Hepatitis C An Overview: USA Public Health Response

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Hepatitis C An Overview USA Public Health
Response Kitty Candelaria Executive
Director National Hepatitis C Institute
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Agenda

• Global Prevalence
• USA response pattern of discrimination
• Underestimated modes of transmission
• Conclusion

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1998 Congressional Quote
Still
true today

Senator
Christopher Shays states Hepatitis C
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.
congressional
hearing titled, Hepatitis C Silent
Epidemic Mute Public Health Response
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World Health Organization

• According to The World Health Organization
• The only means of protection from the
  hepatitis C virus is the implementation of
  standard procedures.
• Mode of Transmission
• Primarily by direct contact with human blood
• Major Causes of Infection Worldwide
• The use of unscreened blood for transfusions
• Re-use of needles and syringes that have not been
  adequately sterilized

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Global Prevalence
http//www.who.int/vaccine_research/diseases/viral
_cancers/en/index2.html
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Global Disease Burden

• Estimated 170 million infected
• 130 million chronically
• 3-4 million new infections a year
• 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

http//www.who.int/vaccine_research/diseases/viral
_cancers/en/index2.html
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HCV Overview

• Blood borne virus
• Asymptomatic in a majority of cases
• 5x more prevalent than HIV/AIDS globally
• Recognized as an infection that affects the liver
  studies indicate HCV is a systemic infection not
  a liver disease
• Complicated progressive disease process
• Population infected is diverse
• Modes of transmission are still not fully
  understood

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USA Public Health Response
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US Disease Prevalence Burden

• An estimated 4 million people are infected
  excluding the institutionalized populations like
  the US military and prisons, and an estimated 12
  million illegal immigrants
• 40-60 of Chronic liver disease in the US is
  related to chronic hepatitis C infection
• Chronic HCV is the leading cause of adult liver
  transplantation
• One of several different viruses affecting the
  liver
• Between 24,000 to 30,000 deaths yearly associated
  with chronic liver disease related to chronic HCV
  
• Approximately 80-90 of people who become
  infected with the hepatitis C virus develop
  chronic infection
• Consensus Statement. 1998 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)

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Viral Hepatitis

• 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
  Drugs 
• Before 1992, Blood Transfusions And Organ
  Transplants
• Sharing Needles, Syringes, Or Other Equipment To
  Inject Drugs
• Needlestick Injuries In Healthcare Settings
• Born To An Infected Mother
•  
• Less Commonly
• Sharing Personal Care Items Such As Razors Or
  Toothbrushes
• Having Sexual Contact With A Person Infected

• 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 contact
• Contaminated food or water

• 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
•  
• Birth
• Sex with an infectd partner
• Sharing needles, syringes, or other drug
  -injection equipment
• Sharing razors or toothbrushes with an infected
  person
• Exposure to blood from needlesticks or other
  sharp instruments

http//www.cdc.gov/vaccines/recs/schedules/child-s
chedule.htm
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Congressional Quote
Still true today Senator Christopher Shays
states Since 1989 when the hepatitis C virus,
was first unmasked, Federal public health
agencies have often pondered, but never
implemented, a comprehensive response to this
insidious infectious agent.
During congressional hearing titled
Hepatitis C Silent Epidemic Mute Public Health
Response
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Public Health Services

• The Public Health Service consists of seven
  operating agencies
• Food and Drug Administration- FDA
• Center for Disease Control- CDC
• National Insitute of Health- NIH
• Substance Abuse and Mental Health Services
  Administration- SAMHSA
• Indian Health Services- HIS
• Health Resources and Services
  Administration-HRSA
• Agency for Health Research and Quality AHRQ
• Partners with the Public Health Services
• Veterans Health Administration- VHA

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CDC Position On HCV

• Virtually ALL transmission of HCV is associated
  with identifiable risk factors.
• With the transfusion risk reduced substantially
  as a result of improved screening, the major risk
  factor, today is IV drug use.
• This is a disease largely under control.
• D. By focusing on marginal populations who
  have high risk behaviors (e.g. IV drug abuse) HCV
  infections will be greatly reduced.
• By tracking acute disease, we can gauge
  prevention strategies.
• F. NHANES was utilized to develop
  prevalence data.

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The Network

Center For Disease Control-CDC
CDC Foundation
National Viral Hepatitis Roundtable (NVHR)
NASTAD
Pharmaceutical Industry
Assortment of Organizations And non-profits
Non profit created by CDC in 1992 to promote
HIV/AIDS funding and policy development
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Mode of Transmission

• CDC Changes Public Health Message
• 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.
• http//www.cdc.gov/hepatitis/

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Who Should be Tested - CDC

• 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.
  
• Received a blood transfusion or organ transplant
  before July 1992.
• Long-term hemodialysis treatment.
• Abnormal liver tests or liver disease.
• Work in healthcare or public safetyand were
  exposed to blood through a needle stick or other
  sharp object injury.
• Those who are infected with HIV.
  
• 
  
  http//www.cdc.gov/hepatitis/
  

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Major Causes of Transmission

• CDC Says.
• Hepatitis C is spread when blood from a person
  infected with the hepatitis C virus enters the
  body of
• someone who is not infected. Today, most people
  become infected with the hepatitis C virus by
• sharing needles or other equipment to inject
  drugs.
• Sharing needles, syringes, or other equipment to
  inject drugs
• Blood transfusion or organ transplant prior to
  1992
• Needlestick injuries in healthcare settings
• Being born to a mother who has hepatitis C
• Sharing personal care items that may have come
  in contact with another persons blood, such as
  razors or toothbrushes
• Having sexual contact with a person infected
  with the hepatitis C virus

http//www.cdc.gov/hepatitis/
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• Sexual Transmission is confusing
• CDC Says
• Risk factors include
• Having sexual contact with a person
  infected with the
• hepatitis C virus
• NIH Says
• Sexual transmission of hepatitis C
  between monogamous
• partners appears to be uncommon Spread
  of hepatitis
• C 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
  patientsPeople
• with multiple sex partners should be
  advised to follow
• safe sex practices, which should
  protect against hepatitis C
• as well as hepatitis B, HIV, and other
  sexually transmitted
• diseases.
• VHA Says
• If you have had multiple sex partners

http//www.hepatitis.va.gov/pdf/va02-pt/pttyp-bro/
130.pdf
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ConfusionNIH says Risk factor includes
- intranasal use of cocaine using shared
equipment or paraphernalia And drops the
CDCs - Sharing personal care items that may
have come in contact with another
persons blood, such as razors or
toothbrushes VHA says - Both are risk
factors, plus tattooing and body piercing
http//digestive.niddk.nih.gov/ddiseases/pubs/chro
nichepc/
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Poster Campaign Confuses The Public
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UNAIDS Defines -

• Stigma Discrimination
• 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.
• This definition applies to those infected with
• HCV as well.

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Published articles on Stigma
Zickmund et al., Stigmatization and the Quality
of Life J Gen Intern Med 2003 18835844.
Patients most commonly articulated three themes
in explaining why they felt stigmatized
Societys association of hepatitis C with
HIV/AIDS, promiscuity, and substance abuse.
Paterson et al, The depiction of stigmatization
in research about hepatitis C
International Journal of Drug Policy 18 (2007)
364373
they are frequently assumed by practitioners to
be injection drug users (IDUs), blamed for
acquiring the disease, and viewed as
irresponsible, immoral, and unworthy.
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Congressional Committee On Reform

• The Findings
• 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.
• Total NIDA HCV Funding   18,281,932

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Domestic Spending on HCV
http//www.cdc.gov/NCHHSTP/docs/NCHHSTP-Annual-Rep
ort-508c.pdf
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HCV is a notifiable disease But NO uniform
hepatitis C surveillance exists.

• Acute cases of HCV reported to the CDC over the
  last 5 years -
• 10/10/ 2009 2008 2007
  2006 2005 2004
• 1,474 878 845 766
  652 720
• 2009 demonstrates an increase
• This increase maybe associated with the recent
  medical outbreaks generating notification and
  testing of the patient population who may have
  received medical attention suspected in outbreak
  over a period of years.

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WHO reports
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, Hepatitis C and Human
Immunodeficiency Viruses Through Unsafe
Injections in The Developing World Model Based
Regional Estimates
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• Examples of activities that are known to be
  modes of transmission
• Injection Vaccination Systems
• Tattoo/body piercing body modification
• Medically acquired HCV

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Needleless Jet Injection System

• 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)
• 8 C.F.R. 3.102, 3.303 (2005).

http//www.hcvets.com/data/transmission_methods/SC
immunizationsbyjetgun.htm
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The Latest Science
The Jetguns are known by the trade names
PedOJet, MedEJet, Hypospray, DermoJet
Recent 2008 FDA Study shows
8.2 contamination for newer "improved" model
called a PCNFI...researchers stopped the test
and rejected the device....  
Kelly K, Loskutov A, Zehrung D, et al. Preventing
contamination between injections with
multiple-use nozzle needle-free injectors a
safety trial. Vaccine. 2008 Mar 426(10)1344-52.
Epub 2008 Jan 18
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Body Modification
Body Modification Tattooing, Body piercing,
Scarification, Branding, And Suspension/Resistance
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The Evolution of Body Modification
Extreme Piercing
Tattooing Extremes
Suspension and resistance
Scarification
Branding
Implants
Implants
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Significant Studies
HALEY, ROBERT W., and R. PAUL FISCHER. "Commercia
l Tattooing as a Potentially Important Source of
Hepatitis C Infection." Medicine 80.2 (March
2001) 134.  In an Interview with the Seattle PI,
Dr. Haley said "Most importantly, we found that
commercially acquired tattoos accounted for more
than twice as many hepatitis C 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.
http//www.seattlepi.com/health/67805_hepc25.shtml
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Participants in this study were from the
Department of Veterans Affairs. American
Association for the Study of Liver Diseases
-Dhalla S, et al "Strong Association Between
Tattoos and Hepatitis C Virus Infection A
Multicenter Study of 3,871 Patients" AASLD
Meeting 2007 Abstract 136 presented Nov. 5.
Author States Tattoos are strongly associated
with hepatitis C virus (HCV) infection, even
among people without traditional risk factors
such as injection drug use and blood
transfusions, ...Conclusion The HCV
infected population was 3 times more likely to
have a tattoo.
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WHO reports

• 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,
• Kane, A. et al Transmission of Hepatitis B,
  Hepatitis C and Human Immunodeficiency
• Viruses Through Unsafe Injections in The
  Developing World Model Based Regional
• Estimates

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Medical Exposures
Source Of Infections Equipment And Or Injection
Environments Facilities Did Not Met Public Health
Safety Standards
Significant Outbreaks Fremont, Nebraska
(2002) Las Vegas, Nevada (2008) Norman, Oklahoma
(2002) Long Island, New York (2007) New York
City, New York (2001) (2007) Laurinburg, North
Carolina (2008)
It took Public Health 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 Physicians Office, Nuclear
Imaging Centers and urology Clinic, Nursing Homes
and Assisted-living Facility.
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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.
http//www.hcvets.com/data/transmissio
n_methods/syringehistory.htm
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Conclusion