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Institute of Medicine recommendations
for the prevention and control of hepatitis B and C
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Hepatology March 2010
Abigail E. Mitchell 1 *, Heather M. Colvin 1, R. Palmer Beasley 2
1Board on Population Health and Public Health Practice, Institute of Medicine of the National Academies, Washington, DC
2Division of Epidemiology and Disease Control, University of Texas School of Public Health, Houston, Texas
email: Abigail E. Mitchell (amitchell@nas.edu)
"Federally funded health-insurance programs - such as Medicare, Medicaid, and the Federal Employees Health Benefits Program - should incorporate guidelines for risk-factor screening for hepatitis B and hepatitis C as a required core component of preventive care so that at-risk people receive serologic testing for HBV and HCV and chronically infected patients receive appropriate medical management."
"The Health Resources and Services Administration should provide adequate resources to federally funded community health facilities for provision of comprehensive viral hepatitis services."
Abstract
Despite federal, state, and local public health efforts to prevent and control hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, these diseases remain serious health problems in the United States. About 1%-2% of the U.S. population has chronic HBV or HCV infections, and each year about 15,000 people die from liver cancer or liver disease related to these preventable infections. The Institute of Medicine formed an expert committee to determine ways to reduce new HBV and HCV infections and the morbidity and mortality related to chronic viral hepatitis and released its findings in a report. The major factor found to impede current efforts to prevent and control HBV and HCV is lack of knowledge and awareness about these diseases among healthcare and social-service providers, members of the public, and policy makers. Because the extent and seriousness of this public health problem is not appreciated, inadequate resources are being allocated to prevention, control, and surveillance programs. This situation has led to continued transmission of HBV and HCV and inadequate identification of and medical management for chronically infected people. Conclusion: To address the situation, the Institute of Medicine report makes recommendations in four areas: improved surveillance for HBV and HCV; improved knowledge and awareness among healthcare and social-service providers and the public, especially at-risk people; improved HBV vaccine coverage; and improved viral hepatitis services and access to those services.
Received: 12 January 2010; Accepted: 13 January 2010
Article Text
In the next 10 years, about 150,000 people in the United States will die from liver cancer and liver disease associated with chronic hepatitis B and hepatitis C.[1] It is estimated that 3.5 to 5.3 million people - 1%-2% of the U.S. population - are living with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections. Of those, 800,000 to 1.4 million have chronic HBV infections and 2.7 to 3.9 million have chronic HCV infections. About 65% and 75% of the infected population are unaware that they are infected with HBV and HCV, respectively.[2][3]
Although the incidence of acute HBV infection is declining in the U.S., due to the availability of HBV vaccines, about 43,000 new acute HBV infections still occur each year.[4] Of those new infections, about 1,000 infants acquire the infection from their HBV-positive mothers.[5] HBV is also transmitted by sexual contact with an infected person, sharing injection drug equipment, and needlestick injuries. The number of people in the U.S. who are living with chronic HBV infection may be increasing as a result of legal immigration from highly endemic countries (especially countries in the western Pacific region, Asia, and sub-Saharan Africa).
HCV is efficiently transmitted by direct percutaneous exposure to infectious blood. Persons likely to have chronic HCV infection include those who received a blood transfusion before 1992 and past or current injection-drug users (IDUs). Most IDUs in the United States have serologic evidence of HCV infection.[6][7] While HCV incidence appears to have declined over the last decade, a large portion of IDUs, who often do not have access to healthcare services, are not identified by current surveillance systems making interpretation of that trend complicated.
Despite federal, state, and local public health efforts to prevent and control HBV and HCV, these diseases remain serious health problems in the U.S. Therefore, the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services' Office of Minority Health, the Department of Veterans Affairs, and the National Viral Hepatitis Roundtable sought guidance from the Institute of Medicine (IOM) in identifying missed opportunities related to the prevention and control of HBV and HCV infections. The IOM assembled an expert committee to address that task; its findings and recommendations are published in a report. This article summarizes the IOM's report Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C.[8]
Abbreviations: CDC, Centers for Disease Control and Prevention; HBV, hepatitis B virus; HCV, hepatitis C virus; IDU, injection drug user; IOM, Institute of Medicine.
Findings and Recommendations
The IOM committee's overall approach to its task is presented in Fig. 1. Major factors that impede efforts to prevent and control hepatitis B and C are the lack of knowledge and awareness on the part of healthcare providers, at-risk populations, the public, and policy makers. Insufficient understanding about the seriousness of this public health problem has led to inadequate allocation of public resources for viral hepatitis prevention, control, and surveillance programs. For example, although there are three to five times more people living with chronic viral hepatitis infections than with HIV infection, just 2% of the CDC NCHHSTP (National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention) fiscal year 2008 budget was allocated for viral hepatitis, but 69% was allocated for HIV/AIDS (J. Ward, CDC, presentation to the IOM committee, December 4, 2008). Inadequate resources for viral hepatitis programs are leading to continued transmission of HBV and HCV and high rates of morbidity and mortality from hepatitis B and hepatitis C. The committee made recommendations in four areas: surveillance, knowledge and awareness, hepatitis B immunization, and services.
Surveillance.
The viral hepatitis surveillance system in the U.S. is highly fragmented and poorly developed. The federal government has provided few resources to local and state health departments to perform surveillance for viral hepatitis. Additional funding sources for surveillance, such as funding from states and cities, vary among jurisdictions. The committee made the following recommendations aimed at making viral hepatitis surveillance systems more consistent among jurisdictions and improving their ability to collect and report data more accurately:
The CDC should develop specific cooperative viral-hepatitis agreements with all state and territorial health departments to support core surveillance for acute and chronic hepatitis B and hepatitis C.
The agreements should include:
(1) A funding mechanism and guidance for core surveillance activities.
(2) Implementation of performance standards regarding revised and standardized case definitions, specifically through the use of:
(a) Revised case-reporting forms with required, standardized components.
(b) Case evaluation and follow-up.
(3) Support for developing and implementing automated data-collection systems, including:
(a) Electronic laboratory reporting.
(b) Electronic medical-record extraction systems.
(c) Web-based, Public Health Information Network-compliant reporting systems.
The CDC should support and conduct targeted active surveillance, including serologic testing, to monitor incidence and prevalence of HBV and HCV infections in populations not fully captured by core surveillance.
(1) Active surveillance should be conducted in specific geographic regions and populations.
(2) Appropriate serology, molecular biology, and follow-up will allow for distinction between acute and chronic hepatitis B and hepatitis C.
Knowledge and Awareness.
The committee found relatively poor awareness about hepatitis B and hepatitis C among healthcare providers, social-service providers (such as staff at drug-treatment facilities and immigrant-services centers), and the public. Lack of awareness about the prevalence of chronic viral hepatitis in the U.S., the target populations, and the appropriate methodology for risk-factor screening, serologic testing, and medical management probably contributes to continuing transmission; missed opportunities for prevention, early diagnosis, and medical care; and poor health outcomes in infected people. To improve knowledge and awareness among healthcare providers and social-service providers, the committee recommends:
The CDC should work with key stakeholders (other government agencies, professional organizations, healthcare organizations, and educational institutions) to develop hepatitis B and hepatitis C educational programs for healthcare and social-service providers.
The educational programs should include at least the following components:
(1) Information about the prevalence and incidence of acute and chronic hepatitis B and hepatitis C both in the general U.S. population and in at-risk populations, particularly foreign-born populations for hepatitis B, and IDUs and incarcerated populations for hepatitis C.
(2) Guidance on screening for risk factors.
(3) Information about prevention, immunization, and monitoring of chronically infected patients.
(4) Information about prevention of HBV and HCV transmission in health-care settings.
To increase knowledge and awareness about hepatitis B and hepatitis C in at-risk populations and the general population, the committee recommends:
The CDC should work with key stakeholders to develop, coordinate, and evaluate innovative and effective outreach and education programs to target at-risk populations and to increase awareness in the general population about hepatitis B and hepatitis C.
The programs should be linguistically and culturally appropriate and should integrate viral hepatitis and liver-health education into other health programs that serve at-risk populations. They should:
(1) Promote better understanding of HBV and HCV infections, transmission, prevention, and treatment in the at-risk and general populations.
(2) Educate pregnant women and women of childbearing age about hepatitis B prevention.
(3) Increase testing rates in at-risk populations.
(4) Promote safe injections among IDUs and safe drug use among noninjection drug users.
(5) Provide educational information for all people who have tested positive for chronic HBV or HCV infections and those receiving treatment.
Immunization.
The longstanding availability of effective hepatitis B vaccines makes the elimination of new HBV infections possible, particularly in children. As noted above, about 1,000 newborns are infected by their HBV-positive mothers at birth each year in the U.S. That number has not declined in the last decade. To prevent transmission of HBV from mothers to newborns, the Advisory Committee on Immunization Practices recommends that infants born to mothers who are positive for hepatitis B surface antigen receive hepatitis B immune globulin and a first dose of the hepatitis B vaccine within 12 hours of birth. To improve adherence to that guideline, the committee recommends:
All infants weighing at least 2,000 g and born to hepatitis B surface antigen-positive women should receive single-antigen hepatitis B vaccine and hepatitis B immune globulin in the delivery room as soon as they are stable and washed.
The Advisory Committee on Immunization Practices recommends administration of the hepatitis B vaccine series to unvaccinated children under 19 years old. School-entry mandates have been shown to increase hepatitis B vaccination rates and to reduce disparities in vaccination rates. Overall, hepatitis B vaccination rates in school-age children are high, but coverage varies among states. Additionally, there are racial and ethnic disparities in childhood vaccination rates - Asian and Pacific Islander, Hispanic, and African American children have lower vaccination rates than non-Hispanic white children. Regarding vaccination of children, the committee recommends:
All states should mandate that the hepatitis B vaccine series be completed or in progress as a requirement for school attendance.
Hepatitis B vaccination for adults is directed at high-risk groups - people at risk for HBV infection from infected sex partners, from IDU, from occupational exposure to infected blood or body fluids, and from travel to regions that have high or intermediate HBV endemicity. Only about half the adults at high risk for HBV infection receive the vaccine. Low coverage of high-risk adults is attributed to the lack of dedicated vaccine programs; limitations of funding, insurance coverage, and cost-sharing; and noncompliance of the involved populations. To increase the rate of vaccination of at-risk adults, the committee recommends:
Additional federal and state resources should be devoted to increasing hepatitis B vaccination of at-risk adults.
(1) Correctional institutions should offer hepatitis B vaccination to all incarcerated persons.
(2) Organizations that serve high-risk populations should offer the vaccine.
(3) Efforts should be made to improve identification of at-risk adults.
(4) Efforts should be made to increase rates of completion of the vaccine series in adults.
(5) Government agencies should annually determine gaps in hepatitis B vaccine coverage among at-risk adults and estimate the resources needed to fill those gaps.
Viral Hepatitis Services.
At the federal, state, and local levels, health services related to viral hepatitis prevention, risk-factor screening and serologic testing, and medical management are both sparse and fragmented. The committee believes that a coordinated approach is necessary. Comprehensive viral hepatitis services should have five core components: outreach and awareness; prevention of new infections; identification of infected people; social and peer support; and medical management of infected people. The committee identified major deficiencies in viral hepatitis services and made recommendations to address the deficiencies for different populations and healthcare venues.
For the general population:
Federally funded health-insurance programs - such as Medicare, Medicaid, and the Federal Employees Health Benefits Program - should incorporate guidelines for risk-factor screening for hepatitis B and hepatitis C as a required core component of preventive care so that at-risk people receive serologic testing for HBV and HCV and chronically infected patients receive appropriate medical management.
For foreign-born populations:
The CDC, in conjunction with other government agencies, should provide resources for the expansion of community-based programs that provide hepatitis B screening, testing, and vaccination services that target foreign-born populations.
For illicit-drug users:
Government agencies should expand programs to reduce the risk of HCV infection through IDU by providing comprehensive HCV prevention programs. The programs should include access to sterile needle syringes and drug-preparation equipment because the shared use of these materials has been shown to lead to transmission of HCV.
In addition,
Federal and state governments should expand services to reduce the harm caused by chronic hepatitis B and hepatitis C. The services should include testing to detect infection, counseling to reduce alcohol use and secondary transmission, hepatitis B vaccination, and referral for or provision of medical management.
For pregnant women:
The CDC should provide additional resources and guidance to perinatal hepatitis B prevention program coordinators to expand and enhance the capacity to identify chronically infected pregnant women and provide case-management services, including referral for appropriate medical management.
For incarcerated populations:
The CDC and the Department of Justice should create an initiative to foster partnerships between health departments and corrections systems to ensure the availability of comprehensive viral hepatitis services for incarcerated people.
For community health centers:
The Health Resources and Services Administration should provide adequate resources to federally funded community health facilities for provision of comprehensive viral hepatitis services.
For other settings that target at-risk populations, such as sexually transmitted disease and HIV clinics, shelter-based programs, and mobile health units:
The Health Resources and Services Administration and CDC should provide resources and guidance to integrate comprehensive viral hepatitis services into those settings that serve high-risk populations.
Discussion
The IOM committee believes that implementation of these and other recommendations in its report would lead to reductions in new HBV and HCV infections, fewer medical complications and deaths as a result of these viral infections of the liver, and lower total health costs. Advances will be needed: in knowledge and awareness about chronic viral hepatitis, in improvement of hepatitis B vaccine coverage, in improvement and better integration of viral hepatitis services, and in improvement of estimates of the burden of disease for resource-allocation purposes.
Acknowledgements
The authors thank the members of the IOM's Committee on Prevention and Control of Viral Hepatitis Infections: Harvey J. Alter, Margaret L. Brandeau, Daniel R. Church, Alison A. Evans, Holly Hagan, Sandral Hullett, Stacene R. Maroushek, Randall R. Mayer, Brian J. McMahon, Martin Jose Sepulveda, Samuel So, David L. Thomas, and Lester N. Wright.
References
1 Centers for Disease Control and Prevention. Viral hepatitis: statistics and surveillance. http://www.cdc.gov/hepatitis/statistics.htm. Accessed January 2010.
2 Lin SY, Chang ET, So SK. Why we should routinely screen Asian American adults for hepatitis B: a cross-sectional study of Asians in California. HEPATOLOGY 2007; 46: 1034-1040. Links
3 Hagan H, Campbell J, Thiede H, Strathdee S, Ouellet L, Kapadia F, et al. Self-reported hepatitis C virus antibody status and risk behavior in young injectors. Public Health Rep 2006; 121: 710-719. Links
4 Daniels D, Grytdal S, Wasley A. Surveillance for acute viral hepatitis - United States, 2007. MMWR Surveill Summ 2009; 58: 1-27. Links
5 Ward JW. Time for renewed commitment to viral hepatitis prevention. Am J Public Health 2008; 98: 779-781. Links
6 Amon JJ, Garfein RS, Ahdieh-Grant L, Armstrong GL, Ouellet LJ, Latka MH, et al. Prevalence of hepatitis C virus infection among injection drug users in the United States, 1994-2004. Clin Infect Dis 2008; 46: 1852-1858. Links
7 Hagan H, Pouget ER, Des Jarlais DC, Lelutiu-Weinberger C. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place. Am J Epidemiol 2008; 168: 1099-1109. Links
8 IOM. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: National Academies Press; 2010.
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