DEP Paper

HEPATITIS B & C DESCRIPTIVE EPIDEMIOLOGY 1

City of Garland Hepatitis B & C Descriptive Epidemiology Report

Students

HHPH 416: Epidemiology

December 2, 2018

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 2

TABLE OF CONTENTS

Part 1: Overview of Hepatitis B & C………..…………………………………………………….3

Part 2: Insight About Selected Health Problem…………………………………….……………10

Part 3: Proposed Solutions……….………………………………………………………………12

Model Programs…………………………………………………………….……………14

Program Proposal………………………………………………………………………...18

Policies and Statutes………………….………………………………………………….19

Conclusion……………………………………………………………………………………….20

References………………………………………………………………………………………..22

Appendices…………………………………………………………………………….…………26

A. Hepatitis C Incidence Rates by State…………………………………………………….26

B. Incidence of Acute Hepatitis C by Race/Ethnicity ……………………………………...28

C. Program outline for B Positive Program………………………………………………...30

D. Map of States with Hep B Mandates ……………………………………………………32

E. Infographic ………………………………………………………………………………34

F. List of Helpful Resources……………...………………………………………………...36

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 3

Part 1: Overview of Hepatitis B and C

There currently is not any local data on the city of Garland for Hepatitis B and C.

Whereas, Hepatitis B and C were not mentioned in the Garland 2017 Community Health

Assessment, or in the 2018 Key Findings of the Community Health Assessment. For the purpose

of this paper, data was extracted from the county, state, and national levels and were applied, and

framed to be relevant for the Garland Public Health Department.

Currently Dallas County has a Hepatitis B (HBV) vaccination rate of 98% amongst

children according to the Dallas County 2016 Community Needs Assessment. This is a relatively

high rate compared to the national average of 90% (CDC, 2016a). While these rates may be high,

the problem lies within keeping the rates at this level. Whereas, with growing controversy

towards vaccines and more parents opting out from vaccinating their children, this rate may

begin to dwindle amongst children and adults. There currently is not any data on adult

vaccination rates in Dallas County or Garland however, Hepatitis B vaccination rates amongst

adults greater than 18 are problematic, as the national vaccination rate is currently at 25% (CDC,

2018b). As the nation struggles with Hepatitis B vaccination rates it is safe to assume that

Garland has similar percentages. A large contributor for these low rates is due to low vaccination

of high-risk adults as a result of the difficulty of identifying high risk candidates (CDC, 2017).

Increasing adult Hepatitis B vaccination rates amongst at-risk groups should be a priority for all

health departments within the United States.

Hepatitis C (HCV) rates in Texas vary amongst counties and are larger in counties with

major cities and counties located near the Texas - Mexican Border. Dallas county, where the city

of Garland is located, is a county that has higher rates of Hepatitis C at approximately 2%

(Yalamanchili, Saadeh, Lepe, & Davis, 2017) This number is significant as Hepatitis C is the

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 4

most common indicator for liver transplantation (Yalamanchili, Saadeh, Lepe, & Davis, 2017)

Therefore, Hepatitis C puts a burden more so on transplant and health care facilities in areas

where Hepatitis C is prevalent such as Dallas County. Therefore, with stakes as high as these, it

is imperative for all health entities to contribute and work together to help reduce Hepatitis C

incidence rates.

Hepatitis B and C are diseases that adversely affect the liver. There are acute and chronic

infections of Hepatitis B and C. Acute infection symptoms for both illnesses range from

asymptomatic to mild disease lasting anywhere from a few weeks up to six months. Compared to

chronic infections that lead to cirrhosis, liver cancer, hepatocellular carcinoma. Nearly 50% of

children who are infected with Hepatitis B will develop chronic HBV and the individual will

most likely deal with the infection the rest of their life. Whereas, 95% adults who are infected

with Hepatitis B infection completely recover and do not progress to the chronic stages of the

illness. One out of every four children diagnosed with chronic HBV will die prematurely

compared to 1 out of every 7 adults who die prematurely as a result of chronic HBV. Hepatitis C

will develop into chronic HCV in approximately 3 out of every 4 people diagnosed with HCV.

Out of those who develop chronic HCV 10 to 20 percent of cases will eventually develop

cirrhosis.

Hepatitis B is a sexually transmitted infection that can also be spread through various

different avenues. Whereas both diseases may be transmitted through infectious blood, HBV

may also be transmitted through other fluids such as semen or other bodily fluids. Those who are

at a higher risk of contracting Hepatitis B are; men who have sex with men, sex partners of

infected person, injection drug users, healthcare and public safety workers. (CDC, 2018a) Those

who are at a higher risk of contracting Hepatitis C are; injection drug users, recipients of donor

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 5

blood, people with HIV infection, babies born to an HCV-infected mother, prisoners or someone

who has ever been in prison, those who received tattoos from an unsterile environment, and

anyone who used a clotting factor concentrate before 1987 (CDC, 2018b; Mayo Clinic, 2018) .

Lack of vaccination and/or engaging in risky behaviors increases the morbidity and

mortality rates of Hepatitis B & C. The World Health Organization (2018) analyzed that around

600,000 people worldwide died of Hepatitis B associated diseases, such as acute and chronic

liver disease. Advanced chronic Hepatitis B & C virus infections may lead to mortality. In the

United States alone, 3,000 to 4,000 people die of Hepatitis B and these are just cases related to

cirrhosis, this does not include cases of mortality from other complications (CDC, 2017b). An

additional 1,000 to 1,500 people die a year in the United States from cancer due to Hepatitis B

(CDC, 2017b).

Different types of determinants contribute to Hep B & C, such as age, sex, and marital

status. For example, in terms of age the group that has the greatest risk of contracting Hepatitis B

include newborn babies and toddlers, this means the carrier risk decreases as people get older

(CDC, 2018c). Figure 1 illustrates the risk associated with children under five contracting

Hepatitis B.

Figure 1

Risk of Chronic HBV Carriage by Age of Infection from 1978-2012

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 6

Although children can get the Hepatitis B virus relatively easier compared to adults,

adults account for the age group that has the most cases of Hepatitis B and C in both acute

infections and chronic infections. Following adults, adolescents make up for the majority of

cases regarding acute infections, in the chronic infection cases the perinatal age group makes the

majority as well. Lastly, children and adults make up the smallest share of acute infections while

chronic infections have adolescents and children making up the smallest share. It is important to

categorize the types of infections among Hepatitis B and C because they affect different age

groups. The distribution of acute and chronic infections of Hepatitis B is illustrated in Figure 2.

Figure 2

Distribution of Chronic and Acute Hepatitis B infections

Note. Data for HBV carriage by age

is provided by (CDC, 2017b).

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 7

There are major risk factors when it comes to contracting Hepatitis B and C. The

likelihood of contracting these viruses increases along with number of years that a person

engages in high-risk behavior (CDC, 2017b). This is illustrated in Figure 3. In this example when

comparing IV drug users and homosexual men along years of risk, the results show that IV drug

users have almost twice the risk of getting infected with the Hepatitis B virus compared to men

who have sex with men. When having another comparison group, health care workers (HCW’s)

and heterosexual individuals, the data shows how low their infection percentages are. The

highest percentage for HCW’s and heterosexual individuals only peaked at 20% compared to

homosexual men who peaked at 50% and IV drug users who peaked at 70%

Figure 3

Hepatitis B Infection by duration of high-risk behavior

Note. This figure is provided

by (CDC, 2017b)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 8

When these high-risk behaviors are broken down to see who is most at risk, the results

point to heterosexuals who have multiple sexual partners accounting for 39% of Hepatitis B and

C cases. The second largest share comes from men who have sex with men (MSM), the third

largest share comes from injecting drug users (IDU), the fourth largest share comes from high-

risk behaviors classified as “other”, and lastly there are unknown risk factors that contribute to

these cases (CDC, 2017b). These risk factors are summarized in Figure 4.

Figure 4

Risk Factors for Hepatitis B and C

Note. This figure is provided by (CDC,

2017b)

Note. This figure was provided by (CDC, 2017b)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 9

Geographical areas, social and economic factors such an income, occupation, and

education are all also important at determining people at risk for Hepatitis B and C. These

contribute to an understanding of vaccination rates. When taking a look at geographical

populations about 45% of the global population live in places that have a high prevalence of

chronic HPV infections, compared to 12% of the population that lives in low prevalence areas

(CDC, 2017b). High prevalence areas include: Amazon Basin, most Pacific Islands, most of

Africa, parts of the Middle East, Southeast Asia, and China. On the other hand, Australia, United

States, and Western Europe are the places that make part of the lowest prevalence areas (CDC,

2017b).

Geographical exposures contribute to Hepatitis B and C, along with social exposures.

These can be healthcare-related, dealing with households, based on occupation, travel, lifestyle,

environment, and many more and they are significant because they account for 5% of incidence

rates. Even though they account for such a low number this number is said to be an rough

estimate since nearly 16% of individuals deny that a certain social exposure was the risk factor

for their infection (CDC, 2017b). It’s important to realize that HBV infection is highly prevalent

in specific groups even if it’s uncommon among adults in the broad populations judging that the

lifetime risk is less than 20% for infection (CDC, 2017b). When highly prevalent specific groups

are being targeted it’s important to pinpoint who they are. The three major risk groups include

men who have sex with men, people in contact with infected persons or heterosexuals with

multiple sexual partners, and injection-drug users. The reason why these groups account for high

prevalent groups is because, health educators have trouble gaining access to them (CDC, 2017b).

This leads to a lack of awareness of risks and consequences that can lead to this disease among

the different groups. In addition, many public health programs are not effective even when they

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 10

target these groups (CDC, 2017b). However, vaccine cost and healthcare accessibility also play a

role Hepatitis B and C rates in these specific population (include the Garland stats on vaccines).

Hepatitis B and C incubation period ranges anywhere from 45 to 160 days with the

average being 120 days. This disease is in a secular trend in the United States. Surprisingly in the

mid-1980’s Hepatitis B reached the highest it has ever been with about 26,000 cases each year.

With the help of more prevention programs, vaccines, and tests to help with Hepatitis B cases

declined and fell below 10,000 cases in 1996 (CDC, 2017b). The major decline came during the

end of the 1980’s and the early 1990’s when high risk groups such as injection-drug users and

men who have sex with men saw reduction in transmissions as a result of HIV prevention efforts.

As the years kept going (1990-2004) incidence of acute Hepatitis B in the U.S decreased by 75%

(CDC, 2017b). This is vital because around 79% people who have been newly infected with

Hepatitis B are engaged in risky health behaviors such as having unprotected sex and injection

drug use. The group that had the best declining rates were children and adolescents, their

incidence rates decreased by 94% due to the increase of Hepatitis B vaccine. As of 2012, in the

United States a total of 2,895 cases were reported which shows the importance of how important

prevention strategies and vaccines are to reduce the number of incidence rates. It’s important to

keep the vaccination rates up even if vaccines have increased the rate of prevention because

before childhood Hepatitis B vaccination was recommended about 80% of HBV infections

happened among adults (CDC, 2017b). For example, in 2015 adults ages 25-45 in the United

States had the highest incidence of acute Hepatitis B (CDC, 2017b).

Part II: Insight about Selected Health Problem

One of the most prevalent key social determinants of Hepatitis B and C are people who

come from foreign countries and people who have HIV. According to the World Health

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 11

Organization(2018), there is an HIV-HBV coinfection of 2.7 million people, those infected with

HBV are most likely to be living with HIV. Those coming from foreign Hepatitis endemic

countries, many times do not have the financial means or accessibility to go to the doctor when

they have symptoms. Spanish-speaking people are also less likely to report HBV (Greene,

Duffus, Xing, King, 2017). There are many factors as to which people contract Hepatitis B or C.

Many people live or are born into environments where Hepatitis is prevalent. Where people are

born into place or society, where they work, where they live, according to age all have risks of

becoming a victim to Hepatitis. HBV and HCV can be transmitted from mother to baby.

Socioeconomic status has much to do with the contraction of Hepatitis as it determines the

quality of life a person may live. People who live with HBV, HCV, and or HIV are more likely

to have experienced homelessness, unemployment, substance abuse, and incarceration. When

related to HIV, Hepatitis C is mainly spread through recipients of blood and substance injections

(Rourke, Sobota, Tucker, Bekele, Gibson, Greene, Bacon, 2011). People can also be uneducated

about HBV or HCV, therefore do not take the precautions to prevent it, such as vaccinations.

Both Hepatitis B and C are mainly spread through bodily fluids, the most prevalent being blood,

but not limited to saliva, vaginal discharge, menstrual blood, breast milk, and semen

(Zuckerman, 1996). HBV, HCV is more common among drug abusers, homosexuals, and

prostitutes. In countries where prostitution is not illegal, the distribution of HBV and HCV is

more prevalent, as it is spread through sexual contact.

Hepatitis both B and C have challenges when it comes to lowering their rates around the

world, specifically acute Hepatitis C among the United States which has continued to gradually

increase between 2012-2016 (CDC, 2016). In 2012 the rate was 0.6 and in 2016 the rate

increased to 1.0 according to the CDC, Acute Hepatitis B rates between 2012-2016 have

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 12

remained steady according to the available data showing the 2015 rate at 1.1 and the 2016 rate at

1.0 according to the CDC website, meaning that the issue with Hepatitis B prevention may be at

a standstill in the United States. With the creation of high approved oral therapies that have the

opportunity to help cure some of the infected population of Hepatitis B and C these numbers

were predicted to have decreased over the years but there seems to be a variety of issues

preventing this from being accomplished. A major issue of Hepatitis B and C is the limited

amount of data, for example Appendix A shows that there are a total of 9 states that have

unavailable data on acute Hepatitis C incidence rates (CDC, 2016). Another distribution gap

within Hepatitis is the low awareness and low perceived risk among the public. This leads to a

missed opportunity of prevention methods. The public is not alone when it comes to low

awareness there are also many gaps of knowledge within health care providers. The lack of

awareness amongst healthcare providers lead to low vaccination rates as well as low testing and

diagnosis rates(Department of Health & Human Service, 2018) Lack of investments within

public health and the health system in addressing Hepatitis results in very little services of

prevention, identification and treatments of the virus B and C. The stigma and discrimination of

Hepatitis is another gap issue when it comes to trying to lower Hepatitis rates around the world.

Appendix B shows that Acute Hepatitis C incident rates are the highest among the American

Indian/ Alaska Native in which surpassed other ethnicities by nearly 2.5 by 100,000 population

this is a key gap among this ethnicity(CDC, 2016 ;Rempel, Uhanova, 2012) With consistent high

rates of Hep C within the American Indian/ Alaska Native community there needs to be a focus

on finding the determinants and reaching this community to minimize this spike in Hep C rates.

Part III: Proposed Solutions

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 13

In most cases, health is affected at home, communities, schools, or workplaces. Most

individuals know that it is good to get checkups and to not engage in risky behaviors. However,

there a lot of health key issues that are prevalent as a result of people still engaging in risky

behavior and not doing routine checkups. In addition, health is determined by the various

economic and social opportunities within an community. To be specific, many social

determinants associated with low coverage of Hepatitis B vaccines are a stem from a lack of

access to health care services, economic opportunities, education, and job opportunities. While at

the same time language barriers, literacy rates, low quality and training among “experts”, diverse

social norms, and socioeconomic conditions also play a role in low Hepatitis B vaccination rates

(Social Determinants of Health, n.d). Experts who work on health education/promotion can

address these social determinants by creating, updating, and using health assessments for their

communities, the state, or even the nation. They can also provide health classes or screenings to

the community so that the community can be knowledgeable about the resources offered to them.

For example, Garland TX currently offers children Hepatitis B vaccines at a low cost or even

free of cost (City of Garland Public Health Department, n.d). Garland also has their own health

assessment that is up to date so that they can keep track of what health issues are within the

community. The nurses also provide health education to the entire community, they offer back-

to-school clinics, flu vaccine clinics, and clinical services at different community events,

locations, and schools (Public Health Clinic, n.d). A current example of the metro area trying to

combat low Hepatitis B vaccines as well as Hepatitis C is displayed through The Dallas-Fort

Worth Hepatitis B Free Project (DFW HEPB Free) (Hep B, n.d). They are hosting two “Hepatitis

B & C Screenings”, one on November 10th, 2018, and the other one on December 8th, 2018. In

addition to their health screening event if a person tests positive for either Hepatitis they are

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 14

referred to a liver doctor in the DFW area which provides additional resources for the individuals

in the community.

Model Programs

The program ENCORE by Rhode Island public health department is a successful

program that has limited the spread of Hepatitis C (HCV). The purpose of the ENCORE program

is to reduce HCV and HIV rates for people who inject drugs (PWID). The term ENCORE stands

for the 5 components of the program; Educate, Needle Exchange, Counseling, Outreach, and

Referrals. As of 2005, ENCORE is Rhode Island’s only free needle exchange program. Evidence

shows that needle exchange programs are effective in reducing incidences of HIV, however,

there is limited evidence showing the effectiveness needle exchange programs have on reducing

new cases of HCV (Joseph, Kofman, Larney, & Fitzgerald, 2014). Joseph et al. (2014) asserts

that a needle exchange component of a HCV reduction program is an integral part of the

intervention.

Initially during the implementation of the program there was public opposition towards a

pilot needle exchange program within Rhode Island. In order to get around public opposition the

Rhode Island Department of Health (RIDH) teamed up with community-based AIDS

organization to coordinate with. By doing so, the RIDH attached the problem of AIDS to their

cause, in order to receive public support for their project.

Participants for the program were recruited via referrals from substance abuse treatment

facilities, the street outreach, or by word of mouth (Joseph et al., 2014). The program currently

has three main facilities and street-based exchange units and operates in over five cities, cities

that are comparable to Garland. Services are only provided to clients over the age of 18 and are

provided anonymously. According to Joseph et al. (2014), tools that are supplied to clients

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 15

include: new syringes, cookers, cotton swabs, sterile water, tourniquets, biohazard sharp

containers, and antibiotic ointments. Training that is provided to employees included; Harm

Reduction 101 provided by the Drug Policy Alliance, safety guidelines in handling and disposing

used syringes, HIV and HCV basics and preventions, and cultural competency training. Other

Services that are provided by ENCORE include free HCV and HIV testing, free male and female

condoms, and hygiene packs.

Garland Public Health Department can benefit from this program in a variety of ways.

First would be to notice the key takeaways from this program, as according to the pre-enrollment

interview of clients, one of the largest contributing factors to the spread of HCV was related to

lack of HCV testing as more than half of the ENCORE clients reported prior exposure to HCV.

Meaning, that if Garland Public Health Department does not have the means or the desire to

implement the entirety of this program, they may have some success in implementing a program

that increasing accessibility to HCV testing. However, if GPH does wish to implement this

program, they may be able to adopt the same methods in jump starting the program by pairing up

with a local AIDS organization in order to gain public support. GPH may also be able to adopt or

adapt the employee educational components of training employees on how to handle used

needles, while also taking advantage of the general cultural competency training for those who

interacted with people who inject drugs.

Although Hepatitis B is not experiencing a drastic up rise in the U.S and has remained

steady, there is plenty of room to lower rates especially since Hep. B is preventable, and in most

cases treatable. The “B Positive” intervention, a multi-pronged and economic modeling

intervention put together by “Cancer Council New South Wales”, a local cancer charity in

Australia in order to reduce the incidence of Hep. B liver cancer (Robotin, Kansil, Porwal,

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 16

Penman, & George, 2014). The goals of the “B Positive” program is to reduce Hepatitis B-

related health disparities specifically among the migrant population by completing a community-

based screening, providing community to care of Hep. B, increasing knowledge and awareness

and surveillance. The program stakeholders included: local practitioners, Cancer Council New

South, Divisions of General Practice, Millennium Institute in Westmead, New South Cancer

Institut, New South Wales Department, Storr Liver Unit, Sydney Medical Foundation of

University of Sydney, National Health and Medical Research Council of Australia. All

contributed to the programs implementation or contributed to the funding of the program.

This three-phase program began in 2007 and took place in Sydney Australia. Phase 1

used economic-modeling to investigate the possible success of the program, the screening and

treatment algorithm for Hep B was put together, along with the desired data that needed to be

collected from the program. Phase 2, stakeholders were confirmed and education testing,

prevention, and treatment of Hep B for local practitioners and the community were provided.

Phase 3 included the changing of the monitoring and evaluation tools after consultation from the

stakeholders. The “B Positive” program involved stakeholders as well as community members

when creating and evaluating the program. Practitioners that were involved were given

incentives to increase participation. The program included a screening and treatment algorithm

that was used to categorize the participant’s severity by low-risk, intermediate, and high risk

which is demonstrated in Appendix C. At enrollment, participants were screened, if they did not

have the virus they were given the vaccination. Those who were positive were separated by

severity with all of the them being evaluated every six months. Low-risk group tests were

evaluated by general practitioners, intermediate groups were assigned enhanced surveillance by

adding a ultrasonographic scan of their liver. High-risk group visits included the same as the

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 17

other groups however they were also referred to a specialist with a possibility of having a liver

biopsy.

The program also provided educational Hepatitis B seminars and activities that were

culturally sensitive and available to practitioners to increase the knowledge of Hepatitis B.

Testing and treatment knowledge were also available to community members to help spread the

knowledge of Hep. B. Materials such as posters, cartoon videos, and education materials were

handed out at community meetings, festivals, fairs, and newspapers in four different languages

that included information about the misconceptions and myths pertaining to Hep B.

With Garlands concern with decreasing and low vaccination rates of Hep B, adopting this

program can improve the awareness, education, and vaccination rates of Hep B. And can

contribute to lowering the rates of Hep B and Chronic Hep B in the Garland community. This

program can extremely benefit the GPHD because it provides a source of data specifically for

Garland. While collecting data, the program also provides the opportunity to vaccinate those who

are not infected to help reduce the spread of Hep. B and help raise awareness of the virus as well

as treatment options. If GPHD were to adopt the program, they would have to adopt the three

phases used in the original program and avoid the barriers that were brought to light during the

original evaluation process such as not involving community members input at the beginning. If

implemented properly Garland can create a major change in their low vaccination rates.

Involving the correct stakeholders support such as the health providers, cancer associations,

hospitals, and so forth within the community can benefit the program. These entities may be able

to provide a place for screenings, access of care for participants, inside input from community

stakeholders and also contribute to funding the program.

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 18

Program Proposal

With these two programs in mind, a recommended program for the City of Garland

would be adopt both programs independently or create fusion of both programs. For the purpose

of this paper, a framework will be provided on how a mixture of the two programs would work.

The first step of the program would be to engage the stakeholders such as the Dallas County

health department, Texas Department of State Health Services, or even the National Institute of

Health or CDC. Once stakeholders have been identified, the leaders of the project should

investigate the community capacity of Garland in order to assess ability of Garland to fully or

partially implement the program.

The goal of this program would be to decrease Hepatitis B and C rates in the city of

Garland. Objectives of the program include:

1. In the first six months of program have over 100 people participate.

2. Host at least two educational sessions during the first three months of the program

implementation.

The main three components from these two programs that should be combined together

to make one programs should be, increased screenings, educational components, and available

prevention measures. First, as shown by both the ENCORE and B Positive program, screenings

play a primary role in decreasing rates of both Hep B and C. Whereas, members of both

communities have cited being exposed to Hepatitis but not knowing their own status. A

screening component of a program will provide participants with the opportunity to know their

status and whether or not they test positive for Hepatitis. This way, those who are positive can

began taking proper prevention methods in order to decrease the likelihood of them spreading the

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 19

disease. After that, the second part of the program should consist of an educational component.

The best way to conduct such classes and have people actually attend would be to suggest it to

those individuals who test positive for hepatitis and have flyers in local clinics demonstrating the

class times/dates. The classes should be informal, at a time later than five in the evening, or

during the weekend on a Saturday, so that it would be accessible to those who work during the

week. To reduce overhead cost the class could be taught by a Certified Health Education

Specialist who would be willing to volunteer their time for the class session. This volunteer may

also be a student from University Texas at Dallas, University Texas at Arlington, Southern

Methodist University, or Texas A&M University – Commerce, that is CHES certified. Finally,

available prevention measures should also be provided. This part of the program is up to Garland

Public Health’s department discretion and may include all or parts of the described prevention

measures. For example, Garland Public Health can decide whether or not to provide needle

exchange program, hygiene kits, condoms, vaccines, or other Hepatitis B and C prevention

methods. The preventative measures provided would be dependent on the community capacity

of Garland Public Health. However, it would be ideal if all of these measures were implemented.

Policies and Statutes

There are several policies at the, local, state, and national level that are targeting viral

hepatitis. These policies come from organizations such as the Center for Disease Control and

Prevention. At a national level, the country is focusing on keeping children in school safe from

hepatitis B as there currently is not a vaccine for hepatitis C. In almost all states across the

country, it is mandatory for each child to be vaccinated with an HBV vaccine. A map with

information on which states require the HBV vaccine according to the Immunization Action

Coalition (2018), can be found in Appendix D.

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 20

At a state level, very few states have already applied policies where needle exchange

programs are taking place to prevent HCV. Policies have been changed for those under

Medicaid, that do not require a period of sobriety to be treated for HCV. In 2015, 24 states

required people under Medicaid to go through a period a sobriety in order to be treated for HCV

(Campbell, Canary, Smith, Teshale, Ryerson, Ward, 2017). The CDC has also recommended that

there be clean needle exchange programs, and available treatments for HCV, in order to reduce

the risk and increase of HCV.

Conclusion and Implication

Communities are dependent on health educators, policy makers, and local health

departments to provide health services to the public, prevent diseases, and control them. This

involves making decisions, plans, and taking the proper actions to reach a certain goal related to

health in a community. There has to be a vision, short and long-term plans, goals, and proper

tools to reach them. Entities such as health educators, policy makers, and local health

departments will be able to use this DEP paper to maintain efforts of keeping the public informed

on diseases such as Hepatitis. They may also be able to take this paper, and the proposals in it, to

adopt their own health program geared towards reducing the rates of hepatitis in Garland.

In this paper, information has been compiled that will help reach the goal of lowering the

risk of Hepatitis at a local level. There is information on the morbidity, mortality, transmission,

risk factors, and social determinants related to Hepatitis B and C. There has also been a proposal

for a program, along with an infographic that could be implemented by the Garland Public

Health Department to address Hepatitis in the community. This proposal has the proper

strategies, goals, and objectives to be implemented by Garland. There is also a list of websites

and articles, that could offer further and more detailed information on how to approach Hepatitis,

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 21

both national and state, with examples and strategies implemented by other states or health

departments. It is of great importance to continue the work of preventing and lowering the risk of

Hepatitis to keep a healthy Garland.

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 22

References

Campbell, C. A., Canary, L., Smith, N., Teshale, E., Ryerson, A. B., & Ward, J. W. (2017,

August 01). State HCV Incidence and Policies Related to HCV Preventive and Treatment

Services for Persons Who Inject Drugs — United States, 2015–2016. Retrieved

November 27, 2018, from https://www.cdc.gov/mmwr/volumes/66/wr/mm6618a2.htm

Center for Disease Control and Prevention. (2016). CDC health disparities and inequalities

report — United States, 2013. MMWR Supplements, 162(Suppl 3), 1-187. Retrieved

from http://www.cdc.gov/mmwr/preview/ind2013_su.html

Center for Disease Control and Prevention.(2017 - a). Immunization. Retrieved October 28,

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HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 26

Appendix A

Hepatitis C Incidence Rates by State

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 27

Adapted from State Acute Hepatitis C Incidence compared to Healthy People 2020 National

Goal. (CDC, 2016).

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 28

Appendix B

Incidence of Acute Hepatitis C by Race/Ethnicity

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 29

Adapted from Incidence of Acute Hepatitis C by race/ethnicity – United States, 2001-2016.

(CDC, 2016)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 30

Appendix C

Program outline for B Positive Program

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 31

Adapted from Screening and Treatment Algorithm Of B Positive Program. (Robotin, 2014).

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 32

Appendix D

Map of States with Hep B Mandates

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 33

Adapted from Hepatitis B Prevention Mandates for Children in Day Care and School

(Immunization Action Coalition, 2018.)

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 34

Appendix E

Infographic

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 35

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 36

Appendix F

List of Helpful Resources

HEPATITIS B&C DESCRIPTIVE EPIDEMIOLOGY 37

1. Viral Hepatitis in the U.S.: What are the Opportunities for Winning the Fight? a. https://www.hhs.gov/hepatitis/blog/2018/04/16/viral-hepatitis-in-the-us-what-

are-the-opportunities.html 2. National Viral Hepatitis Action Plan 2017-2020 (Action Plan) - PDF

a. https://www.hhs.gov/sites/default/files/National%20Viral%20Hepatitis%20Actio n%20Plan%202017-2020.pdf

3. NATIONAL HIV/AIDS STRATEGY for the UNITED STATES a. https://files.hiv.gov/s3fs-public/nhas-update.pdf

4. Viral Hepatitis (Center for Disease Control) a. https://www.cdc.gov/hepatitis/index.htm

5. LiverLearning® by American Association for the Study of Liver Diseases a. https://liverlearning.aasld.org/fundamentals-of-liver-disease

6. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices a. https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm

7. International Network on Hepatitis in Substance Abusers a. http://inhsu.org

8. New York State Viral Hepatitis Strategic Plan 2016-2020 a. https://www.health.ny.gov/publications/1806.pdf

9. Global policy report on the prevention and control of viral hepatitis in WHO member states a. http://apps.who.int/iris/bitstream/handle/10665/85397/9789241564632_eng.p

df;jsessionid=97C0AB51B4AFE6B15EF0C4D2B0CAA351?sequence=1 10. Integrating Viral Hepatitis Prevention into Public Health Programs Serving People at

High Risk for Infection: Good Public Health a. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831807/

11. HIVandHepatitis.com a. http://www.hivandhepatitis.com/home1706522085/about-us

12. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C a. https://www.nap.edu/catalog/12793/hepatitis-and-liver-cancer-a-national-

strategy-for-prevention-and