26/09/2014. Types of Viral Hepatitis. Prevention of Viral Hepatitis as a Health Disparity for American Indians: Successes and Challenges

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1 Rate per, Types of Viral Hepatitis A E B D C Prevention of Viral Hepatitis as a Health Disparity for American Indians: Successes and Challenges Source of virus Feces Feces Blood/bloodderived body fluids derived body Blood/blood- (blood rarely) fluids; requires HBV Route of Fecal-oral Fecal-oral Percutaneous Percutaneous transmission permucosal permucosal Blood/bloodderived body fluids Percutaneous permucosal Chronic No Yes- immuno- Yes Yes Yes infection compromised John W. Ward, M.D. Division of Viral Hepatitis Centers for Disease Control and Prevention Severity Acute disease severity increases with pre-existing liver disease and age at infection Most infections are cllinically silent; can cause liver failure Mortality risk 1-% of chronically infected develop chronic liver disease, including cirrhosis, liver -7% of Co-infection can chronically increase disease infected develop severity; liver disease; Superinfection can 1-% will die from accelerate cirrhosis or liver highest for failure, or liver progression to cancer pregnant women cancer cirrhosis and (-%) hepatitic decompensation Division of Viral Hepatitis National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention American Indians and Alaskan Natives in The United States. M identify as AI/AN in the US; 1.7% of US pop..9 M AI/AN alone (.9%).3M with another race (.%) Comprise 1 tribes ~% live in states Alaska, Arizona, California, New Mexico, Oklahoma, Texas Indian Health Service is a major health care provider Chronic Liver is a Health Disparity for American Indian / Alaskan Natives th leading cause of death; 11 th for white Americans 7% of all deaths Increased mortality risk fold increase overall; 7 fold increase for persons - years Regional variation 9% of mortality related to cirrhosis Attributable cause Alcohol abuse- % HCV 11% HBV- 1% Combination of above- 3% Suryprasad A, et al AJPH 1 Chronic Liver Disease Mortality Increased % for American Indian compared to 1% for Whites REPORTED CASES OF HEPATITIS A, UNITED STATES, Source: NNDSS, CDC Suryprasad A et al, AJPH 1. 1

2 Reported cases per, population 199 ' '9 '9 199 ' '9 199 ' ' 199 ' Incidence of hepatitis A by County, Reports of Hepatitis A in the Pre- Hepatitis A Vaccine Era Source: CDC. MMWR 199;(No. RR-1):1--3. United States: Incremental Recommendations for Hepatitis A Vaccination of Children Children living in communities with the highest disease rates Persons at high risk for infection Children living in states and communities with consistently elevated rates during baseline period 17 primarily Western and Southwestern states Approximately one third of US population Nationwide 1-3 month old cohort Hepatitis A incidence based on passive reporting All ages *Per, population 7 Rate* 9 19 > NYC DC NNDSS, CDC unpublished Impact of Policy Changes on Hepatitis A Vaccination in Arizona Arizona had highest incidence of hepatitis A- 199 American Indians (AI) represent % of the population Policies 199- Vaccinate all AI children -1 yrs Vaccine required to enter child care in largest county (Maricopa) Vaccinate all children > years Lower vaccination age to 1 months Impact 199: 11 fold increase in hepatitis A vaccination of AI children 199: 3 fold increase in Maricopa; 1.3 fold increase for AI 1999:. fold increase state wide; 1.3 fold in AI : fold increase statewide; fold for AI Older AI children had the highest hepa vaccination coverage Incidence of Reported Hepatitis A, by Race and Ethnicity, United States, American Indian/Alaskan Native Asian/Pacific Islander Black (non Hispanic) Hispanic White (non Hispanic) Ernst KC, et al Pub Hlth Rep 11

3 Cases/, population Infectious-Disease Outbreaks among American Indians and Alaska Natives, 19. % Decrease in Hepatitis A related Hospitalization for AI/AN Overall Male Female - yrs Cheek JE, et al Am J Epidemiology 11. Byrd KK, et al Pub Hlth Rep 11 Routine Vaccination Coverage for American Indian/ Alaskan Native Children Coverage among AI/AN children similar to or better than White Children Groom AV, et al Pediatrics, 1 Advisory Committee on Immunization Practices Vaccine-based Strategy to Eliminate HBV Transmission in U.S. Maternal HBsAg testing, if HBsAg+ HBIG*/ HepB vaccine birth dose <1 hours of birth Universal infant vaccination- three dose series (1991) Catch up vaccination adolescents 11-1 years (199) all persons <19 years (1999) Universal birth dose () Universal vaccination in settings serving adults at high risk () *HBIG: Hepatitis B immunoglobulin 1 1 Hepatitis B Vaccine Policy and Rates of Acute Hepatitis B, U.S.,19-11 High-risk groups,* 19 Universal maternal HBsAg testing 19 Infants of HBsAg-positive women, 19 All US infants, 1991 Ages -1 years, 1999 Birth dose, Adults < years with Diabetes *Health care providers, MSM, IDU, hemodialysis patients, household & sexual partners of persons with chronic HBV, persons in certain institutional settings, e.g, inmates of long-term correctional facilities. Source: National Notifiable Disease Surveillance System (NNDSS) 1 3

4 Cases/, Hepatitis B Incidence Among Persons 19 Yrs By Race/Ethnicity, 199- Black 1 No Significant Change in Hepatitis B related Hospitalization for AI/AN Asian/Pacific Islander 1 AI/AN Hispanic White Overall Male Female - yrs Byrd KK, et al Pub Hlth Rep 11 Recommendations for Identification and Management of Persons with Chronic HBV Infection Testing recommendations 1 Populations with > % prev) Foreign born- (e.g. Asia, Africa) MSM, IDU HIV Candidates for immunosuppression therapy Management guidance Patient counseling Contact management Referral for care and treatment Screening and treatment cost effective ($9,3/QALY ) USPSTF Grade B- 1 % % 3% 3% % % 1% % % % Hepatitis B Testing and Infection 3% Testing Infection 39% % 39% 3% 13% % % % 3% Total API Blacks Hispanics AI/AN 1 MMWR ; 7 (No. RR-):1-; Eckman, MH, CID 11: Hu DJ, et al Hepatology 13 Education level Black Hispanic Asian AI/ AN < high -school 9.3%.%.7%.3% High-school.1%.3% 3.9% 1.9% Some college 1.% 9.%.% 1.3% College graduate.7% 1.1% 39.% 3.% Annual HH income <$,.1% 3.3%.3% 19.1% $, $9,999 7.%.%.% 7.% $, $7,999 1.% 11.% 39.% 1.3% $7, 1.% 1.3% 3.% 3.% Health insurance Seeing a Physician for Hepatitis B by Socio-Economic Factors Yes.% 3.%.%.% No 19.%.9%.7% 1.% Hu DJ, et al Hepatology 13 Prevalence of Current HCV Infection Among Persons in the United States Prevalence Civilian, Non-Institutionalized Populations (NHANES) Estimated HCV Infection Among Homeless and Incarcerated Persons (Not Included in NHANES) Denniston M, Ann Int Med 1. Chak E, Liver Int million (.-3. million) 1.% (.%-1.%) 3,-, %-%

5 Reported cases/, population Proportion Anti-HCV-Positive, % Proportion Anti-HCV-Positive, % Two of Three Americans Living with HCV Were Born During Reflects historical high HCV incidence The Birth Cohort For individuals born during 19 to 19 Five-fold higher prevalence than other US adults (3.39% vs.%) Of all HCV infected US adults 1% were born in this cohort Of all HCV-related mortality in US, 73% were born in this cohort Age at Time of Survey, y of Birth Smith, AASLD Liver Meeting 11. Armstrong, Ann Int Med. Kramer, Hepatology 11. Ly, Ann Int Med A 3% Increase in Hepatitis C related Hospitalization for AI/AN Overall Male Female - yrs Byrd KK, et al Pub Hlth Rep 11 HCV Related Mortality by Race/Ethnicity- 7 compared to 11 Recent Increases in HCV Infection 1 Between 7 and states reported increases 1 states had > % increase % of cases < 3 yrs. AI/AN Black Hispanic White PWID: Persons who inject drugs. Byrd KK, et al Pub Hlth Rep 11 Suryprasad AG, et al. CID 1 USPSTF* and CDC Recommendations for HCV Testing 1. American Indian/Alaskan Native 1. Asian/Pacific Islander 1 Black White. Hispanic... Source: National Notifiable Diseases Surveillance System (NNDSS) One time screening test for persons born without ascertainment of risk (USPSTF Grade B) Major risk Past or present injection drug use Other risks Received blood/organs prior to June 199 Received blood products made prior to 197 Ever on chronic hemodialysis Infants born to HCV infected mothers Intranasal drug use Unregulated tattoo History of incarceration Medical Persistently elevated ALT HIV * US Preventive Services task Force. Updated recommendation for screening June 13 MMWR Aug 1.; Moyer VA, Ann Int Med 13. *

6 HCV Screening for American Indians Clinic-based screening 3 patients in Omaha Nebraska; 3 tribes 11.% anti-hcv positive Risks included use of cocaine and injected drugs Screening of pregnant women pregnant women in northern plains (median age years) % anti-hcv positive Injection drug use only risk factor Screening of persons born % of cohort screened by HIS; 7% increase in testing HCV testing data pending HCV Test, Care, and Cure Continuum, United States % 9% % 7% % % % 3% % % % ~ 3 million persons living with HCV 1. M (%) 1. M (3%) 7, (3%) 3, (11%), (%) Neumeister AS, et al J Natl Med Assoc, 7; Dubray C, J Health Disparities Research and Practice 11 Holmberg S, et al, NEJM, 13 (Note: analysis based on data from NHANES [3, adults osurveyed during 1-,]. and chronic hepatitis cohort study [1. million persons seen at four large health care organization in US cities during -]) Extension for Community Health care Outcomes (ECHO) Expand Primary care capacity in HCV management Rural and underserved populations Use videoconferencing Share best practices Case based learning Similar cure rates to those in HCV clinics Conclusions Liver Disease is a major health disparity for American Indians/ Alaskan Natives This population is at increased risk for viral hepatitis Hepatitis A and B vaccination-based strategies have reduced incidence and hepatitis A disease Hepatitis is a large and cause of morbidity and mortality Comprehensive strategies are needed to Reduce high risk behaviors (e.g, alcohol and drug use) Expand access to harm reduction and drug treatment Improve the quality of HBV and HCV testing with linkages to recommended care and treatment N Engl J Med 11;3: U.S. Viral Hepatitis Action Plan (Updated 1-1) Contributors A nation committed to combating the silent epidemic of viral hepatitis Vision of the Action Plan for the Prevention, Care and Treatment of Viral Hepatitis CDC Kathleen Ly Indian Health Service Lisa Neal Amy Groom 3

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