CDC's Position on Tattooing and HCV Infection
Although some studies have found an association between tattooing and
HCV infection in very selected populations, it is not known if these
results can be generalized to the whole population. Any percutaneous
exposure has the potential for transferring infectious blood and
potentially transmitting bloodborne pathogens (e.g., HBV, HCV, or HIV);
however, no data exist in the United States indicating that persons with
exposures to tattooing alone are at increased risk for HCV infection.For example, during the past 20 years, less than 1% of persons with
newly acquired hepatitis C reported to CDC's sentinel surveillance
system gave a history of being tattooed. Further studies are needed to
determine if these types of exposures, and the settings in which they
occur, are risk factors for HCV infection in the United States. CDC is
currently conducting a large study to evaluate tattooing as a potential
risk.
www.cdc.gov/ncidod/diseases/hepatitis/c/tattoo.htm
2004.12.14: CDC's Activities to Prevent Hepatitis C Infection
... of infection from intranasal cocaine
use, tattooing, and body ... He joined CDC in 1987
as an Epidemic ... of Viral Hepatitis in a variety of positions
including Chief ...
www.hhs.gov/asl/testify/t041214.html - 21k - Feb
3, 2005
Testimony
Statement by Rima Khabbaz, M.D.
Associate Director for Epidemiologic Science
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Department of Health and Human Services
on CDC's Activities to Prevent Hepatitis C Infection
before the Committee on Government Reform
U.S. House of Representatives
December 14, 2004
Good afternoon Mr. Chairman and Members of the Committee. I am Dr. Rima
Khabbaz, Associate Director for Epidemiologic Science of the National
Center for Infectious Diseases, Centers for Disease Control and
Prevention (CDC). I am accompanied today by Dr. Eric Mast, Acting
Director of CDC's Division of Viral Hepatitis. We are pleased to be here
today to describe the activities CDC has undertaken with partners to
implement the National Hepatitis C Prevention Strategy, which this
Committee was instrumental in initiating in 1998.
Background
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV),
which is found in the blood of persons who have this disease. Although
hepatitis C can lead to cirrhosis or scarring of the liver, to liver
failure, and liver cancer, the consequences of chronic liver disease
from hepatitis C may not become apparent for 10 to 20 years, so many
individuals infected with HCV are not aware of their infection. HCV
infection is spread primarily by exposures that involve direct passage
of blood through the skin, and it is the most common chronic bloodborne
infection in the United States. About 4 million Americans have already
been infected, of whom approximately 3 million are chronically infected,
and about 30,000 Americans become newly infected each year. Unlike
hepatitis A and hepatitis B, there is no vaccine to prevent infection
with HCV.
Risk Factors Associated with HCV Infection
Before blood donor testing for non-A, non-B hepatitis became available
beginning in the mid-1980s, and then a specific test for HCV infection
beginning in 1990, blood transfusions accounted for 10-25 percent HCV
infections. However, specific testing of blood donors has reduced the
risk of infection from a unit of blood to less than one in 1,000,000
units transfused.
Injection drug use is now the risk factor for infection among about 50
percent of persons with past HCV infection, and since the mid-1980s,
injection drug use accounts for approximately two-thirds of new
infections among Americans. Of persons injecting drugs for at least 5
years, 60-80 percent are infected with HCV, a risk that is 2 to 3 times
higher than for the human immunodeficiency virus (HIV). This high rate
of infection accounts for the 15-30 percent prevalence of HCV infection
that has been found among inmates of correctional facilities. Other risk
factors for infection include occupational exposure to blood through a
needle stick from an infected person, transmission to an infant from an
infected mother, and less efficiently through sex with an infected sex
partner.
Consequences of Infection with HCV
Approximately 75-85 percent of persons with an acute hepatitis C virus
infection develop a chronic infection, and about 60-70 percent of those
persons develop chronic hepatitis. Lower rates of chronic infection and
liver disease appear to occur among persons who were infected as
children.
Over a period of 20 to 30 years, cirrhosis of the liver occurs in 10-20
percent of persons with chronic hepatitis C virus infection and liver
cancer developing in 1-5 percent of them. Surveillance studies conducted
by CDC and the National Institutes of Health (NIH) show that HCV
accounts for 40-60 percent of chronic liver disease in the United
States. Chronic liver disease is the tenth leading cause of death among
adults in the United States, and HCV causes between 8,000 and 10,000 of
these deaths each year. HCV is the most frequent indication for liver
transplantation in this country; the number of patients on transplant
waiting lists has doubled in the past 5 years, and about 50 percent of
these patients die while awaiting liver transplant.
About one quarter of HIV-infected persons in the United States are also
infected with HCV. HCV is transmitted primarily by large or repeated
direct exposures to contaminated blood. Therefore, coinfection with HIV
and HCV is common among HIV-infected injection drug users (IDUs).
Coinfection is also common among persons with hemophilia who received
clotting factor concentrates before concentrates were effectively
treated to inactivate both viruses (i.e., products made before 1987). As
highly active antiretroviral therapy (HAART) and preventive treatment of
opportunistic infections increase the life span of persons living with
HIV, HCV-related liver disease has become a major cause of hospital
admissions and deaths among HIV-infected persons. Persons living with
HIV who are not already coinfected with HCV can adopt measures to
prevent acquiring HCV. Such measures will also reduce the chance of
transmitting their HIV infection to others.
Treatment of Chronic HCV Infection
Current antiviral treatment completely eliminates HCV infection in 50-55
percent of selected patients, with 95 percent of those remaining virus
free for at least 5 years. While antiviral therapy is indicated for many
patients with chronic HCV infection, treatment is less effective and may
not be indicated for patients with severe liver disease. Also, alcohol
abuse appears to worsen the outcome of HCV, and antiviral treatment is
more difficult among persons with ongoing abuse.
In addition to the benefits of antiviral treatment, patients with
chronic HCV infection can benefit from counseling, immunizations, and
other services to prevent progression of chronic liver disease. Because
alcohol use is one of the most important contributing factors to
progression of chronic liver disease in HCV-infected persons, it is
important to identify infected persons as early as possible so that they
can be counseled to limit alcohol consumption. In addition, persons with
HCV should be vaccinated against diseases, including hepatitis A and
hepatitis B, that may produce further liver injury or increase their
risk of death.
CDC's Current Prevention and Control Efforts
Identification of HCV-infected persons and prevention of new infections
are the major objectives of the National Hepatitis C Prevention
Strategy. Identification of infected persons provides the opportunity
for medical evaluation to: 1) determine the extent of their chronic
liver disease, 2) determine if they are candidates for antiviral
therapy, 3) determine if they need treatment for other conditions such
as alcohol or drug abuse that will worsen their HCV, and 4) provide
health education about how to prevent HCV transmission to others.
Identification of HCV infected persons, as well as persons at risk of
HCV infection, is best achieved through the integration of hepatitis
prevention services into community-based clinical and public health
programs that serve at-risk persons. Because the majority of persons
with HCV do not have symptoms of liver disease, their identification
requires that testing be conducted on persons with risk factors for
infection. CDC has conducted a number of community-based demonstration
projects - the Viral Hepatitis Integration Projects, or VHIPs -- which
have shown the feasibility and effectiveness of including hepatitis
prevention services in a variety of clinical and public health settings.
I will now highlight some specific components of the National Hepatitis
C Prevention Strategy.
Health Communications: CDC has developed evidence-based guidelines for
identification and testing of persons at risk of hepatitis C. In
addition, CDC has provided a broad range of materials about hepatitis C
for health care professionals and the public. Examples include web-based
continuing medical education programs for health care professionals, a
Hepatitis C Toolkit for primary care providers and their patients, and
health education materials for high school teachers. These materials are
available on CDC's web site and can be found at: www.cdc.gov/ncidod/diseases/hepatitis.
CDC has also funded 12 viral hepatitis education and training
cooperative agreements with academic centers, health departments and
non-governmental organizations.
Community-based Prevention Programs: To accelerate the integration of
hepatitis C testing, counseling and referral for medical evaluation into
community-based programs that provide clinical and public health
services, CDC has made funding available for Hepatitis C Coordinators.
Currently, there are 53 coordinators in States, large metropolitan
areas, and in the Indian Health Service (IHS). One activity that
coordinators have been involved in is the development of comprehensive
State hepatitis C prevention plans. Currently, 23 States have a plan or
are in the process of developing such a plan. In addition, CDC has
funded the VHIPs in 21 State and local health departments and in the IHS
to provide models and best practices for integration of viral hepatitis
prevention services into clinical and public health programs, such as
those in STD clinics, drug treatment facilities, HIV/AIDS prevention
programs, and correctional settings. Additionally, CDC, in collaboration
with the IHS Division of Epidemiology, provides technical assistance to
Tribes, IHS facilities, Urban Indian Health Programs, and other American
Indian/Alaskan Native groups to implement hepatitis C prevention
activities.
Surveillance and Program Evaluation: Since 2003, chronic HCV infection
has been a condition that is reportable by States to CDC. In 2003, 19
States submitted case reports. CDC has also developed surveillance
guidelines for case investigation and follow-up of persons with chronic
HCV infection. CDC will continue to work to develop and maintain
enhanced national surveillance systems in order to monitor the
effectiveness of hepatitis C prevention efforts. In addition, a study is
underway to evaluate the effectiveness of the VHIPs and determine future
directions for such demonstration projects.
Research: There continue to remain a number of unanswered questions
concerning the epidemiology and natural history of HCV infection that
need to be answered to develop interventions to prevent transmission of
HCV and to prevent disease progression among persons with chronic
infection. Priority areas in which studies are underway or in the
planning stages include those that determine: 1) incidence and risk
factors for HCV transmission among household contacts of infected
persons; 2) risk factors for transmission from mother to infant at
birth; 3) risk of infection from intranasal cocaine use, tattooing, and
body-piercing; 4) prevalence and incidence of infection in incarcerated
populations; 5) risk of infection among steady heterosexual partners of
HCV-infected persons; 6) risk factors for infection among persons on
chronic hemodialysis; 7) the dynamics of HCV acquisition among injection
drug users and the effectiveness of harm reduction strategies in
preventing infection; 8) disease burden, including chronic liver disease
and liver cancer mortality; and 9) risk factors for health care related
transmission.
In conclusion, since 1998, there has been considerable progress made in
raising awareness about the prevention of hepatitis C both among
healthcare providers and the public. In addition, many States have
initiated hepatitis C prevention programs, which are being facilitated
by the federally funded Hepatitis C Coordinators.
To help us make further improvements in this area, CDC has established a
National Viral Hepatitis Roundtable in conjunction with representatives
from national voluntary health organizations, nongovernmental
organizations, professional societies, health insurers, industry, and
other governmental agencies. The Roundtable is designed to coordinate
efforts by CDC and our partners to address hepatitis C and other forms
of viral hepatitis. It helps to make sure efforts of CDC and its
partners are targeted and not duplicated, so we can all make maximum use
of our resources.
Thank you very much for this opportunity to update you on what has
happened with hepatitis C prevention since this was last addressed by
this Committee. I will be happy to answer any questions you may have.
RIMA KHABBAZ, M.D.
Associate Director for Epidemiologic Science
National Center for Infectious Diseases (NCID)
Centers for Disease Control and Prevention
Department of Health and Human Services
Dr. Khabbaz received her B.S. in 1975 and her M.D. in 1979 from the
American University of Beirut (AUB) in Beirut, Lebanon. She first joined
CDC as an Epidemic Intelligence Officer in 1980 after 2 years of
internal medicine training at the AUB Medical Center in Beirut. She
subsequently completed her residency in internal medicine at the Union
Memorial Hospital in Baltimore and a fellowship in infectious diseases
at the University of Maryland. She is board certified in Internal
Medicine. During her CDC career, she has worked primarily in the areas
of infection control in healthcare settings, viral infections including
non-HIV retroviruses and hantavirus, and blood safety. She is currently
Associate Director for Epidemiologic Science in the National Center for
Infectious Diseases (NCID), CDC, and before that was Deputy Director of
the Division of Viral and Rickettsial Diseases, NCID for 5 years. Her
interests include emerging infections, viral diseases, blood safety,
food safety, and the transmissible spongiform encephalopathies. She
played a leading role in developing CDC's programs related to blood
safety and was active in enhancing DVRD's programs under the Food Safety
Initiative. She is a fellow of the Infectious Disease Society of America
(IDSA), and a member of the American Epidemiologic Society, the American
Society for Microbiology, and the American Society of Tropical Medicine
and Hygiene. She served on the Blood Product Advisory Committee of the
Food and Drug Administration from 1995-1999, and on the IDSA's Annual
Meeting Scientific Program Committee from 1999-2002. She is the author
of over 100 research and review papers including book chapters. NCID is
currently working to address domestic and global challenges posed by
emerging infectious diseases and the threat of bioterrorism.
ERIC E. MAST, M.D., M.P.H.
Acting Director, Division of Viral Hepatitis
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Department of Health and Human Services
Dr. Mast is a graduate of the University of Illinois College Of Medicine
and the Harvard School of Public Health. He completed a pediatric
residency at the University of Wisconsin Hospital and Clinics and is
board certified in pediatrics. He joined CDC in 1987 as an Epidemic
Intelligence Service Officer assigned to the Wisconsin Department of
Health and Human Services. Since 1990, Dr. Mast has been working in the
Division of Viral Hepatitis in a variety of positions including Chief of
the Hepatitis Surveillance Unit, Medical Officer assigned to the
Expanded Programme on Immunization at the World Health Organization,
Acting Associate Director for Global Health, and Chief of the Prevention
Branch. He is an author of more than 70 scientific manuscripts. His
primary area of expertise is prevention and control of viral hepatitis.
Dr. Mast is also an officer in the Commissioned Corps of the United
States Public Health Service.
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