WASHINGTON — Stepped-up vaccination requirements, a boost in resources for prevention and treatment, and a public awareness campaign similar to the effort that dispelled the stigma of HIV/AIDS are needed to curb the health threats posed by hepatitis B and hepatitis C, says a new report from the Institute of Medicine.
Chronic hepatitis B and C cause thousands of cases of liver cancer, liver disease, and death each year — taking the heaviest toll among Asians, Pacific Islanders, and blacks in the U.S. — and these infections account for nearly half of the liver transplantations that must be performed annually. Resources and efforts to contain the viruses that cause hepatitis B and C lag behind those directed at other infectious diseases of similar impact to public health, noted the committee that wrote the report.
“Although hepatitis B and C are preventable, the rates of infection have not declined over the past several years, underscoring the conclusion that we have allowed gaps in screening, prevention, and treatment to go unchecked,” said committee chair R. Palmer Beasley, professor of epidemiology and disease control, University of Texas School of Public Health, Houston. “This report outlines the additional resources and actions needed to reduce the unacceptably high burden of liver disease and cancer associated with these viruses.”
An estimated 800,000 to 1.4 million Americans have chronic hepatitis B and between 2.7 million and 3.9 million have chronic hepatitis C. The majority of infected individuals are not aware of their condition until they develop symptoms of liver cancer or liver disease. Few among the populations most at risk — immigrants from countries where the diseases are endemic, non-Hispanic black men, injection-drug users, and people who had blood transfusions before 1992 — seek testing or information on how to protect themselves from infection. Moreover, health care and social service providers’ knowledge about hepatitis B and C is generally poor, and many fail to follow guidelines for screening patients and providing prevention, treatment, and follow-up services.
The report calls for a public awareness initiative along the lines of the effort that succeeded in increasing recognition, prevention, and treatment of HIV/AIDS, which affects three to five times fewer Americans than viral hepatitis. Educational programs and materials that outline risk factors for viral hepatitis and provide information on immunization, prevention, and proper monitoring of infected individuals should be developed and made available to all health professionals and social service providers.
Steps need to be taken to eliminate the stigma associated with viral hepatitis. Negative attitudes about hepatitis B in some cultures may contribute to immigrants’ reluctance to seek testing. In China, for example, people with chronic hepatitis B face job and social discrimination. In addition, negative perceptions about illicit-drug users, who make up the greatest percentage of those with hepatitis C, can affect the care they receive or their willingness to seek care.
Although the availability of an effective vaccine against hepatitis B has significantly reduced its spread, some 1,000 infants born to infected mothers develop chronic infections each year, a number that has not declined over the past decade. Moreover, three states — Alabama, Montana, and South Dakota — still do not require that children be vaccinated against hepatitis B before entering daycare or school. All full-term newborns whose mothers test positive for hepatitis B should receive the vaccine once they are stable and before leaving the delivery room rather than up to 12 hours after birth as is currently recommended. All states should make hepatitis B vaccination a requirement for school attendance, and health plans need to fully cover the costs associated with the immunization. Particular attention should be given to screening and vaccinating children who were born in countries where hepatitis B circulates widely. Each year, roughly 40,000 to 45,000 people legally emigrate to the United States from countries where hepatitis B is endemic.
Health care and social services related to viral hepatitis are sparse and fragmented among providers and organizations, leading to missed opportunities to prevent the spread of infection and to lessen the impact of chronic infections, the report concludes. The committee recommended several steps to create a more-coordinated approach, including ways to improve identification of infected individuals, social and peer support to reduce the stigma of infection, and medical management of those with chronic hepatitis B or C. These strategies are aimed at not just health professionals in hospitals and doctors’ offices, but also individuals and groups that provide services to at-risk populations, including prisons and jails, HIV and STD clinics, shelter-based programs, and mobile health units.
People at greatest risk for hepatitis B include individuals born in East and Southeast Asia, sub-Saharan Africa, and other areas where the virus circulates widely; infants born to women with the disease; and those who have sexual contact or share injection-drug equipment with an infected person. Asians and Pacific Islanders make up 4.5 percent of the U.S. population but account for more than 50 percent of chronic hepatitis B cases. Those at greatest risk for hepatitis C are individuals who received a blood transfusion before 1992 and past or current injection-drug users. The chances of contracting hepatitis C increase with years of drug use and may be as high as 90 percent among long-term users. Deaths related to hepatitis C have increased, with the highest number occurring among middle-aged men, non-Hispanic blacks, and American Indians.
The report was sponsored by the U.S. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services’ Office of Minority Health, U.S. Department of Veterans Affairs, and the National Viral Hepatitis Roundtable. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.
Copies of HEPATITIS AND LIVER CANCER: A NATIONAL STRATEGY FOR PREVENTION AND CONTROL OF HEPATITIS B AND C are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above. Additional information on the study can be found at HTTP://WWW.IOM.EDU/VIRALHEPATITIS.
[ This news release and report are available at HTTP://NATIONAL-ACADEMIES.ORG ]
INSTITUTE OF MEDICINE
Board on Population Health and Public Health Practice
COMMITTEE ON PREVENTION AND CONTROL OF VIRAL HEPATITIS INFECTIONS IN THE UNITED STATES
R. PALMER BEASLEY, M.D. (CHAIR)
Ashbel Smith Professor and Dean Emeritus
School of Public Health
University of Texas
HARVEY J. ALTER, M.D. 1,2
Infectious Diseases Section
Department of Transfusion Medicine
National Institutes of Health
MARGARET L. BRANDEAU, PH.D.
Department of Management Science and Engineering
DANIEL R. CHURCH, M.P.H.
Epidemiologist and Adult Viral Hepatitis Coordinator
Bureau of Infectious Disease Prevention, Response, and Services
Massachusetts Department of Health
ALISON A. EVANS, SC.D.
Department of Epidemiology and Biostatistics
Drexel University School of Public Health
Drexel Institute of Biotechnology and Viral Research
HOLLY HAGAN, PH.D., M.P.H.
Senior Research Scientist
College of Nursing
New York University
New York City
SANDRAL HULLETT, M.D., M.P.H. 2
CEO and Medical Director
Cooper Green Hospital
STACENE R. MAROUSHEK, M.D., PH.D., M.P.H.
Department of Pediatrics
Hennepin County Medical Center
RANDALL R. MAYER, M.S., M.P.H.
Bureau of HIV, STD, and Hepatitis
Iowa Department of Public Health
BRIAN J. MCMAHON, M.D.
Liver Disease and Hepatitis Program
Alaska Native Tribal Health Consortium
MARTIN JOSE SEPULVEDA, M.D., M.P.H., FACP
Integrated Health Services
SAMUEL SO, M.B., B.S.
Lui Hac Minh Professor
Asian Liver Center
School of Medicine
DAVID L. THOMAS, M.D., M.P.H.
Division of Infectious Diseases
Department of Medicine
Johns Hopkins School of Medicine
LESTER N. WRIGHT, M.D., M.P.H.
Deputy Commissioner and Chief Medical Officer
New York Department of Correctional Services
ABIGAIL MITCHELL, PH.D.
1 Member, National Academy of Sciences
2 Member, Institute of Medicine