Addressing Viral Hepatitis Jonathan Mermin, MD, MPH National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC NASTAD National Hepatitis Technical Assistance Meeting December 6, 2016 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Office of the Director

Importance of Viral Hepatitis Massive public health burden Major cause of morbidity and mortality Substantial health inequity Discongruity between burden, attention, resources Extraordinary opportunities for public health Moment in time HCV testing of persons born between 1945 and 1965 can save over 120,000 lives and avert $2.5 billion in health care costs. Treating HCV is considered to be cost-effective: $29,000/QALY and $14,700 for 55 and 35-year olds respectively are each less than the $50,000/QALY willingness-to-pay threshold (assumed).

Hepatitis A Matters 53% coverage of HAV vaccine, lowest of any childhood vaccine 76 HAV-related deaths in 2014 CDC, National Notifiable Diseases Surveillance System (NNDSS)

Hepatitis A Outbreaks in 2016 Multistate outbreak from frozen strawberries imported from Egypt 141 HAV cases in 8 states (107 in Virginia) 54 hospitalizations Outbreak in Hawaii linked to raw scallops from Philippines 292 HAV cases confirmed 74 hospitalizations 2 deaths HAV Cases by Onset Date, Multistate Outbreak from Frozen Strawberries, May-September 2016

Hepatitis B Matters HBV prevalence estimated at 850,000 to 2.2 million 1,843 deaths in 2014 Source: National Notifiable Diseases Surveillance System (NNDSS)

Addressing Hepatitis B Virus: Vaccination and Testing and Therapy Benefits of HBV Testing and Therapy U.S. cohorts had 50% reduction in risk for liver cancer Tenofovir may become cheaper, as patent ends in 2018 HBV Rates Decline with Vaccination Source: National Notifiable Disease Surveillance System (NNDSS) Lai, Hepatology, 2013. Gordon, Clin Gastro Hepatol 2014

>20,000 deaths per year Hepatitis C Matters Source: National Notifiable Diseases Surveillance System (NNDSS)

HCV diagnosis and treatment Cascade to Cure 50% 38% 23% 6% 11% Holmberg S, et al, NEJM, 2013

Coverage Restrictions Most public and private insurers have criteria for treatment Advanced fibrosis or cirrhosis Abstinence from alcohol, marijuana, and illicit drug use No malignancy Prescriber specialty or “extensive experience” treating hepatitis C

Access to Syringe Services Programs and Related Interventions

Viral Hepatitis Health Disparities About half of HBV chronic infections among Asian Americans and Pacific Islanders Acute HCV incidence rising among people who inject drugs, especially poor, rural, medically underserved Chronic HCV is health disparity, especially for African Americans and American Indians and Alaska Natives

What to Do?