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Breaking the Silence on Viral Hepatitis - opinion
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ONLINE FIRST - Ideas and Opinions
Ronald O. Valdiserri, MD, MPH; and Howard K. Koh, MD, MPH
Ann Intern Med. Published online 29 April 2014
Until recently, the silent epidemic of viral hepatitis has eluded a unified national public health strategy for controlling morbidity and mortality. Consequently, untreated chronic viral hepatitis affects between 3.5 and 5.3 million Americans and continues to fuel rising incidences of progressive liver disease, liver failure, and liver cancer (1). Chronic hepatitis C virus (HCV) infection affects some 2.7 million noninstitutionalized Americans (2), represents the leading indication for liver transplantation in the United States (3), and has caused more deaths annually than HIV since 2007 (4). Although effective vaccination strategies have contributed to a decline in new cases of acute hepatitis B virus (HBV) since 1990, cases of acute HCV increased by 44% in 2011 compared with 2010, with the largest increases among persons younger than 29 years (5). This increase is thought to reflect a trend in greater cases of HCV among adolescent and young adults who inject drugs (5).
Although many community leaders and organizations have made valuable, individual contributions to address these issues, a coordinated national approach to tackling viral hepatitis had been lacking until 2011, when the U.S. Department of Health and Human Services (HHS) unveiled the nation's first Action Plan for the Prevention, Care and Treatment of Viral Hepatitis in the United States (6). The plan spurred leaders throughout the country to join forces to improve health outcomes for individuals and communities and focused on 6 fundamental priorities: educate providers and communities about viral hepatitis; improve diagnosis and treatment to prevent liver disease; strengthen our ability to detect outbreaks and monitor the sequelae of chronic viral hepatitis; eliminate vaccine-preventable viral hepatitis, including perinatal transmission of HBV; reduce viral hepatitis transmission associated with drug use; and protect patients and workers from health care-associated viral hepatitis. These priorities represent a call to action to advance both prevention and treatment of viral hepatitis.
Since the plan's release, persons at both the federal and community levels have added their voices to its call to action. In 2011, the White House issued a proclamation raising awareness about World Hepatitis Day and has since hosted annual national meetings to bring attention to the estimated 500 million persons worldwide who are chronically infected with hepatitis B and C. Policymakers are implementing the Patient Protection and Affordable Care Act to bring health insurance coverage to persons who may have been previously denied coverage due to a preexisting condition of chronic viral hepatitis. Since 2012, advocates have introduced and implemented National Hepatitis Testing Day on May 19, featuring education and early detection activities. The Centers for Disease Control and Prevention has developed new educational campaigns (such as Know More Hepatitis), introduced new online risk assessment tools to help people easily determine their risk status and access resources, and disseminated new outreach materials in multiple Asian languages. In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended screening for hepatitis C for all persons born between 1945 and 1965 (7). The potential, afforded by these guidelines, to diagnose hundreds of thousands of infected baby boomers represents a major advance in public health.
Examples also abound in the community. Advocates committed to hepatitis B elimination have joined to create Hep B United, a national campaign supporting local community coalitions that promote HBV awareness and action. Medical leaders in birthing hospitals have rallied around new efforts for delivering HBV vaccination as a birth dose to eliminate perinatal transmission of hepatitis B. Civil rights agencies have reinvigorated efforts to eliminate discrimination against health profession students with chronic viral hepatitis. And, in a fast moving arena, private industry is developing a range of new treatments, making a cure for hepatitis C possible for more patients. In response to the burgeoning new treatment options, professional organizations have joined together to develop and release hepatitis C treatment guidelines reflecting the dynamic pace of drug development.
One example of how HHS's action plan is breaking the silence around viral hepatitis can be found in a recent national gathering of expert consultants convened to identify approaches for confronting the rising cases of HCV among young persons who have recently transitioned from oral opioid abuse to drug injection (8). The consultants' observations underscored gaps in current surveillance, program, and research activities that will inform future federal directions and priorities. In addition to the consultants' endorsement of intensified efforts to prevent drug abuse and provide developmentally appropriate therapy for young persons with opioid addiction, they advocated strongly for an expansion of HCV test-and-treat strategies as a prevention method. Of note, modelers exploring the feasibility of interferon-free HCV treatment as prevention report that scaling up HCV antiviral treatment could reduce both HCV incidence and prevalence among injection drug users (9). Treatment as prevention, which has emerged as a viable strategy for HIV, could offer similar promise for HCV, especially among injection drug users. Despite the obvious differences between HIV and HCV and the surrounding contexts, achieving success in both arenas will require the expertise and full collaboration of many partners.
We are encouraged by the actions taken since the plan's release in 2011, but more remains to be done. We need new partners, heightened commitment, and concrete evidence that our efforts are making a difference for the health of Americans. Because the 2011 plan did not outline specific action steps beyond 2013, the HHS has released an updated version of the Viral Hepatitis Action Plan for 2014-2016 (10). The updated plan builds on the goals of its predecessor but is enhanced: It spells out specific actions to be undertaken by federal partners in 2014-2016, emphasizes the need for a comprehensive national response by calling out potential contributions of clinical and other nongovernmental partners, and expands the focus on evaluation with the addition of specific metrics to monitor the plan's 4 major goals. The framework and vision offered by this updated plan will continue to provide a critical platform for medical, public health, and community actions. In light of its release, we call for further commitments to break the silence, stop this epidemic, and propel our nation toward a healthier future where viral hepatitis no longer exerts such a profound toll in morbidity and mortality.
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