Strategic Plan: Implementation and Recommendations

Prevention Focus Area

Overview

Primary prevention of infection with hepatitis viruses can be achieved either through immunization (i.e., HAV or HBV) or through behavioral interventions to reduce risk factors for infection. Secondary prevention attempts to reduce the risk of transmission from those infected to those not infected. Tertiary prevention focuses on persons already infected with hepatitis and includes appropriate medical management and counseling (i.e., avoid alcohol, vaccination if indicated) , in order to prevent further damage to the liver and reduce the risk of chronic liver disease.

Prevention of Hepatitis A

Vaccination is the most effective means to prevent HAV infection and reduce disease incidence. Pre-exposure vaccination is recommended for persons at highest risk for infection and persons for whom infection would result in adverse consequences. These include men who have sex with men, users of injection and non-injection illegal drugs, persons who receive blood product replacement therapy, children and adolescents living in states with historically elevated rates of hepatitis A, travelers to countries with high endemicity for hepatitis A infection and persons with chronic liver disease of any etiology.

Postexposure immunization with immune globulin is >85% effective in preventing hepatitis A after exposure of an unvaccinated person to an infected person if administered less than 2 weeks after exposure. Prompt contact tracing can identify individuals who could benefit from postexposure prophylaxis. In addition, education and counseling regarding modes of transmission and the importance of proper hand washing can help prevent transmission to others.

Since New York State has a relatively low rate of hepatitis A, children are not routinely immunized. However, immunization is recommended for all at-risk adults and adolescents and free vaccine is available through the state-funded "Adult Hepatitis Vaccination Program" at most local health departments.

Prevention of Hepatitis B

Prevention of acute and chronic HBV infection and elimination of HBV transmission in all age groups is most effectively achieved through hepatitis B vaccination. The national strategy to eliminate HBV transmission has four components: 1) prevention of perinatal HBV infection through maternal screening and postexposure prophylaxis of newborns of HBsAg-positive mothers; 2) hepatitis vaccination of all infants to prevent infection in early childhood; 3) vaccination of all adolescents not previously vaccinated; and 4) vaccination of adults in groups at increased risk for infection. Hepatitis B vaccination has been included in routine health care visits for children and adolescents, but not for all adults at risk for infection. In New York State, public health laws have been passed over the past decade that protect infants born to hepatitis B infected mothers and require hepatitis B immunization for entry into daycare, kindergarten, and seventh grade.

Persons aged <19 years who are not covered by private insurance are covered under the federally funded Vaccines for Children Program. However, similar coverage does not exist for adults, and cost reimbursement is a substantial barrier to vaccination for adults. In response to this issue, the NYSDOH established the state funded "Adult Hepatitis Vaccination Program". This program provides free hepatitis A and B vaccine through local health departments to clinic settings that serve high-risk adults, such as STD clinics and HIV counseling and testing sites. In addition, a pilot program is under way in eleven upstate counties to provide hepatitis A and B vaccine to jail inmates. According to studies, approximately 56% of persons with hepatitis B have either been treated for an STD (36%) or incarcerated (29%), in settings where routine hepatitis B vaccination is recommended. Targeting high-risk populations with vaccination and counseling messages has proven to be very successful in reducing the incidence of hepatitis B. For example, federal mandates requiring that all health care workers be offered hepatitis B vaccination and receive education and counseling regarding safe handling of sharps and use of standard precautions has resulted in a significant decrease in the incidence of hepatitis B in this population.

Secondary and tertiary prevention efforts for HBV include identification of persons with HBV infection in order to reduce risks for chronic liver disease through appropriate medical management and education and counseling messages (e.g., do not share personal items with others; use condoms) . In addition, further transmission of HBV can be prevented through contact tracing, testing, and vaccination of those who are susceptible. Immunization with hepatitis B vaccine and/or hepatitis B immuneglobulin (HBIG) within a relatively short period of time after exposure to HBV can effectively prevent acute infection.

Prevention of Hepatitis C

CDC's national strategy to prevent HCV infection includes: 1) prevention of transmission during high-risk activities (e.g., injection drug use and unprotected sex with multiple partners) through risk reduction counseling, testing and appropriate medical management of infected persons; 2) donor screening and product inactivation procedures to eliminate transmission from blood, blood products, donor organs, and tissue; and 3) improved infection control practices to further reduce risk of transmission during medical procedures.

Primary prevention is directed at lowering the incidence of HCV infection. Because no vaccine exists to prevent HCV infection, prevention must focus on risk reduction through counseling of persons who have admitted to, or are at risk for, injection drug use or high risk sexual practices. For injection drug users, access to substance abuse treatment and harm reduction programs, including syringe access, are important HCV prevention measures. Counseling and testing to prevent HCV infection should be conducted in settings where persons at high risk are identified, including STD clinics, HIV/AIDS and substance abuse programs, and correctional settings.

Identification of HCV-infected persons is required to initiate secondary and tertiary prevention activities to reduce the risks for HCV transmission and chronic liver disease. Anti-HCV positive persons require further evaluation for chronic HCV infection and liver disease, and persons with chronic hepatitis C require evaluation for possible antiviral therapy and the need for further medical management. Persons with chronic hepatitis C are at-risk for increased morbidity from additional hepatic insults. Hepatitis A and B can be prevented by vaccination and infected person should be counseled not to use alcohol because its use has been associated with more rapid progression to cirrhosis and liver cancer. Persons chronically infected with, or at risk for, HCV can benefit from health education on topics including substance abuse treatment, clean needle and syringe access and use, risks of sharing drug paraphernalia and condom use. Counseling and educational materials should include information concerning reducing further liver damage, as well as treatment options for those with chronic liver disease.

NYSDOH Prevention Efforts

The NYSDOH has initiated efforts aimed at preventing further transmission of hepatitis infection. In addition to the hepatitis vaccination initiatives previously described, the NYSDOH has published various hepatitis educational materials aimed at the prevention of hepatitis A, B and C and sponsors a Web site devoted to hepatitis at www.health.state.ny.us. NYSDOH staff conducted regional training workshops, including the Fall 2002 Hepatitis Integration Workshops and the Fall 2003 Hepatitis Surveillance Workshops. The Hepatitis B and C Coordinators have participated in state and national conferences, speaking on a variety of hepatitis related topics. The department has formed two hepatitis workgroups, one dedicated to the prevention of hepatitis A and B through vaccination initiatives; the other dedicated to preventing further transmission of viral hepatitis through interagency collaboration with programs that serve high-risk populations. Agencies participating in these workgroups include the NYSDOH's Hepatitis C, HIV/AIDS, STD and Immunization programs, New York State Department of Corrections (DOCS), and the New York State Office of Alcohol and Substance Abuse services (OASAS). Through collaborative efforts, the NYSDOH has also been successful in securing additional CDC funding for a comprehensive hepatitis training initiative.

The NYSDOH AIDS Institute has several programs and harm-reduction initiatives that are instrumental in not only preventing new HIV infections, but in preventing the spread of viral hepatitis. Such programs include:

  • Substance Abuse Initiative The Substance Abuse Initiative is designed to develop a co-located continuum of comprehensive HIV prevention and primary care services in substance abuse treatment settings throughout New York State. Outreach, HIV education, risk/harm reduction services, viral hepatitis services, including access to HCV treatment, capacity building for smaller drug treatment programs and transitional case management for active substance users not in treatment, are also featured in this model. The Substance Abuse Initiative has been instrumental in broadening the mission of the substance abuse treatment community from a singular focus on rehabilitation to the provision of public health service.
  • Harm Reduction Initiative One component of this Initiative is the development of harm reduction/syringe exchange programs. There are currently 13 harm reduction/syringe exchange programs in NYS that have been granted a waiver to obtain, possess and furnish hypodermic syringes and needles without a prescription, in programs designed to reduce the transmission of HIV and other bloodborne pathogens.
  • Expanded Syringe Access Program (ESAP) ESAP is designed to reduce the transmission of bloodborne diseases, including HIV and hepatitis, by enhancing access to clean (new) syringes. Under this program, up to ten syringes may be sold or furnished to a person 18 years of age or older without a prescription by pharmacists, health care facilities and health care practitioners who have registered with the New York State Department of Health. In addition to the above initiatives, the AIDS Institute has been successful in increasing the Medicaid reimbursement for HCV PCR and genotype testing.

In August 2004, the NYSDOH AIDS Institute was awarded a five-year grant from the CDC to reduce the impact and spread of hepatitis infections among injection drug users. This will be accomplished by integrating existing HIV and HCV prevention service delivery models in methadone maintenance treatment programs (MMTP) and by enhancing HAV, HBV and HCV prevention services for injecting drug users not in treatment. More specifically, this entails: 1) modifying and integrating existing HIV and hepatitis training for medical and non-medical staff as well as marketing and educational materials for clients; 2) modifying existing HCV prevention service delivery models to include substance abuse counselors; 3) screening and vaccinating active IDUs for HAV and HBV at two harm reduction sites in the Bronx and Manhattan; 4) strengthening off-site referral linkages for HCV treatment; 5) facilitating access to drug treatment among active IDUs; and 6) replicating program successes in other substance abuse settings. Finally, a statewide hepatitis media campaign has been proposed to increase public awareness regarding the risks for hepatitis and how transmission can be prevented, as well as, the development of provider educational materials and resources such as the integrated risk assessment tool are under way.

Major Themes from the Hepatitis Summit

Participants at the Hepatitis Strategic Planning Summit identified the following major themes in the hepatitis prevention focus area:

  • Increase public and provider awareness and knowledge about viral hepatitis,
  • Develop standardized protocols for screening, testing, counseling, vaccination, referral and treatment for viral hepatitis,
  • Provide hepatitis vaccines to all at risk individuals regardless of ability to pay, and
  • Establish a comprehensive hepatitis referral network.

Long Term Goal # 1: Substantially increase awareness and knowledge about viral hepatitis through a comprehensive statewide viral hepatitis prevention and education initiative.

Strategy # 1:

Develop and implement a targeted statewide consumer media campaign to increase awareness and provide risk reduction messages about viral hepatitis.

Action Plans

  • During years one and two, NYSDOH should:
    • Develop campaign messages, products, and target populations,
    • Identify vendors and pricing for various products, and
    • Identify funding source for the campaign.
  • During year three, NYSDOH should develop campaign products (e.g., posters, brochures, videos, public service announcements).
  • During year four, NYSDOH should implement the media campaign in selected regions of New York State, staggering the release of the various products.
  • During year five, NYSDOH should evaluate the campaign using methods such as phone surveys or Web site visits.

Strategy # 2:

Provide timely continuing education opportunities to primary care providers in New York State on appropriate diagnosis, testing, and management of those at-risk for or infected with hepatitis.

Action Plans

  • During year one, NYSDOH should:
    • Identify managed care organizations (MCOs) and/or large health plans as par tners in educating primary care providers and
    • Identify an academic institution as a par tner to assist with continuing education credits and promotion of programs and materials.
  • During year two, NYSDOH, MCOs, and health plans should:
    • Develop strategies to provide educational programs and materials targeting primary care providers and
    • Review materials currently available from other organizations (i.e., CDC, NIH) .
  • During year three, NYSDOH, MCOs and health plans should:
    • Develop training programs and materials,
    • Obtain continuing education credits for training programs and materials,
    • Set up a schedule for implementation and distribution of materials, and
    • Identify potential sites for continuing education programs.
  • During years four and five, NYSDOH, MCOs and health plans should:
    • Implement programs and distribute materials and
    • Evaluate continuing education programs.

Strategy # 3:

Integrate viral hepatitis education into other appropriate health education materials.

Action Plans

  • During year one, NYSDOH, NYCDOHMH, NYSDOCS, OASAS and other partners should:
    • Collect and review existing educational materials (i.e., booklets, brochures, fact sheets) per taining to HIV, STDs and infection control and determine where viral hepatitis information may appropriately be integrated and
    • Develop a draft of the hepatitis messages/information that could be integrated into these existing materials.
  • During year two, NYSDOH and partners should:
    • Finalize integrated messages,
    • Integrate messages into existing materials such as HIV and STD, and
    • Print materials for distribution.
  • During years three, four, and five, NYSDOH and partners should:
    • Develop distribution plans for materials and distribute accordingly,
    • Post materials on NYSDOH Web site and partners' Web sites, and
    • Maintain supply of materials in NYSDOH distribution center.

Long Term Goal # 2: All providers and appropriate agencies will use NYSDOH viral hepatitis protocols for screening, testing, counseling, vaccination, referral and treatment.

Strategy # 1:

Develop and implement a hepatitis A, B, and C universal risk assessment screening tool for all populations.

Action Plans

  • During year one, NYSDOH should:
    • Develop a list of populations that will most likely use the risk assessment tool,
    • Recruit members and form a workgroup to develop the risk assessment tool,
    • Gather and review current risk assessment screening tools,
    • Draft a universal risk assessment screening tool, and
    • Circulate the draft tool for comments.
  • During year two, NYSDOH should solicit for a vendor to:
    • Conduct focus groups using the risk assessment tool to get further comments and suggestions,
    • Conduct a 6-month pilot of the risk assessment screening tool, and
    • Evaluate the pilot program and make any changes to the risk assessment tool.
  • During year three, NYSDOH should disseminate the risk assessment tool to clinics serving high-risk populations.
  • During years four and five, NYSDOH and workgroup should utilize, evaluate and revise the risk assessment tool.

Strategy # 2:

Develop and implement cost-effective viral hepatitis testing guidelines based on risk assessment.

Action Plans

  • During year one, NYSDOH should:
    • Review existing viral hepatitis testing guidelines (e.g., CDC, other states),
    • Review data and literature on cost-effective strategies for hepatitis testing, and
    • Solicit input from providers and appropriate agencies on draft testing guidelines.
  • During year two, NYSDOH should:
    • Identify sites to conduct pilot testing of guidelines using a cross-section of providers and appropriate agencies,
    • Evaluate results of pilot based on ease of use, number of tests conducted, and cost-effectiveness, and
    • Revise guidelines based on evaluation.
  • During year three, NYSDOH should:
    • Implement the testing guidelines statewide and
    • Educate providers and appropriate agencies on the testing guidelines.
  • During year four, NYSDOH should:
    • Evaluate the effectiveness of the guidelines based on ease of use, number of tests conducted, and cost-effectiveness and
    • Identify areas for improvement.
  • During year five, NYSDOH should:
    • Maintain and update, as needed, the viral hepatitis testing guidelines,
    • Develop strategies for targets areas in need of improvement, and
    • Maintain testing guidelines statewide.

Strategy # 3:

Develop culturally sensitive counseling messages and protocols to incorporate into all aspects of viral hepatitis prevention and care.

Action Plans

  • During year one, NYSDOH should:
    • Work with the CDC, consumers, providers and local health departments to gather existing information,
    • Identify what messages are missing and what needs to be developed, and
    • Convene focus groups to determine how to develop targeted materials (e.g., MSM, IDU, adolescents), types of materials, and methods to deliver the message.
  • During year two, NYSDOH should:
    • Identify sources of funding to suppor t the development of counseling materials,
    • Determine types of materials, target audiences, and languages,
    • Train and educate health care providers and consumers on the materials, and
    • Pilot developed materials.
  • During year three, NYSDOH should revise materials as per pilot results and disseminate materials statewide.
  • During year four, NYSDOH should evaluate impact of the materials through marketing tools, survey research, and/or focus groups.
  • During year five, NYSDOH should revise and distribute updated materials.

Strategy # 4:

Provide hepatitis A and B vaccination to all who are susceptible to viral hepatitis, regardless of ability to pay.

Action Plans

  • During year one, NYSDOH and LHDs should identify facilities/agencies that have the capacity to conduct vaccination services.
  • During years two and three, NYSDOH should:
    • Explore all funding options (federal, state, private) for increasing vaccination efforts and providing incentives to ensure series completion and
    • Expand existing publicly funded vaccination efforts that target populations at risk for viral hepatitis (STD, HIV, inmates and prisoners, IDUs, substance abuse treatment centers, MSMs, persons with chronic liver disease).
  • During year four, NYSDOH and LHDs should:
    • Provide technical assistance to providers and agencies to acquire personnel/resources necessary to provide vaccination services and
    • Identify strategies (i.e., work with medical associations and insurers) to promote hepatitis vaccination in the private sector.
  • During year five, NYSDOH and partners should:
    • Assess the effectiveness of existing and newly initiated vaccination efforts and
    • Identify barriers/access issues and modify implementation, as needed.

Strategy # 5:

Establish a referral network that ensures people have universal access for appropriate, timely services and treatment for viral hepatitis, regardless of ability to pay.

Action Plans

  • During year one, NYSDOH and partners should:
    • Conduct and publish a comprehensive sur vey of existing providers of viral hepatitis services,
    • Institute a regional gaps analysis of the completed survey,
    • Assist with expansion of services and addition of services where needed, and
    • Maximize efficacy and access by bundling services into existing programs where targeted populations receive services.
  • During year two, NYSDOH and partners should implement mechanisms to manage/update referral network on a yearly basis.
  • During years three, four and five, NYSDOH and LHDs should:
    • Develop Centers of Excellence utilizing existing universities, medical centers, community health centers,
    • Utilize the CDC model to bring together providers and consumers to provide feedback and recommendations, and
    • Utilize needs assessment and gaps analysis to determine additional resources and ways to access services through public and private sector.