Larry Cuellar Adult Viral Hepatitis Prevention Coordinator Texas Department of State Health Services 2010 STREET OUTREACH WORKERS CONFERENCE June 21, 2010 Austin, Texas The State of Hepatitis in the State of Texas: A Comparison of Activities with the Viral Hepatitis National Plan

 Why is the IOM Report is so important?  What does this have to do with me?  What are the findings and recommendations?  How are we doing in the state?

Issues IOM was asked to address  Strategies for preventing HBV and HCV infections  Strategies for reducing morbidity and mortality from chronic HBV and HCV infections  Assess the type and quality of data needed from state and local viral hepatitis surveillance systems to guide and evaluate prevention services

 Chronic viral hepatitis is ◦ a serious public health problem in the U.S. ◦ poorly understood by providers, public, and policy makers  Lack of awareness and knowledge results in ◦ Missed opportunities for prevention  Inadequate investments in viral hepatitis services and care

The Current Situation  Hepatitis B virus (HBV) 800,000 to 1.4 million people are chronically infected with HBV in United States  3,000 deaths each year are due to hepatitis B-related liver disease  Hepatitis C virus (HCV) million people are chronically infected with hepatitis C virus (HCV) in United States  12,000 deaths each year are due to hepatitis C-related liver disease  Over 150,000 deaths due to hepatitis B and hepatitis C are projected to occur in next 10 years

The Issues by Comparison VirusPrevalence% of Population Unaware of Infection Status Deaths in 2006 Related to Infection HBV800,000 –1.4 million About 65%3,000 HCV2.7–3.9 millionAbout 75%12,000 HIV1.1 millionAbout 21%14,016 Sources: CDC; Lin et al, 2007; Hagan et al 2006

Populations at increased risk Asian/Pacific Islanders – in the US, 1 out of 10 API are chronically infected with hepatitis B Injecting Drug Users – 60% - 90% of IDUs are infected with hepatitis C What are some of the other populations at high risk?

Lack of Public Awareness Lack of Provider Awareness Lack of Public Resource Allocation Morbidity and Mortality related to hepatitis B and hepatitis C  At-risk people do not know how to prevent becoming infected  At-risk people may not have access to preventive services  Chronically infected people do not know that they are infected  Providers do not screen people  Providers do not know how to manage infected patients  Inadequate access to testing and medical management  Inadequate disease-surveillance systems

Domestic HIV 69% TB 14% STD 15% National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention Funding $1 Billion Total Hepatitis 2% Source: CDC The Fiscal Issues

Lack of Public Awareness Lack of Provider Awareness Lack of Public Resource Allocation Morbidity and Mortality related to hepatitis B and hepatitis C The Consequences Improved Provider and Community Education Integration and Enhancement of Viral Hepatitis Services Improved Immunization Improved Disease Surveillance

Recommendation: Surveillance IOM REPORT:  CDC should develop specific cooperative agreements to support core surveillance for acute and chronic HBV and HC  CDC should support and conduct active surveillance to monitor incidence and prevalence of hepatitis B and C infections in populations not fully captured by core surveillance.

Current Hepatitis Surveillance Activities in Texas  What does the state require to be reported to the health department regarding hepatitis infection? Hepatitis A, B, C, D, E (acute) Hepatitis B (acute and chronic) identified prenatally or at delivery

Recommendation: Improved Provider Education IOM REPORT:  CDC should work with key stakeholders to develop hepatitis B and C educational programs for health-care and social-service providers.  CDC should work with key stakeholders to develop hepatitis B and C educational programs for target at-risk populations and the general public.

DSHS Activities  Convene two annual meetings, Hepatitis Summits, to raise awareness and education ◦ Houston, April 16, 2010 ◦ Austin, October 22, 2010  Course on the Basics of Hepatitis available on TRAIN Texas website. ◦ Four hour training ◦ Covers hepatitis A, B and C

Recommendation: Immunization IOM REPORT:  Ensure the recommendations of the Advisory Committee on Immunization practice be in effect for all infants.  CDC should work with key stakeholders to ensure hepatitis B vaccine series is as a requirement for school attendance.  Additional resources should be devoted to increasing hepatitis B vaccine of at-risk adults.

Adult Hepatitis B Vaccination Initiative

DSHS Clinical Standards  STD program operating procedures contain an expectation that all STD clinics will provide routine Hepatitis A and B immunizations to all unimmunized patients, regardless of risk factors.  HIV care entities should have a similar expectation.

Recommendation: Viral Hepatitis Services IOM REPORT:  Federally funded health-insurance programs should incorporate guidelines for risk-factor screening for hepatitis B and C and infected patients should received appropriate medical management.

Expansion of Hepatitis C Testing  In 2010, went from 11 HIV counseling and testing sites to 16 sites.  Working to expand to substance abuse sites conducting HIV testing.  Working to expand to sites in Houston.

Barriers to Hepatitis C Testing No financial resources available for hepatitis C testing. No resources available for confirmatory testing. No treatment available for those that test positive. Not my job, don’t pay me to do this, just one more thing I have to do…

HCV Disease Progression Progression of HCV Monoinfection Over Years These numbers are rough estimates based on people with HCV only. Cofactors like HIV infection or alcohol use increase the risk of disease progression.

Texas Hepatitis Network The Texas Hepatitis Network was created in response to the community’s need for a place to exchange hepatitis resources and information for Texans. As part of this community we have created an interactive resource map for you.

Recommendation: Viral Hepatitis Services IOM REPORT:  CDC should work with key stakeholders to expand programs to reduce the risk of hepatitis C infection through injection-drug use, at minimum programs should include access to sterile syringes and drug-prep equipment.

Recommendation: Viral Hepatitis Services IOM REPORT:  CDC and HRSA should provide resources and guidance to integrate comprehensive services into settings serving high-risk populations.

Facilities Providing On-site Infectious Disease Screening: 2007 Source: 2007 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).

Comprehensive viral hepatitis services consist of five core components:  Community outreach and awareness  Vaccination and harm reduction  Identification of infected people  Social and peer support  Medical management Box 5-3 pg 126

HCV and HIV Coinfection  Up to 240,000 people in the U.S. are co-infected with HIV/HCV  Majority have chronic disease (85%)  1/3 of HIV+ people are co-infected with HCV  10% of HCV+ people are co-infected with HIV  In urban areas, up to 90% of HIV+ IDUS are co-infected with HCV

Potential Co-infection Effect of HIV on HCV Disease  HIV infection may worsen HCV disease  Weakened immune system allows HCV to replicate faster  More infectious because higher viral load  Accelerates and increases disease progression  May not respond well to HCV treatment

Potential Co-Infection Effect of HCV on HIV Disease  HCV disease does not appear to accelerate HIV disease  Higher toxicity from HAART  As people live longer with HIV, many more HIV deaths are caused by HCV-related end stage liver disease  There is still a lot of research to be done on these effects

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