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How a Simple Test Can Save 120,000 Lives

Hepatitis C, the “silent epidemic” afflicting baby boomers, is twice as prevalent among African-Americans, but preventive measures may save $2.5 billion in health care costs, a CDC official says.

John Ward directs the CDC's Division of Viral Hepatitis. He earned his bachelor's from the University of Alabama in biology and history and his M.D. from UA-Birmingham.
National Journal
John Ward
Feb. 27, 2014, 5:36 a.m.

John Ward, 58, has spent his ca­reer at the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, start­ing in 1984 work­ing on AIDS, then as ed­it­or of the Mor­bid­ity and Mor­tal­ity Weekly Re­port, and since 2005 as dir­ect­or of the vir­al hep­at­it­is di­vi­sion.

In this role, the Alabama nat­ive and his team lead an ef­fort to im­ple­ment a simple test to de­tect hep­at­it­is C, a vir­us iden­ti­fied 25 years ago that of­ten gives rise to liv­er dis­ease and is most pre­val­ent among Afric­an-Amer­ic­ans.

This in­ter­view, con­duc­ted by Jody Bran­non, has been ed­ited for length and clar­ity.

I’ve been in­ter­ested in com­mu­nic­able dis­eases throughout my ca­reer at CDC, and after the long-stand­ing di­vi­sion dir­ect­or left, I was for­tu­nate to be se­lec­ted to lead our work against a group of dis­eases trans­mit­ted in mul­tiple ways.

When we got here, we began to draw at­ten­tion to what’s been called a si­lent epi­dem­ic — 3.5 mil­lion to 5.3 mil­lion people liv­ing with hep­at­it­is, of B or C type — in­fec­ted in dif­fer­ent ways and now liv­ing with it for dec­ades. We began to see a rising rate of liv­er can­cer — a great ma­jor­ity caused by hep­at­it­is — and rising num­bers of deaths from it.

It af­fects Afric­an-Amer­ic­ans dis­pro­por­tion­ately. They have twice the rate of death from hep­at­it­is C as white Amer­ic­ans, and they have twice as high a rate of in­fec­tion. So we have called at­ten­tion to test­ing the baby-boomer gen­er­a­tion for hep­at­it­is C — people born from 1945 to 1965 — be­cause that pop­u­la­tion were young adults be­fore this vir­us was found in 1989 and be­fore pre­ven­tion meas­ures were put in place. They may have been ex­posed to hep­at­it­is through blood trans­fu­sions, ex­pos­ures in the health care set­tings, or through drug use, or oth­er ex­pos­ures.

This pop­u­la­tion has an in­creased rate of hav­ing hep­at­it­is C, and you re­main in­fec­ted for life. As years go by, the vir­us eats away si­lently at the liv­er and causes late symp­toms. So our big fo­cus is get­ting more people tested and aware of their in­fec­tion status, and, if they’re in­fec­ted, dir­ec­ted to prop­er treat­ment.

Ad­dress­ing health dis­par­it­ies and people with high pre­val­ence, the pre­val­ence is at least two times as high in black Amer­ic­ans as in white. So we want to be care­ful to share the right mes­sage to pro­viders and the com­munity it­self. There’s a simple blood test, and the very ex­cit­ing news is there are safe, short-act­ing cur­at­ive treat­ments for hep­at­it­is C.

If you test and cure them for C, you lower their rate for mor­tal­ity by 50 per­cent and for liv­er can­cer by 70 per­cent, so there’s a huge health pay­off through test­ing and treat­ment.

This wave of treat­ments is very new — only li­censed in Novem­ber or Decem­ber. It al­lows you to have an or­al treat­ment re­gi­men that can be a hand­ful of pills for 12 weeks — maybe 24 — of treat­ment. Be­fore that, and even now, some pa­tients re­quire in­jec­tions of in­ter­fer­on every week with side ef­fects that are quite no­tice­able.

The old treat­ment had a bad repu­ta­tion if you had to live with liv­er dis­eases. To get rid of your in­fec­tion, we have to cor­rect a lot of in­ac­cur­ate im­pres­sions — how they make you feel, what’s in­volved — and we’re at a dif­fer­ent place now.

It comes at an im­port­ant time with rising dis­ease and mor­tal­ity, which is totally pre­vent­able if we can get people tested and treated. We want all people born in that era to be tested for hep­at­it­is, re­ferred for care, and to re­ceive the treat­ments that are in­dic­ated.

In our eco­nom­ic stud­ies, when we look at the cost of avert­ing death and ex­tend­ing lives, we es­tim­ate that it costs about $32,000 to ex­tend a per­son’s life for one year. That’s the tra­di­tion­al way in­ter­ven­tions are eval­u­ated. That fol­lows well in the range of oth­er pre­vent­ive ser­vices for check­ing blood pres­sure, cho­les­ter­ol, and flu vac­cin­a­tions for older adults. It shows it­self to be a very reas­on­able in­ter­ven­tion that has a pay­off in avert­ing death for a reas­on­able amount of money.

We es­tim­ate that if we fully im­ple­ment this birth-co­hort strategy, we can identi­fy 800,000 people not aware they’re in­fec­ted, and avert 120,000 deaths and save $2.5 bil­lion in health care costs.

The obstacles are get­ting clini­cians aware of our re­com­mend­a­tions and help­ing them make it part of their routine prac­tice. The more that can be handled by your nurse or mid-level pro­vider rather than a doc­tor means it can be im­ple­men­ted more quickly. So we’re look­ing to in­sert an elec­tron­ic re­mind­er in­to a pa­tient’s re­cord, like for pa­tients whose birth­days are between 1945 and ‘65, auto­mat­ic­ally you’re offered this test. So we’re look­ing to get that in place.

The U.S. Pre­vent­ive Ser­vices Task Force also made a sim­il­ar re­com­mend­a­tion for test­ing for this group. The be­ne­fit of that is the USP­STF re­com­mend­a­tions are covered as a no-co-pay pre­vent­ive ser­vice. That means, for most private health care ser­vices, the pa­tient won’t have ex­penses, so that re­duces one bar­ri­er. Some­times pro­viders will listen to their pat­ents, and that re­in­forces our mes­sage. They draw blood and add the test on without ad­di­tion­al cost to the pa­tient more of­ten than not since it’s covered by in­sur­ance.

We’re also edu­cat­ing the pub­lic, so the pa­tient knows the im­port­ance, and then we’re gath­er­ing data to see where it’s work­ing and where it’s not and to im­prove it, with par­tic­u­lar at­ten­tion to Afric­an-Amer­ic­ans and com­munit­ies where pre­val­ence is highest.

I’ve had friends in my own com­munity and ac­quaint­ances who un­for­tu­nately have waited too late to be tested and treated, so they’d already de­veloped liv­er dis­ease so ad­vanced they could no longer be­ne­fit from treat­ment. The reas­on is that there are so few symp­toms un­til the ad­vanced stage that a pa­tient can­not rely on how they’re feel­ing. Only through test­ing is that pos­sible. The drugs work bet­ter when the liv­er dis­ease is milder, so the earli­er the test and treat­ment, the bet­ter.

Most pa­tients, when they learn of the reas­ons for test­ing, they read­ily ac­cept it, and I have ex­amples of people say­ing, “Thank you for catch­ing this in time.” In fact, CDC-sup­por­ted test­ing pro­grams get thank-you notes from people who pre­vi­ously didn’t know of their con­di­tion.

So pro­viders and doc­tors will provide a ser­vice that’s ap­pre­ci­ated by pa­tients. Among those people tested and treated and for­tu­nate to clear their in­fec­tion, they say, “I didn’t really know how bad I felt un­til I got rid of this in­fec­tion.” The days of feel­ing slug­gish, out of sorts, los­ing their get-up-and-go, they at­trib­ute to just get­ting older, when it was really hep­at­it­is C that was caus­ing symp­toms. They’re so mild and non­spe­cif­ic no one really seeks med­ic­al care, but ac­tu­ally they have it.

The pro­spect of sav­ing 120,000 lives — well, you don’t get those op­por­tun­it­ies in pub­lic health very of­ten. As­sem­bling at­ten­tion that this de­serves and get­ting pro­viders and the health com­munity on board is mak­ing a dif­fer­ence.

For more in­form­a­tion about the CDC’s Hep­at­it­is C pub­lic edu­ca­tion cam­paign, Know More Hep­at­it­is, please vis­it: ht­tp://www.cdc.gov/know­more­hep­at­it­is/

MY VIEW OF THE NEXT AMER­ICA

MY VIEW OF THE NEXT AMERICA

Are you part of the demo­graph­ic that is the Next Amer­ica? Are you a cata­lyst who fosters change for the next gen­er­a­tion? Or do you know someone who is? The Next Amer­ica wel­comes first-per­son per­spect­ives from act­iv­ists, thought lead­ers, and people rep­res­ent­at­ive of a di­verse na­tion. Email us. And please fol­low us on Twit­ter and Face­book.

Jody Brannon contributed to this article.
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