Hepatitis: Blah Blah Blah - CDC Viral Hepatitis Action Coalition

Workforce Development for Viral Hepatitis
Screening and Care: CDC Perspective
Alycia Downs, MPH
Cynthia Jorgensen, DrPH
Viral Hepatitis Action Coalition Meeting – AASLD
October 31, 2010

Institute of Medicine’s Report
Key Finding
There is a lack of
knowledge and
awareness about chronic
viral hepatitis on the part
of the health care
providers which impedes
current efforts to prevent
and control these
diseases.

IOM Recommendation
• Recommendation 3-1. The Centers for Disease
Control and Prevention should work with key
stakeholders to develop hepatitis B and
hepatitis C educational programs for healthcare
and social-service providers.

CDC Challenges
• Resources
• Mission of CDC vs. other federal agencies
• Public health covers a broad spectrum of issues
and audiences
– Clinicians
– Public health workforce
– Consumers
– Persons at risk
• Traditional public health audiences vs. everyone
– “low hanging” fruit vs. underserved and most at need

How can CDC implement this
recommendation to increase
knowledge and awareness of
health care providers

What CDC Has Done and Can Do
• Select CDC Examples – reaching health care
providers
– Immunization Education and Trainings
– Clinician Outreach and Communication Activity
– STD Training in Medical School Curriculum
– NCHHSTP Training Overview
• What Division of Viral Hepatitis is currently doing
– Cooperative Agreements with Educational Institutions
– State and local government
– Professional Tools, Trainings & Resources
– Other groups

CDC Examples

Immunization Education & Training
• Immunization courses
– Several formats: broadcasts, webcasts, DVD, CD ROM
and web-based
• Epidemiology & Prevention of Vaccine-
Preventable Diseases Course
– Principles of vaccination, recommendations, immunization
strategies, vaccine-preventable diseases and vaccines
• NetConferences: Current Issues in Immunization
– Live, 1-hour presentations with question and answer session
• On-Site Training
– Live course by CDC trainers, available for a state or region.
• Podcasts
– Download to desktop and portable music/video player

Clinician Outreach and
Communication Activity (COCA)
• CDC’s Emergency Communication System
• Partner with over 180 clinician organizations
• Connect directly with clinicians
• Work collaboratively in times of emergency &
preparedness
• Provide tools, training and consultation
• Evaluation data show direct impact on clinical
practice

Medical School Curriculum
• National Center for HIV, Viral Hepatitis, STDs and
TB Prevention (NCHHSTP) worked to integrate
comprehensive STD training into medical school
curriculum
• IOM report advocates for development of improved
curricula to ensure graduates are knowledgeable
about chronic viral hepatitis
– Prevalence, risk factors, preventive actions, appropriate
diagnostics, screening recommendations, appropriate
follow-up for chronically infected and those susceptible to
infection

NCHHSTP Training Overview
• Division of HIV/AIDS Prevention & Division of STD
Prevention jointly fund the Prevention Training
Centers
– Part I: STD Clinical Training - 10 regional sites
– Part II: Behavioral Interventions – 4 regional sites
– Part III: Partner Services & Program Support Training –
4 regional sites
• Division of Tuberculosis Elimination funds the TB
Regional Training and Medical Consultation
Centers
– 4 regional sites

The Federal Training
Centers Collaboration (FTCC)
• The purpose of the FTCC is to increase
collaboration among DHHS funded training
centers involved in educating health care
workers about HIV/AIDS and other comorbidities
that affect similar populations
• Primary focus on HIV/AIDS due to funding
• There are no viral hepatitis “training centers”
– Represent two training cooperative agreements

Division of Viral Hepatitis
Examples

HepWebStudy.org
• University of Washington
– Purpose: To educate clinicians on prevention,
management and treatment of hepatitis A,B, and C
– Format: interactive, clinically-relevant case studies.
– Free CME and CNE credits available
– Audience: Physicians, other clinicians
– Web-based trainings to reach the maximum numbers
– Funded at $150,000/year

KnowHepatitis.org
• University of Alabama, Birmingham
– Purpose: To enhance knowledge and skills by providing
practice-focused opportunities on viral hepatitis
prevention and control
– Format: distance learning
– Target Audience: Frontline workers in community based
organizations and clinics–those in direct contact with
people who are at risk for viral hepatitis
– Actual Audience: Frontline workers and health care
providers (physicians and nurses)
– Funded at $150,000/year

Adult Viral Hepatitis Prevention
Coordinators
• One CDC funded position per state/territory and
select cities
• Coordinators provide the technical expertise for
activities directed toward prevention of viral
hepatitis infections and integration of prevention
services into health care settings and public health
programs

CDC – Web Based Resources
• Viral Hepatitis Serology Training
– Target Audience: Physicians, Registered Nurses, Public
Health Professionals
– Objectives:
• Understand the different serologic tests for hepatitis
• Understand the serological diagnosis of hepatitis,
acute and chronic
• Understand the meanings of serologic markers and
interpret serologic test results
• Professional Tools and Cheat Sheets
– Professional Resource Center

www.cdc.gov/hepatitis

Medscape
• CDC Expert Commentary Series
– Dr. Ward - Screening Asian Patients for Chronic
Hepatitis B
• CME activity based on CDC’s chronic hepatitis B
testing guidelines

Next Steps:
A National Education Campaign

Our Vision for a National Campaign
Goal: Decrease the disease burden of
viral hepatitis
• Raise awareness
• Engage opinion leaders, policy makers,
media, & the public
• Change perceptions & decrease stigma
• Educate providers & build capacity
• Encourage testing
• Save lives with early intervention

Campaign Strategies
• Implemented in 3 overlapping phases
• Multi-media strategies tailored for each phase
• Provider education strategically planned prior
to the direct-to-consumer component
• Separate public campaigns for hepatitis B
and hepatitis C
• Supplemented by education and community
mobilization grants
• Pilot tested in 3 different cities

Campaign Phases
Phase I Opinion Leaders, Policy Makers, Media,
Healthcare Providers, General Public
Raise
Awareness
Support
Action
Phase II
Educate
About
Hepatitis &
Guidelines
Build
Capacity to
Screen,
Refer, Treat
Healthcare Providers
Phase III Populations at Risk
Encourage Testing

Community
Mobilization
Spheres of Influence
General Public
Opinion
Leaders
&
Policy
Makers
Healthcare Providers
Populations at Risk
B C

Proposed Communication Channels
Opinion
Leader
Outreach
News/Media
Advocacy
Digital &
Social Media
Professional
Education
National
Education
Campaign
Public Service
Advertising
(earned &
paid if
possible)
Community
Mobilization
& Outreach
Special
Events
Public-
Private
Partnerships
Collateral
Materials

Potential Campaign Messages
• Millions of Americans are living with hepatitis –
many don’t know it
• Hepatitis is a leading cause of liver cancer
• Early intervention can save lives
• 1 in 12 Asian Americans has
hepatitis B
• Protect your loved ones
• New treatments are helping
people live longer, healthier lives
Phase I
Provider Education and Capacity Building
Phase II
Educate about Viral Hepatitis &
Existing & Upcoming Recommendations
Phase III
•1 in 30 Baby Boomers has hepatitis C
• 3 of every 4 people with this disease
may not know they are infected
• If you are at risk, get tested
•Treatment can eliminate the virus

Campaign Planning Process
• News media outreach - ongoing
• Formative or Market Research
– Providers
– Public
• Strategies and Material Development
– Developed and vetted
– Tested in controlled settings
– Implemented in pilot cities
• Roll out of National Campaign

Findings from the Literature
Provider Knowledge and Attitudes
• Inadequate knowledge
– Risk factors ─ Screening/Testing
– Disease progression ─ Treatment
• Stigma associated with disease
• Perceptions about treatment efficacy are not
current
Provider Practices
• Risk assessment often not done
• Screening often not performed

Findings – con’t
Clinical Features
• Infection goes unnoticed until symptoms of
advanced liver disease develop
Patient Factors
• Patients avoid disclosing risk behaviors due to
stigmatization
System Issues
• Lack of coverage or reimbursement may hinder
screening
• Screening guidelines inconsistent

Resulting in…
• Lack of screening
• Confusion over guidelines
• Patients failing to receive:
– Risk assessment
– Screening
– Vaccination
– Clinical testing
– Treatment

CDC’s Response
• Issuance of guidelines/recommendations
• Formative research
• Intervention research and evaluation
• Technical assistance
• Support/funding for medical education
• Development and dissemination of trainings
• Fostering collaborations and partnerships

Proposed Research Questions
Primary Care Providers
• Do they screen for viral hepatitis Why or why not
• What influences their screening behavior
– Knowledge levels
– Patient preference
– System or organizational influences
• Are they aware of CDC’s guidelines
– Chronic Hepatitis B vs. Hepatitis C
• What can we learn from awareness of CDC’s
chronic B guidelines to help in planning for new
hepatitis C guidelines
• Which organizations/guidelines have the most
influence and credibility

Thank you
For more information, please contact the Centers for Disease Control and Prevention
Division of Viral Hepatitis
1600 Clifton Rd, Mail Stop G-37
Atlanta, Georgia 30333
404-718-8596
www.cdc.gov\hepatitis