1
Introduction

The global epidemic of hepatitis B and hepatitis C is a serious public-health problem. Using mortality data from 2003, Weiss and McMichael (2004) ranked the public-health importance of various infectious diseases and other conditions (see Figure 1-1). Those data underscore that chronic hepatitis B and hepatitis C are among the leading causes of preventable death worldwide.

Hepatitis B and hepatitis C are contagious liver diseases caused by the hepatitis B virus (HBV) and the hepatitis C virus (HCV), respectively. HBV is a 42-nanometer, partially double-stranded DNA virus classified in the Hepadnaviridae family; there are eight major HBV genotypes. HCV is a 55-nanometer, enveloped, positive-strand RNA virus classified as a separate genus, Hepacavirus, in the Flaviviridae family; there are at least six major HCV genotypes.

Hepatitis B and hepatitis C can be either acute or chronic. The acute form is a short-term illness that occurs within the first 6 months after a person is exposed to HBV or HCV. The diseases can become chronic, although this does not always happen and, particularly in the case of hepatitis B, the likelihood of chronicity depends on a person’s age at the time of infection. Chronic hepatitis B and chronic hepatitis C are serious and can result in liver cirrhosis and a type of liver cancer, hepatocellular carcinoma (HCC). The prevention of chronic hepatitis B and chronic hepatitis C prevents the majority of HCC cases because HBV and HCV are the leading causes of this type of cancer. Key characteristics of hepatitis B and hepatitis C are summarized in Table 1-1 and discussed below and in later chapters.



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1 Introduction T he global epidemic of hepatitis B and hepatitis C is a serious public-health problem. Using mortality data from 2003, Weiss and McMichael (2004) ranked the public-health importance of various infectious diseases and other conditions (see Figure 1-1). Those data under- score that chronic hepatitis B and hepatitis C are among the leading causes of preventable death worldwide. Hepatitis B and hepatitis C are contagious liver diseases caused by the hepatitis B virus (HBV) and the hepatitis C virus (HCV), respectively. HBV is a 42-nanometer, partially double-stranded DNA virus classified in the Hepadnaviridae family; there are eight major HBV genotypes. HCV is a 55-nanometer, enveloped, positive-strand RNA virus classified as a separate genus, Hepacavirus, in the Flaviviridae family; there are at least six major HCV genotypes. Hepatitis B and hepatitis C can be either acute or chronic. The acute form is a short-term illness that occurs within the first 6 months after a per- son is exposed to HBV or HCV. The diseases can become chronic, although this does not always happen and, particularly in the case of hepatitis B, the likelihood of chronicity depends on a person’s age at the time of infection. Chronic hepatitis B and chronic hepatitis C are serious and can result in liver cirrhosis and a type of liver cancer, hepatocellular carcinoma (HCC). The prevention of chronic hepatitis B and chronic hepatitis C prevents the majority of HCC cases because HBV and HCV are the leading causes of this type of cancer. Key characteristics of hepatitis B and hepatitis C are summarized in Table 1-1 and discussed below and in later chapters. 

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0 HEPATITIS AND LIVER CANCER Caused by viruses Other causes 7 Tobacco HIV Malaria HBV + HCV Road accidents 6 Non-HIV TB Measles RSV, Rota Flu 5 Dengue Log10 global death rate Hospital infection HPV 4 Suicide West Nile 3 SARS Ebola Polio 2 Hanta vCJD 1 FIGuRE 1-1 Approximate global preventable death rate from selected infectious diseases and other causes, 2003. Abbreviations: HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus; RSV, respiratory syncytial Hepatitis human papilloma vi- Figure 1-1 virus; HPV, R01623 rus; SARS, severe acute respiratory syndrome; TB, tuberculosis; vCJD, variant Creutzfeldt-Jakob disease. vector editable SOURCE: Weiss and McMichael, 2004. Reprinted with permission from Macmillan Publishers Ltd: Nature Medicine 10(12 Suppl):S70-S76, copyright 2004.

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 INTRODUCTION TABLE 1-1 Key Characteristics of Hepatitis B and Hepatitis C Hepatitis B Hepatitis C Causative agent Partially double-stranded DNA Enveloped, positive-strand RNA virus virus Hepadnaviridae family Hepacavirus genus, Flaviviridae family Statistics In the United States, 0.8–1.4 In the United States, 2.7–3.9 million people are chronically million people are chronically infected with HBV infected with HCV Routes of Contact with infectious blood, Contact with blood of an infected transmission semen, and other body fluids, person, primarily through: • Sharing of contaminated primarily through: • Birth to an infected mother needles, syringes, or other • Sexual contact with an injection-drug equipment infected person • Sharing of contaminated Less commonly through: • Sexual contact with an infected needles, syringes, or other injection-drug equipment person • Birth to an infected mother • Contact with infectious blood Less commonly through: • Contact with infectious through medical procedures blood through medical procedures • Persons born in geographic • Persons who have ever injected Persons at risk regions that have HBsAg illegal drugs, including those prevalence of at least 2% who injected only once many • Infants born to infected years ago • Recipients of clotting-factor mothers • Household contacts of concentrates made before 1987 • Recipients of blood transfusions persons who have chronic HBV infection or solid-organ transplants • Sex partners of infected before July 1992 • Patients who have ever received persons • Injection-drug users long-term hemodialysis • Sexually active persons treatment • Persons who have known who are not in long-term, mutually monogamous exposures to HCV, such as relationships (for example, health-care workers after more than one sex partner needlesticks involving HCV- during previous 6 months) positive blood and recipients of • Men who have sex with men blood or organs from donors who later tested HCV-positive • All persons who have HIV infection continued

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 HEPATITIS AND LIVER CANCER TABLE 1-1 Continued Hepatitis B Hepatitis C • Health-care and public- • Patients who have signs or Persons at risk safety workers at risk for symptoms of liver disease (for occupational exposure to example, abnormal liver-enzyme blood or blood-contaminated tests) • Children born to HCV-positive body fluids • Residents and staff of mothers (to avoid detecting facilities for developmentally maternal antibody, these disabled persons children should not be tested • Persons who have chronic before the age of 18 months) liver disease • Hemodialysis patients • Travelers to countries that have intermediate or high prevalence of HBV infection Potential for Among newly infected, 75–85% of newly infected persons chronic infection unimmunized persons, chronic develop chronic infection infection occurs in: • >90% of infants • 25–50% of children aged 1–5 years • 6–10% of older children and adults • 15–25% of chronically • 60–70% of chronically infected Clinical outcomes infected persons will die from persons develop chronic liver cirrhosis, liver failure, or disease • 5–20% develop cirrhosis over a hepatocellular carcinoma • 3,000 deaths each year are period of 20–30 years • 1–5% will die from cirrhosis or due to hepatitis B-related liver disease in the United hepatocellular carcinoma • 12,000 deaths each year are States due to hepatitis C-related liver disease in the United States Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HBsAg, hepatitis B surface antigen. SOURCE: Adapted from CDC, 2009a. PREvALENCE AND INCIDENCE OF HEPATITIS B AND HEPATITIS C WORLDWIDE Worldwide, about 1 in 12 persons (480–520 million people) are chroni- cally infected with HBV or HCV (Lavanchy, 2008; WHO, 2009). An estimated 78% of cases of primary liver cancer (HCC) and 57% of cases

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 INTRODUCTION of liver cirrhosis are caused by chronic HBV or HCV infection (Perz et al., 2006). Chronic liver disease due to coinfection with HBV or HCV has become a major cause of death in persons infected with HIV (Sulkowski, 2008), and coinfection presents additional treatment challenges (Kumar et al., 2008). It is estimated that HBV and HCV infections cause nearly a million deaths each year (Perz et al., 2006). Chronic viral hepatitis is a silent killer. Without testing for infection, many chronically infected persons are not aware that they have been in- fected until symptoms of advanced liver disease appear. Advanced liver cancer has a 5-year survival rate of below 5% (American Cancer Society, 2009). Although much progress has been made in reducing the morbidity and mortality through effective treatment of chronic viral hepatitis, there is no global program to provide chronically infected persons with access to affordable treatment. HBV is 50–100 times more infectious than HIV (WHO, 2009). Acute HBV infection in adults, although often asymptomatic, can cause severe ill- ness and is associated with a 0.5–1% risk of death from liver failure (CDC, 2007). Chronic HBV infection, which occurs when the acute infection is not cleared by the immune system, is associated with a 15–25% risk of prema- ture death from liver cancer or end-stage liver disease (Beasley and Hwang, 1991; WHO, 2009). The World Health Organization (WHO) estimates that up to 2 billion people worldwide have been infected with HBV; about 350 million people live with chronic HBV infection, and about 600,000 people die from HBV-related liver disease or HCC each year (WHO, 2009). The major transmission routes and prevalence of chronic HBV infec- tion vary by age and geography. Primary HBV infection acquired at an early age (through vertical transmission from an infected mother to her newborn or horizontal transmission during early childhood) is associ- ated with the highest risk of chronic infection and is common in people born in or residing in the highly endemic countries of the western Pacific region, Asia, and sub-Saharan Africa (Shepard et al., 2006). In countries with a low prevalence of HBV carriers, primary infection usually occurs during adolescence or young adulthood as a result of unsafe injections and unprotected sexual activity. An estimated 21 million new HBV infections each year are due to unsafe injections in health-care settings (Hauri et al., 2004). Hepatitis B is also a major basis for social injustice in some endemic countries. For example, myths and misinformation about modes of HBV transmission have resulted in widespread discrimination against chronically infected persons in some endemic countries, such as China, the country with the world’s largest population of chronically infected people, who are not allowed to work in the food industry, are often required to undergo routine pre-employment HBV testing, and can be expelled from school or work because of a positive test (The Economist, 2006).

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 HEPATITIS AND LIVER CANCER An estimated 130–170 million people live with chronic HCV infection worldwide, and an estimated 350,000 die of HCV-related liver disease each year (Perz et al., 2006). There are about 2.3–4.7 million new HCV infections each year from nosocomial transmission alone (Lavanchy, 2009). Unsafe mass immunization has led to exceedingly high HCV prevalence in some areas, such as Egypt, where 14–20% of the population has HCV anti- bodies (Frank et al., 2000; Lavanchy, 2008). In most populations in Africa, North America, South America, Europe, and Southeast Asia, the prevalence in the general population is less than 3% (Lavanchy, 2008). HCV is efficiently transmitted via direct percutaneous exposure to in- fectious blood. Hepatitis C became a global epidemic in the 20th century as blood transfusions, hemodialysis, and the use of injection needles to admin- ister licit and illicit drugs increased throughout the world (Drucker et al., 2001; Pybus et al., 2007). For example, the extremely high prevalence of HCV in Egypt is due to a schistosomiasis-eradication campaign that began in the 1960s, when more than 35 million injections were administered to about 6 million Egyptians (Deuffic-Burban et al., 2006; Frank et al., 2000; Lehman and Wilson, 2009). The identification of the virus in 1989 led to measures to reduce health-care–related exposure to HCV, particularly in industrialized nations. However, more than six billion unsafe injections are given worldwide each year (Hutin et al., 2003). With the reduction in health-care–related exposures to HCV and the recent introduction of the practice of illicit-drug injection in new regions of the world, HCV infection through injection-drug use has become the major source of exposure to HCV worldwide. Explosive increases in HCV infection have occurred in regions of Asia and central and eastern Europe because of poor access to sterile injection equipment and lack of drug treatment. A recent meta-analysis reported that HCV prevalence was 84% in injection-drug users (IDUs) surveyed in the Guangxi region bordering the Golden Triangle in China (Xia et al., 2008). In that region, drug use is highly stigmatized, which reduces community support for prevention ef- forts and inhibits IDUs’ access to prevention services. Antiviral treatments for chronic HBV and HCV infections can effectively reduce the associated morbidity and mortality from liver disease. However, access to treatment is often limited by high costs of care and by the asymptomatic nature of chronic HBV and HCV infections. Therefore, many infected people are not identified in time to benefit from antiviral treatment. Global eradication or elimination of new HBV infections is plausible because the infections can be prevented with the hepatitis B vaccine. No vaccine to prevent hepatitis C has been licensed. Given the limitations of the scope of the committee’s work, it did not assess global prevention and control efforts for hepatitis B and hepatitis C and did not consider the in- ternational effects of its recommendations.

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 INTRODUCTION PREvALENCE AND INCIDENCE OF HEPATITIS B AND HEPATITIS C IN THE uNITED STATES HBV and HCV infections pose a major public-health problem in the United States and are major causes of chronic liver disease. Three to five times more people are living with chronic viral hepatitis infections than with HIV infection. Table 1-2 presents the burden of HBV, HCV, and HIV infections in the United States. The US Centers for Disease Control and Prevention (CDC) estimates that 3.5–5.3 million people in the United States—1–2% of the population—are living with chronic HBV or HCV infection—about 800,000 to 1.4 million people with chronic hepatitis B and an additional 2.7–3.9 million people with chronic hepatitis C (CDC, 2009d). However, an accurate estimate is difficult to obtain because there is no national chronic-hepatitis surveillance program. Each year, about 15,000 deaths are caused by HBV- or HCV-associated liver cancer or end- stage liver disease (CDC, 2009d). Almost half the liver transplantations in the United States are necessitated by end-stage liver disease associated with HBV or HCV infection (Kim et al., 2009). The annual costs of HBV and HCV infections are difficult to determine. The direct medical cost associated with HBV infection has been estimated at $5.8 million based on the number of new cases in 2000 among persons 5–24 years old (Chesson et al., 2004). An estimated $1.8 billion in medical care costs was associated with HCV infections in 1997 (Leigh et al., 2001). Indirect costs, such as lost productivity, add to the HCV-associated cost burden. Because of the aging of people now infected (including some people with asymptomatic infections who will become symptomatic), HCV-related illnesses, deaths, and costs are all expected to rise substantially during the next two decades (Pyenson et al., 2009; Wong et al., 2000). Hepatitis B The national strategy for preventing new HBV infection in infants and children—including routine screening of pregnant women for hepatitis B surface antigen (a blood marker for chronic HBV infection), universal infant hepatitis B immunization, and catchup vaccination of unvaccinated children and adolescents—has resulted in a dramatic reduction in chronic HBV infection in infants and acute HBV infection in children of all eth- nicities (CDC, 2004; Mast et al., 2005, 2006). Despite those achievements, the goal of eliminating perinatal HBV transmission has not been achieved, largely because coverage of newborns with a birth dose of hepatitis B vac- cine is incomplete (CDC, 2008c). As a result, CDC estimates that each year about 1,000 newborns develop chronic HBV infection, which puts them at risk for premature death from HBV-related liver disease (Ward, 2008b).

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 TABLE 1-2 Burden of Selected Serious Chronic Viral Infections in the United States Percentage of Population unaware Deaths in 2006 Percentage of CDC of Infection Related to vaccine- Transmission NCHHSTP FY 2008 virus Prevalencea,b Statusc,d,e Infectiona,b Preventable Routes Budgetf HBV 0.8–1.4 million About 65% 3,000 Yes Birth, blood, sex 2% combined HCV 2.7–3.9 million About 75% 12,000 No Birth, blood, sex HIV/AIDS 1.1 million About 21% 14,016 No Birth, blood, sex 69% (domestic activities) Abbreviations: CDC NCHHSTP, Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV/AIDS, human immunodeficiency virus/acquired immu- nodeficiency syndrome. SOURCES: aCDC, 2009b; bCDC, 2009d; cLin et al., 2007; dHagan et al., 2006; eCDC, 2008b; fWard, 2008a.

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 INTRODUCTION Based upon surveillance data and modeling, CDC estimates that there has been an 82% decline in incidence of acute HBV infection since 1990 with the total number of new infections in 2007 estimated at 43,000 (Daniels et al., 2009). Because many children have been vaccinated against HBV, most reported cases of acute HBV infection are in adults. The national strategy for preventing HBV transmission in adults—by recommending hepatitis B vaccination selectively for high-risk adults (including men who have sex with men, IDUs, and correctional-facility inmates)—has had only little success in reducing the incidence of acute HBV infection in US adults (Mast et al., 2006). Acute HBV infections are often asymptomatic or have symptoms similar to those of other common illnesses, such as influenza, so there is a high probability of underreporting. In the United States, data on reported cases of acute HBV infection in 2007 indicate that the highest rate of infection is in non-Hispanic black men: 2.3 per 100,000. The incidence is substantially lower in other popu- lations: 0.9 per 100,000 Asians and Pacific Islanders (APIs) and 1.0 per 100,000 non-Hispanic whites and Hispanics. There also appear to be geo- graphic variations in incidence; the highest rates of acute HBV infection are in the South1 (Daniels et al., 2009). Although the incidence of acute HBV infection is declining in the United States, the number of people who are living with chronic HBV infection may be increasing as a result of immigration from highly endemic countries (that is, the hepatitis B surface antigen prevalence is ≥ 2%). On the basis of immigration patterns in the last decade, it is estimated that every year 40,000–45,000 people enter the United States legally from HBV-endemic countries (Mast et al., 2006; U.S. Department of Homeland Security, 2009). Some populations are at higher risk for chronic HBV infection, including API Americans, who make up only 4.5% of the general US population (U.S. Census Bureau, 2008) but account for more than 50% of Americans who are living with chronic HBV infection (CDC, 2009c). The prevalence of chronic HBV infection in API Americans is as high as 15% in some studies and constitutes an important health disparity (CDC, 2006). Having been born in an HBV-endemic country appears to be the major risk factor for chronic HBV infection in the API population (Lin et al., 2007). Recent studies suggest that routine HBV testing of all adult API Ameri- cans is cost-effective (Hutton et al., 2007), but almost two-thirds of chroni- cally infected API Americans are unaware of their infection status because they have not been tested for HBV (CDC, 2006; Lin et al., 2007). 1 CDC’s southern region includes Alabama, Arkansas, Delaware, the District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

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 HEPATITIS AND LIVER CANCER Hepatitis C Persons likely to have chronic HCV infection include those who re- ceived a blood transfusion before 1992 and past or current IDUs. US veterans who use the Department of Veterans Affairs (VA) health-care sys- tem have a higher prevalence of HCV infection (4–35%) than the general population (about 2%) (Cheung, 2000; Dominitz et al., 2005; Groom et al., 2008; Sloan et al., 2004), so VA has established a program to test all VA patients for HCV infection and to manage HCV-positive patients clinically (Kussman, 2007). As is the case with HBV infection, most patients who have acute or chronic HCV infection are asymptomatic, and their disease remains undiagnosed (Kamal, 2008). In the United States, most IDUs have serologic evidence of HCV in- fection, but the prevalence is highly variable. For example, in a study of young IDUs in four US cities, the prevalence of HCV antibody was 35% overall but varied from 14% in Chicago and 27% in Los Angeles to 51% in Baltimore and New York City (Amon et al., 2008). Prevalence is strongly associated with time engaged in risky behaviors, rising as the number of years of drug-injecting accumulates and reaching 65–90% in longer-term injectors (Hagan et al., 2008). HCV prevalence in IDUs in industrialized nations has fallen in recent years. For example, in IDUs injecting for less than 1 year, HCV prevalence fell from 46% before 1995 to 32% in a more recent period and in IDUs injecting for 5 years or more, prevalence fell from 67% before 1995 to 53% in the period after 1995 (Hagan et al., 2008). Most of the estimates of HCV incidence rates in IDUs in the United States have been between 15 and 30 per 100 person years at risk, with higher incidence found in recent-onset injectors (Garfein et al., 1998; Hagan et al., 2001, 2008; Hahn et al., 2002; Maher et al., 2006; Smyth et al., 2000; Thorpe et al., 2002). The prevalence of HCV infection in the incarcerated population has been reported to vary from 12% to 35% (Boutwell et al., 2005; Weinbaum et al., 2003). Although some HCV transmission occurs within correctional settings (Hunt and Saab, 2009; Macalino et al., 2004), the vast majority of HCV-infected inmates became infected by injection-drug use in the com- munity and not while incarcerated (Weinbaum et al., 2003). Although reporting of acute HCV infection does not accurately reflect the underlying incidence in the United States, the number of acute HCV infections peaked in the late 1980s and declined throughout the 1990s (Armstrong et al., 2006; Shepard et al., 2005). The decline observed in the 1990s may reflect changes in IDUs’ behavior and practices, including greater participation in needle-exchange programs (Wasley et al., 2008). It is consistent with results of studies summarized previously that suggest that HCV seroconversion rates in IDUs have declined since 1995 (Armstrong

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 INTRODUCTION et al., 2006; Shepard et al., 2005). The decline slowed and then leveled off starting in 2003, and there was a slight increase in reported acute cases in 2006 (Wasley et al., 2008). Interpretation of those trends is complicated, however, inasmuch as reporting is related to access to health care and di- agnosis of acute infection; many IDUs, who often have limited access to health care and no symptoms from infection, are not included in the trend analysis. LIvER CANCER AND LIvER DISEASE FROM CHRONIC HEPATITIS B vIRuS AND HEPATITIS C vIRuS INFECTIONS Both chronic HBV and HCV infections can lead to HCC, a type of liver cancer, and liver disease (But et al., 2008; McMahon, 2004, 2008; Tan et al., 2008). The two most important risk factors for HCC are chronic HBV and HCV infections. As stated above, an estimated 78% of HCC cases and 57% of liver cirrhosis cases are caused by chronic HBV and HCV infections (Perz et al., 2006). In the United States, an estimated 3,000 people die each year from HCC or chronic liver disease caused by HBV infection (CDC, 2008a). However, risks of those outcomes vary and are higher in men and in people who are older, ingest large amounts of alcohol, and are coinfected with HIV (McMahon, 2004; Pungpapong et al., 2007). Outcomes of HBV infections occur much more often in those with high blood concentrations of HBV DNA, in persons over 40 years old, and in persons infected with HBV genotype C (Chen et al., 2006; Dehesa-Violante and Nuñez-Nateras, 2007; McMahon, 2004; Pungpapong et al., 2007). There are an especially high prevalence of chronic HBV infection and a high risk of HCC in the API American population, who make up the largest pool of chronically infected persons in the United States and are most commonly infected with HBV genotype C (Chang et al., 2007). HCC incidence tripled in the United States from 1975 through 2005, and the highest incidence is in API Americans who immigrated to the United States (Altekruse et al., 2009). American Indian and Alaska Native peoples have been found to have the highest rate of liver-related death of ethnic groups in the United States (Vong and Bell, 2004). The age-specific rate of death in American Indian and Alaska Native peoples due to chronic liver disease is much higher than that in any other population and chronic HBV infection and increasing rates of chronic HCV infection play a large role (Vong and Bell, 2004). In the United States, about 12,000 people die from complications of chronic hepatitis C each year (CDC, 2008a). Deaths related to hepatitis C have increased; the highest number of deaths are in middle-aged men, non-Hispanic blacks, and American Indians (Wise et al., 2008). As is the case with chronic hepatitis B, complications occur more often in men and

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0 HEPATITIS AND LIVER CANCER in people who are older, have metabolic syndrome secondary to obesity, ingest large amounts of alcohol, and are coinfected with HIV (Ghany et al., 2009; Missiha et al., 2008; Pradat et al., 2007). There are also impor- tant ethnic and racial differences in the burden of chronic hepatitis C. The prevalence of HCV infection is higher in blacks than in whites (Armstrong et al., 2006; Thomas et al., 2000). Blacks also are less likely to respond to interferon-alpha-based treatment for chronic hepatitis C; this seems to be explained to a large extent by differences in DNA sequences near the interferon lambda 3 gene (Ge et al., 2009; Jeffers et al., 2004; Muir et al., 2004; Thomas et al., 2009). Likewise, there appears to be a greater burden of chronic hepatitis C and reduced response to treatment in Hispanic whites than in non-Hispanic whites (Armstrong et al., 2006; Bonacini et al., 2001; Rodriguez-Torres et al., 2009). In both Hispanics and blacks, HCC risk is increasing, in large part because of chronic hepatitis C (Altekruse et al., 2009). However, there is less evidence than in the case of HBV infection that different HCV genotypes or higher blood HCV concentrations increase the risk of long-term disease outcomes. Health-care use trends from 1994 to 2001 show a 20–30% yearly increase in HCV-related hospitalizations, length of hospital stays, total hospitalization costs, and hospital deaths (Grant et al., 2005). THE COMMITTEE’S TASK CDC has developed recommendations for the prevention and control of hepatitis B (Mast et al., 2005, 2006; Weinbaum et al., 2008) and hepatitis C (CDC, 1998, 2001). The National Institutes of Health (NIH) has developed consensus documents on the management of hepatitis B (NIH, 2008) and hepatitis C (NIH, 2002). WHO has published guidelines related to hepatitis B vaccination of children (WHO, 2001). A number of not-for-profit organi- zations have also worked to increase awareness of the diseases, educate the public about prevention, and advocate for those chronically infected with HBV and HCV. Although government and nongovernment efforts have led to a decline in the number of cases, chronic hepatitis B and hepatitis C continue to be serious public-health problems in the United States. For that reason, CDC in conjunction with the National Viral Hepatitis Roundtable, a not-for-profit coalition of public, private, and voluntary organizations; the Department of Health and Human Services Office of Minority Health; and VA sought guidance from the Institute of Medicine (IOM) in identi- fying missed opportunities related to the prevention and control of HBV and HCV infections. IOM was asked to focus on hepatitis B and hepatitis C because they are common in the United States and can lead to chronic disease. This report does not address hepatitis A virus, hepatitis E virus, or hepatitis D virus (also called the hepatitis delta virus) infections.

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 INTRODUCTION The specific charge to the committee follows: The IOM will form a committee to determine ways to reduce new HBV and HCV infections and the morbidity and mortality related to chronic viral hepatitis. The committee will assess current prevention and con- trol activities and identify priorities for research, policy, and action. The committee will highlight issues that warrant further investigations and opportunities for collaboration between private and public sectors. In conducting its work, the committee might want to consider: Strategies for preventing new HBV and HCV infections: • Improving vaccine coverage among vulnerable populations to reach national transmission elimination goals. • Increasing the proportion of persons aware of their chronic infection status. • Identifying barriers to the identification, counseling, and testing of persons at risk for chronic hepatitis, and ways they can be reduced and eliminated. • Promoting prevention among adolescents and adults who engage in risky behaviors, particularly those known to have screened positive for HCV and HBV infection. • Determining optimal ways to identify, develop, and implement preven- tion programs among at-risk populations. • Development of an effective HCV vaccine. Strategies for reducing morbidity and mortality from chronic HBV and HCV infections: • Providing appropriate medical referral, evaluation, and management of chronically infected persons. • Assessing health-care utilization and outcomes for persons with chronic infections, and opportunities for prevention and care to reduce health- care-related costs. • Reducing health disparities in morbidity and mortality from viral hepatitis. • Improving clinical surveillance of markers of disease progression and stage of hepatocellular carcinoma associated with chronic viral hepatitis and associated cirrhosis. Assess the type and quality of data needed from state and local viral hepa- titis surveillance systems to guide and evaluate prevention services: • Assess the role of acute disease surveillance in monitoring new infec- tions, detecting outbreaks, identifying vaccine failures and documenting the elimination of HBV transmission. • Assess the role of state and local chronic disease surveillance in describ- ing the burden of morbidity and mortality related to chronic hepatitis B and hepatitis C and related liver cirrhosis and cancer, the extent of

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 HEPATITIS AND LIVER CANCER ongoing risk behaviors, and the impact of HIV co-infection and other cofactors. • Assess the role of state and local disease registries in the delivery of prevention and care services for persons with chronic hepatitis B and persons with hepatitis C. • Assess the role of laboratory testing strategies for the identification of markers for acute HCV infection. • Assess laboratory testing strategies for identification of antiviral resis- tance for HBV and HCV. Finally, the committee should pay attention to addressing the special needs of specific subpopulations at high risk, such as Asian Americans, African Americans, and persons born in HBV-endemic countries. THE COMMITTEE’S APPROACH TO ITS TASK To address its charge, the committee first reviewed available evidence on a variety of topics related to the prevention of hepatitis B and hepatitis C, management of these diseases, and surveillance activities related to viral hepatitis. The evidence was drawn from the published literature and from open-session presentations by recognized experts in the field (see Appen- dix B). Oral testimony presented by members of the public during the open sessions was also taken into account. Additional information was obtained from written testimony submitted to the committee (available from the National Academies’ Public Access Records Office, publicac@nas.edu). A comprehensive review and evaluation of treatments for HBV and HCV infections (for example, which medications to use) is beyond the scope of this report. However, treatment information can be found in guide- lines published by the American Association for the Study of Liver Diseases (Ghany et al., 2009; Lok and McMahon, 2009) and in NIH consensus statements on the management of hepatitis B (NIH, 2008) and hepatitis C (NIH, 2002). The committee also has not been tasked with comprehensively review- ing information about the safety of the hepatitis B vaccine. Safety issues surrounding this vaccine were reviewed in the IOM report Immunization Safety Review: Hepatitis B Vaccine and Demyelinating Neurological Dis- orders (IOM, 2002). The committee that wrote that report concluded that the evidence favored rejection of a causal relationship between hepatitis B vaccine administered to adults and incident multiple sclerosis and multiple- sclerosis relapse. It also found the evidence inadequate for accepting or rejecting a causal relationship between hepatitis B vaccine and the first episode of a central nervous system demyelinating disorder, acute dissemi- nated encephalomyelitis, optic neuritis, transverse myelitis, Guillain-Barré syndrome, or brachial neuritis. IOM has undertaken another review of the

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 INTRODUCTION safety of the hepatitis B vaccine, and the findings are expected to be avail- able in 2011. The committee that wrote the present report met five times in the period December 2008–August 2009. During the meetings, the committee evalu- ated the evidence and deliberated on issues relevant to its charge. Types of evidence taken into consideration included international, federal, state, and community guidelines, programs, and other activities aimed at preventing new cases of HBV and HCV infection, identifying chronic cases of hepa- titis B and hepatitis C, and managing those cases. It also explored federal and state surveillance mechanisms for identifying and tracking hepatitis B and hepatitis C cases. The committee began by identifying problems with and gaps in the current prevention and control systems. It also examined model programs for other infectious diseases, such as those covered under the Ryan White CARE Act (Health Resources and Services Administration, 2009). The committee developed evidence-based recommendations to ad- dress the problems with the current systems to reduce the numbers of new HBV and HCV infections, to manage the care of chronically infected people more effectively by reducing morbidity and mortality, and to improve sur- veillance of chronic hepatitis B and hepatitis C cases. The committee focused on making recommendations that could be implemented with existing knowledge and available tools to advance pre- vention and control of chronic viral hepatitis in a timely manner. Although the committee recognizes the importance of basic research in this field, it believes that given the scope of the problem and the lack of available resources, its focus should be on improving prevention and control ser- vices. As a result, the committee did not address basic-research questions in the field extensively. Nor did it conduct cost–benefit analyses of its recommendations. The committee’s general approach is presented in Figure 1-2. After defining the scope of the problem and reviewing the available evidence, the committee identified the primary underlying factors that impede cur- rent efforts to prevent and control hepatitis B and hepatitis C. The com- mittee believes that a lack of awareness about viral hepatitis among both the general public and health-care and social-service providers is leading to continued high rates of morbidity and mortality from hepatitis B and hepatitis C. Consistent themes were found in all the materials reviewed by the committee; as a result, this report is organized according to four principal categories: • Improved disease surveillance (Chapter 2). • Improved knowledge and awareness on the part of health-care and social-service providers and the public (Chapter 3).

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• 0.8–1.4 million people are chronically inf cted with hepatitis B virus (HBV) in United States e  — 3,000 deaths each year are due to hepatitis B-related liver disease • 2.7–3.9 million people are chronically inf cted with hepatitis C virus (HCV) in United States e The Problem — 12,000 deaths each year are due to hepatitis C-related liver disease • Over 150,000 deaths due to hepatitis B and hepatitis C are projected to occur in next 10 years Lack of Public Awareness Lack of Provider Awareness Underlying issues Lack of Public Resource Allocation • At-risk people do not know that they are at risk or how to prevent becoming infected • At-risk people may not have access to preventive services • Chronically infected people do not know that they are infected Consequences • Many medical providers do not screen people or know how to manage those infected • Infected people often have inadequate access to testing and medical management • Inadequate disease-sur veillance systems underrepor t both acute and chronic infections Improved Disease Improved Provider and Integration and Enhancement Recommendations Surveillance Community Education of Viral Hepatitis Services • Screening is widely used as a par t of good primary care • At-risk people and communities actively seek testing, preventive services, and appropriate medical management • Better information leads to — Improved understanding of hepatitis B and hepatitis C Outcomes — More effective and targeted prevention programs — More research on effective vaccination and treatment options • Infected people have better health outcomes • Decreased transmission leads to fewer carriers of HBV and HCV and fewer cases of hepatitis B and hepatitis C FIGuRE 1-2 The committee’s approach to its task.

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