CDC Division of Viral Hepatitis: PCSI-related Issues and Selected Updates on Viral Hepatitis Prevention Activities Geoff Beckett, PA-C, MPH Prevention Branch Division of Viral Hepatitis National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention

Overview • Organization, Mission and History • Activities in States and Cities • Integration • Current and Upcoming Issues

Viral Hepatitis, Syndemics and Integration • Nature of viral hepatitis demands an integrative approach • Route of Transmission: • Affected Populations (IDU, sexual transmission, race and ethnicity, refugees and immigrants, incarcerated) • Services: STD

Four DVH Strategic Imperatives •

Protect vulnerable populations from infections that cause viral hepatitis

•

Prevent disease from chronic hepatitis B and hepatitis C

•

Collect, analyze and disseminate strategic data to guide disease prevention

•

Act globally to disseminate effective interventions and detect emerging threats

Alignment of DVH Resources with Strategic Imperatives (FY 2010) Protect Vulnerable Populations from Infection

4% 27%

$9.2M

35%

Prevent Disease from Chronic Viral Hepatitis $8.9M Collect, Analyze, and Disseminate Data to Guide Prevention $7.2M

*FY10 Estimate

34%

Act Globally to Disseminate Effective Interventions

$1.1M

77 full time employees (FTE) and approximately 30 non-FTEs

DVH HIGHLIGHTS - 2011 – Updating HCV Screening Recommendations – HHS Plan: Response to the IOM Report on HBV and HCV (April 2011) – Updating AVHPC FOA’s (2012)

Prevention Branch – Develop, implement and evaluate programs to prevent viral hepatitis – Support viral hepatitis programs at state level

– Conduct prevention effectiveness and health services research – Plan, develop & implement information, education and communications systems – Develop policies, standards, and indicators for viral hepatitis prevention and control

2010 IOM National Strategy for Prevention and Control of Hepatitis B and Hepatitis C

Underlying Issues Lack of Resources

Lack of Public Awareness

Lack of Provider Awareness

The Consequences Lack of Resources Lack of Public Awareness

• • • • •

Lack of Provider Awareness

Inadequate surveillance systems - true burden of disease is unknown Many do not know they are at risk or how to prevent infection Access to preventive services is lacking Many people do not know that they are infected Many healthcare providers do not screen for risk factors or know how to manage infected people • Inadequate access to testing, social support & medical management services

Adult Viral Hepatitis Prevention Coordinator Cooperative Agreement (AVHPC) • Purpose: Improve delivery of viral hepatitis prevention services in health care settings and public health programs that serve adults at risk • Goals: Decrease incidence of HAV, HBV, and HCV and decrease burden of liver disease among persons with chronic infection.

Adult Viral Hepatitis Prevention Coordinators

1

10

2

8 9

7 6

49 states 6 Cities: NYC, Philadelphia, Chicago, Houston, Los Angeles and District of Columbia

5

3

4

AVHPC’ s: Core VH Prevention Services

• Promote screening for risk factors (HAV, HBV, HCV) • Facilitate screening to identify chronic HBV and HCV

• Training for professionals serving adults at risk for VH • Coordinate VH prevention services for HIV+ persons including testing & HAV and HBV vaccination • Developing state/project area VH prevention plan to guide delivery and coordination of prevention services, training, education and community prevention messages

AVHPC PROGRAM

$5.2M/yr for 5 years (Avg. award: $90K)

• Serve as focal point for integration of viral hepatitis prevention and control activities in public health programs that serve adults at risk for viral hepatitis • Facilitate secondary prevention services for those impacted by viral hepatitis Funding Period: November 2007

– October 2012

DVH Interaction with PCSI • Participation on Ground Round Integration Program workgroups/meetings – Provides Project Officers and Program Consultants (PO/PCs) an opportunity to exchange information about a given jurisdiction’s challenges and successes across programs. – Identifies inter-related issues, opportunities for shared programming and technical assistance needs, and develops action steps for joint work within a jurisdiction. – Foster communication and stimulate collaboration across NCHHSTP Divisions.

• Participate on Quarterly Project Officer/Project Consultant Meetings • Conducted mandatory joint site visits. (AR, HI)

DVH Interaction with PCSI • Provided Content for 3 FOAs – CDC - Expanded HIV Testing for Disproportionately Affected Populations – CDC-RFA-PS10-10138 – CDC - Addressing Syndemics Through PCSI - CDC-RFAPS10-10175

– HRSA - Hepatitis C Treatment Expansion Initiative Demonstration Sites – HRSA-10-090

Program Operations and AVHPC: Directions in 2011 -2012 • Working to develop FOA for FY 2013 to support state and local health departments in implementing comprehensive services to improve prevention, detection, referral and care. (Announcement summer 2012)

• Wish List: Support for competitive health department awards for implementing evaluated demonstration projects: • Enhanced HBV screening and linkage to care •

Enhanced HCV screening and linkage to care

• Enhanced primary HCV prevention among young injection drug users

Selected PRET Activities • HCV Screening Studies – In Primary Care Settings – In Managed Care Settings – Cost Effectiveness Models for Comparison of Screening Strategies

• Rapid HCV Tests – Laboratory Evaluation – Field Evaluations • NHBS • UCSD/STAHR

PRET: Directions in 2011 • Complete retrospective phase of BEST-C Study • Draft revised HCV Screening Recommendations (2012) • Conduct Demonstration Study integrating rapid HCV assays into HIV testing settings and lab evaluation of rapid HCV tests on HIV+ specimens • Work with DVH Global AD to lead DVH Workgroup on Viral Hepatitis among Refugees

Education and Training Activities • Support the implementation of CDC guidelines • Conduct formative research • Develop education and training tools to support viral hepatitis prevention and control – Professionals • Clinicians • Public Health Community • Community Based Organizations

– Public • General audience • Target audience at risk

Visit www.cdc.gov/hepatitis

VHET Awardees Part A: NASTAD and NVHR - networking, partnership activities Part B: CENTERFORCE - incarcerated populations Part C: 1. Asian Coalition of Illinois - Asian populations 2. University of California at San Francisco - young injection users Part D: 1. University of Washington - clinicians and other public health professionals 2. University of Alabama at Birmingham – integration into HIV/STD community based organizations

Education and Training Team: Directions in 2011

Addressing the Hidden Epidemic:

A National Viral Hepatitis Education Campaign Education and Training Team Division of Viral Hepatitis

Our Vision for a National Campaign Goal: Decrease the disease burden of viral hepatitis • Raise awareness • Engage opinion leaders, policy makers, media, & the public • Change perceptions & decrease stigma • Educate providers & build capacity • Encourage testing of those at risk • Save lives with early intervention

Campaign Phases Phase I

Opinion Leaders, Policy Makers, Media, Healthcare Providers, General Public

Phase II Healthcare Providers Raise Awareness Educate About Hepatitis & Guidelines Support Action

Build Capacity to Screen, Refer, Treat

Phase III Populations at Risk Encourage Testing

Updating HCV Screening and Prevention Recommendations • MMWR Recommendations and Reports (2012) will provide policy recommendations for enhancing screening and detection of prevalent HCV chronic infections in the “baby boomer” birth cohort (19451965) • Further recommendations on prevention, counseling and testing/screening will follow in a second publication (2012-2013)

Rationale for Updating Recommendations • New evidence suggests elevated prevalence among persons born from 1945 to 1965

Prevalence of antibodies to hepatitis C virus (HCV) by age group (A) and year of birth (B) in the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and the current NHANES (1999–2002).

Armstrong, 2006

Prevalence of Anti-HCV by Age 1999-2002 NHANES1 Overall prevalence: anti-HCV 1.6% (4.1 million) chronic HCV 1.3% (3.2 million)

•

Prevalence of anti-HCV

8%

•

7%

Men

6%

Women

•

4% 3% 2% 1% 55+

50-54

45-49

40-44

35-39

20-34

0% 6-19

3.27% anti-HCV+ • 4.5X higher than all others

5%

ALL

1999-2008 NHANES analysis - 1945-19652

Age Group (years)

Born ~1945-1965 1 Armstrong et al. Ann Intern Med, 2006; 2 Unpublished CDC Data

75.9% of all anti-HCV

High Proportions of Unidentified Anti-HCV Study Site

Identified Anti-HCV Prevalence

Expected Anti- Unidentified HCV Prevalence Anti-HCV

Kaiser Permanente Georgia1

0.22%

1.6%*

85%

Montefiore Medical Centers2

4.2%

7.7%§

45%

CHeCS4

0.66%

1.6%*

59%

Kaiser Permanente N.Cal3

1.6%

2.7%#

40%

* Based on NHANES population estimate § Based on risk profile of clinic population # Based on insured NHANES population estimate for 1945-1964 Birth Cohort 1. Roblin, et al. Am J Man Care, under review. 2. Southern, et al. Journal of Viral Hepatitis, 2010. Manos, et al, AASLD Poster, 2010. 4 Holmberg, et al. AASLD Poster, 2010.

Other Issues • • • • •

HBV Screening and Linkage to Care Young IDU and HCV Incidence Vaccination for High Risk Adults Health Care Associated Infections Diabetes and HBV in LTC