Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C

Released: January 11, 2010

Type: Consensus Report

Topic(s): Diseases, Public Health

Activity: Prevention and Control of Viral Hepatitis Infections in the United States

Board(s): Board on Population Health and Public Health Practice

Up to 5.3 million people—2 percent of the U.S. population—are living with chronic hepatitis B or hepatitis C. These diseases are more common than HIV/AIDS in the U.S. Yet, because hepatitis B and hepatitis C often present no symptoms, most people who have them are unaware until they develop liver cancer or liver disease many years later.

A new IOM study finds that these diseases are not widely recognized as serious public health problems, and as a result, that viral hepatitis prevention, control, and surveillance programs have inadequate resources. The report concludes that the current approach to the prevention and control of chronic hepatitis B and hepatitis C is not working. As a remedy, the IOM recommends increased knowledge and awareness about chronic viral hepatitis among health care providers, social service providers, and the public; improved surveillance for hepatitis B and hepatitis C; and better integration of viral hepatitis services.

http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspx

Background

Approximately 350 million people worldwide are infected with hepatitis B, a deadly disease that often goes undetected despite the fact that it causes about 80% of all primary liver cancers.

Hepatitis B, a liver disease caused by the hepatitis B virus (HBV), can lead to lifelong infection, scarring of the liver, liver cancer, and death. In the U.S., it is estimated that 1 in 20 people will become infected with HBV, and 1 in 4 chronic hepatitis B carriers will die of liver cancer or liver failure.

Within Asian American, Native Hawaiian, and other Pacific Islander (AA & NHOPI) populations, this "silent disease" has had an especially devastating health impact. AA & NHOPIs comprise more than half of the 2 million estimated hepatitis B carriers in the United States and, consequently, have the highest rate of liver cancer among all ethnic groups.

Issues

Although infection is preventable with a safe and effective hepatitis B vaccine, many people live with (and often unknowingly pass on) this chronic disease. Compounding this problem, hepatitis B screening and vaccination rates among AA & NHOPIs are alarmingly low, given the disease's disproportionate affect on this population. For example, a 2005 study done in New York City found that more than half (56.6%) of AA & NHOPIs had not been previously screened for HBV and 15% of those unscreened individuals were indeed chronically infected with HBV.

Recommendations

• Support and promote community and faith based efforts to educate and mobilize AA & NHOPI communities at risk for and living with hepatitis B
• Support programs that educate health care providers on hepatitis B's high prevalence among AA & NHOPIs
• Support the Viral Hepatitis and Liver Cancer Control Act of 2009, which calls for the prevention, control, and appropriate treatment for hepatitis B through vaccination programs, preventive education, early detection and research. This act also supports expanded outreach and preventative HBV programs specific to AA & NHOPIs and other groups disproportionately affected by hepatitis B.

There is no federal funding to provide core
public health services for viral hepatitis.

Funds are needed for hepatitis B and C counseling, testing, and medical referral. States receive on average only $90,000 annually for adult hepatitis prevention. This provides for little more than one staff position - the Adult Viral Hepatitis Prevention Coordinator (AVHPC) - in an entire state health department. The AVHPC works to integrate hepatitis prevention messages into existing programs without funding for actual services. Additionally, there is no funding for community-based organizations to provide services

AASLD Guidelines: Periodic Surveillance for Hepatocellular Carcinoma

• At risk hepatitis B carriers
  • Asian males >40 years of age
  • Asian females >50 years of age
  • All cirrhotic hepatitis B carriers
  • Family history of hepatocellular carcinoma
  • Africans >20 years of age
  • Those with measurable HBV DNA levels and those with ongoing hepatic inflammatory activity remain at risk for hepatocellular carcinoma
• Liver ultrasound every 6 to 12 months

There is no dedicated federal funding for adult vaccine, which is essential to eliminating hepatitis A and B.

Vaccines to prevent hepatitis A virus (HAV) and HBV have been available for over 10 and 20 years, respectively. The HBV vaccine prevents liver cancer. Although CDC recommends vaccination for high-risk adults, rates are low due to lack of dedicated funding for adult vaccine programs and infrastructure for delivery. Vaccination of persons living with or at risk for HCV and HIV is critical. HAV can be fatal in persons with chronic HCV and viral hepatitis co-infection accelerates liver disease progression.

Funding for Treatment and Medical Management

HBV and HCV are treatable—in fact, HCV is curable. Yet, despite staggering numbers of chronically infected people, and projections of a dramatic increase in morbidity and mortality from viral hepatitis, there is no dedicated funding stream for chronic disease management of HBV and HCV. Furthermore, low-income Americans who can best benefit from treatment do not qualify for disability-based public insurance such as Medicaid. Access to care, treatment and support services are critical for preventing morbidity and mortality from viral hepatitis, and for preventing new infections by reducing the pool of infectious persons. While not all infected individuals will require treatment, they do need access to health care so that they are educated about self-care and can be monitored for disease progression.

Funding for hepatitis B and C care and treatment for the mono-infected.

There is no dedicated funding stream for medical management and treatment of HBV and HCV, but low-income patients can and do seek services at Community Health Centers (CHCs). Congress can show leadership by adequately funding the CHCs, and through funding and directing HRSA to initiate demonstration projects utilizing existing Ryan White Program infrastructure to provide case management and treatment for HBV and HCV mono-infected persons.

• CDC's National Hepatitis C Prevention Strategy (2001),
• NIH Consensus Development Conference Statement on Management of Hepatitis C (2002),
• NIH's Action Plan for Liver Disease Research (2004) and subsequent annual updates (2005-2007),
• National Viral Hepatitis Roundtable's National Hepatitis Elimination Strategy (2006),
• NIH Consensus Development Conference Statement on Management of Hepatitis B (2008), and
• CDC's Testing and Pubic Health Management of Persons with chronic HBV (2008).

Baruch S. Blumberg, M.D., Ph.D.

Nobel Laureate, 1976 for discovery of the hepatitis B Virus
Invention of the Hepatitis B Vaccine

Viral Hepatitis and Liver Cancer Control and Prevention Act (HR3974)

To amend the Public Health Service Act to establish, promote, and support a comprehensive prevention, research, and medical management referral program for chronic hepatitis B and chronic hepatitis C virus infection, to include the following:

• EDUCATION AND TRAINING – heightens awareness and enhances knowledge and understanding of hepatitis B and C among health care professionals and the public;
• HEPATITIS B and C DISEASE CONTROL – promotes and supports State, local, and tribal programs for voluntary hepatitis B & C testing, counseling, and referrals for medical management;
• SURVEILLANCE – promotes and supports establishment and maintenance of State chronic hepatitis B and C surveillance databases;
• IMMUNIZATION – expands the current vaccination programs (hepatitis A & B) to protect all susceptible adults, particularly those infected with HCV, highprevalence ethnic populations, and other high risk groups, from the risks of acute and chronic hepatits B infection and ensures all children continue to be covered by Vaccine for Children (VFC) funding;
• ADULT VIRAL HEPATITIS COORDINATORS – provides program funding for Adult Viral Hepatitis Prevention Coordinators in State health departments to enhance the additional management, networking, and technical expertise needed to ensure successful integration of HBV and HCV prevention and control activities into existing public health programs;
• INTEGRATION WITH EXISTING PROGRAMS – integrates program elements of the Act into existing State, local, and tribal clinical and public health programs, where appropriate;
• UNDERSERVED AND DISPROPORTIONATELY AFFECTED POPULATIONS – implements provisions of the Act so as to promote expanded resources for persons with limited access to health education, testing and health care services and groups that may be disproportionately affected by HBV and HCV;
• MEDICAL REFERRAL – supports referral of persons infected with or at risk for HBV and HCV for drug or alcohol abuse treatment, where appropriate, and on for ongoing medical management of HBV and HCV; and,
• RESEARCH ─ supports research through National Institutes of Health (NIH) on best practices, populations affected, liver cancer, noninvasive testing, and treatment.