Viral Hepatitis & Serving Seniors in Community Health Centers Corinna Dan, RN, MPH Office of HIV/AIDS and Infectious Disease Policy U.S. Department of Health and Human Services April 23, 2013

Webinar Overview Brief Epidemiology of Viral Hepatitis Viral Hepatitis Action Plan- Federal Response Viral Hepatitis in the Care of Seniors: – CDC Recommends Hepatitis C Testing for Persons born – Hepatitis B Testing in Seniors – Hepatitis B Vaccination Recommendations Resources for Providers

Viral Hepatitis Epidemiology, U.S. 3 Hepatitis B VirusHepatitis C Virus Incident cases (annual) 35,000 (2010) * *82%  since ,000 (2010) Chronic (prevalent cases) 800,000 – 1.4 million3.2 million Est. perinatal (annual) 800 – 1,000 Deaths (annual) 3,00015,000 (2010)

HHS Viral Hepatitis Action Plan- United States  EDUCATING PROVIDERS AND COMMUNITIES TO REDUCE HEALTH DISPARITIES  IMPROVING TESTING, CARE, AND TREATMENT TO PREVENT LIVER DISEASE AND CANCER  STRENGTHENING SURVEILLANCE TO DETECT VIRAL HEPATITIS TRANSMISSION AND DISEASE  ELIMINATING TRANSMISSION OF VACCINE- PREVENTABLE VIRAL HEPATITIS  REDUCING VIRAL HEPATITIS CASES CAUSED BY DRUG- USE BEHAVIORS  PROTECTING PATIENTS AND WORKERS FROM HEALTH- CARE-ASSOCIATED VIRAL HEPATITIS 4

Proposed 2020 Goals of the Viral Hepatitis Action Plan (full implementation) Increase from 33% to 66% the proportion of persons who are aware of their HBV infection Increase from 45% to 66% the proportion of persons who are aware of their HCV infection Reduce by 25% the number of new HCV infections Eliminate mother-to-child HBV transmission 5

Action Plan Implementation in the Office of HIV/AIDS & Infectious Disease Policy Viral Hepatitis Implementation Group established – Coordinate and collaborate across agencies and offices – HHS Offices and Agencies: AHRQ, CDC, CMS, FDA, IHS, HRSA, NVPO, OMH, OWH, SAMHSA – Federal Partners: Department of Veteran’s Affairs, Department of Justice Bureau of Prisons, Department of Housing & Urban Development Identify opportunities to leverage existing resources, set priorities, and advance policy Year 1 Interagency Implementation Progress Report completed:

“The committee concludes that insufficient provider knowledge leads to missed opportunities for providers to: educate patients about prevention of HBV and HCV, identify patients who may be at risk for these infections, and test for chronic HBV and HCV infection in patients, …family members and …..contacts… ” Institute of Medicine, Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of HBV and HCV, 2010

Hepatitis C Testing Recommendations Bryce Smith, PhD Team Lead, Prevention Research and Evaluation Division of Viral Hepatitis Centers for Disease Control and Prevention

Hepatitis B Testing Testing for Hepatitis B is recommended for certain groups of people, including: People born in Asia, Africa, and other regions with moderate or high rates of Hepatitis B Unvaccinated people whose parents are from regions with high rates of Hepatitis B Anyone having sex with a person infected with Hepatitis B People who live with someone with Hepatitis B Men who have sexual encounters with other men People who inject drugs All pregnant women People with HIV infection People on hemodialysis People who receive chemotherapy or other types of immunosuppressive therapy

Why Hepatitis B Testing is Important Many people with HBV do not know they are infected since they do not look or feel sick. Over time, approximately 15%–25% of people with chronic HBV develop serious liver problems, including: - liver damage, - cirrhosis, - liver failure, and - liver cancer. Every year, approximately 3,000 people in the US die from HBV-related liver disease. Kowdley, K. V., Wang, C. C., Welch, S., Roberts, H. and Brosgart, C. L. (2012), Prevalence of chronic hepatitis B among foreign-born persons living in the United States by country of origin. Hepatology, 56: 422–433. doi: /hep.24804

Hepatitis B Testing & Immunosuppresive Therapy Persons with chronic HBV infection who initiate cytotoxic or immunosuppressive therapy are at risk for HBV reactivation and associated morbidity and mortality including: – chemotherapy for malignant diseases, – immunosuppression related to organ transplantation, and – immunosuppression for: Rheumatologic disorders, Gastroenterologic disorders, and Dermatologic disorders. Recommended testing for serologic markers of HBV infection include: – HBsAg, anti-HBc, and anti-HBs Prophylactic antiviral therapy can prevent reactivation and possible fulminant hepatitis in HBsAg positive patients. Refer to/consult with specialist prior to initiating new therapies

Hepatitis B Vaccination Recommendations Immunization strategy to eliminate transmission of hepatitis B virus (HBV) in the United States Universal vaccination of infants beginning at birth Prevention of perinatal HBV infection through: – routine screening of all pregnant women for hepatitis B surface antigen (HBsAg), and – immunoprophylaxis of infants born to HBsAg positive women or to women with unknown HBsAg status Routine vaccination of previously unvaccinated children and adolescents Vaccination of previously unvaccinated adults at risk for HBV infection CDC. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the US. MMWR 2006;55 (No. RR-16).

Adults Recommended for Hepatitis B Vaccination (2006): Persons at risk for infection by sexual exposure Sex partners of hepatitis B surface antigen (HBsAg) positive persons Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months) Persons seeking evaluation or treatment for a sexually transmitted disease Men who have sex with men Persons at risk for infection by percutaneous or mucosal exposure to blood Current or recent injection-drug users Household contacts of HBsAg-positive persons Residents and staff of facilities for developmentally disabled persons Health-care and public safety workers with risk for exposure to blood or blood-contaminated body fluids Persons with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis, and home dialysis patients Others International travelers to regions with high or intermediate levels (HBsAg prevalence of >2%) Persons with chronic liver disease Persons with HIV infection All other persons seeking protection from HBV infection

Hepatitis B Vaccination for Diabetics (2011) 2011 ACIP recommendations: Hepatitis B vaccination should be administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 years (recommendation category A; evidence type 2). Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged ≥60 years (recommendation category B; evidence type 2). Rationale: Of twenty-nine outbreaks reported CDC in long-term care facilities, twenty-five involved adults receiving assistance with blood glucose monitoring. CDC. Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: Recommendations of the ACIP. MMWR 2011;60 ( ).

Challenges & Opportunities for FY 13 and Beyond Raise awareness among: – The Public – Communities at Highest Risk, e.g., African American, Asian Pacific Islander American – Health & Social Service Providers Rapidly evolving science base in HCV therapy Expand, share and improve viral hepatitis data: public health and clinical Take active advantage of a reformed health care system as a means to improve diagnosis, treatment, and prevention of viral hepatitis Continue to push the boundaries of “leveraging resources”

Viral Hepatitis RESOURCES

RiskAssessment/ Hepatitis Risk Assessment

May is Hepatitis Awareness Month & May 19 th is National Hepatitis Testing Day Online resources available: urces.htm urces.htm Order free posters & other resources:

Thank you! Corinna Dan, RN, MPH Viral Hepatitis Policy Advisor Office of HIV/AIDS & Infectious Disease Policy Department of Health and Human Services