENTION AND TESTING Prevention is the first step to making HBV and HCV infections rare. Hepatitis B is preventable with immunization, so prevention is a matter of ensuring widespread vaccination and taking steps to prevent transmission from mother to child.
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From page 76... ...
. In the United States, better attention to adult vaccination and changes to the management of HBsAg+ pregnant women may be all that stands in the way of ending the transmission of HBV.
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From page 77... ...
Advisory Committee on Immunization Practices (ACIP) recommended universal adult hepatitis B vaccination in places where a high proportion of people are likely at risk for HBV infection, such as clinics targeting people who inject drugs or men who have sex with men; it also recommended a standing order to identify adults for whom hepatitis B immunization is recommended in primary care and specialty clinics; it recommended that all diabetes patients be immunized against HBV in 2011 (CDC, 2011b; Mast et al., 2006)
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From page 78... ...
. All states now authorize pharmacists to vaccinate, but many restrict the types of vaccines and circumstances under which pharmacists can administer them (American Pharmacists Association, 2015; Bach and Goad, 2015; Immunization Action Coalition, 2016)
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From page 79... ...
. Timely hepatitis B vaccination and hepatitis B immune globulin after birth are highly effective in preventing most infants born to HBsAg+ mothers from developing chronic hepatitis B infection (Mast et al., 2005)
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From page 80... ...
A prospective observational study in Australia found that 9 percent of infants born to mothers with HBV DNA greater than 20 million IU/mL (7.3 log10 IU/mL or 100 million copies/mL) developed chronic hepatitis B infection (despite post-exposure prophylaxis with hepatitis B vaccine and immune globulin)
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From page 81... ...
. The 2015, AASLD2 guidelines set a lower threshold, recommending pregnant women with an HBV DNA level greater than 200,000 IU/mL be considered for prophylactic antiviral therapy, while acknowledging the need for research to establish a more precise treatment threshold (Terrault et al., 2016)
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From page 82... ...
. Recommendation 4-2: The Centers for Disease Control and Preven tion, the American Association for the Study of Liver Diseases, the Infectious Diseases Society of America, and the American College of Obstetricians and Gynecologists should recommend that all HBsAg+ pregnant women have early prenatal HBV DNA and liver enzyme tests to evaluate whether antiviral therapy is indicated for prophylaxis to eliminate mother-to-child transmission or for treatment of chronic active hepatitis.
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From page 83... ...
. Opioid Agonist Therapy The most effective way to prevent hepatitis C among people who inject drugs is to combine strategies that improve the safety of injection with those that treat the underlying addiction (Cox and Thomas, 2013; Hagan et al., 3 Also called syringe services.
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From page 84... ...
. Syringe Exchange Syringe exchange programs in the United States do not have sufficient coverage even in cities; availability is worse in rural areas (Des Jarlais et al., 4 Including full agonist therapy with methadone and partial agonist therapy with buprenor phine, sometimes complemented with the antagonist treatment naloxone (SAMHSA, 2015c, 2016)
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From page 85... ...
Three-quarters of syringe exchange programs responding to a 2013 survey reported offering HCV testing, though the proportion was lower in rural areas (Des Jarlais et al., 2015)
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From page 86... ...
that saw a 364 percent increase in acute HCV infection between 2006 and 2012 have documented unmet needs for syringe services (Des Jarlais et al., 2015; Zibbell et al., 2015)
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From page 87... ...
. Mobile syringe exchange has the potential to reach a wide cross-section of people who inject drugs.
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From page 88... ...
. Police officers in some areas have come to favor exchange programs, citing reduced risk of needle stick injury on the job and benefit to the community
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From page 89... ...
Expansion of opioid agonist therapy will also be essential to preventing viral hepatitis infections. The Surgeon General's 2016 report Facing Addiction in America concluded that while medications are effective in treating serious substance use disorders, too few providers are able to prescribe them (HHS, 2016a)
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From page 90... ...
. A better discussion of reaching people who inject drugs and people in prisons with a range of viral hepatitis services follows in the next chapter.
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From page 91... ...
, such • Intranasal drug users as sub-Saharan Africa and • Persons with an unregulated central and Southeast Asia tattoo • HIV-positive persons • Persons with other • Injection drug users percutaneous exposures • Men who have sex with • Adults born between 1945 men and 1965 • Household contacts or • Recipients of clotting factor sexual partners of persons concentrates made before with HBV infection 1987 • Persons with HIV infection NOTE: HBV = hepatitis B virus; HCV = hepatitis C virus; USPSTF = U.S. Preventive Services Task Force.
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From page 92... ...
Persons who should be tested routinely for HCV infection based on a rec ognized exposure: • ealth care, emergency medical, and public safety workers after needle H sticks, sharps, or mucosal exposures to HCV-positive blood. • hildren born to HCV-positive women.
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From page 93... ...
It also has the potential to cause distress in patients, especially when the disease screened for carries a social stigma, as viral hepatitis does. On the other hand, society stands to benefit from any measure that sheds light on the subclinical burden of HBV and HCV infections.
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From page 94... ...
Curing Chronic HCV Infection Hepatitis C treatments are costly, a topic discussed in detail in Chapter 6. The combination of cost and demand for these medicines has strained the budgets of many payers (Brennan and Shrank, 2014; Saag, 2014; Steinbrook and Redberg, 2014; Trooskin et al., 2015)
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From page 95... ...
, compared to Medicare (5.0 percent refusal; adjusted risk relative to commercial insurance patients: 0.61; 95 percent CI: 0.43 to 0.86) or commercial insurance patients (10.2 percent refusal)
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From page 96... ...
. By the same token, failure to treat chronic HCV infection enlarges the reservoir for transmission, while denying treatment can cause anxiety and may provoke distrust of the health system.
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From page 97... ...
2015. Hepatitis C guidance underscores the importance of treating HCV infection: Panel recommends direct-acting drugs for nearly all patients with chronic hepatitis C
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From page 98... ...
2014. Factors associated with hepatitis B vaccine series completion in a randomized trial for injection drug users reached through syringe exchange programs in three U.S.
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2015. Prevention, treatment and care of hepatitis C virus infection among people who inject drugs.
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2016i. Surveillance for viral hepatitis -- United States, 2014.
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2013. Randomized, community-based pharmacy intervention to expand services beyond sale of sterile syringes to injection drug users in pharmacies in New York City.
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2015. Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department.
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2009. The influence of needle exchange programs on injection risk behaviors and infection with hepatitis C virus among young injection drug users in select cities in the United States, 1994-2004.
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2010. Drug use trends in Victoria and Vancouver, and changes in injection drug use after the closure of Victoria's fixed site needle exchange.
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1998. Community support for needle exchange programs and pharmacy sale of syringes: A household survey in Baltimore, Maryland.
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2011. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: Results of systematic reviews.
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2011. Sustained virologic response to antiviral therapy for chronic hepatitis C virus infection: A cure and so much more.
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Clinical Infectious Diseases 55(Suppl 1)
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2016. White, rural drug users lack needle exchange programs to prevent HIV infections.
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2014. Confronting the emerging epidemic of HCV infection among young injection drug users.
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From page 111... ...
2015. Systematic review: Patient-reported outcomes in chronic hepatitis C -- The impact of liver disease and new treatment regimens.
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