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

2. September 11, 2001 Anthrax Attacks Bioterrorism Preparedness

3. 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

4. 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

5. Hepatitis A Incidence, United States,
1995 vaccine licensure
1996 ACIP recommendations
1999 ACIP recommendations
As you know, the incidence of hepatitis A has generally be cyclic, with peaks every 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 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

6. 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

7. 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 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)

8. 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 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)

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

10. 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

11. 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

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

13. National Hepatitis C Prevention Strategy
Prevent HCV infection
Detect and control chronic liver disease
Evaluate effectiveness of activities
Conduct surveillance and research

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

15. Why Include Viral Hepatitis with Other Prevention Programs ?

16. 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

17. 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

18. 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

19. State-Based Hepatitis C PreventionMA
NYC RI DC
Demonstration Project
Coordinator

20. 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

21. 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.

22. Hepatitis C, Total ExpendituresFY 5 10 15 20 25
1997
1998
1999
2000
2001
2002
Year
$ millions

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

24. 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

25. 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.

26. 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.