The National Hepatitis C Institute Presents: Hepatitis C An Overview: USA Public Health Response November 16, 2009

2 Senator Christopher Shays, During The Congressional Hearing Titled: “HCV Silent Epidemic Mute Public Health Response” 1998 Congressional Quote: “HCV virus, poses a daunting challenge to public health. Chronic infection can linger without symptoms for more than 20 years, then produce profound health consequences, including liver failure and cancer. There is no preventative vaccine or generally effective treatment.”

3 World Health Organization According to the World Health Organization… "The Only Means Of Protection From The HCV Virus Are The Implementation of Universal Precautions (Standard Guidelines For Medial And Dental Procedures) Mode Of Transmission: Primarily By Direct Contact With Human Blood Primarily By Direct Contact With Human Blood Major Causes Of Infection Worldwide: The Use Of Unscreened Blood For Transfusions The Use Of Unscreened Blood For Transfusions Re-use Of Needles And Syringes That Have Not Been Adequately Sterilized Re-use Of Needles And Syringes That Have Not Been Adequately Sterilized

4 Scientific Community Statement: “You Cannot Contract HCV Unless You were Exposed To Infected Blood”

5 Global Prevalence

6 Global Disease Burden –130 Million Chronically –1 In 3 Woman And 1 In 2 Men Will Develop Cirrhosis And/Or Liver Cancer –Responsible For 50-76% Of ALL Liver Cancer Cases –Responsible For 2/3 Of ALL Liver Transplants In The Developed World Estimated 170 Million Infected…

7 Global Message: 1 in 12 Understanding Viral Hepatitis Hepatitis B is spread when blood, semen, or other body fluid enters the body of a person who is not infected. People can become infected with the virus during activities such as BirthBirth Sex with an infected partnerSex with an infected partner Sharing needles, syringes, or other drug -injection equipmentSharing needles, syringes, or other drug -injection equipment Sharing razors or toothbrushes with an infected personSharing razors or toothbrushes with an infected person Exposure to blood from needlesticks or other sharp instrumentsExposure to blood from needlesticks or other sharp instruments According To The WHO- HCV Is Just As, If Not More Contagious, Than HBV And Many Times More Infectious Than HIV Hepatitis A is spread when the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (or stool) of an infected person. Hepatitis A is spread when the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (or stool) of an infected person. Transmission: Person to person contactPerson to person contact Contaminated food or waterContaminated food or water HCV is spread when blood from a person infected with the HCV Virus enters the body of someone who is not infected. HCV is spread when blood from a person infected with the HCV Virus enters the body of someone who is not infected. Today, Most Infections Occur From: Sharing Needles Or Other Equipment To Inject DrugsSharing Needles Or Other Equipment To Inject Drugs Before 1992, Blood Transfusions And Organ TransplantsBefore 1992, Blood Transfusions And Organ Transplants Sharing Needles, Syringes, Or Other Equipment To Inject DrugsSharing Needles, Syringes, Or Other Equipment To Inject Drugs Needlestick Injuries In Healthcare SettingsNeedlestick Injuries In Healthcare Settings Born To An Infected MotherBorn To An Infected Mother Less Commonly: Sharing Personal Care Items Such As Razors Or ToothbrushesSharing Personal Care Items Such As Razors Or Toothbrushes Having Sexual Contact With A Person InfectedHaving Sexual Contact With A Person Infected

8 HCV Overview Cognitive Impairment Nervous System Damage Visual Impairment Dermatological Damage Nephrological Damage Rheumatological Damage Blood Borne Virus Majority Asymptomatic Cases 5x More Prevalent Than HIV/AIDS Globally Complicated Progressive Disease Process Diverse Population Mode Of Transmission Not Fully Understood Emphasis On Behavior Driven Transmission American Association for the Study of Liver Disease “In Ten Years” HCV will be a major burden on Healthcare System increasing: 60%: Incidences Of Cirrhosis 68%: Incidences Hepatocellular Carcinoma 279%: Incidences Hepatic Decompensation 528%: Need For Transplantation 223%: Liver Death Rate HCV Is A Systemic Infection- Not Just A Liver Disease

9 The US Public Health Response

10 Health & Human Service Public Health Services

11 Core Function of Public Health Assessment and Surveillance: The foundation for public health activities is an assessment and surveillance capacity that identifies problems, provides data to assist in decisions about appropriate actions, and monitors progress Policy Development: Is the means by which problem identification, technical knowledge of possible solutions, and societal values join to set a course of action Assurance Of Access To The Benefits Of Public Health: Assurance of the availability of the benefits of public health to all citizens reflects a primary reason for the existence of public health activities

12 USA Disease Prevalence & Burden An Under-Estimated 4 Million People Are Infected But These Figures Exclude The Institutionalized Populations Like The US Military And Prisons, Or The Estimated 12 Million Illegal ImmigrantsAn Under-Estimated 4 Million People Are Infected But These Figures Exclude The Institutionalized Populations Like The US Military And Prisons, Or The Estimated 12 Million Illegal Immigrants 40-60% Of Chronic Liver Disease In The US Is Related To Chronic HCV Infection40-60% Of Chronic Liver Disease In The US Is Related To Chronic HCV Infection Chronic HCV Is The Leading Cause Of Adult Liver TransplantationChronic HCV Is The Leading Cause Of Adult Liver Transplantation Possible Greater Than 30,000 Deaths Yearly Associated With Chronic Liver Disease Related To Chronic HCV *Possible Greater Than 30,000 Deaths Yearly Associated With Chronic Liver Disease Related To Chronic HCV * Approximately 75%–85% Of People Who Become Infected With HCV Virus Develop Chronic InfectionApproximately 75%–85% Of People Who Become Infected With HCV Virus Develop Chronic Infection *Consensus Statement National Institutes of Health (NIH) state; An estimated 8,000 to 10,000 deaths each year result from HCV-associated chronic liver disease… without effective treatment… that number could triple in the next 10 to 20 years) An Under-Estimated 4 Million People Are Infected But These Figures Exclude The Institutionalized Populations Like The US Military And Prisons, Or The Estimated 12 Million Illegal ImmigrantsAn Under-Estimated 4 Million People Are Infected But These Figures Exclude The Institutionalized Populations Like The US Military And Prisons, Or The Estimated 12 Million Illegal Immigrants 40-60% Of Chronic Liver Disease In The US Is Related To Chronic HCV Infection40-60% Of Chronic Liver Disease In The US Is Related To Chronic HCV Infection Chronic HCV Is The Leading Cause Of Adult Liver TransplantationChronic HCV Is The Leading Cause Of Adult Liver Transplantation Possible Greater Than 30,000 Deaths Yearly Associated With Chronic Liver Disease Related To Chronic HCV *Possible Greater Than 30,000 Deaths Yearly Associated With Chronic Liver Disease Related To Chronic HCV * Approximately 75%–85% Of People Who Become Infected With HCV Virus Develop Chronic InfectionApproximately 75%–85% Of People Who Become Infected With HCV Virus Develop Chronic Infection *Consensus Statement National Institutes of Health (NIH) state; An estimated 8,000 to 10,000 deaths each year result from HCV-associated chronic liver disease… without effective treatment… that number could triple in the next 10 to 20 years)

13 Congressional Quote: Still True Today… Senator Christopher Shays, During The Congressional Hearing Titled: “HCV Silent Epidemic Mute Public Health Response “Since 1989 when the HCV virus, was first unmasked, Federal public health agencies have often pondered, but never implemented, a comprehensive response to this insidious infectious agent.”

14 Research & Prevention Federally Funded Domestic Programs

15 Domestic Funding FY

16 Actual Funding FY 2008

17 Actual Research Funding 2008 HCV Other Total SpendingNIH

18 Congressional Committee On Reform The Findings… The Federal Response to the HCV Epidemic Lacked Energy and Focus The Federal Response to the HCV Epidemic Lacked Energy and Focus “It is noteworthy that the National Institute on Drug Abuse [NIDA] spent the most NIH resources and continues to spend the most resources on HCV research, which may reflect an institutional bias within HHS that HCV is a disease of injection drug users. This bias may have worked against early recognition of HCV as a broader public health threat.”“It is noteworthy that the National Institute on Drug Abuse [NIDA] spent the most NIH resources and continues to spend the most resources on HCV research, which may reflect an institutional bias within HHS that HCV is a disease of injection drug users. This bias may have worked against early recognition of HCV as a broader public health threat.” Total National Institutes of Health- NIDA HCV Funding $18,281,932 National Institutes of Health

19 CDC Plan For Prevention The National Hepatitis C Prevention Strategy

20 CDC Position On HCV A.With The Transfusion Risk Reduced Substantially As A Result Of Improved Screening, The Major Risk Factor, Today Is IV Drug Use. B.Virtually All Transmission Of HCV Is Associated With Identifiable Risk Factors. C.This Is A Disease Largely Under Control D.By Focusing On Marginal Populations Who Have High Risk Behaviors (E.G. Sex, IV Drug Abuse) HCV Infections Will Be Greatly Reduced E.By Tracking Acute Disease, We Can Gauge Prevention Strategies F.States Only Need To Report Acute Disease NHANES Was Utilized To Develop Prevalence Data

21 Mode of Transmission CDC Changes Public Health Message: Old Statement: Any percutaneous exposure can put you at risk. Old Statement: Any percutaneous exposure can put you at risk. New Statement: Contact with the blood of an infected person, primarily through sharing contaminated needles to inject drugs. New Statement: Contact with the blood of an infected person, primarily through sharing contaminated needles to inject drugs.

22 Who Should be Tested - CDC Current Or Former Injection Drug User, Even If You Injected Only One Time Or Many Years Ago.Current Or Former Injection Drug User, Even If You Injected Only One Time Or Many Years Ago. Treated For A Blood Clotting Problem Before 1987.Treated For A Blood Clotting Problem Before Received A Blood Transfusion Or Organ Transplant Before July 1992.Received A Blood Transfusion Or Organ Transplant Before July Long-term Hemodialysis Treatment.Long-term Hemodialysis Treatment. Abnormal Liver Tests Or Liver Disease.Abnormal Liver Tests Or Liver Disease. Work In Healthcare Or Public Safety And Were Exposed To Blood Through A Needle Stick Or Other Sharp Object Injury.Work In Healthcare Or Public Safety And Were Exposed To Blood Through A Needle Stick Or Other Sharp Object Injury. Those Who Are Infected With HIV.Those Who Are Infected With HIV. Breakdown- HCV Infection Among USA Citizens

23 Major Causes of Transmission CDC Says…. HCV is spread when blood from a person infected with the HCV virus enters the body of someone who is not infected. Today, most people become infected with the HCV virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, HCV was also commonly spread through blood transfusions and organ transplants. Transmission Activities: –Sharing needles, syringes, or other equipment to inject drugs – Needlestick injuries in healthcare settings – Born to a mother who has HCV Less Common Transmission –Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes –Sexual contact with a person infected with the HCV virus

24 CDC Message About Sexual Transmission Is Confusing CDC Says… Risk factors include: “ Having sexual contact with a person infected with the HCV virus” NIH Says… “Sexual transmission of HCV between monogamous partners appears to be uncommon… Spread of HCV to a spouse or partner in stable, monogamous relationships occurs in less than 1 percent of partners per year. For these reasons, changes in sexual practices are not recommended for monogamous patients…People with multiple sex partners should be advised to follow safe sex practices, which should protect against HCV as well as hepatitis B, HIV, and other sexually transmitted diseases.” VHA Says… “If you have had multiple sex partners”

25 Poster Campaigns – Add to Confusion

26 Scientist Say: Sexual Transmission Is Not a Risk Factor FY No evidence of a HCV epidemic in HIV negative gay men Dr Turner et al. Data from attendees at a London GUM clinic suggest that there is no increase in HCV infections amongst HIV negative gay men.No evidence of a HCV epidemic in HIV negative gay men FY Injection Behavior, Not Sexual Contact, Accounts for Couples' HCV Risk NEW YORK (Reuters Health) - Injection behavior, rather than sexual contact, accounts for the clustering of HCV virus (HCV) infection in heterosexual couples, according to a report in the June 1st issue of The Journal of Infectious Diseases.Injection Behavior, Not Sexual Contact, Accounts for Couples' HCV Risk FY 2004 No Evidence of Sexual Transmission of HCV among Monogamous Couples: Results of a 10-Year Prospective Study The risk of sexual transmission of HCV virus (HCV) infection was evaluated among 895 monogamous heterosexual partners of HCV chronically infected individuals in a long-term prospective study, which provided a follow-up period of 8,060 person-years.No Evidence of Sexual Transmission of HCV among Monogamous Couples: Results of a 10-Year Prospective Study

27 We Need To Adhere To The Scientific Facts

28 Scientist Say: #1 Source of Transmission “Supplies of free needles and bleach disinfection kits have been distributed in many cities to control disease transmission among injection drug users.” However, the transmission of disease to health care workers and between injection drug users in industrialized countries is only a fraction of the total transmission from contaminated needles and syringes worldwide.” Kane, A. et al (Transmission of Hepatitis B, HCV and Human Immunodeficiency Viruses Through Unsafe Injections in the Developing World: Model Based Regional Estimates) Bulletin of the WHO (1999)

29 U.S. Expert Say: Syringe Reuse A Widespread Problem Jodie Sinnema, Edmonton Journal Oct. 28, 2008 "Injection safety was often thought of as a developing world problem and we kind of took it for granted in the U.S. and other developed countries," said Joseph Perz, who works at the Centers for Disease Control and Prevention in Atlanta. "But as a result of accumulating evidence from outbreaks and surveys, we are taking a firmer stand on the need for education and firmer standards.“

30 Other Known Modes of Transmission Needleless Injection –Vaccinator Systems Body Modification –Tattoo/Piercing Medically Acquired

31 Needleless Jet Injectors FINDING OF FACT: HCV is a result of receiving immunizations in service by means of a multi-use jet gun injector. CONCLUSION OF LAW: HCV was incurred in service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.102, (2005).

32 The Latest Jet Injection Science The MUNJIs or “Jetguns” are known by the trade names: Ped–O–Jet®, Med–E–Jet®, Hypospray®, DermoJet® Global ALERT! Recent 2008 FDA Study Show 8.2% Contamination For Newer "Improved" Model Called A “PCNFI”... Researchers Stopped The Test And Rejected The Device.... The Test And Rejected The Device.... PATH, 1455 NW Leary Way, Seattle, WA 98107, USA. Vaccine Mar 4;26(10): Epub 2008 Jan 18.Preventing contamination between injections with multiple-use nozzle needle-free injectors: a safety trial. Kelly K, Loskutov A, Zehrung D, et al.

33 Body Modification

34 Evaluation of Body Modifications ImplantsImplants

35 Largest Single Contributor To Epidemic Largest Single Contributor To HCV Epidemic Scientist Say: "Commercial Tattooing as a Potentially Important Source of HCV Infection." HALEY, ROBERT W., and R. PAUL FISCHER. Medicine 80.2 (March 2001): 134."Commercial Tattooing as a Potentially Important Source of HCV Infection." HALEY, ROBERT W., and R. PAUL FISCHER. Medicine 80.2 (March 2001): 134. –"Most importantly, we found that commercially acquired tattoos accounted for more than twice as many HCV infections as injection-drug use, "Haley said. "This means that it may have been the largest single contributor to the nationwide epidemic of this form of hepatitis.“ American Association for the Study of Liver Diseases Dhalla S, et alAmerican Association for the Study of Liver Diseases Dhalla S, et al –"Strong Association Between Tattoos and HCV Virus Infection: A Multicenter Study of 3,871 Patients" AASLD Meeting 2007; Abstract 136 presented Nov. 5. –Conclusion: “The HCV infected population was 3 times more likely to –Conclusion: “The HCV infected population was 3 times more likely to have a tattoo.”

36 Tattoos & Piercings Are Mainstream

37 Underestimated Magnitude of Transmission 1998 Acute HCV Case Definition Tested All Elevated ALT Levels For Acute Or Chronic HCV 98.9% Acute Had ALT Levels= >2.5 Uln98.9% Acute Had ALT Levels= >2.5 Uln 18% Chronically Infected Had ALT Levels= >2.5 Uln18% Chronically Infected Had ALT Levels= >2.5 Uln –Investigate 20% Of Every 1000 Cases 5% of Chronic Infection Reported Cases Investigated for Acute Infection5% of Chronic Infection Reported Cases Investigated for Acute Infection Change: Efficient And More Specific Criterion- Distinguish Acute From Chronic Infection 2004 Case Definition- Limits Set For Alt –Threshold >7 Times Upper Limits Of Normal 4% of Chronic Infection Reported Cases Investigated for Acute Infection4% of Chronic Infection Reported Cases Investigated for Acute Infection Reason For Modification: Obtain 22% Increase Acute Case Identification Facilitate Surveillance Less Cases Investigated Balance Resources Follow-up To Positive Persons Assess Risk Factors For HCV Transmission Ensure Outbreaks Are Identified Provide Information For Monitoring Support Trends In The Incidence Of HCV 2007 Case Definition Modification ALT levels > 400 IU/L Men Normal High IU/L Women Normal High IU/L Public Health took years to discover the outbreaks and many more months to isolate the source. The incidents occurred at Multiple Veterans Affairs Medical Centers, Public and Private Medical Centers, Cardiology Clinics, Endoscopy and Ambulatory Surgery Clinics, Hematology and Oncology Clinics, Pain Remediation Clinic and Private Physician's Office, Nuclear Imaging Centers and Urology Clinic, Nursing Homes and Assisted-living Facility. Source Of Infections: Equipment And Or Injection Environments Facilities Did Not Met Public Health Safety Standards CSTE Position Statements 2000 ID-#7 COMMITTEE:

38 Medical Exposures : Significant Outbreaks Fremont, Nebraska (2002) Norman, Oklahoma (2002) New York City, New York (2001) (2007) Long Island, New York (2007) Laurinburg, North Carolina (2008) Las Vegas, Nevada (2008) Denver, Colorado (2009)

39 Also Carry High Risk “Enormous numbers of additional injections are given outside the Health sector, in markets, by traditional and unlicensed practitioners with the “family syringe”, and by dentists. Other parenteral exposures, such as scarification, skin piercing, circumcision, tattooing and acupuncture also carry high risk of transmission of bloodborne pathogens, and are not included in these estimates.” Kane, A. et al (Transmission of Hepatitis B, HCV and Human Immunodeficiency Viruses Through Unsafe Injections in the Developing World: Model Based Regional Estimates) Bulletin of the WHO (1999)

40 HCV Surveillance

41 Washington State: One of 50 States Population: 6,549,224 State Department Of Health & 37 Health Districts

42 Surveillance Is Non-Existent National Notifiable Diseases Surveillance System htm htm CDC USA Stats- Reportable Cases Source: Summary of Notifiable Diseases United States, 2006, Morbidity and Mortality Weekly Report, Vol. 55, No. 53, March 21, Table 175 HCV/Non-A, non-B \6 (1,000) *2007 *2008 *2009 (\2) , (\2) , \6 includes some persons positive for antibody to HCV Virus *Data from MMWR Weekly October 16, 2009 / 58(40); Notifiable Diseases/ Deaths The Gauge to Measure Preventive Strategies is Flawed (Oct 10) WA State Reportable Cases 24,789 CDC Reportable Cases 4,615 Washington State: Reportable Cases Chronic HCV Surveillance Report 10/10/ /10/ Note: Most cases of HCV are asymptomatic and very seldom diagnosed in acute stages 1,474

43 Washington State HCV Surveillance Overview: HCV Surveillance began in 2000HCV Surveillance began in 2000 –Surveillance Limitations– Lack of funding affects reportingLack of funding affects reporting Lack of a well developed educational campaign to providersLack of a well developed educational campaign to providers Lack of general population testing by targeted campaignsLack of general population testing by targeted campaigns –The targeted federal government educational campaign does not include the 653,000 veterans, or approximately 1 out of 11 Washington State residents, that served in the US military.

44 Common Age Of Diagnosis

45 WA State HCV Reports- Deaths

46 WA State HCV Reports- Screening Evaluations

47 WA State HCV Reports- Race/Ethnicity Diagnoses thru March 2009 Confirmed plus probable cases

48 Is Integration The Solution? The Goal Of HIV Case Management HIV Access Primary Medical CareHIV Access Primary Medical Care MedicationsMedications Identify And Remove BarriersIdentify And Remove Barriers Medical CareMedical Care Ensure AdherenceEnsure Adherence Prescribed Treatment PlanPrescribed Treatment Plan Why Integration Will Not And Has Not Worked: Modes Of Transmission (HCV Is More Diverse And Is Not An STD)Modes Of Transmission (HCV Is More Diverse And Is Not An STD) Case Verse Medical ManagementCase Verse Medical Management Risk Not Medical AssessmentRisk Not Medical Assessment Marginal Verses General PopulationMarginal Verses General Population Lacks Responsibility!Lacks Responsibility!

49 HIV/AIDS Programs in USA HAP Prevention Overview: Monitoring Progression In Each State Planning Prevention Efforts Guides Allocation Of Resources Treatment Care Other Supportive Services Surveillance: Care and Treatment: Assist HIV-infected/Affected Clients Supportive Services Primary Medical Care HIV Medication Assistance Insurance Assistance Home Health, & Housing. Dental Behavioral Interventions Educational Activities PreventionPrevention Activities Partner Counseling Referral Services Behavioral Intervention HIV Counseling & Testing Purpose: Reduce The Spread The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) is interested in what can be done to build a more comprehensive approach to address health disparities in infectious diseases and to design and establish a strong framework to integrate all of NCHHSTP’s prevention activities.

50 Hepatitis Education Project Created groups from Same Funding Streams National Viral Hepatitis Roundtable (NVHR) - is transferred to -Task Force for Child Survival and Development in 2005 – Changed name to Task Force for Global Health in 2008 – (funding comes from global HIV/AIDS programs and CDC) Hepatitis B & Immunization groups National HCV Advocacy Council NVHR HIV/AIDS, STD and Needle exchange programs NASTAD - Created by CDC in 1992 – liaison between CDC and state health departments to oversee HIV/AIDS funding and distribution. Substance Abuse Programs and Funding HCV Appropriations Partnership 2002 CDC Foundation Forms National Viral Hepatitis Roundtable Created by Roche & Schering-Plough Pharmaceuticals in (1998)- the groups above were seeded by the pharmaceutical industry to look like grassroots organizations in partnership with the CDC Foundation (Our public health partner) and Universities (heavily funded by private research dollars supplied by the drug companies). The Proposed Federal Bill “HCV Epidemic and Control Act” was created by these participants. HCV Support Project/HCV Advocate

51 The Network The US Congress Approved The Creation Of A Non-profit Connected/Created By The CDC Pharmaceutical Industry Largest Contributor The Non-profit and Schering Plough Partnered To Educate The Foundation Creates The National Viral Hepatitis Roundtable (NVHR) As A Non-profit The NVHR Is Moved To Another Non-profit Within The CDC Foundation That Was Created By The United Nations. NVHR Drops Its Non-profit Status To Lobby USA Congress

52 Definition of Stigma: “…a ‘process of devaluation’ of people either living with or associated with HIV and AIDS… Discrimination follows stigma and is the unfair and unjust treatment of an individual based on his or her real or perceived HIV status.” UNAIDS Definition- Discrimination Stigma

53 Conclusion: The data suggests that the public health response may be the direct result of a system in disarray – seemingly captured by special interest with political agendas that have influenced the response to the epidemic. This approach has created disparities in access to health care and created “social labels” that have fostered discrimination, responsible for the reduction in quality of life.The data suggests that the public health response may be the direct result of a system in disarray – seemingly captured by special interest with political agendas that have influenced the response to the epidemic. This approach has created disparities in access to health care and created “social labels” that have fostered discrimination, responsible for the reduction in quality of life. Public health privatization policies and pharmaceutical driven coalitions are agents driving legislation, underscoring the need to evaluate programs at this level. These industry coalitions and their “for profit” and “non-profit” counterparts, fight for government funding thru regulation by fomenting scientific uncertainty that work against broader public health threats.Public health privatization policies and pharmaceutical driven coalitions are agents driving legislation, underscoring the need to evaluate programs at this level. These industry coalitions and their “for profit” and “non-profit” counterparts, fight for government funding thru regulation by fomenting scientific uncertainty that work against broader public health threats. The enduring legacy and indifference for governments, nonprofits, advocates, political parties or economic elites, has grave and global consequences.The enduring legacy and indifference for governments, nonprofits, advocates, political parties or economic elites, has grave and global consequences.

54 Contact Information: Kitty Candelaria- Executive Director,National Hepatitis C InstituteNational Hepatitis C Institute Phone: Patricia Lupole- Nat'l Director, Hepatitis Movement For Awareness Phone: Bill Remak, B.Sc. MT, B. Public Health, SGNA; Chairman, National Association of Hepatitis Task ForcesTask Forces, Chairman, CACA Hepatitis C Task ForceHepatitis C Task Force, Board of Directors, Fair FoundationFair Foundation Phone: Harry Hooks- Director, HCVets.com Educational Website & Support Forum Phone: