Hepatitis and Primary Care Integration

In the United States, the most common types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C. According to CDC estimates, 3.5 million people in the United States are living with the hepatitis C virus (HCV) and over 850,000 people are living with the hepatitis B virus (HBV, CDC, 2017). Recent outbreaks of hepatitis A, hepatitis B, and hepatitis C have been linked to the opioid epidemic through both injection and non-injection drug use (CDC, 2018). Although baby boomers (adults born between 1945-1965) have the highest prevalence of chronic hepatitis C infection, the highest incidence of new hepatitis C cases occurs among young adults aged 20-29 years (CDC, 2017).

Many individuals at risk for or living with viral hepatitis are members of vulnerable populations and underserved communities. These individuals may also be at risk for other illnesses or chronic conditions, including HIV and substance use disorder.

Health centers emphasize coordinated and comprehensive care, and the ability to manage patients with multiple health care needs. Primary care integration of viral hepatitis testing, vaccination, other prevention, care, and treatment can increase access and improve health outcomes for at-risk patients and patients with chronic infection. Health centers report data on hepatitis B and hepatitis C testing and diagnoses as part of the Uniform Data System.

• In 2017, health centers tested 718,715 patients for hepatitis B and provided services to 47,790 patients diagnosed with hepatitis B.
• In 2017, health centers tested 966,976 patients for hepatitis C and provided services to 208,508 patients diagnosed with hepatitis C.

Action Steps and Guidelines for Health Centers

The National Viral Hepatitis Action Plan 2017-2020 details specific opportunities for health care providers, patients, and community leaders to help address viral hepatitis. Hepatitis A and hepatitis B are vaccine preventable. Viral hepatitis testing and vaccination are covered preventive services (CDC, 2016). Viral hepatitis can be a short-term illness, but hepatitis B and hepatitis C can become a long-term chronic infection.

Health centers working to improve viral hepatitis clinical quality and advance integration of hepatitis-related services into primary care may benefit from the following resources.

Screen and Understand Results

The only way to diagnose chronic viral hepatitis is blood testing. Viral hepatitis screening includes multiple tests and can be complex. These resources may help to identify which tests are most appropriate for your patient.

• The U.S. Preventive Services Task Force (USPSTF) has published recommendations to screen for hepatitis B in pregnant women as well as hepatitis B and hepatitis C in persons at high risk for infection.
• CDC provides these resources on viral hepatitis screening:
  
  • Hepatitis A, hepatitis B, and hepatitis C testing guidelines and recommendations that include PDF resources for testing sequences and interpreting test results;
  • Hepatitis B testing guidelines, recommendations, and resources for pregnant women and infants to prevent perinatal transmission of hepatitis B; and
  • Hepatitis B and hepatitis C testing and diagnosis FAQs for health professionals.

Vaccinate

Safe and effective vaccines are available for hepatitis A and hepatitis B. These vaccines are routinely provided during the primary infant vaccination series and are recommended for vulnerable adolescents and adults as well as anyone seeking protection. There is no vaccine for hepatitis C.

• Vaccines.gov provides overall guidance on the hepatitis A vaccine and hepatitis B vaccine that includes who needs to get the vaccines and the vaccination schedules.
• CDC provides these resources on hepatitis A and hepatitis B vaccination:
  
  • Hepatitis B vaccination guidelines and recommendations for infants, children, and adolescents and for adults; and
  • Hepatitis A vaccine and hepatitis B vaccine FAQs for health professionals.

Treat Disease and Manage Patients

Safe and effective treatments for hepatitis B and hepatitis C are available. These treatments have been shown to reduce the likelihood of developing cirrhosis and liver cancer. They consist of oral medications and in the case of hepatitis C, treatment can result in a virologic cure.

There are also many interventions providers can recommend for people with chronic hepatitis B and hepatitis C to stay healthy and decrease the chance of disease progression. These include reducing alcohol intake, maintaining a healthy weight, using care with over-the-counter medications, and receiving regular care including monitoring for liver cancer.

• CDC provides these resources on managing persons with chronic hepatitis B or hepatitis C infection:
  
  • Hepatitis B testing and public health management; and
  • Hepatitis C management and treatment FAQ for health professionals.
• The American Association for the Study of Liver Diseases (AASLD) develops evidence-based practice guidelines for treating hepatitis B and hepatitis C. 
• HCVguidelines.org provides recommendations for testing, managing, and treating hepatitis C.

Provider Training and Resources

• HRSA:
  

  • HRSA hosted “HEP Talks” in May 2019 as part of Hepatitis Awareness Month. Like TED Talks, these were condensed and informative presentations focused on emerging and important viral hepatitis topics.

    Each session featured a brief talk by a viral hepatitis expert followed by an opportunity for discussion and questions. View the recordings below:

    • Hepatitis B Testing
    • Hepatitis C and the Opioid Epidemic
    • Hepatitis C and the Cure
    • Hepatitis B and Perinatal Transmission
  • Health Center Care Delivery Models for Primary Care Integration of Viral Hepatitis and Substance Use Disorder Treatment (2018) – On-Demand Webinar
  • Health Center Strategies to Advance Prevention of Perinatal Transmission of Hepatitis B (2017) – On-Demand Webinar
• CDC:
  
  • Viral Hepatitis Serology Training videos
  • Know Hepatitis B and Know More Hepatitis (Hepatitis C) multilingual patient education campaign and materials
  • 5-minute Hepatitis Risk Assessment for patients
  • Hepatitis C Counseling and Testing Manual for use in primary care practices
• Additional Resources:
  
  • AIDS Education and Training Centers Program:
    
    • National HIV/HCV Co-infection Curriculum  with free continuing education credits (2017)
    • National Clinician Consultation Center Hepatitis C Consultation Service (Warmline)  with online or phone consultations
  • Addiction Technology Transfer Center Network: HCV Current online curriculum and resources for medical and behavioral health professionals at health centers (2017)
  • University of Washington: Hepatitis C Online curriculum with free continuing education credits
  • National Nurse-Led Care Consortium (a HRSA-funded National Cooperative Agreement): Hepatitis Awareness Month Webinar Series with free continuing education credits (2018)
    
    • Part 1: Implications of National Trends in Opioid Use and HCV Infection
    • Part 2: Best Practices for HCV Programming at Health Centers
    • Part 3: Sustaining HCV Programming at Your Health Center