State of the Program Division of Viral Hepatitis National Center for Infectious Diseases Centers for Disease Control and Prevention January 26, 2002

September 11, 2001 Anthrax Attacks Bioterrorism Preparedness

The Division Officially established June 15, 2002 Staff 139 (65 FTEs) Broad number of professions and skills Represent 20 countries Organization – 3 Branches Epidemiology Laboratory Prevention Budget ~ $25 million

Disease Burden from Viral Hepatitis United States, 2001 Disease Burden Hepatitis A Hepatitis B Hepatitis C 25,000 78,000 93,000 Acute infections 2.7 million 1.25 million None Persons with chronic Infection 8-10,000 5,000 None Chronic liver disease deaths

Hepatitis A Incidence, United States, 1980-2001 1995 vaccine licensure 1996 ACIP recommendations 1999 ACIP recommendations As you know, the incidence of hepatitis A has generally be cyclic, with peaks every 10-15 years. [click] In 1995 hepatitis A vaccine was licensed by FDA and became available in the United States, and [click] in 1996 the Advisory Committee on Immunization Practices (ACIP) published the first national recommendations for its use in hepatitis A prevention. These recommendations were updated [click] and extended in 1999. As you can see, hepatitis A incidence has been falling, beginning in 1998 to dip below recorded historic lows, even if we look all the way back to when national hepatitis surveillance first began in the 1960’s. The 2001 rate [click] of 3.8/100,000 is well below the previously-recorded lowest rate of about 9/100,000. This overall rate is an indicator of truly transformed hepatitis A epidemiology, some examples of which I’ll show you in a moment. To put this in context, though, first I’d like to to describe the epidemiologic rationale behind the recommendations, which, as you’ll see, represent a somewhat novel approach to childhood vaccination. Source: National Notifiable Disease Surveillance System, CDC

Hepatitis A Rate, by Age and Sex United States, 2001 Female Male Age <5 2.2 2.5 5-9 4.7 4.7 10-14 3.5 3.6 15-19 2.8 3.4 20-24 3.8 6.3 3.6 7.5 25-29 30-34 2.8 9.3 2.3 8.7 35-39 So where is disease occurring now, albeit at lower rates? Well, most of the disease in occurring among adults, and this is reflected in the national data by a marked shift in the age groups and sex in which rates are highest. You recall from a previous slide that the decline in rates among adults has not kept pace with declines among children. Here we show this in another way, and highlight that incidence is particularly high among adult men. This is primarily a reflection of disease among adults in certain risk groups, primarily men who have sex with men and users of illicit drugs. 2.1 6.1 40-44 45-49 2.2 5.6 50-54 2.6 5.2 55-59 2.4 3.6 60+ 2.4 2.8 Rate Adapted from: National Notifiable Disease Surveillance System, CDC

Incidence of Acute Hepatitis B United States, 1980-2001 Vaccine licensed 67% incidence decline The most straightforward way to assess progress in hepatitis B control in the United States is to examine trends in acute disease incidence as reported to the NNDSS. Hepatitis B vaccine was licensed in 1982. As you can see, the number of acute hepatitis B cases declined since the mid 1980’s. click By 2001, the number of cases had declined 67% compared to 1980. However, since 1999 incidence has reached a plateau, remaining nearly constant at about 2.8 per 100,000. Source: National Notifiable Diseases Surveillance System (NNDSS)

Hepatitis B, by Age Group, 1990-2001 89% decline 0-11 years old 65% decline 85% decline 20+ years old 12-19 years old If we look at the incidence data by age group, we notice two things – first, that incidence has declined in all age groups, including persons younger than 12, seen on this inset Click …..because the incidence is so much lower. Second, that the decline has been greater among persons under age 20. In fact, there has been only a 65% decline Click …..in incidence among persons older than 20 since 1990, compared to the 85% decline among 12-19 year olds, and the 89% decline among children less than 12. In 2001, more than 96% of cases were among adults. The plateau noted in the overall incidence slide, and here, is because of a slowing of the decline in adult infections. Among 12 to 19 year olds, the decline since 1999 has been 37%, and among those less than 12 it has been 45%, compared to only 5% among those 20 and older. Pink it out Fonts, line up % Source: National Notifiable Diseases Surveillance System (NNDSS)

Estimated Incidence of Acute HCV Infection United States, 1960-1999 Source: Hepatology 2000;31:777-82; Hepatology 1997;26:62S-65S

State and Local Agencies Non-Governmental Organizations What is the Program ? Federal Agencies State and Local Agencies National Hepatitis Prevention Program Private Sector Non-Governmental Organizations

Recommendations for the Prevention and Treatment of Viral Hepatitis Hepatitis A ACIP – immunization Hepatitis B ACIP – Immunization - eliminate HBV transmission Treatment guidelines Hepatitis C CDC / PHS – Testing and counseling NIH – treatment guidelines FDA – blood screening

Don’t Have a National Strategy for the Prevention and Control of Viral Hepatitis

National Hepatitis C Prevention Strategy Prevent HCV infection Detect and control chronic liver disease Evaluate effectiveness of activities Conduct surveillance and research http://www.cdc.gov/hepatitis/c/plan/index.htm

National Hepatitis C Prevention Strategy Implementation Components Communication About Hepatitis C State-based Prevention Programs National Prevention Strategy Research Surveillance & Program Evaluation

Why Include Viral Hepatitis with Other Prevention Programs ?

Prevention of Childhood Infections HBsAg testing -- routine prenatal care Hepatitis B vaccine early childhood immunization schedule adolescent health visit(s) Hepatitis A vaccine childhood and adolescent healthcare visits

Prevention of Infections in Adults STD prevention and treatment HIV/AIDS prevention and treatment Substance abuse prevention and treatment Corrections health care Primary and specialty clinical care

The Comprehensive Approach to Prevention Among High-Risk Adults High- Risk Individuals Test - HIV/STD/HCV Immunize - HAV HBV Medical Evaluation/Treatment HIV + STD + HCV + Status Appropriate Prevention Counseling & Social Services

State-Based Hepatitis C Prevention MA NYC RI DC Demonstration Project Coordinator

Viral Hepatitis Integration Projects (VHIPs) Determine the feasibility of integrating hepatitis prevention services into existing programs serving high risk populations Identify the most effective strategies to provide services to clients at high risk for viral hepatitis 2002 New STD Rx guidelines - incorporate annual HIV test for MSM, hepatitis immunization too All these things demand are re-think programs

What Have the VHIPs Taught Us? HCV testing feasible in STD programs and confidential HIV/AIDS testing sites Hepatitis B immunization feasible in STD clinics Medical referral for HCV positive IDU modest in all settings Very difficult to deliver viral hepatitis prevention services in anonymous HIV/AIDS counseling and testing sites Despite these challenges however, the implementation of this system has resulted in several notable accomplishments. By providing data on the number and characteristics of HCV-infected persons reported to the state, information collected through this system is being used to help develop minimum estimates of the burdern of HCV infection in the staqte and to assess the needs of the community. The system has also been used to facilitate prevention efforts. To date, 931 …. And in collaboration with other programs in the states, HAV and HBv Vax provided the HCV-infected uninsured. Finally the development of this databased of chronically ifnec’d persons has been used as a springboard for add’l projects including… Thus, although there are obviously still issues that need to be resolved, I think the system has been very helpful in Arizona –they’re now hoping to expand investigation of cases to include other counties – and provides some ideas for other states that are setting up chronic infection databases. Of course, it’s only one example so far and it’s going to be interesting to compare it to the experience in other states…but all in all I think it’s an encouraging start.

Hepatitis C, Total Expenditures FY 1997 - 2002 5 10 15 20 25 1997 1998 1999 2000 2001 2002 Year $ millions

HCV Expenditures (Extramural) FY1997-2002 Communications Surveillance Research State Programs 1 2 3 4 5 6 $ Millions 1997 1998 1999 2000 2001 2002 Fiscal Year

Gaps Lack of funding for HCV testing and counseling Immunization of adults Medical evaluation and antiviral treatment Studies to determine ways to improve viral hepatitis prevention outcomes Expand best practices into existing programs

National Viral Hepatitis Prevention Roundtable Despite these challenges however, the implementation of this system has resulted in several notable accomplishments. By providing data on the number and characteristics of HCV-infected persons reported to the state, information collected through this system is being used to help develop minimum estimates of the burdern of HCV infection in the staqte and to assess the needs of the community. The system has also been used to facilitate prevention efforts. To date, 931 …. And in collaboration with other programs in the states, HAV and HBv Vax provided the HCV-infected uninsured. Finally the development of this databased of chronically ifnec’d persons has been used as a springboard for add’l projects including… Thus, although there are obviously still issues that need to be resolved, I think the system has been very helpful in Arizona –they’re now hoping to expand investigation of cases to include other counties – and provides some ideas for other states that are setting up chronic infection databases. Of course, it’s only one example so far and it’s going to be interesting to compare it to the experience in other states…but all in all I think it’s an encouraging start.

Have a Great Conference ! Despite these challenges however, the implementation of this system has resulted in several notable accomplishments. By providing data on the number and characteristics of HCV-infected persons reported to the state, information collected through this system is being used to help develop minimum estimates of the burdern of HCV infection in the staqte and to assess the needs of the community. The system has also been used to facilitate prevention efforts. To date, 931 …. And in collaboration with other programs in the states, HAV and HBv Vax provided the HCV-infected uninsured. Finally the development of this databased of chronically ifnec’d persons has been used as a springboard for add’l projects including… Thus, although there are obviously still issues that need to be resolved, I think the system has been very helpful in Arizona –they’re now hoping to expand investigation of cases to include other counties – and provides some ideas for other states that are setting up chronic infection databases. Of course, it’s only one example so far and it’s going to be interesting to compare it to the experience in other states…but all in all I think it’s an encouraging start.