NATIONAL ASSOCIATION NATIONAL ASSOCIATION OfOf

HEPATITIS TASK FORCESHEPATITIS TASK FORCESState and County State and County

Startup Orientation Startup Orientation

By By BILL REMAK, ChairmanBILL REMAK, Chairman

KEN MORGAN, TreasurerKEN MORGAN, TreasurerCalifornia Hepatitis C Task ForceCalifornia Hepatitis C Task Force

6/02 Rev 12/02, Rev 3/04 Series Ca-16/02 Rev 12/02, Rev 3/04 Series Ca-1Economic reference slides provided by: James Economic reference slides provided by: James

HoytHoyt(c) 2004 CAHCVTF(c) 2004 CAHCVTF

ABSTRACTABSTRACT Industry leaders work together to “ Slay Industry leaders work together to “ Slay

the Dragon”: working together to meet the Dragon”: working together to meet the medical need, the financial impact on the medical need, the financial impact on our economy, and the political necessity our economy, and the political necessity of addressing the epidemic of Hepatitis. of addressing the epidemic of Hepatitis. Public Health Administrators, Chief Public Health Administrators, Chief Financial Officers, and Chief Executive Financial Officers, and Chief Executive Officers must find a common ground to Officers must find a common ground to wield the sword of collaboration to wield the sword of collaboration to spearhead an cooperative initiative to spearhead an cooperative initiative to stop the social stigma of Hepatitis that stop the social stigma of Hepatitis that effects so many of our work force, effects so many of our work force,

impacting negatively on Corporate impacting negatively on Corporate revenue through the high cost of revenue through the high cost of workers comp, employee health care workers comp, employee health care benefits and loss of productivity. This is benefits and loss of productivity. This is a direct appeal for commercial/corporate a direct appeal for commercial/corporate America to get involved in funding America to get involved in funding Hepatitis medical research and Hepatitis medical research and addressing the socioeconomic impact of addressing the socioeconomic impact of a major chronic disease. Providing the a major chronic disease. Providing the tools to build an educational tools to build an educational collaborative for hepatitis to focus on collaborative for hepatitis to focus on initiatives to effect policy changes in the initiatives to effect policy changes in the Business Schools and Institutions of Business Schools and Institutions of Higher Learning and bringing Higher Learning and bringing

together key stakeholders to identify a together key stakeholders to identify a vision,vision,

mission, core values, strategy, goals, andmission, core values, strategy, goals, and

measures of success for hepatitis measures of success for hepatitis education,education,

prevention and treatment.prevention and treatment.

Bill Remak Bill Remak

Chairman, CHCVTF Chairman, CHCVTF

Liver DiseaseLiver Disease• Liver disease mirrors America. 25,000,000 Liver disease mirrors America. 25,000,000

Americans – 1 in every 10 – are or have Americans – 1 in every 10 – are or have been afflicted with some sort of liver been afflicted with some sort of liver related disease.related disease.

• There are over 5.3 million people who There are over 5.3 million people who have been infected with hepatitis C and have been infected with hepatitis C and most of the people infected do not know most of the people infected do not know they have the virus.they have the virus.

• Because of the shortage of organs, it is Because of the shortage of organs, it is estimated that over 1,600 prospective estimated that over 1,600 prospective recipients died in 2001 while waiting for a recipients died in 2001 while waiting for a liver for transplantation. There are liver for transplantation. There are currently over 20,000 people waiting for a currently over 20,000 people waiting for a liver transplant. In 2002 over 2,800 people liver transplant. In 2002 over 2,800 people died nationwide due to a shortage of died nationwide due to a shortage of organs.organs.

•Vietnam-era veteran Vietnam-era veteran ††

Blood transfusion before 1992Blood transfusion before 1992Past or present intravenous drug usePast or present intravenous drug useUnequivocal blood exposure of skinUnequivocal blood exposure of skin

or mucous membranesor mucous membranesHistory of multiple sexual partners History of multiple sexual partners ††††

History of hemodialysisHistory of hemodialysisTattoo or repeated body piercingTattoo or repeated body piercingHistory of intranasal cocaine useHistory of intranasal cocaine useUnexplained liver diseaseUnexplained liver diseaseUnexplained/abnormal ALTUnexplained/abnormal ALTIntemperate or immoderate use of alcohol Intemperate or immoderate use of alcohol ††††††

†† As currently determined by dates of service or in the age range of 40 to 55 yearsAs currently determined by dates of service or in the age range of 40 to 55 years†††† Defined as more than 10 lifetime sexual partnersDefined as more than 10 lifetime sexual partners†††††† Defined as more than 50g of alcohol per day for ten or more years (roughly 10-14g of Defined as more than 50g of alcohol per day for ten or more years (roughly 10-14g of alcohol = 1 beer)alcohol = 1 beer)Note:Note: These variables may be interrelated and are not necessarily independently related to These variables may be interrelated and are not necessarily independently related to risk for HCV infection.risk for HCV infection.

This is the external surface of a normal liver. The color is brown and This is the external surface of a normal liver. The color is brown and the surface is smooth. A normal liver is about 1200 to 1600 grams.the surface is smooth. A normal liver is about 1200 to 1600 grams.

Here is an example of macronodular cirrhosis. Viral hepatitis (B or C) is the most Here is an example of macronodular cirrhosis. Viral hepatitis (B or C) is the most common cause for macronodular cirrhosis. Wilson's disease and alpha-1-common cause for macronodular cirrhosis. Wilson's disease and alpha-1-antitrypsin deficiency also can produce a macronodular cirrhosis.antitrypsin deficiency also can produce a macronodular cirrhosis.

Here is a hepatocellular carcinoma with a greenish yellow hue. One clue to the Here is a hepatocellular carcinoma with a greenish yellow hue. One clue to the presence of such a neoplasm is an elevated serum alpha-fetoprotein. Such presence of such a neoplasm is an elevated serum alpha-fetoprotein. Such masses may also focally obstruct the biliary tract and lead to an elevated masses may also focally obstruct the biliary tract and lead to an elevated alkaline phosphatase.alkaline phosphatase.

Visualize a candy bar &Visualize a candy bar &everything involved in everything involved in making itmaking it

• People who pick the sugar canePeople who pick the sugar cane

• Processing of the caneProcessing of the cane

• Picking the nutsPicking the nuts

• Making the candy itselfMaking the candy itself

• The truck driverThe truck driver

• The people employed at the storeThe people employed at the store

• Many hands are involved in the process Many hands are involved in the process before you even buy itbefore you even buy it

Impact on one personImpact on one person

• How it impacts his familyHow it impacts his family• His jobHis job• Access to HealthcareAccess to Healthcare• His lifestyleHis lifestyle

““THROUGH THE LOOKING GLASS: THE HEALTH THROUGH THE LOOKING GLASS: THE HEALTH AND SOCIO-ECONOMIC STATUS OF HEPATITIS AND SOCIO-ECONOMIC STATUS OF HEPATITIS C POSITIVE TRANSFUSION RECIPIENTS, 1986-C POSITIVE TRANSFUSION RECIPIENTS, 1986-

1990”1990”

Medical CostMedical Cost

Availability of HealthcareAvailability of Healthcare

MedicationsMedications

Physicians Physicians

Hospital stayHospital stay

TransplantsTransplants

Only part of the costsOnly part of the costs

Individual ImpactIndividual Impact

Income is reducedIncome is reduced

Health InsuranceHealth Insurance

Employment opportunitiesEmployment opportunities

RelationshipsRelationships

IsolationIsolation

BankruptcyBankruptcy

Possible HomelessnessPossible Homelessness

The Total Economic-ImpactThe Total Economic-Impact

Medical costs ‘X’Medical costs ‘X’

Loss of buying power ‘Y”Loss of buying power ‘Y”

Loss of Productivity ‘Z’Loss of Productivity ‘Z’

Total cost to economy Total cost to economy ??

The real total cost to an The real total cost to an economy is economy is

just beginning to be recognizedjust beginning to be recognized

Total infectedTotal infected

Numbers vary depending on sourceNumbers vary depending on source

0.7 to 6.8 million 0.7 to 6.8 million

With HCVWith HCV

Data collection methodsData collection methods

Total number of those infected ARE Total number of those infected ARE

under-reportedunder-reported

Alter MJ. N Engl J Med. 1999;341:556 (NHANES III, 1988–1994).

Prevalence of HCV Infection by Prevalence of HCV Infection by AgeAgeUnited States, 1988-1994United States, 1988-1994

Pre

vale

nce

of A

nti-

HC

V (

%)

Age (yr)

0

1

2

3

4

6–11 12–19 20–29 30-39 40–49 50–59 60–69 70–79 80+

Average Prevalence = ~1.8%

# Infected Nationwide = ~3.9 million

Population Stats for Population Stats for USAUSATotal pop for the year 2000.….281 millionTotal pop for the year 2000.….281 millionWorking class (age 15-70)……175 millionWorking class (age 15-70)……175 million

Institutionalized.........................Institutionalized.........................++ 2 million 2 millionNot included in stats…..Welfare & disabled & Not included in stats…..Welfare & disabled &

those not workingthose not working

Roughly 61% bearing the economic Roughly 61% bearing the economic weightweight

HCV & HIV/AIDS hits those who are HCV & HIV/AIDS hits those who are considered in the working classesconsidered in the working classes

Future Hepatitis C CostsFuture Hepatitis C Costs

• $10.7 billion$10.7 billion in direct medical care expenditures in direct medical care expenditures• $ 75.5 billion in societal (indirect) costs$ 75.5 billion in societal (indirect) costs

Wong JB, et al. AJPH 2000; 90(10): 1562-1569.

SocietySociety

Loss of ProductivityLoss of ProductivityHigher Costs of Goods & ServicesHigher Costs of Goods & Services

Higher taxes for those workingHigher taxes for those workingReduction in Government ServicesReduction in Government Services

Reduction in Charity MoniesReduction in Charity MoniesHigher Interest RatesHigher Interest Rates

Lower availability of Investment moniesLower availability of Investment monies

Impacts on IndustryImpacts on Industry

Loss of workers– Expenses for recruiting/training replacements

– Reduced productivity in case of skilled worker or manager

Lost work days due to sickness– 30 - 240 days per year

Lost work days due to funeral leave

Increased health care costs– 50% illness due to AIDS

 

Total ImpactTotal Impact

Everyone will feel the effects of these Everyone will feel the effects of these diseases...HCV is currently having a diseases...HCV is currently having a

greater impact than HIV/AIDSgreater impact than HIV/AIDS

Why should I care?Why should I care?

Because everyone is going to Because everyone is going to

feel the effects offeel the effects of

HCV.HCV.

The FutureThe Future

More than 2% of our population isMore than 2% of our population isnow infectednow infected

..HIV/AIDS..…1 millionHIV/AIDS..…1 millionHepatitis B...1 millionHepatitis B...1 million

_Hepatitis C ….5.2 million__Hepatitis C ….5.2 million_Total infected…7.2 millionTotal infected…7.2 million

We will all feel the impacts of theseWe will all feel the impacts of theseDiseases Diseases

Directly or IndirectlyDirectly or Indirectly

Future expectationsFuture expectations

• AIDS studies in Africa - AIDS studies in Africa - >> 2% infection 2% infection rate begins to impact the economyrate begins to impact the economy

• Begins to change the economic Begins to change the economic structure of a societystructure of a society– Changes in standards of livingChanges in standards of living– Changes in tax base (higher taxes for those Changes in tax base (higher taxes for those

still working)still working)– Changes in Governmental Services Changes in Governmental Services

providedprovided

Implications for United Implications for United StatesStates

•Highly advanced Highly advanced

•Loss of most productive groupsLoss of most productive groups

•Loss of highly skilled professionalsLoss of highly skilled professionals

•Time lag to re-educate loss Time lag to re-educate loss employeesemployees

•Loss of production capabilitiesLoss of production capabilities

ConclusionConclusion

•2% of the population infected2% of the population infected

• Increases in various costsIncreases in various costs

•Decreases in productivityDecreases in productivity

• Time to act is when the problem is Time to act is when the problem is smallsmall

• The greater the problem-the more The greater the problem-the more pronounced the changes will bepronounced the changes will be

• Denial of problem only enhances Denial of problem only enhances the future impact of these diseasesthe future impact of these diseases

• HIV/AIDS has not had an impact as HIV/AIDS has not had an impact as of yetof yet

• Hepatitis C is having an impact Hepatitis C is having an impact NOWNOW

• HCV medical treatment is more HCV medical treatment is more costly than AIDS treatmentcostly than AIDS treatment

•Recognition of the Recognition of the Problem is the first stepProblem is the first step

•then developing then developing solutions/alternatives is solutions/alternatives is the next stepthe next step

•Constantly re-evaluating Constantly re-evaluating the resultsthe results

More Statistics More Statistics

U.S. PopulationU.S. Population• 2% overall2% overall

• 2.1% Mexican-2.1% Mexican-AmericansAmericans

• 3.4 African 3.4 African AmericansAmericans

CaliforniaCalifornia• 650,000 infected 650,000 infected

with HCVwith HCV

• 85-95% - IDU’s85-95% - IDU’s

• Prison’s – >63,500 Prison’s – >63,500 inmates infected or inmates infected or (>41%)(>41%)

These are the annual medical costs taken from actual statements beginning 1995 These are the annual medical costs taken from actual statements beginning 1995 until January 2002. 4 years after transplantation, a case that developed type two until January 2002. 4 years after transplantation, a case that developed type two diabetes and HCC after 30 years:diabetes and HCC after 30 years:

Doctor visits including GI, EYE, Endocrinologist...........$5,200Doctor visits including GI, EYE, Endocrinologist...........$5,200

Regular blood draws and lab work ..........................$6,750Regular blood draws and lab work ..........................$6,750

MRI's, CAT Scans, X-Rays, other exams .....................$4,900MRI's, CAT Scans, X-Rays, other exams .....................$4,900

Liver biopsy ..............................................$4,300Liver biopsy ..............................................$4,300

Interferon treatment .....................................$19,000Interferon treatment .....................................$19,000

other medications related to transplant and diabetes .....$12,000other medications related to transplant and diabetes .....$12,000

transportation costs medically related ....................$ 850transportation costs medically related ....................$ 850

Total year 2001.......................................... $64,000Total year 2001.......................................... $64,000

Data taken from previous years statements:Data taken from previous years statements:

total year 2000 .........................................$103,000total year 2000 .........................................$103,000

total year 1999 .........................................$154,000total year 1999 .........................................$154,000

total year 1998 year of transplant and hospitalization ..$487,000total year 1998 year of transplant and hospitalization ..$487,000

total year 1997 hospitalization, doctors, meds, etc......$162,000total year 1997 hospitalization, doctors, meds, etc......$162,000

total year 1996 hospitalizations & medical procedures...$ 53,000total year 1996 hospitalizations & medical procedures...$ 53,000

total year 1995 year of surgeries & hospitalizations ....$ 78,000total year 1995 year of surgeries & hospitalizations ....$ 78,000

since January 1995 total until December 2001 ............$934,000since January 1995 total until December 2001 ............$934,000

by Oct of this year patient will have exceeded med costs of..$1,000,000by Oct of this year patient will have exceeded med costs of..$1,000,000

HEPATITIS C THE MAJOR HEALTH HEPATITIS C THE MAJOR HEALTH CONCERNCONCERN

Public Health/Financial Implications

•• Most infected individuals: 30Most infected individuals: 30--49 years49 years•• By the year 2008, estimates suggest:By the year 2008, estimates suggest:

61% 61% in cirrhosisin cirrhosis279% 279% in decompensationin decompensation

68% 68% in HCCin HCC528% 528% in need for liver transplantationin need for liver transplantation223% 223% in liverin liver--related deathsrelated deaths

Davis GL. Davis GL. HepatologyHepatology. 1998;28(4 pt 2):390a.. 1998;28(4 pt 2):390a.

Chronic Hepatitis CChronic Hepatitis C

Predicted Future HCV Mortality

0

5000

10000

15000

20000

25000

30000

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

An

nual

De

aths

An

nual

De

aths

YearYearWong et al Am J Public Health. 2000; 1990:1562

Predicted Future HCV Costs

0

200

400

600

800

1000

1200

1400

1600

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

An

nual

Med

ical

Car

e C

osts

A

nnu

al M

edic

al C

are

Cos

ts

($ M

illio

n)($

Mill

ion)

YearYearWong et al Am J Public Health. 2000; 1990:1562

HEPATITIS Task ForcesHEPATITIS Task Forces• Collaborative effort between local Hepatitis Task Collaborative effort between local Hepatitis Task

Forces, local and state health systems are essential Forces, local and state health systems are essential to a comprehensive, nationwide effort that will to a comprehensive, nationwide effort that will provide funding for the highest quality research and provide funding for the highest quality research and development of public awareness as well as development of public awareness as well as providing adequate resources for education and providing adequate resources for education and research programs at the local level.research programs at the local level.

• The strength of the Hepatitis Task Force movement The strength of the Hepatitis Task Force movement is accomplished through broad-based community is accomplished through broad-based community support and activities. Our combined team efforts support and activities. Our combined team efforts can result in more effective treatments and can result in more effective treatments and prevention, improved care, and the potential for prevention, improved care, and the potential for Hepatitis eradication.Hepatitis eradication.

• The ALF encourages and supports this endeavor The ALF encourages and supports this endeavor along with the Surgeon General and our Lt. Governor.along with the Surgeon General and our Lt. Governor.

STATE HEPATITIS TASK FORCESSTATE HEPATITIS TASK FORCES a shared partnershipa shared partnership PURPOSEPURPOSE

•Identify and Develop resources (includes funding)Identify and Develop resources (includes funding)

•General Advice General Advice

•Policy RecommendationsPolicy Recommendations

•Support for legislative issues and reform pertaining to HepatitisSupport for legislative issues and reform pertaining to Hepatitis

•Non-support for legislative actions that negatively impact HepatitisNon-support for legislative actions that negatively impact Hepatitis

•Statewide clearinghouse for information on: Statewide clearinghouse for information on:

Task force formation, basic screening, testing and evaluation, education, Task force formation, basic screening, testing and evaluation, education, provider education and current activities throughout Californiaprovider education and current activities throughout California

•ConferencingConferencing

•Technical Assistance Technical Assistance •Act as trustees in identifying the resources to expedite the eradication Act as trustees in identifying the resources to expedite the eradication of Hepatitisof Hepatitis•Support the existing infrastructureSupport the existing infrastructure•Build into system a method for collecting and measuring testing data. Build into system a method for collecting and measuring testing data. Should include incentives for physicians to track dataShould include incentives for physicians to track data if needed if needed

What is a Hepatitis Task What is a Hepatitis Task Force ?Force ?

• A Community Response To A Major A Community Response To A Major Health Concern Health Concern

• Resource Partners with a Resource Partners with a Commitment to Prevention, Commitment to Prevention, Education, Screening, Patient Education, Screening, Patient Support, Outreach, Public Support, Outreach, Public Awareness, Treatment and AdvocacyAwareness, Treatment and Advocacy

Mission StatementMission Statement The State Hepatitis Task Force will The State Hepatitis Task Force will

develop and improve existing develop and improve existing Hepatitis prevention, education, Hepatitis prevention, education, treatment, testing and reporting treatment, testing and reporting practices. We will support policy practices. We will support policy that removes barriers and provides that removes barriers and provides incentives to improve the quality incentives to improve the quality of care for persons with Hepatitis, of care for persons with Hepatitis, and that prevents new cases of the and that prevents new cases of the disease. We will report our disease. We will report our progress to the public annuallyprogress to the public annually

StructureStructure

Local County Hepatitis Task Forces share data, Local County Hepatitis Task Forces share data, resources and forms partnerships on projects that resources and forms partnerships on projects that better serve their communities.better serve their communities.  The State Hepatitis Task Force structure provides a The State Hepatitis Task Force structure provides a forum to develop and/or expedite assistance for the forum to develop and/or expedite assistance for the sharing of information and collaborations with sharing of information and collaborations with legislative support to lead to an increase in legislative support to lead to an increase in funding, awareness, training and treatment of funding, awareness, training and treatment of Hepatitis. Hepatitis. Bill Remak, Chairman CHCVTFBill Remak, Chairman CHCVTF 12-11-0212-11-02

Conference Planning

Outreach Task Force

Development

Policy Reform Legislative Advocacy

Grant Funding

Technical Assistance

Provider Education

Prevention Harm

Reduction

Executive Administration

CommunicationWebsite Newsletter

Education Patient

Awareness and Support

Public Affairs/HCV Awareness

California Hepatitis C Task Force

Board of Directors Advisory Board

Local County HCV Task Forces

Local County HCV Task Forces

Local County HCV Task Forces

VOLUNTEER DRIVENVOLUNTEER DRIVEN

Composition of Group:Composition of Group:• Local County Health DepartmentsLocal County Health Departments• Non-profit OrganizationsNon-profit Organizations• Local Community Health FoundationsLocal Community Health Foundations• Advisory GroupsAdvisory Groups• Veterans OrganizationsVeterans Organizations• Pharmaceutical companiesPharmaceutical companies• Treatment and Recovery Community Treatment and Recovery Community • Providers Providers • Professional Associations and UnionsProfessional Associations and Unions

A Community A Community PartnershipPartnership• County Health OfficerCounty Health Officer• First Responders, EMS or paramedic serviceFirst Responders, EMS or paramedic service• Medical professional who treats HCV Medical professional who treats HCV

patients.patients.• A representative from you local community A representative from you local community

health foundation.health foundation.• VA liaison officer or veterans servicesVA liaison officer or veterans services• Drug and Alcohol agencyDrug and Alcohol agency• County Program director for HIV/HCVCounty Program director for HIV/HCV• Hospital, major medical provider and Hospital, major medical provider and

community clinic for low income or community clinic for low income or uninsureduninsured

A Community A Community PartnershipPartnership

• County jail RNCounty jail RN

• Blood bankBlood bank

• Director of DPH prevention department.Director of DPH prevention department.

• Local RN’s, health education director or Local RN’s, health education director or agenciesagencies

• Biotech and/or pharmaceuticalBiotech and/or pharmaceutical

• Director of a local benefits counseling Director of a local benefits counseling agencyagency

• American Liver Foundation and othersAmerican Liver Foundation and others

• HCV support group facilitatorsHCV support group facilitators

Hepatitis Reform GoalsHepatitis Reform Goals• Hepatitis programs including public Hepatitis programs including public

awareness, education, access to screening awareness, education, access to screening and testing.and testing.

• Access to local physicians trained in current Access to local physicians trained in current Hepatitis case management technologyHepatitis case management technology..

• Advocacy efforts resulting in greater Advocacy efforts resulting in greater programs for harm reduction, healthcare for programs for harm reduction, healthcare for the under-insured and the de-stigmatization the under-insured and the de-stigmatization of Hepatitis as a stand alone disease with a of Hepatitis as a stand alone disease with a fair allocation of national research funding:fair allocation of national research funding:

1. HCV vaccine development.1. HCV vaccine development. 2. Broader use of Hepatitis A & B vaccines 2. Broader use of Hepatitis A & B vaccines 3. Clinical trials to assess safety and efficacy 3. Clinical trials to assess safety and efficacy

of new medications.of new medications.

Public Policy/HepatitisPublic Policy/Hepatitis

• Support expansion of VA to treat Support expansion of VA to treat veterans with hepatitis and other veterans with hepatitis and other liver diseases. liver diseases.

• Expand CDC Hepatitis C Expand CDC Hepatitis C epidemiological studies, public health epidemiological studies, public health and education initiatives. and education initiatives.

Public Policy/HepatitisPublic Policy/Hepatitis

• Support legislation to create an Support legislation to create an Hepatitis medication assistance Hepatitis medication assistance program and legislation for education, program and legislation for education, screening and public awareness screening and public awareness

• Monitor and support the NIH Hepatitis Monitor and support the NIH Hepatitis Consensus Conference and initiate Consensus Conference and initiate efforts to develop an action planefforts to develop an action plan

• Expand Hepatitis researchExpand Hepatitis research

LETTER FROM SURGEON GENERALLETTER FROM SURGEON GENERAL

7/27/20007/27/2000