Global & Disaster Medicine

Archive for the ‘Hepatitis C’ Category

Médecins Sans Frontières (MSF) has announced that it has secured deals for generic hepatitis C medicines for as low as US$1.40 per day, or $120 per 12-week treatment course for the key medicines sofosbuvir and daclatasvir.

MSF

“…..In the US, pharmaceutical corporation Gilead launched sofosbuvir at $1,000 per pill in 2013;  Bristol-Myers Squibb (BMS) launched daclatasvir at $750 per pill in 2015. This led to the original price tag of $147,000 for a person’s 12-week combination treatment course. The corporations have also been charging exorbitant prices in many developing countries, paralysing the launch of national treatment programmes and causing treatment rationing in many countries around the world….”

CDC

Hepatitis C FAQs for Health Professionals

Overview and Statistics

What is the case definition for acute hepatitis C?

Because the clinical characteristics are similar for all types of acute viral hepatitis, the specific viral cause of illness cannot be determined solely on the basis of signs, symptoms, history, or current risk factors, but must be verified by specific serologic testing. For specific serologic tests required to meet the case definition, see the following link:

What is the case definition for chronic hepatitis C?

Laboratory testing is required for confirmation of the etiologic cause of viral hepatitis. For specific serologic tests, see the following link:

Is additional guidance on viral hepatitis Case determination and surveillance available?

Yes. See the Guidelines for Viral Hepatitis Surveillance and Case Management, available here(https://www.cdc.gov/hepatitis/scripts/sharebuttononoff.js).

What is the incidence of HCV infection in the United States?

In 2014, a total of 2,194 cases of acute hepatitis C were reported to CDC from 40 states. The overall incidence rate for 2014 was 0.7 cases per 100,000 population, an increase from 2010–2012. After adjusting for under-ascertainment and under-reporting, an estimated 30,500 acute hepatitis C cases occurred in 2014.

What is the prevalence of chronic HCV infection in the United States?

An estimated 2.7-3.9 million people in the United States have chronic hepatitis C.

Who is at risk for HCV infection?

The following persons are at known to be at increased risk for HCV infection:

  • Current or former injection drug users, including those who injected only once many years ago
  • Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed
  • Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available
  • Chronic hemodialysis patients
  • Persons with known exposures to HCV, such as
    • health care workers after needlesticks involving HCV-positive blood
    • recipients of blood or organs from a donor who tested HCV-positive
  • Persons with HIV infection
  • Children born to HCV-positive mothers

Is it possible for someone to become infected with HCV and then spontaneously clear the infection?

Yes. Approximately 15%–25% of persons clear the virus from their bodies without treatment and do not develop chronic infection; the reasons for this are not well known.

How likely is HCV infection to become chronic?

HCV infection becomes chronic in approximately 75%–85% of cases.

Why do most persons remain chronically infected with HCV?

A person infected with HCV mounts an immune response to the virus, but replication of the virus during infection can result in changes that evade the immune response. This may explain how the virus establishes and maintains chronic infection.

What are the chances of someone developing chronic HCV infection, chronic liver disease, cirrhosis, or liver cancer or dying as a result of hepatitis C?

Of every 100 persons infected with HCV, approximately

  • 75–85 will go on to develop chronic infection
  • 60–70 will go on to develop chronic liver disease
  • 5–20 will go on to develop cirrhosis over a period of 20–30 years
  • 1–5 will die from the consequences of chronic infection (liver cancer or cirrhosis)

Can persons become infected with a different strain of HCV after they have cleared the initial infection?

Yes. Prior infection with HCV does not protect against later infection with the same or different genotypes(https://www.cdc.gov/osels/ph_surveillance/nndss/casedef/hepatitisccurrent.htm) of the virus. This is because persons infected with HCV typically have an ineffective immune response due to changes in the virus during infection. For the same reason, no effective pre- or postexposure prophylaxis (i.e., immune globulin) is available.

Is hepatitis C a common cause for liver transplantation?

Yes. Chronic HCV infection is the leading indication for liver transplants in the United States.

How many deaths can be attributed to chronic HCV infection?

CDC estimates that there were 19,659 deaths with HCV as an underlying or contributing cause of death in 2014. Current information indicates these represent a fraction of deaths attributable in whole or in part to chronic hepatitis C.

Is there a hepatitis C vaccine?

No vaccine for hepatitis C is available. Research into the development of a vaccine is under way.

Transmission and Symptoms

How is HCV transmitted?

HCV is transmitted primarily through large or repeated percutaneous (i.e., passage through the skin) exposures to infectious blood, such as

  • Injection drug use (currently the most common means of HCV transmission in the United States)
  • Receipt of donated blood, blood products, and organs (once a common means of transmission but now rare in the United States since blood screening became available in 1992)
  • Needlestick injuries in health care settings
  • Birth to an HCV-infected mother

HCV can also be spread infrequently through

  • Sex with an HCV-infected person (an inefficient means of transmission)
  • Sharing personal items contaminated with infectious blood, such as razors or toothbrushes (also inefficient vectors of transmission)
  • Other health care procedures that involve invasive procedures, such as injections (usually recognized in the context of outbreaks)

What is the prevalence of HCV infection among injection drug users (IDUs)?

The most recent surveys of active IDUs indicate that approximately one third of young (aged 18–30 years) IDUs are HCV-infected. Older and former IDUs typically have a much higher prevalence (approximately 70%–90%) of HCV infection, reflecting the increased risk of continued injection drug use. The high HCV prevalence among former IDUs is largely attributable to needle sharing during the 1970s and 1980s, before the risks of bloodborne viruses were widely known and before educational initiatives were implemented.

Is cocaine use associated with HCV transmission?

There are very limited epidemiologic data to suggest an additional risk from non-injection (snorted or smoked) cocaine use, but this risk is difficult to differentiate from associated injection drug use and sex with HCV-infected partners.

What is the risk of acquiring HCV infection from transfused blood or blood products in the United States?

Now that more advanced screening tests for HCV are used in blood banks, the risk is considered to be less than 1 chance per 2 million units transfused. Before 1992, when blood screening for HCV became available, blood transfusion was a leading means of HCV transmission.

Can HCV be spread during medical or dental procedures?

As long as Standard Precautions(https://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html) and other infection control practices are used consistently, medical and dental procedures performed in the United States generally do not pose a risk for the spread of HCV. However, HCV has been spread in health care settings when injection equipment, such as syringes, was shared between patients or when injectable medications or intravenous solutions were mishandled and became contaminated with blood. Health care personnel should understand and adhere to Standard Precautions, which includes Injection Safety(https://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html) practices aimed at reducing bloodborne pathogen risks for patients and health care personnel. If health care-associated HCV infection is suspected, this should be reported to state and local public health authorities.

Can HCV be spread within a household?

Yes, but this does not occur very often. If HCV is spread within a household, it is most likely a result of direct, through-the-skin exposure to the blood of an infected household member.

What are the signs and symptoms of acute HCV infection?

Persons with newly acquired HCV infection usually are asymptomatic or have mild symptoms that are unlikely to prompt a visit to a health care professional. When symptoms occur, they can include:

  • Fever
  • Fatigue
  • Dark urine
  • Clay-colored stool
  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Vomiting
  • Joint pain
  • Jaundice

What percentage of persons infected with HCV develop symptoms of acute illness?

Approximately 20%–30% of those newly infected with HCV experience fatigue, abdominal pain, poor appetite, or jaundice.

How soon after exposure to HCV do symptoms appear?

In those persons who do develop symptoms, the average time period from exposure to symptom onset is 4–12 weeks (range: 2–24 weeks).

What are the signs and symptoms of chronic HCV infection?

Most persons with chronic HCV infection are asymptomatic. However, many have chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer. Chronic liver disease in HCV-infected persons is usually insidious, progressing slowly without any signs or symptoms for several decades. In fact, HCV infection is often not recognized until asymptomatic persons are identified as HCV-positive when screened for blood donation or when elevated alanine aminotransferase (ALT, a liver enzyme) levels are detected during routine examinations.

Testing and Diagnosis

Who should be tested for HCV infection?

HCV testing is recommended for anyone at increased risk for HCV infection, including:

  • Persons born from 1945 through 1965
  • Persons who have ever injected illegal drugs, including those who injected only once many years ago
  • Recipients of clotting factor concentrates made before 1987
  • Recipients of blood transfusions or solid organ transplants before July 1992
  • Patients who have ever received long-term hemodialysis treatment
  • Persons with known exposures to HCV, such as
    • health care workers after needlesticks involving HCV-positive blood
    • recipients of blood or organs from a donor who later tested HCV-positive
  • All persons with HIV infection
  • Patients with signs or symptoms of liver disease (e.g., abnormal liver enzyme tests)
  • Children born to HCV-positive mothers (to avoid detecting maternal antibody, these children should not be tested before age 18 months)

What blood tests are used to detect HCV infection?

Several blood tests are performed to test for HCV infection, including:

  • Screening tests for antibody to HCV (anti-HCV)
    • enzyme immunoassay (EIA)
    • enhanced chemiluminescence immunoassay (CIA)
  • Qualitative tests to detect presence or absence of virus (HCV RNA polymerase chain reaction [PCR])
  • Quantitative tests to detect amount (titer) of virus (HCV RNA PCR)

How do I interpret the different tests for HCV infection?

A table on the interpretation of results of tests for hepatitis C Virus (HCV) infection and further actions is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_graph.pdf[PDF – 1 page](https://www.cdc.gov/hepatitis/hcv/pdfs/hcv_graph.pdf).

Is an algorithm for HCV diagnosis available?

A flow chart that outlines the serologic testing process beginning with anti HCV testing is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_flow.pdf [PDF – 1 page](https://www.cdc.gov/hepatitis/scripts/sharebuttononoff.js).

How soon after exposure to HCV can anti-HCV be detected?

HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4–10 weeks after infection. Anti-HCV can be detected in >97% of persons by 6 months after exposure.

How soon after exposure to HCV can HCV RNA be detected by PCR?

HCV RNA appears in blood and can be detected as early as 2–3 weeks after infection.

Under what circumstances is a false-positive anti-HCV test result likely?

False-positive anti-HCV tests appear more often when persons at low risk for HCV infection (e.g., blood donors) are tested. Therefore, it is important to follow-up all positive anti-HCV tests with a RNA test to establish current infection.

Under what circumstances might a false-negative anti-HCV test result occur?

Persons with early HCV infection might not yet have developed antibody levels high enough that the test can measure. In addition, some persons might lack the (immune) response necessary for the test to work well. In these persons, further testing such as PCR for HCV RNA may be considered.

Can a patient have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis C?

Yes. It is common for patients with chronic hepatitis C to have liver enzyme levels that go up and down, with periodic returns to normal or near normal levels. Liver enzyme levels can remain normal for over a year despite chronic liver disease.

Where can I learn more about hepatitis C serology?

CDC offers an online training that covers the serology of acute and chronic hepatitis C and other types of viral hepatitis, available at https://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm(https://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm).

Management and Treatment

What should be done for a patient with confirmed HCV infection?

HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination.

When might a specialist be consulted in the management of HCV-infected persons?

Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C; this can include some internal medicine and family practice physicians as well as specialists such as infectious disease physicians, gastroenterologists, or hepatologists.

What is the treatment for acute hepatitis C?

Treatment for acute hepatitis C is similar to treatment for chronic hepatitis C. This issue was addressed in the 2009 AASLD Practice Guidance, the response rate to treatment is higher among persons with acute than with chronic HCV infection. However, the optimal treatment regimen and when it should be initiated remains uncertain.

What is the treatment for chronic hepatitis C?

The treatment for hepatitis C virus (HCV) infection has evolved substantially since the introduction of highly effective HCV protease inhibitor therapies in 2011. Since that time new drugs with different mechanisms of action have become and continue to become available. For a complete list of currently approved FDA therapies to treat hepatitis C, please visit http://www.hepatitisc.uw.edu/page/treatment/drugs.

To provide healthcare professionals with timely guidance as new therapies are available and integrated into HCV regimens, the Infectious Diseases Society of America (IDSA) and American Association for the Study of Liver Diseases (AASLD), in collaboration with the International Antiviral Society–USA (IAS–USA), developed evidence-based, expert-developed recommendations for hepatitis C management: http://www.hcvguidelines.org.

How many different genotypes of HCV exist?

At least six distinct HCV genotypes (genotypes 1–6) and more than 50 subtypes have been identified. Genotype 1 is the most common HCV genotype in the United States.

Is it necessary to do viral genotyping when managing a person with chronic hepatitis C?

Yes. Because there are at least six known genotypes and more than 50 subtypes of HCV, genotype information is helpful in defining the epidemiology of hepatitis C and in making recommendations regarding appropriate treatment regimen. In the United States, HCV genotype 1 is most common, accounting for 74% of prevalent cases. Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection.

Can superinfection with more than one genotype of HCV occur?

Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon.

Does chronic hepatitis C affect only the liver?

A small percentage of persons with chronic HCV infection develop medical conditions due to hepatitis C that are not limited to the liver. These conditions are thought to be attributable to the body’s immune response to HCV infection. Such conditions can include:

  • Diabetes mellitus, which occurs three times more frequently in HCV-infected persons
  • Glomerulonephritis, a type of kidney disease caused by inflammation of the kidney
  • Essential mixed cryoglobulinemia, a condition involving the presence of abnormal proteins in the blood
  • Porphyria cutanea tarda, an abnormality in heme production that causes skin fragility and blistering
  • Non-Hodgkins lymphoma, which might occur somewhat more frequently in HCV-infected persons

Counseling Patients

What topics should be discussed with patients who have HCV infection?

  • Patients should be informed about the low but present risk for transmission with sex partners.
  • Sharing personal items that might have blood on them, such as toothbrushes or razors, can pose a risk to others.
  • Cuts and sores on the skin should be covered to keep from spreading infectious blood or secretions.
  • Donating blood, organs, tissue, or semen can spread HCV to others.
  • HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils or drinking glasses, or through food or water.
  • Patients may benefit from a joining support group.

What should HCV-infected persons be advised to do to protect their livers from further harm?

  • HCV-positive persons should be advised to avoid alcohol because it can accelerate cirrhosis and end-stage liver disease.
  • Viral hepatitis patients should also check with a health professional before taking any new prescription pills, over-the counter drugs (such as non-aspirin pain relievers), or supplements, as these can potentially damage the liver.

Should HCV-infected persons be restricted from working in certain occupations or settings?

CDC’s recommendations for prevention and control of HCV infection(https://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm) specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact.

Hepatitis C and Health Care Personnel

What is the risk for HCV infection from a needlestick exposure to HCV-contaminated blood?

After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is approximately 1.8% (range: 0%–10%).

Other than needlesticks, do other exposures, such as splashes to the eye, pose a risk to health care personnel for HCV transmission?

Although a few cases of HCV transmission via blood splash to the eye have been reported, the risk for such transmission is expected to be very low. Avoiding occupational exposure to blood is the primary way to prevent transmission of bloodborne illnesses among health care personnel. All health care personnel should adhere to Standard Precautions(https://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm) . Depending on the medical procedure involved, Standard Precautions may include the appropriate use of personal protective equipment (e.g., gloves, masks, and protective eyewear).

Should HCV-infected health care personnel be restricted in their work?

There are no CDC recommendations to restrict a health care worker who is infected with HCV. The risk of transmission from an infected health care worker to a patient appears to be very low. All health care personnel, including those who are HCV positive, should follow strict aseptic technique and Standard Precautions(https://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm) , including appropriate hand hygiene, use of protective barriers, and safe injection practices.

What is the recommended management of a health care worker with occupational exposure to HCV?

Postexposure prophylaxis (PEP) of hepatitis C is not recommended, as outlined in the 2001 MMWR on management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids. Test the source for HCV RNA. If the source is HCV RNA positive, or if HCV infection status unknown, follow this testing algorithm[PDF – 2 pages](https://www.cdc.gov/hepatitis/pdfs/Testing-Followup-Exposed-HC-Personnel.pdf) (update to 2001 guidance).

After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is approximately 1.8%. If the health care worker does become infected, follow AASLD/IDSA guidelines for management and treatment of hepatitis C.

Pregnancy and HCV Infection

Should pregnant women be routinely tested for anti-HCV?

No. Since pregnant women have no greater risk of being infected with HCV than non-pregnant women and interventions to prevent mother-to-child transmission are lacking, routine anti-HCV testing of pregnant women is not recommended. Pregnant women should be tested for anti-HCV only if they have risk factors for HCV infection(https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#a6).

What is the risk that an HCV-infected mother will spread HCV to her infant during birth?

Approximately 6 of every 100 infants born to HCV-infected mothers become infected with the virus. Transmission occurs at the time of birth, and no prophylaxis is available to prevent it. The risk is increased by the presence of maternal HCV viremia at delivery and also is 2–3 times greater if the woman is coinfected with HIV. Most infants infected with HCV at birth have no symptoms and do well during childhood. More research is needed to find out the long-term effects of perinatal HCV infection.

Should a woman with HCV infection be advised against breastfeeding?

No. There is no evidence that breastfeeding spreads HCV. However, HCV-positive mothers should consider abstaining from breastfeeding if their nipples are cracked or bleeding.

When should children born to HCV-infected mothers be tested to see if they were infected at birth?

Children should be tested for anti-HCV no sooner than age 18 months because anti-HCV from the mother might last until this age. If diagnosis is desired before the child turns 18 months, testing for HCV RNA could be performed at or after the infant’s first well-child visit at age 1–2 months. HCV RNA testing should then be repeated at a subsequent visit, independent of the initial HCV RNA test result.


WHO: A record 3 million people were able to obtain treatment for hepatitis C over the past two years, and 2.8 million more people embarked on lifelong treatment for hepatitis B in 2016.

WHO

Close to 3 million people access hepatitis C cure

World Hepatitis Summit 2017 calls for accelerated action to eliminate viral hepatitis

News release

On the eve of the World Hepatitis Summit in Brazil, WHO reports increasing global momentum in the response to viral hepatitis. A record 3 million people were able to obtain treatment for hepatitis C over the past two years, and 2.8 million more people embarked on lifelong treatment for hepatitis B in 2016.

“We have seen a nearly 5-fold increase in the number of countries developing national plans to eliminate life-threatening viral hepatitis over the last 5 years,” says Dr Gottfried Hirnschall, Director of WHO’s Department of HIV and Global Hepatitis Programme. “These results bring hope that the elimination of hepatitis can and will become a reality.”

Hosted by the Government of Brazil, the World Hepatitis Summit 2017 is being co-organized by WHO and the World Hepatitis Alliance. The Summit aims to encourage more countries to take decisive action to tackle hepatitis, which still causes more than 1.3 million deaths every year and affects more than 325 million people.

“We cannot lose sight of the fact that last year 194 governments committed to eliminating viral hepatitis by 2030. For sure we are still a long way from this goal but that doesn’t mean it’s some unattainable dream. It’s eminently achievable. It just requires immediate action,” says Charles Gore, President of World Hepatitis Alliance. “The World Hepatitis Summit 2017 is all about how to turn WHO’s global strategy into concrete actions and inspire people to leave with a ‘can do’ attitude.”

“Brazil is honored to host the World Hepatitis Summit 2017 – and welcomes this extraordinary team of experts, researchers, managers and civil society representatives to discuss the global health problem posed by viral hepatitis,” says Dr Adele Schwartz Benzaken, Director of the Brazilian Ministry of Health’s Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis.”Brazil is committed to taking recent advances in its response to hepatitis forward – on the road to elimination.”

Progress in treatment and cure

Many countries are demonstrating strong political leadership, facilitating dramatic price reductions in hepatitis medicines, including through the use of generic medicines—which allow better access for more people within a short time.

In 2016, 1.76 million people were newly treated for hepatitis C , a significant increase on the 1.1 million people who were treated in 2015. The 2.8 million additional people starting lifelong treatment for hepatitis B in 2016 was a marked increase from the 1.7 million people starting it in 2015. But these milestones represent only initial steps – access to treatment must be increased globally if the 80% treatment target is to be reached by 2030.

However, funding remains a major constraint: most countries lack adequate financial resources to fund key hepatitis services.

Diagnosis challenge

To achieve rapid scale-up of treatment, countries need urgently to increase uptake of testing and diagnosis for hepatitis B and C. As of 2015, an estimated 1 in 10 people living with hepatitis B, and 1 in 5 people living with hepatitis C, were aware of their infection. Countries need to improve policies, and programmes to increase awareness and subsequent diagnosis.

Prevention gaps

Countries need to provide a full range of hepatitis prevention services that are accessible to different population groups, particularly those at greater risk.

Largely due to increases in the uptake of hepatitis B vaccine, hepatitis B infection rates in children under 5 fell to 1.3% in 2015, from 4.7% in the pre-vaccine era.

However, the delivery of other prevention services, such as birth-dose vaccination for hepatitis B, harm reduction services for people who inject drugs, and infection control in many health services, remains low. This has led to continuing rates of new infections, including 1.75 million new hepatitis C cases every year.

Need for innovation

Innovation in many aspects of the hepatitis response must continue. New tools required include a functional cure for hepatitis B infection and the development of more effective point-of-care diagnostic tools for both hepatitis B and C.

“We cannot meet the ambitious hepatitis elimination targets without innovation in prevention interventions and approaches, and implementing them to scale,” said Dr Ren Minghui Assistant Director-General for Communicable Diseases, WHO. “The great successes of hepatitis B vaccination programmes in many countries need to be replicated and sustained globally in the context of moving forward to universal health coverage.”

Implementation of elimination strategy

The World Hepatitis Summit 2017 will be attended by over 900 delegates from more than 100 countries, including Ministers of Health, national programme managers, and representatives from organizations of people affected by viral hepatitis. The Summit will review progress and renew commitments by global partners to achieve the elimination of viral hepatitis by 2030 – a target reflected in WHO’s elimination strategy and the UN Sustainable Development Goals.

For more information, please contact:

Tunga Namjilsuren
WHO Communications Officer
Mobile: +41 79 203 3176
Email: namjilsurent@who.int

Pru Smith
WHO Communications Officer
Mobile: +41 79 477 1744
Email: smithp@who.int

Tara Farrell
World Hepatitis Alliance
Telephone: +44 20 7378 0159
Email: Tara.farrell@worldhepatitisalliance.org

Grace Perpétuo
Government of Brazil, Ministry of Health
Telephone: +55 61 99968 6541
Email: grace.perpetuo@aids.gov.br


CDC recommendations to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas during the period of September 2017 – March 2018.

CDC

Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)
CDCHAN-00408

Summary
The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.

 

Background
Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.

 

Recommendations

These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

  • Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
  • Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
  • All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
  • In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
  • For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
  • Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
  • Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.

 

For More Information


Viral hepatitis in the world

Global hepatitis report - infographics


World Hepatitis Day

WHO

Eliminate hepatitis: WHO

News release

New WHO data from 28 countries – representing approximately 70% of the global hepatitis burden – indicate that efforts to eliminate hepatitis are gaining momentum. Published to coincide with World Hepatitis Day, the data reveal that nearly all 28 countries have established high-level national hepatitis elimination committees (with plans and targets in place) and more than half have allocated dedicated funding for hepatitis responses.

On World Hepatitis Day, WHO is calling on countries to continue to translate their commitments into increased services to eliminate hepatitis. This week, WHO has also added a new generic treatment to its list of WHO-prequalified hepatitis C medicines to increase access to therapy, and is promoting prevention through injection safety: a key factor in reducing hepatitis B and C transmission.

From commitment to Action

“It is encouraging to see countries turning commitment into action to tackle hepatitis.” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Identifying interventions that have a high impact is a key step towards eliminating this devastating disease. Many countries have succeeded in scaling-up the hepatitis B vaccination. Now we need to push harder to increase access to diagnosis and treatment.”

World Hepatitis Day 2017 is being commemorated under the theme “Eliminate Hepatitis” to mobilize intensified action towards the health targets in the 2030 Sustainable Development Goals. In 2016, the World Health Assembly endorsed WHO’s first global health sectors strategy on viral hepatitis to help countries scale up their responses.

The new WHO data show that more than 86% of countries reviewed have set national hepatitis elimination targets and more than 70% have begun to develop national hepatitis plans to enable access to effective prevention, diagnosis, treatment and care services. Furthermore, nearly half of the countries surveyed are aiming for elimination through providing universal access to hepatitis treatment. But WHO is concerned that progress needs to speed up.

“The national response towards hepatitis elimination is gaining momentum. However, at best one in ten people who are living with hepatitis know they are infected and can access treatment. This is unacceptable,” said Dr Gottfried Hirnschall, WHO’s Director of the HIV Department and Global Hepatitis Programme.

“For hepatitis elimination to become a reality, countries need to accelerate their efforts and increase investments in life-saving care. There is simply no reason why many millions of people still have not been tested for hepatitis and cannot access the treatment for which they are in dire need.”

Viral hepatitis affected 325 million people worldwide in 2015, with 257 million people living with hepatitis B and 71 million people living with hepatitis C – the two main killers of the five types of hepatitis. Viral hepatitis caused 1.34 million deaths in 2015 – a figure close to the number of TB deaths and exceeding deaths linked to HIV.

Improving access to hepatitis C cure

Hepatitis C can be completely cured with direct acting antivirals (DAAs) within 3 months. However, as of 2015, only 7% of the 71 million people with chronic hepatitis C had access to treatment.

WHO is working to ensure that DAAs are affordable and accessible to those who need them. Prices have dropped dramatically in some countries (primarily in some high-burden, low-and lower middle income countries), facilitated by the introduction of generic versions of these medicines. The list of DAAs available to countries for treating hepatitis C is growing.

WHO has just prequalified the first generic version of one of these drugs: sofosbuvir. The average price of the required three-month treatment course of this generic is between US$260 and US$280, a small fraction of the original cost of the medicine when it first went on the market in 2013. WHO prequalification guarantees a product’s quality, safety and efficacy and means it can now be procured by the United Nations and financing agencies such as UNITAID, which now includes medicines for people living with HIV who also have hepatitis C in the portfolio of conditions it covers.

Global hepatitis report - infographics

Hepatitis B treatment

With high morbidity and mortality globally, there is great interest also in the development of new therapies for chronic hepatitis B virus infection. The most effective current hepatitis B treatment, tenofovir, (which is not curative and which in most cases needs to be taken for life), is available for as low as $48 per year in many low and middle income countries. There is also an urgent need to scale up access to hepatitis B testing.

Improving injection safety and infection prevention to reduce new cases of hepatitis B and C

Use of contaminated injection equipment in health-care settings accounts for a large number of new HCV and HBV infections worldwide, making injection safety an important strategy.Others include preventing transmission through invasive procedures, such as surgery and dental care; increasing hepatitis B vaccination rates and scaling up harm reduction programmes for people who inject drugs.

Today WHO is launching a range of new educational and communication tools to support a campaign entitled “Get the Point-Make smart injection choices” to improve injection safety in order to prevent hepatitis and other bloodborne infections in health-care settings.

World Hepatitis Summit

World Hepatitis Summit 2017, 1–3 November in São Paulo, Brazil, promises to be the largest global event to advance the viral hepatitis agenda, bringing together key players to accelerate the global response. Organised jointly by WHO, the World Hepatitis Alliance (WHA) and the Government of Brazil, the theme of the Summit is “Implementing the Global health sector strategy on viral hepatitis: towards the elimination of hepatitis as a public health threat”.

For more information, please contact:

Pru Smith
Communications Officer
Telephone: +41 22 791 4586
Mobile: +41 794 771 744
E-mail: smithp@who.int

Tunga (Oyuntungalag) Namjilsuren
Information Manager
WHO Department of HIV, Global Hepatitis Programme
Mobile: +41 79 203 3176
Email: namjilsurent@who.int


During 2009–2014, maternal HCV infections nearly doubled among reporting states in the United States

MMWR

Hepatitis C Virus Infection Among Women Giving Birth — Tennessee and United States, 2009–2014

Stephen W. Patrick, MD1; Audrey M. Bauer, DVM2; Michael D. Warren, MD2; Timothy F. Jones, MD2; Carolyn Wester, MD2

Summary

What is already known about this topic?Hepatitis C virus (HCV) infection affects approximately 3.5 million persons in the United States, making it the most common bloodborne infection in the nation. Recent surveillance data demonstrate increased rates of HCV infection among adolescents and adults who are predominantly white, live in nonurban areas, and have a history of injection drug use.

What is added by this report?During 2009–2014, maternal HCV infections nearly doubled among reporting states in the United States, with substantial state-to-state variation in prevalence. In adjusted analyses of Tennessee births, residence in a rural county was associated with a more than threefold increase in the odds of maternal HCV infection. Smoking during pregnancy and concurrent hepatitis B virus infection imparted fourfold and nearly 17-fold increased odds of maternal HCV infection, respectively.

What are the implications for public health practice?Screening for HCV infection in women of childbearing age and provision of treatment services might reduce perinatal transmission of HCV, and monitoring of HCV-exposed infants can aid in early identification of HCV infection and related liver disease.

Hepatitis C virus (HCV) affects an estimated 3.5 million persons in the United States (1), making it the most common bloodborne infection in the country. Recent surveillance data showed increased rates of HCV infection among adolescents and adults who are predominantly white, live in nonurban areas, and have a history of injection drug use.* U.S. birth certificate data were used to analyze trends and geographic variations in rates of HCV infection among women giving birth during 2009–2014. Birth certificates from Tennessee were used to examine individual characteristics and outcomes associated with HCV infection, using a multivariable model to calculate adjusted odds of HCV-related diagnosis in pregnancy among women with live births. During 2009–2014, HCV infection present at the time of delivery among pregnant women from states reporting HCV on the birth certificate increased 89%, from 1.8 to 3.4 per 1,000 live births. The highest infection rate in 2014 (22.6 per 1,000 live births) was in West Virginia; the rate in Tennessee was 10.1. In adjusted analyses of Tennessee births, the odds of HCV infection were approximately threefold higher among women residing in rural counties than among those in large urban counties, 4.5-fold higher among women who smoked cigarettes during pregnancy, and nearly 17-fold higher among women with concurrent hepatitis B virus (HBV) infection. HCV infection among pregnant women is an increasing and potentially modifiable threat to maternal and child health. Clinicians and public health officials should consider individual and population-level opportunities for prevention and risk mitigation.

Data from 2009–2014 were obtained from the National Vital Statistics System and Tennessee Department of Health vital records. The outcome of interest was HCV infection in pregnant women at the time of delivery (maternal HCV infection) as indicated on the infant’s birth certificate. The maternal HCV infection rate per 1,000 deliveries in Tennessee was compared with that from hospital billing data in the Tennessee Hospital Discharge Data System, an all-payer administrative database that includes data for all inpatient admissions in the state. National data were compared with nationally weighted estimates obtained from the National Inpatient Sample, the largest all payer database in the United States.

The first phase of the analysis examined rates of maternal HCV infection reported on infant birth certificates to approximate HCV infection among pregnant women in the United States. Because HCV infection is a revised 2003 birth certificate item, states gradually reported this item over time as they adopted the revised certificate; therefore, rates were calculated based on records from all states§ with available data at any time during 2009 and 2014. The second phase of the analysis used data from Tennessee vital records to assess sociodemographic characteristics, gravidity, health behaviors, and other infections during pregnancy associated with HCV infection in pregnancy. Overall, <1% of data for variables included in the study were missing, with the exception of timing of prenatal care, which was missing for 6.2% of records. To account for missing data, multiple imputation using chained equations with 20 imputations was used. A multivariable logistic regression model was fit to the data to determine increased odds of HCV infection in pregnancy, simultaneously adjusting for maternal age, education, marital status, race/ethnicity, county of residence, number of previous pregnancies, late or no prenatal care, smoking during pregnancy, and other infections present at delivery, including chlamydia, gonorrhea, syphilis, herpes simplex virus, and HBV. The statistical significance level was set to p<0.05 for all tests. The study was approved by the Tennessee Department of Health’s institutional review board.

During 2009–2014, the prevalence of maternal HCV infection among reporting states increased 89%, from 1.8 to 3.4 per 1,000 live births (p<0.001). There was substantial state-to-state variation in maternal HCV rates: in 2014, the highest rate (22.6 per 1,000 live births) was in West Virginia, and the lowest (0.7) was in Hawaii (Figure 1). In Tennessee, the prevalence of maternal HCV infection increased 163%, from 3.8 per 1,000 live births in 2009 to 10.0 in 2014 (p<0.001). Within Tennessee, there was substantial variation among 95 counties, with the highest rates in the 52 Appalachian counties in the eastern part of the state. For example, in 2014, Campbell County had the highest rate in Tennessee (78 per 1,000 births); 19 other counties had rates of ≤1 per 1,000 births, including 18 counties that reported no cases (Figure 2). Analysis of maternal HCV infection rates based on hospital discharge data resulted in similar findings.

In adjusted analyses of Tennessee births from 2009 to 2014, compared with women without HCV infection, women with diagnosed HCV at the time of live birth had higher odds of having a high school education or less, being unmarried, having late or no prenatal care, and smoking cigarettes. Compared with pregnant non-Hispanic white women, non-Hispanic black women had nearly 80% lower odds, and Hispanic women nearly 70% lower odds of having a diagnosis of HCV. Residing in a rural county was also associated with higher odds of maternal HCV infection. When compared with large central metro areas (counties with >1,000,000 population), the odds of HCV infection among pregnant women from rural areas (counties with <50,000 population) were threefold higher. Concurrent infections also were associated with higher odds of having an HCV diagnosis, with HBV infection resulting in nearly 17-fold increased odds of HCV (Table).

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Discussion

From 2009 to 2014, the prevalence of HCV infection among U.S. women giving birth in reporting states nearly doubled. This increase in maternal HCV infection mirrors increases in HCV infection incidence among adults, particularly nonpregnant young adults in the United States. A recent study identified a similar increase in HCV prevalence among women with recent live births (2); this study builds upon those findings, identifying several patient-level characteristics associated with maternal HCV infection, including white race, rural county residence, cigarette smoking during pregnancy, having a high school education or less, and having a concurrent HBV infection. In the United States, CDC and the American College of Obstetricians and Gynecologists recommend selective screening of pregnant women at high risk for HCV infection (i.e., history of injection drug use or long-term hemodialysis) (3). These data might inform expansion of the definition of women at risk, thereby improving clinical detection, particularly in areas of a state reporting increasing or high rates of incident HCV infection.

The recent increase in maternal HCV infection appears to have disproportionately affected rural and white populations; states and Tennessee counties with the highest prevalence of HCV infection among pregnant women in 2014 were in predominately Appalachian regions.** A recent analysis of state surveillance data examining acute HCV infections in the general population found a near doubling of cases in the United States during 2006–2012, and also found that states in or near Appalachian regions had the highest numbers of cases (4), suggesting that primary prevention and testing and treatment strategies for HCV infection could be targeted to these populations and areas at high risk.

This increase in HCV infection is particularly concerning in light of recent research highlighting poor follow-up of HCV-exposed infants (5). The rate of vertical transmission from infected mothers to infants is estimated at 6% (11% if the mother is coinfected with human immunodeficiency virus [HIV]) (6); therefore, it is important that exposed infants be followed for evidence of seroconversion. Because passively acquired maternal antibodies can persist for up to 18 months, anti-HCV antibody tests cannot be completed until that time; however, testing for HCV RNA can be performed earlier (7). A recent study in Philadelphia found that only 16% of HCV-exposed infants were appropriately followed (5), suggesting that infected infants might go undetected.

The increase in maternal HCV infection coincides with the rising heroin and prescription opioid epidemics occurring in the United States that have also disproportionately affected rural and white populations (8,9). There has also been a recent surge in opioid use among pregnant women (8). Whereas HCV infections have historically been associated with heroin use, a recent outbreak of HIV and HCV in rural Indiana demonstrates that these infections can also be transmitted through use of injectable forms of prescription opioids (10).

The findings in this report are subject to at least three limitations. First, vital records data rely on accurate coding of birth certificates; some variables such as HCV might be undercoded, and misclassification bias might occur. However, evaluation of hospital administrative data reporting of HCV infections suggests that this effect is small. Second, the proportion of live births from which data were collected on HCV status increased during the study period, as more states adopted the revised certificate each year. Because the original reporting states in 2009 were not held constant over time for this analysis, it is possible the trend could be subject to ascertainment bias; however, two additional confirmatory analyses were performed: 1) comparison with the National Inpatient Sample demonstrated similar rates of HCV infection during 2009–2013 (1.8 per 1,000 to 3.1 per 1,000), and 2) the same trend analysis was performed holding the original 28 reporting states in 2009 constant. Results were the same as when using all 47 states that incorporated reporting over time. Because women are not universally screened for HCV in pregnancy, these estimates and analyses do not represent the actual prevalence of HCV in pregnant women. However, the findings of increased disease prevalence among white and rural populations are similar to those of recent studies in nonpregnant populations (4). Instances of multiple births might have resulted in a slight overestimation of rates of maternal HCV infection. Finally, it is important to consider that HCV infections in a given state might represent not only the prevalence of a condition but also the public health efforts implemented to detect and treat the infection.

The prevalence of maternal HCV infection appears to have increased sharply in the United States, presenting concerns for maternal and child health. Ensuring that women of childbearing age have access to HCV testing and treatment and consideration of universal screening among women of reproductive age residing in areas with high HCV prevalence might mitigate risk and prevent transmission.


* https://www.cdc.gov/hepatitis/statistics/2014surveillance/index.htm.

Maternal records were included in the analysis if they had one or more International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes or Diagnosis Related Groups indicating delivery. HCV-positive women were identified using the following ICD-9-CM codes: 070.41, 070.44, 070.51, 070.54, 070.7, 070.70, and 070.71.

§ Data were available for all states except Connecticut, New Jersey, and Rhode Island. Data also were not available for the District of Columbia.

Births records where HCV status was either unknown or not collected were excluded from national estimates. Percentage of total births excluded for each year: 31.9% (2009), 22.6% (2010), 14.2% (2011), 11.7% (2012), 9.6% (2013), and 3.6% (2014).

** https://www.arc.gov/counties.

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References

  1. Edlin BR, Eckhardt BJ, Shu MA, Holmberg SD, Swan T. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology 2015;62:1353–63. CrossRef PubMed
  2. Koneru A, Nelson N, Hariri S, et al. Increased hepatitis C virus (HCV) detection in women of childbearing age and potential risk for vertical transmission—United States and Kentucky, 2011–2014. MMWR Morb Mortal Wkly Rep 2016;65:705–10. CrossRef PubMed
  3. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 86: viral hepatitis in pregnancy. Obstet Gynecol 2007;110:941–56. CrossRef PubMed
  4. Suryaprasad AG, White JZ, Xu F, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006–2012. Clin Infect Dis 2014;59:1411–9. CrossRef PubMed
  5. Kuncio DE, Newbern EC, Johnson CC, Viner KM. Failure to test and identify perinatally infected children born to hepatitis C-positive women. Clin Infect Dis 2016;62:980–5. CrossRef PubMed
  6. Benova L, Mohamoud YA, Calvert C, Abu-Raddad LJ. Vertical transmission of hepatitis C virus: systematic review and meta-analysis. Clin Infect Dis 2014;59:765–73. CrossRef PubMed
  7. American Academy of Pediatrics. Red book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012
  8. Patrick SW, Dudley J, Martin PR, et al. Prescription opioid epidemic and infant outcomes. Pediatrics 2015;135:842–50. CrossRef PubMed
  9. Zibbell JE, Iqbal K, Patel RC, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep 2015;64:453–8. PubMed
  10. Conrad C, Bradley HM, Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep 2015;64:443–4. PubMed

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Return to your place in the textFIGURE 1. Rate of hepatitis C infection among pregnant women per 1,000 live births, by state — United States, 2014

The above figure is a map of the United States, showing the rate of hepatitis C infection among pregnant women per 1,000 live births, by state in 2014.


Return to your place in the textFIGURE 2. Rate of hepatitis C infection among pregnant women per 1,000 live births, by county — Tennessee, 2014

The above figure is a map of Tennessee, showing the rate of hepatitis C infection among pregnant women per 1,000 live births, by county in 2014.


WHO’s Global Hepatitis Report, 2017: Since 2000, deaths from viral hepatitis have increased by 22%.


Global hepatitis report, 2017: 325 million people, or roughly 4% of the world’s population, lives with viral hepatitis, and the disease causes 1.34 million deaths per year

Overview

In May 2016, the World Health Assembly endorsed the Global Health Sector Strategy (GHSS) on viral hepatitis 2016–2021. The GHSS calls for the elimination of viral hepatitis as a public health threat by 2030 (reducing new infections by 90% and mortality by 65%).

This WHO Global hepatitis report describes, for the first time, the global and regional estimates on viral hepatitis in 2015, setting the baseline for tracking progress in implementing the new global strategy.

The report focuses on hepatitis B and C, which are responsible for 96% of all hepatitis mortality. It presents data along the fi ve strategic directions (strategic information, interventions, equity, financing and innovation) – key pillars of the GHSS to facilitate monitoring of progress in countries, regions and globally, and to measure the impact of interventions on reducing new infections and saving lives between 2015 and 2030.

Related links


New research: The absolute burden and relative rank of viral hepatitis increased between 1990 and 2013.

The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013                                              Stanaway, Jeffrey D et al.                                                                                                                                                                                                                                                      The Lancet

“….Between 1990 and 2013, global viral hepatitis deaths increased from 0·89 million (95% uncertainty interval [UI] 0·86–0·94) to 1·45 million (1·38–1·54); YLLs (years of life lost) from 31·0 million (29·6–32·6) to 41·6 million (39·1–44·7); YLDs (years lived with disability) from 0·65 million (0·45–0·89) to 0·87 million (0·61–1·18); and DALYs (Disability-adjusted life-years) from 31·7 million (30·2–33·3) to 42·5 million (39·9–45·6).
 
In 2013, viral hepatitis was the seventh (95% UI seventh to eighth) leading cause of death worldwide, compared with tenth (tenth to 12th) in 1990……”

 


CDC: Eliminating Hepatitis C in the Country of Georgia

CDC

Global Disease Detection Stories: Going Above and Beyond to Eliminate Hepatitis C in the Country of Georgia

Georgia is the first country to take on the challenge of completely eliminating Hepatitis C (HCV) – a serious viral infection – and they’re using a team of international disease detectives to find out how it’s spreading.

To stop a disease in its tracks, you need to get ahead of it. Sometimes this means going off the beaten path, into remote villages where your GPS doesn’t work, into people’s homes and businesses. Sometimes the people there speak your language, sometimes they don’t. But when the disease you’re tracking doesn’t know any boundaries, neither can you.

In the country of Georgia, the culprit is Hepatitis C (HCV). HCV is a serious viral infection that, over time, can cause liver damage and even liver cancer. Almost 7% of Georgia’s population is affected by this disease — the third highest rate in the world. As part of an ongoing collaboration, epidemiologist Dr. Stephanie Salyer, who is based at the Centers for Disease Control and Prevention (CDC) in Atlanta, and her team have been in the field conducting a door-to-door survey to find out how HCV is spreading.

A unique set of challenges

Particularly in the country of Georgia, language barriers can present a challenge. In some areas, Georgian citizens speak Armenian and Azerbaijani languages, but little to no Georgian. To address this, a diverse group of 45 field staff from Georgia’s National Center for Disease Control (NCDC), joined by Field Epidemiology Training Program residents from Georgia, Armenia and Azerbaijan, were selected and trained to conduct the survey.

Each team surveyed 25 households per day, which is harder than it sounds. Teams used GPS units and Google maps to locate homes to survey, but, particularly in rural areas, navigation proved challenging. More than once, teams – which included interviewers, nurses, and drivers — ended up hiking in the middle of nowhere past abandoned houses. The teams worked long hours and became “like a family,” said Salyer.

Perhaps the most difficult challenge was “hearing heartbreaking stories from people in the field with Hepatitis C. A lot of team members personally knew people impacted by this disease. That is why we were so invested in this project. This really highlights the tragedy of Hepatitis C in Georgia: it has touched almost everybody in the country,” said Salyer.

Putting data to work

Teams in the field used smart phone technology to enter the survey responses, automatically uploading the data into the cloud. Survey participants benefited by learning their HCV status, receiving health education materials in their preferred language, and getting their BMI and blood pressure measured. Public health nurses on the survey teams referred participants to local health care facilities and national information hotlines if needed.

Survey results are already informing national strategy. Experts assumed that HCV in Georgia could be traced back to intravenous drug use, reusing syringes, or being previously incarcerated. New information may indicate that transmission could also be associated with lack of infection control surrounding medical and dental procedures, and even tattoo parlors and manicure salons. Data is making researchers look in a new direction.

A strong commitment

The team locates survey households in Georgia.

The team locates survey households in Georgia. Georgia’s survey teams really went above and beyond.

The results from this survey will inform where to target prevention messages and who can benefit from treatment and screening. A remarkable public-private partnership with pharmaceutical manufacturer Gilead Sciences is supporting the program by providing 5,000 courses of the medication Sovaldi for the initial phase, followed by 20,000 courses of Harvoni free annually.

Several factors make HCV elimination a possibility in Georgia: the availability of effective diagnostics and treatment; the country’s small size and population; experience with HIV prevention and control programs; and strong political will and public support. Despite this, limitations exist in Georgia’s ability to track cases, reduce transmission, and provide care and treatment. Most infected people remain untested and unaware of their infection.

The principal investigator and one of the team’s phlebotomists even appeared on a local talk show to educate the public about Hepatitis C and encourage survey participation in cities.

Salyer recalls the commitment of the survey teams: “They went above and beyond. I would have to force them to come back at the end of the day.”

Progress in eliminating HCV in Georgia is a product of strong collaboration with the U.S. CDC’s Division of Viral Hepatitis in Atlanta and Georgia’s National Center for Disease Control. This work is coordinated through the GDD Regional Center for Georgia and the South Caucasus, which is part of CDC’s country office. Georgia is one of 30 U.S. partner countries named in the Global Health Security Agenda.  

 

At a Glance expanded expanded

  • Hepatitis C (HCV) is a serious viral infection that can cause liver cancer
  • HCV affects an estimated 7% of the population in the country of Georgia
  • Georgia is the first country in the world to try to eliminate HCV nationwide
  • The results from a collaborative survey will be used to target prevention messages and treatment

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