IOM Report Says Primary Care Docs Lack Knowledge About Hepatitis B, Hepatitis C

[Guest guest]

http://www.aafp.org/online/en/home/publications/news/news-now/clinical-care-rese\

arch/20100407iom-hep-rpt.html

IOM Report Says Primary Care Docs Lack Knowledge About Hepatitis B, Hepatitis C

Committee's Call for Increased Screening Conflicts with AAFP, USPSTF Recs

By

4/7/2010

According to a report from the Institute of Medicine, or IOM, inadequate

resources are being allocated to viral hepatitis prevention, control and

surveillance programs in the United States, and a lack of awareness among health

care professionals and people in at-risk populations is creating a barrier to

prevention and control efforts.

This transmission electron micrograph reveals the presence of hepatitis B

virions. The large round virions are known as Dane particles. Many health care

providers -- especially primary care health professionals -- are unaware of the

high prevalence of hepatitis B virus, or HBV, and hepatitis C virus, or HCV,

infection in some U.S. populations and often fail to identify infected

individuals and those at risk for infection so they can be managed

appropriately, says the report.

However, some of the actions recommended in the report -- specifically those

related to screening -- conflict with existing guidelines from the AAFP and the

U.S. Preventive Services Task Force, or USPSTF.

Lack of Awareness Creates Barrier

About 5 million Americans are living with chronic hepatitis B or hepatitis C,

says the report, and an estimated 43,000 Americans develop acute HBV infections

each year. In addition, 15,000 people annually die of liver disease related to

hepatitis B or hepatitis C.

" Unless action is taken to prevent chronic hepatitis B and hepatitis C,

thousands more Americans will die each year from liver cancer or liver disease

related to these preventable diseases, " the report warns.

It singles out primary care providers (e.g., physicians, physician assistants

and nurse practitioners) and social services providers (e.g., staff of drug

treatment programs, needle-exchange programs and immigrant services centers) as

having " generally poor " knowledge of chronic hepatitis B and hepatitis C.

For example, says the report, one survey of primary care health professionals

found that 44 percent of respondents didn't know that chronic HBV infection

could be controlled with medication.

The report calls for improved surveillance and integration of viral hepatitis

services. Specifically, it recommends that the CDC collaborate with stakeholders

-- including professional and health care organizations and educational

institutions -- to develop educational programs for health care and social

services providers that address factors such as

•the overall incidence and prevalence of acute and chronic HBV and HCV

infection;

•guidance on screening for risk factors;

•prevention strategies and monitoring of chronically infected patients;

•prevention of transmission in health care settings; and

•health care disparities related to hepatitis B and hepatitis C.

Appropriate Vaccination Is Key to Prevention

The CDC's Advisory Committee on Immunization Practices, or ACIP, has recommended

that children in the United States receive routine hepatitis B vaccinations

since 1991. According to the CDC, (2-page PDF; About PDFs) the reported

incidence of acute HBV infection in children and adolescents dropped by more

than 95 percent from 1991 to 2007, and the overall incidence among all age

groups decreased by 75 percent.

A 2008 CDC survey estimated that nearly 92 percent of teens ages 13-15 had

completed the three-dose hepatitis B vaccine series.

Still, say the report's authors, in 2004, less than 55 percent of adults

considered to be at increased risk for HBV infection had received the vaccine.

Among health care workers, who are one of the groups recommended for

vaccination, (2-page PDF; About PDFs) only 75 percent had received the

three-dose vaccine series.

Sepulveda, M.D., vice president of integrated health services for IBM

Corp. and a member of the IOM committee that produced the report, told AAFP News

Now that there were few instances when the committee was at odds with the ACIP's

recommendations. However, he noted, committee members wanted more clarity from

the USPSTF regarding subpopulations for whom routine, aggressive HBV screening

is warranted.

IOM Differs From USPSTF in Defining " Screening "

The IOM committee defined a two-part process for identifying infected

individuals:

•risk-factor screening (i.e., determining whether a person is at risk for being

chronically infected or becoming infected with HBV or HCV, such as by being born

in a country where the disease is prevalent or engaging in specific high-risk

behaviors, including illicit drug use and having multiple sexual partners) and

•serologic testing (i.e., laboratory testing of blood specimens for biomarker

confirmation of hepatitis B or hepatitis C viral infection).

From that perspective, said Sepulveda, " screening " doesn't necessarily mean

serologic testing but, rather, screening for risk by first asking questions. For

primary care physicians, he added, this means that they need to understand not

only where their patients were born, but also where their patients' parents were

born, because the risk is highest for first-generation immigrants.

Both the AAFP and the USPSTF recommend using serologic testing to screen all

pregnant women for HBV during their first prenatal visit. However, the two

groups recommend against routinely screening the general asymptomatic population

for chronic HBV infection, saying that strategies used to identify individuals

at high risk have poor predictive value because 30 percent to 40 percent of

infected individuals don't have any easily identifiable risk factors.

The main risk factors for HBV infection in the United States, according to the

USPSTF, include

•diagnosis with an STD,

•a history of intravenous drug use or sexual contact with multiple partners,

•male homosexual activity, and

•household contacts of chronically infected individuals.

In addition to the at-risk groups specifically identified by the USPSTF, the

American Association for the Study of Liver Diseases, or AASLD, recommends that

the following groups also be screened for HBV infection using serologic testing:

•inmates of correctional facilities;

•people with chronically elevated alanine transaminase or aspartate transaminase

levels;

•people infected with HCV or HIV;

•patients undergoing renal dialysis; and

•people born in areas with high and intermediate prevalence rates of HBV

infection.

In the long term, said Doug Campos-Outcalt, M.D., M.P.A., who is the AAFP's

liaison to the ACIP, concerns about hepatitis B screening could prove moot,

given the continuing success of national efforts to boost hepatitis B vaccine

uptake among children and adolescents.

Hepatitis C Screening Also at Issue

The IOM report is similarly critical of primary care health professionals'

knowledge about hepatitis C, although it acknowledges that far less research has

been published on this topic.

The AAFP and the USPSTF recommend against routine screening for HCV infection in

asymptomatic adults who are not at increased risk. In addition, the Academy and

the task force have found insufficient evidence to recommend for or against

routine screening for HCV infection in adults at high risk for infection.

The USPSTF said in its recommendations that it found no evidence that screening

for HCV infection in high-risk adults improves long-term health outcomes.

Campos-Outcalt, who also is associate head of the department of family and

community medicine at the University of Arizona College of Medicine, Phoenix,

and the AAFP's staff liaison to the USPSTF, reiterated that hepatitis C

screening has not been shown to improve long-term outcomes; in addition, it

increases health care costs.

Sepulveda, however, said increased screening for those at high risk could help

prevent the spread of disease. He also said the committee's recommendations were

based on more recent data than the AAFP and USPSTF recommendations, which were

made in 2004.

[Guest guest]

http://www.aafp.org/online/en/home/publications/news/news-now/clinical-care-rese\

arch/20100407iom-hep-rpt.html

IOM Report Says Primary Care Docs Lack Knowledge About Hepatitis B, Hepatitis C

Committee's Call for Increased Screening Conflicts with AAFP, USPSTF Recs

By

4/7/2010

According to a report from the Institute of Medicine, or IOM, inadequate

resources are being allocated to viral hepatitis prevention, control and

surveillance programs in the United States, and a lack of awareness among health

care professionals and people in at-risk populations is creating a barrier to

prevention and control efforts.

This transmission electron micrograph reveals the presence of hepatitis B

virions. The large round virions are known as Dane particles. Many health care

providers -- especially primary care health professionals -- are unaware of the

high prevalence of hepatitis B virus, or HBV, and hepatitis C virus, or HCV,

infection in some U.S. populations and often fail to identify infected

individuals and those at risk for infection so they can be managed

appropriately, says the report.

However, some of the actions recommended in the report -- specifically those

related to screening -- conflict with existing guidelines from the AAFP and the

U.S. Preventive Services Task Force, or USPSTF.

Lack of Awareness Creates Barrier

About 5 million Americans are living with chronic hepatitis B or hepatitis C,

says the report, and an estimated 43,000 Americans develop acute HBV infections

each year. In addition, 15,000 people annually die of liver disease related to

hepatitis B or hepatitis C.

" Unless action is taken to prevent chronic hepatitis B and hepatitis C,

thousands more Americans will die each year from liver cancer or liver disease

related to these preventable diseases, " the report warns.

It singles out primary care providers (e.g., physicians, physician assistants

and nurse practitioners) and social services providers (e.g., staff of drug

treatment programs, needle-exchange programs and immigrant services centers) as

having " generally poor " knowledge of chronic hepatitis B and hepatitis C.

For example, says the report, one survey of primary care health professionals

found that 44 percent of respondents didn't know that chronic HBV infection

could be controlled with medication.

The report calls for improved surveillance and integration of viral hepatitis

services. Specifically, it recommends that the CDC collaborate with stakeholders

-- including professional and health care organizations and educational

institutions -- to develop educational programs for health care and social

services providers that address factors such as

•the overall incidence and prevalence of acute and chronic HBV and HCV

infection;

•guidance on screening for risk factors;

•prevention strategies and monitoring of chronically infected patients;

•prevention of transmission in health care settings; and

•health care disparities related to hepatitis B and hepatitis C.

Appropriate Vaccination Is Key to Prevention

The CDC's Advisory Committee on Immunization Practices, or ACIP, has recommended

that children in the United States receive routine hepatitis B vaccinations

since 1991. According to the CDC, (2-page PDF; About PDFs) the reported

incidence of acute HBV infection in children and adolescents dropped by more

than 95 percent from 1991 to 2007, and the overall incidence among all age

groups decreased by 75 percent.

A 2008 CDC survey estimated that nearly 92 percent of teens ages 13-15 had

completed the three-dose hepatitis B vaccine series.

Still, say the report's authors, in 2004, less than 55 percent of adults

considered to be at increased risk for HBV infection had received the vaccine.

Among health care workers, who are one of the groups recommended for

vaccination, (2-page PDF; About PDFs) only 75 percent had received the

three-dose vaccine series.

Sepulveda, M.D., vice president of integrated health services for IBM

Corp. and a member of the IOM committee that produced the report, told AAFP News

Now that there were few instances when the committee was at odds with the ACIP's

recommendations. However, he noted, committee members wanted more clarity from

the USPSTF regarding subpopulations for whom routine, aggressive HBV screening

is warranted.

IOM Differs From USPSTF in Defining " Screening "

The IOM committee defined a two-part process for identifying infected

individuals:

•risk-factor screening (i.e., determining whether a person is at risk for being

chronically infected or becoming infected with HBV or HCV, such as by being born

in a country where the disease is prevalent or engaging in specific high-risk

behaviors, including illicit drug use and having multiple sexual partners) and

•serologic testing (i.e., laboratory testing of blood specimens for biomarker

confirmation of hepatitis B or hepatitis C viral infection).

From that perspective, said Sepulveda, " screening " doesn't necessarily mean

serologic testing but, rather, screening for risk by first asking questions. For

primary care physicians, he added, this means that they need to understand not

only where their patients were born, but also where their patients' parents were

born, because the risk is highest for first-generation immigrants.

Both the AAFP and the USPSTF recommend using serologic testing to screen all

pregnant women for HBV during their first prenatal visit. However, the two

groups recommend against routinely screening the general asymptomatic population

for chronic HBV infection, saying that strategies used to identify individuals

at high risk have poor predictive value because 30 percent to 40 percent of

infected individuals don't have any easily identifiable risk factors.

The main risk factors for HBV infection in the United States, according to the

USPSTF, include

•diagnosis with an STD,

•a history of intravenous drug use or sexual contact with multiple partners,

•male homosexual activity, and

•household contacts of chronically infected individuals.

In addition to the at-risk groups specifically identified by the USPSTF, the

American Association for the Study of Liver Diseases, or AASLD, recommends that

the following groups also be screened for HBV infection using serologic testing:

•inmates of correctional facilities;

•people with chronically elevated alanine transaminase or aspartate transaminase

levels;

•people infected with HCV or HIV;

•patients undergoing renal dialysis; and

•people born in areas with high and intermediate prevalence rates of HBV

infection.

In the long term, said Doug Campos-Outcalt, M.D., M.P.A., who is the AAFP's

liaison to the ACIP, concerns about hepatitis B screening could prove moot,

given the continuing success of national efforts to boost hepatitis B vaccine

uptake among children and adolescents.

Hepatitis C Screening Also at Issue

The IOM report is similarly critical of primary care health professionals'

knowledge about hepatitis C, although it acknowledges that far less research has

been published on this topic.

The AAFP and the USPSTF recommend against routine screening for HCV infection in

asymptomatic adults who are not at increased risk. In addition, the Academy and

the task force have found insufficient evidence to recommend for or against

routine screening for HCV infection in adults at high risk for infection.

The USPSTF said in its recommendations that it found no evidence that screening

for HCV infection in high-risk adults improves long-term health outcomes.

Campos-Outcalt, who also is associate head of the department of family and

community medicine at the University of Arizona College of Medicine, Phoenix,

and the AAFP's staff liaison to the USPSTF, reiterated that hepatitis C

screening has not been shown to improve long-term outcomes; in addition, it

increases health care costs.

Sepulveda, however, said increased screening for those at high risk could help

prevent the spread of disease. He also said the committee's recommendations were

based on more recent data than the AAFP and USPSTF recommendations, which were

made in 2004.