IOM urges increased awareness of viral hepatitis

One possible screening mechanism is to add questions about HBV and HCV risk factors to intake forms.

By Susan J. Landers, amednews staff. Posted Jan. 25, 2010.

Washington -- Some 3 million to 5 million people in the United States are chronically infected with hepatitis B and hepatitis C, a number far greater than those carrying the AIDS virus, yet there is little attention paid to screening and treatment for viral hepatitis, according to a Jan. 11 Institute of Medicine report.

About 15,000 people die from liver diseases caused by HBV or HCV each year, yet most people are unaware they are infected until they develop liver cancer or liver disease, according to the report. The infections also lead to about half of the nation's liver transplants necessitated by end-stage liver disease.

Risk factors
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"Although hepatitis B and C are preventable, 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 R. Palmer Beasley, MD, chair of the IOM panel that drafted the report. Dr. Beasley is a professor and dean emeritus of the University of Texas Health Science Center's School of Public Health.

"The committee strongly believes it is possible for the U.S. to do considerably better, but it will take better resources and approaches," Dr. Beasley said.

The federal budget includes very little funding for viral hepatitis, said panel member Samuel So, MD, director of Stanford University's Asian Liver Center in California. "Chronic viral hepatitis is probably one of the most neglected public health problems in the country."

More than 1 million Americans have chronic hepatitis B; nearly 4 million have chronic hep C.

Daniel Church, MPH, also a panel member and adult viral hepatitis coordinator at the Massachusetts Dept. of Public Health, said the average grant to a major city is $90,000, "which usually covers one salary." There is no funding for surveillance, he said.

Dr. Beasley, Dr. So and Church spoke during a briefing to release the report.

An estimated 800,000 to 1.4 million Americans have chronic HBV, and 2.7 million to 3.9 million have chronic HCV. 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 and their families from infection.

An efficient screening mechanism

It's likely that physicians, especially primary care physicians, don't have time to query each patient about risk factors for viral hepatitis, said panel member David Thomas, MD, MPH, chief of the Division of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore.

To boost screening efforts, Dr. Thomas suggests physicians "take 15 minutes some day this week to look at your intake form and think about how to add screening questions." For example, patients could be asked whether they have traveled in countries with a high prevalence of viral hepatitis, whether they have used intravenous drugs or had blood transfusions before 1992. "You could ask in a way that's not pejorative."

The IOM report was applauded by the American Assn. for the Study of Liver Diseases, which said it would work with federal agencies to implement the IOM recommendations.

There is also congressional support for increasing resources for viral hepatitis. The Viral Hepatitis and Liver Cancer Control and Prevention Act was introduced in October 2009 by Reps. Mike Honda (D, Calif.) and Bill Cassidy, MD (R, La.). The measure would amend the Public Health Service Act to include education, training, surveillance and immunization for hepatitis B and C.

In addition, Rep. Hank Johnson (D, Ga.) announced in December 2009 that he has been treated for chronic hepatitis C since 1998. He said he did not know how he contracted the disease. His announcement was hailed by the National Viral Hepatitis Roundtable, a coalition of advocacy groups, for providing heightened attention to the disease.

This content was published online only.

ADDITIONAL INFORMATION:

Risk factors

A new Institute of Medicine report stresses the need for physicians to screen patients at risk for viral hepatitis, including:

Hepatitis B

People born in areas in which the disease is endemic, including all countries in Africa, Asia, Central America and the Middle East; Alaska natives; and indigenous populations of northern Canada
Infants born to infected mothers
Household contacts of people with chronic HBV infection
Injection drug users
Sexually active people who are not in long-term, mutually monogamous relationships
Men who have sex with men
Health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids
Patients with chronic liver disease
Patients receiving hemodialysis
Travelers to countries that have a high prevalence of HBV infection

Hepatitis C

People who have ever injected illegal drugs
Recipients of clotting-factor concentrates made before 1987
Recipients of blood transfusions or organ transplants before July 1992
Patients who have ever received long-term hemodialysis treatment
People who have known exposures to HCV, such as health care workers who sustained needlesticks involving HCV-positive blood and recipients of organs or blood from donors who later tested positive for HCV
All people with HIV
Patients who have abnormal liver enzyme tests or other signs of liver disease
Children born to HCV-positive mothers (test after 18 months of age to avoid detecting maternal antibodies)

Source: "Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C," Institute of Medicine, January (books.nap.edu/openbook.php?record_id=12793)