Transcript Document

Hepatitis C
An Overview: USA
Public Health Response
Kitty Candelaria
Executive Director
National Hepatitis C Institute
Agenda
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Global Prevalence
USA response –pattern of discrimination
Underestimated modes of transmission
Conclusion
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”
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
Global Prevalence
http://www.who.int/vaccine_research/diseases/viral_cancers/en/index2.html
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
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
USA Public Health Response
US Disease Prevalence & Burden
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An estimated 4 million people are infected excluding the
institutionalized populations like the US military and prisons, and an
estimated 12 million illegal immigrants
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40-60% of Chronic liver disease in the US is related to chronic hepatitis
C infection
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Chronic HCV is the leading cause of adult liver transplantation
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One of several different viruses affecting the liver
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Between 24,000 to 30,000 deaths yearly associated with chronic liver
disease related to chronic HCV *
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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)
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
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
Less Commonly:
•Sharing Personal Care Items Such As Razors Or
Toothbrushes
•Having Sexual Contact With A Person Infected
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-schedule.htm
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”
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 AdministrationSAMHSA
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
CDC Position On HCV
A.
Virtually ALL transmission of HCV is associated with identifiable
risk factors.
B.
With the transfusion risk reduced substantially as a result of
improved screening, the major risk factor, today is IV drug use.
C.
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.
E.
By tracking acute disease, we can gauge prevention strategies.
F.
NHANES was utilized to develop prevalence data.
The Network
Funding
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
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/
Who Should be Tested - CDC
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Current or former injection drug user, even if you injected only one time or many years
ago.
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Treated for a blood clotting problem before 1987.
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Received a blood transfusion or organ
transplant before July 1992.
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Long-term hemodialysis treatment.
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Abnormal liver tests or liver disease.
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Work in healthcare or public safety
and were exposed to blood through
a needle stick or other sharp object
injury.
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Those who are infected with HIV.
http://www.cdc.gov/hepatitis/
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.
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Sharing needles, syringes, or other
equipment to inject drugs
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Blood transfusion or organ transplant prior to 1992
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Needlestick injuries in healthcare settings
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Being born to a mother who has hepatitis C
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Sharing personal care items that may have
come in contact with another person’s blood,
such as razors or toothbrushes
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Having sexual contact with a person
infected with the hepatitis C virus
http://www.cdc.gov/hepatitis/
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 patients…People
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
Confusion:
NIH says…
Risk factor includes:
- intranasal use of cocaine using shared
equipment or paraphernalia
And drops the CDC’s:
- Sharing personal care items that may have
come in contact with another person’s blood,
such as razors or toothbrushes
VHA says…
- Both are risk factors, plus tattooing and body piercing
http://digestive.niddk.nih.gov/ddiseases/pubs/chronichepc/
Poster Campaign –
Confuses The Public
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.
Published articles on Stigma
Zickmund et al., Stigmatization and the Quality of Life
J Gen Intern Med 2003; 18:835–844.
Patients most commonly articulated three themes in
explaining why they felt stigmatized:
Society’s 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) 364–373
…they are frequently assumed by practitioners to be
injection drug users (IDUs), blamed for acquiring the
disease, and viewed as irresponsible, immoral, and
unworthy.
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
Domestic Spending on HCV
NIH
Total Spending
HCV
Other
http://www.cdc.gov/NCHHSTP/docs/NCHHSTP-Annual-Report-508c.pdf
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
1,474
2008
878
2007 2006 2005 2004
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.
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”
Examples of activities that are known to
be modes of transmission:
• Injection Vaccination Systems
• Tattoo/body piercing – body
modification
• Medically acquired HCV
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/SCimmunizationsbyjetgun.htm
The Latest Science
The “Jetguns” are known by the trade names:
Ped–O–Jet®, Med–E–Jet®, 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 4;26(10):134452. Epub 2008 Jan 18
Body Modification
Body Modification:
Tattooing, Body piercing,
Scarification, Branding, And
Suspension/Resistance
The Evolution of Body Modification
Extreme
Piercing
Tattooing
Extremes
Suspension and resistance
Branding
Implants
Implants
Scarification
Significant Studies:
HALEY, ROBERT W., and R. PAUL FISCHER. "Commercial
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
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.”
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”
Medical Exposures
Significant Outbreaks:
Source Of Infections: Equipment And Or Injection
Environments Facilities Did Not Met Public Health Safety
Standards
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 Physician’s Office, Nuclear
Imaging Centers and urology Clinic, Nursing Homes and Assisted-living Facility.
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/transmission_methods/syringehistory.htm
Conclusion