Case Finding for Hepatitis B and Hepatitis C

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1 Case Finding for Hepatitis B and Hepatitis C John W. Ward, M.D. Division of Viral Hepatitis Centers for Disease Control and Prevention Atlanta, Georgia, USA Division of Viral Hepatitis National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention

2 Role of Case Finding Primary prevention of transmission Secondary prevention of disease and mortality Policy and planning Public health surveillance and program evaluation

3 Not All Prevention Interventions Require Knowledge of Serostatus Hepatitis B vaccination Blood donor recruitment (e.g., voluntary donors) Universal practices for infection control Safer sex practices Harm reduction/drug treatment

4 Primary Prevention of Transmission Improved by Case Finding Maternal HBsAg testing improves perinatal HBV prevention HBIG/HepB superior to vaccine alone (RR 0.08 vs. 0.28) Anti-viral prophylaxis for mothers with high viral load (i.e., > 6 log 10 HBV copies/ml) HCV therapy to cure infection and prevent transmission Other Vaccination of household contacts (50% risk of HBV infection) Screen blood/tissue/organ donors (HBsAg, anti-hcv, PCR testing) Enhance infection control (e.g., HBsAg testing of patients on dialysis) Enhance harm reduction (behavior change) C Lee, BMJ 2006; H Zhang Hepatology 2014; CDC.gov/Hepatitis

5 Outcomes of Infants Born to HBsAg+ Women United States % 100% 80% 89%% 95% 96% 60% 40% 20% 0% Total Foreign born HepB <12 hrs.95% HBIG <12 hrs. 1% HBsAg+ infants 17, 951 mother infant pairs; 11,,335 with data for HBIG/HepB status; 100 HBsAg+ infants S Schillie, Pediatrics 2015

6 Anti-viral Therapy Can Reduce HCV Prevalence and Incidence Among Persons Who Inject Drugs Martin, N et al. Hepatology epub March 2013.

7 Case Finding for (Secondary) Prevention of Morbidity and Mortality Testing and counseling Risks of disease Liver protection ( e.g., alcohol avoidance/cessation) Linkage to care and treatment Manage co- factors of disease e.g., alcohol use, HIV, obesity, Hep A vaccination Assess stage of liver disease and monitor for liver cancer Therapy to suppress virus replication or cure infection

8 Benefits of HBV Case Finding : Therapy Lowers Risk of Liver Cancer US cohort observed for 5 years 50% reduction in liver cancer with HBV therapy (median 45 mos.) 83% reduction for persons with viral load >20,000 IU/mL Studies in Asian countries 56%-78% reduction in risk Benefit for patients with and without cirrhosis Greatest benefit with nucleoside/nucleotide analog treatment * Lai, Hepatology, 2013; Gordon, Clin Gastro Hepatol 2014

9 Benefits of HCV Case Finding: Curative Therapies Reduce Morbidity/Mortality 50%- 74% reduction in all cause mortality 75% reduction in liver cancer 93% reduction in liver failure 93% reduction in liver related mortality * van der Meer JAMA 2012, Morgan Ann Int Med 2012

10 Knowledge of HCV Status is Low United States Journal of Viral Hepatitis pages 1-5, 5 JAN 2015 DOI: /jvh

11 Impact of More Effective HCV Therapy Alone or with Expanded Testing Deuffic-Burban, Gastroenterology 2012

12 U.S. Viral Hepatitis Action Plan Priorities EDUCATING PROVIDERS AND COMMUNITIES TO REDUCE HEALTH DISPARITIES IMPROVING TESTING, CARE, AND TREATMENT TO PREVENT LIVER DISEASE AND CANCER STRENGTHENING SURVEILLANCE TO DETECT VIRAL HEPATITIS TRANSMISSION AND DISEASE ELIMINATING TRANSMISSION OF VACCINE- PREVENTABLE VIRAL HEPATITIS REDUCING VIRAL HEPATITIS CASES CAUSED BY DRUG-USE BEHAVIORS PROTECTING PATIENTS AND WORKERS FROM HEALTH-CARE-ASSOCIATED VIRAL HEPATITIS

13 National Policies for HBV and HCV Testing HBV testing June 2014 Foreign born- persons from Asia, Africa ( countries > 2% prevalence) MSM, IDU For populations > 2% HBsAg+ $31,600/QALY HCV testing - June 2013 Persons born one time Persons who inject drugs Others (e.g., transfusion <1992) Birth cohort testing- $ 31-35,000/QALY MMWR Aug Moyer VA, Ann Int Med ; 3 Eckman, MH, CID 2011:52, Rein CID 2015

14 Most New Reports of HBV in the United States Are Among the Foreign Born Global Burden of HBV Disease HBsAg+ Persons Reported by Place of Birth,

15 Number of cases Proportion Anti-HCV-Positive, % Twin Epidemics of HCV Transmission and Disease Rising Number of New Acute HCV Cases related to injection drug use 3,500 HCV seroprevalence highest for persons born ,000 2, ,000 1,500 1, Year of Birth Year

16 Educating Providers and Communities

17 01/01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/2014 HCV Antibody Test Volume Increased after Electronic Medical Record (EMR) Prompt Persons Born EMR prompt CDC testing guidelines Average = 438 Average = 303 tests/4 weeks tests/4 weeks Average = 1192 tests/4 weeks Boomers Beth Israel Deaconess Medical Center, Boston, MA, Quality Outcomes Data, 6/5/14

18 Algorithms to Guide Quality Testing for Current Infection HBV: HBsAg HCV: Antibody + PCR testing 50% of HCV Ab+ persons do not receive second test A single test would improve access

19 HCV Core Ag Utility of HCV Core Antigen as a Single Test to Detect Current HCV Infection 551 serum/plasma samples Anti-HCV - /HCV RNA + r=0.959, p<0.001 Sensitivity: 100% Anti-HCV + / HCV RNA + HCV RNA Sensitivity 94.3% Mix son-hayden et al J Clin Virol

20 Rate per 1,000 Quest patients Monitor Implementation Trends in HCV Testing by Birth Cohort % of tests ordered in primary care Anti-HCV + 8.7% +41% Pre CDC USPSTF Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q Quest Laboratories, unpublished data

21 Implementation Research HBV Testing and Linkage to Care Nine Community Sites, ,144 tested, 1,317 (5.7%) HBsAg-positive 100% 80% 90% 85% 83% 60% 40% 46% 20% 0% Received Results Post-Test Counseling Referred to Medical Care Attended First Medical Appointment CDC, 2015, unpublished

22 Case Finding for HBV and HCV Summary Prevention of transmission and disease Public health case surveillance Evidence for policy development Monitoring and evaluation data

23 HBV and HCV Case Finding Case finding is dependent on testing Many if not most persons are unaware of their infection Strategies to improve access to testing Planning Education of providers and public Health system change Delivery of services where persons receive care Simplification of testing, care, and treatment

24 Potential Impact on Future Burden of Hepatitis C Related Mortality in the US % test and treat 25% test and treat 50% test and treat 75% test and treat No Testing treat 15% treat 25% treat 50% treat 75% 24

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