1. Chronic Hepatitis B Surveillance Kathleen Harriman California Department of Public Health Immunization Branch November 1, 2012

2. Surveillance CDC: “The ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health.” CSTE: “To provide actionable health information to public health staff, government leaders, and the public to guide public health policy and programs.” Surveillance data can be used for immediate public health action, program planning and evaluation, and formulating research hypotheses. Data can also be used to reduce morbidity and mortality through public policy, appropriate resource distribution, and programmatic and educational interventions.

3. Surveillance “The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow.” Foege WH et al. Int J Epidemiology 1976 The collection of data without analysis, interpretation and dissemination of the data is of no value.

4. http://www.cdph.ca.gov/Documents/California_Adult_Viral_Hepatitis_Prevention_Strategic_Plan,_2010-2014.Final.pdf Goal: Reduce the impact of viral hepatitis among adults in California Recommendations: 1.Generate statewide surveillance reports and share data with partners 2.Evaluate reporting requirements to improve quality and use of surveillance data 3.Increase state and local surveillance capacity 4.Incorporate viral hepatitis surveillance into the CalREDIE system 5.Assess viral hepatitis prevalence and risk factors among at risk groups in California California Adult Viral Hepatitis Prevention Strategic Plan, 2010-2014

5. Primary Surveillance Goal Develop an accurate epidemiological profile of adult viral hepatitis morbidity and mortality in California

6. Specific Surveillance Goals Develop a statewide chronic hepatitis B/hepatitis C registry Develop county specific HBV and HCV prevalence estimates Map reported HBV and HCV cases, to identify disproportionately impacted communities Map the availability of testing and vaccination services and laboratory capacity for performing confirmatory testing Develop integrated surveillance reports to assess rates of HIV, STDs, HBV, HCV, and TB co-morbidities in California Summarize incidence, prevalence, and coinfection estimates, and other adult viral hepatitis outcome data for California Post surveillance reports and other data on the local health departments’ and CDPH websites and share them with community- based organizations, policy makers and other partners

7. What’s happened so far? One-time CDC grant awarded; used for staff funding >25,000 HCV lab reports and CMRs, which had been accumulating in boxes since 2007 when HCV became lab reportable, have been back-entered through 2011 Merged these reports into one centralized, deduplicated chronic HCV database for California and repeated this process for chronic HBV Currently drafting California’s first ever chronic HBV and chronic HCV surveillance report for public distribution Working with seven local health departments to do case follow-up interviews for a sample of reported chronic HCV cases (El Dorado, Long Beach, Monterey, Orange, Placer, Riverside, Yolo)

8. Before CDC Grant (2009) Boxes of >25,000 lab and CMR reports No staff to enter lab reports, analyze data or remove duplicate reports

9. After CDC Grant (2012) Chronic HBV and Chronic HCV Databases Data from the boxes of paper lab and provider reports* Lab #1, Lab #2* (line-listed data) Data from San Francisco Data from other counties (AVSS and CalREDIE) *HCV data only

10. Next Steps Prepare for electronic lab reporting in CalREDIE Disseminate viral hepatitis surveillance reports:  Chronic HBV and chronic HCV, 2007-2011  Maps of HBV and HCV data by county Implement new CDC grant (if awarded)  Match HBV and HCV data with other data sources: o HIV registry, death records, cancer registries  Investigate all acute HBV and HCV cases >age 50 years o Healthcare-associated infections?  Investigate chronic HCV cases age <21 years

11. Chronic Hepatitis B Cases Reported in California, 1989-2011

12. Selected Data from Chronic Hepatitis B Registries at Four State Health Departments CharacteristicConnecticutMinnesotaMultnomah County, OR New York State Year of inception1992198719932001 Number of cases entered2,87412,4442,3946,423 Race White37%16%35%32% Black18%25%8%24% Asian/Pacific Islander44%57%56%39% Behavioral risk factors History of IDU12%4%10%--- Sexual7%5%7%--- Foreign born55%86%72%--- Other26%12%36%---

13. Value of California Chronic HBV and HCV Surveillance Data We don’t fully know yet what the value will be of the chronic HBV and HCV data that have been collected for the past 15+ years because this will be the first time that it’s been looked at in depth CDPH frequently receives data requests from advocates and service providers who are applying for grants and need to demonstrate the burden of disease in their communities - this was particularly important with the recent CDC funding opportunity for HBV and HCV testing

14. Funding Opportunity: Early Identification, and Linkage to Care for Persons with Chronic HBV and HCV Infections Funds aimed at supporting implementation of a hepatitis testing initiative to increase early identification of persons with HBV and HCV infections Enhanced testing efforts must target populations disproportionately affected by chronic HBV and HCV, especially those that are medically underserved Services provided must:  Enhance testing for HBV and HCV infections among persons for whom testing is indicated; and  Ensure that persons living with HBV or HCV are informed, appropriately counseled, and provided with linkage to care, treatment, and preventive services

15. 2012 Funding Opportunity Half of the 50 U.S. cities eligible to apply for HBV testing funds were located in California because of the large population of persons born in Asia The following California organizations received CDC HBV and/or HCV testing funds:  City and County of San Francisco, HIV Education and Prevention Project of Alameda County, Tarzana Treatment Centers (Los Angeles), UC San Diego As more of these resources become available, surveillance data will be critical to local health departments who wish to receive such funding These activities are also consistent with the California Adult Viral Hepatitis Prevention Strategic Plan, 2010-2014, which has broad buy-in from state, local, and community partners, including CACDC

16. Viral Hepatitis Resources Are Increasing 2010 IOM Report: A National Strategy for Prevention and Control of HBV and HCV CDC Professional Justification to Senate: Cost to address recommendations in IOM report: $300M in phases over ten years 2011 HHS Action Plan for the Prevention, Care & Treatment of Viral Hepatitis CDC: ELC Grant: $179,500 for California viral hepatitis surveillance infrastructure 2012 CDC: HBV, HCV, and Telemedicine Grant ($1.5M - $5M nationally) CDC: Prevention and Surveillance Grant ($5.2M nationally) CDPH: Viral Hepatitis Surveillance, 2011

17. IOM: Role of Chronic HBV and HCV Surveillance Identify chronic HBV and HCV cases and measure prevalence Develop accurate estimates of the burden of chronic HBV and HCV disease in the United States Prevent secondary cases  HBV: education, vaccination, and screening  HCV: education, harm reduction, and screening Link cases to appropriate services, including medical management Evaluate current practices and prevention efforts

18. The Surveillance Conundrum You can’t get any data without any money! You can’t get any money without any data! And sometimes even with data you can’t get any money!

19. Why are the data important? Despite the large number of people and communities affected by HBV and HCV, and the fact that mortality from HCV now exceeds that from HIV, the resources available for addressing viral hepatitis are only a small fraction of those available for addressing HIV CDC’s National Center for HIV/AIDS, Viral Hepatitis, STDs, and TB Prevention had a budget of almost $1 billion for 2008, and only 2% of it was allocated to HBV and HCV; 69% of the budget was allocated for HIV, 15% for STDs, and 14% for TB

20. Domestic HIV 69% STDs 15% Total budget: ~$1 billion HIV, Viral Hepatitis, STD and TB Prevention Appropriated Funds, FY 2008 TB 14% Hepatitis 2% ↑

21. Other Purposes of Hepatitis B Surveillance* 1.Identify contacts of cases who require postexposure prophylaxis; 2.Detect outbreaks; 3.Identify infected persons who need counseling and referral for medical management; 4.Monitor disease incidence and prevalence; and 5.Determine the epidemiologic characteristics of infected persons, including the source of their infection, to assess and reduce missed opportunities for vaccination. *CDC VPD Surveillance Manual, 5th Edition, 2011 Hepatitis B: Chapter 4 http://www.cdc.gov/vaccines/pubs/surv-manual/chpt04-hepb.pdf

22. Beyond Surveillance – Other Public Health Activities CDC recommendations for management of HBV-infected persons http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm  Identify sex partners and household and needle-sharing contacts  Unvaccinated past and present sex partners, household and needle-sharing contacts should be tested for HBsAg and for anti- HBc and/or anti-HBs and should receive the first dose of hepatitis B vaccine as soon as the blood sample collected  Susceptible persons should complete the vaccine series using an age-appropriate vaccine dose and schedule  Contacts who have not been fully vaccinated should complete the vaccine series  Contacts determined to be HBsAg-positive should be referred for medical care Whose responsibility is this? Healthcare providers or public health?

23. What does CDC say? Healthcare providers and public health authorities treating persons with chronic HBV infection should obtain the names of their sex contacts and household members and a history of drug use. Providers then can help to arrange for evaluation and vaccination of contacts, either directly or with assistance from state and local health departments. With sufficient resources, identification of contacts should be accompanied by health counseling and include referral of patients and their contacts for other services when appropriate. The success of contact management for hepatitis B varies widely, depending on local resources.

24. What really happens? One study determined that ~50% of providers caring for patients with chronic HBV infection recommended contact vaccination, and <20% of contacts initiated vaccination In the national perinatal HBV prevention program, ~26% of all persons identified as contacts of HBsAg- positive women were tested and evaluated for vaccination by public health departments Targeted efforts by several state and local programs have evaluated up to 85% of identified contacts However, many public health departments have no contact identification programs outside of the perinatal HBV prevention program

25. What else? CDC says that given the potential for contact notification to disrupt networks of HBV transmission and reduce disease incidence, healthcare providers should encourage patients with HBV infection to notify their sex partners, household members, and injection-drug sharing contacts and urge them to seek medical evaluation, testing, and vaccination Does this work? What is the role of public health?

26. Future HBV/HCV Surveillance Issues Electronic laboratory reporting will potentially alleviate the data entry and reporting burden for local health jurisdictions CDPH will be able to do deduplication at the state level while allowing LHJs to focus on those cases they want to prioritize for follow-up, e.g., pregnant women and acute cases The increasing availability of “at home” tests for HBV and HCV will make such tests more accessible to the public, but results are generally not reportable to public health – possible effects on surveillance are unknown

27. Stay tuned for… Electronic laboratory reporting in CalRedie CDPH implementation of CDC surveillance grant (if funded)  Mapping of county-level chronic HBV and HCV cases  Matching of HBV and HCV data with HIV registry, death records, and liver cancer registry  Follow-up of HBV and HCV cases among selected, CDC priority target populations CDPH development and dissemination of comprehensive viral hepatitis surveillance reports