State-funded programs have requested technical assistance from CDC for materials to train counselors. These materials are in the final stages of development, along with a hepatitis training curriculum for the national STD Prevention and Training Center network. There is need for the further development and distribution of a wide range of client-centered counseling materials for use in settings where persons at risk for HCV infection are identified (e.g., HIV/AIDS counseling and testing sites, STD clinics, drug treatment facilities, correctional facilities).

Education of the general public and groups at increased risk for infection.   CDC has joined with a number of non-governmental organizations to ensure widespread distribution of hepatitis C health education and prevention messages.

Providing resources to these and other partners will continue to ensure that health education materials and messages consistent with CDC’s recommendations are distributed to the public as well as to persons in groups at increased risk for infection. Public service advertising and media outreach in various formats are needed to increase public awareness of the importance of hepatitis C prevention and control. Continued formative research is needed to determine what messages and formats might best reach intended audiences, such as past and present injecting drug users and individuals with high-risk sexual activity. Print materials and public service advertising for persons at risk for transfusion-acquired HCV infection have been developed and are being distributed, but their effectiveness remains to be evaluated.

Education and advertising materials and campaigns will be developed to reach persons in other risk groups. CDC’s Hepatitis website regularly provides updated information for both health professionals and the public and links with partners for additional information. In addition, CDC’s Hepatitis Information Line and Hotline provide both "live" and recorded information in both English and Spanish.

State-based Hepatitis C Prevention and Control Programs.   Hepatitis C counseling and testing programs need to be implemented at the state and local levels. Although a recent survey of local health officers showed that 87 percent of city and county health departments provide education about HIV/AIDS and 77 percent provide HIV testing, less than 50 percent provide hepatitis C counseling and only 23 percent provide HCV testing⁶.

Currently, no federal funding is available to support nationwide establishment of hepatitis C counseling and testing services at the state or local level. In response to this lack of federal funding, a number of state and local health departments have funded hepatitis C counseling and testing projects.

Most of these local programs have relied heavily on technical support and materials developed by CDC. However, prevention services need to be expanded, especially for disenfranchised populations and populations with health disparities (e.g., African-Americans, Native Americans), which can only be assured by a national program.

A major goal of the National Hepatitis C Prevention Strategy is funding of a ‘Hepatitis C Coordinator’ for every state and large metropolitan health department to meet the expressed needs of state and local public health officials. The Hepatitis C Coordinator provides the management, networking, and technical expertise required for successful integration of hepatitis C prevention and control activities into existing public health programs (Figure 4). Coordinators assist state or local health departments in: 1) identifying public health and clinical activities in which HCV counseling and testing should be incorporated; 2) ensuring training of health care professionals in effective hepatitis C prevention activities; 3) developing the capacity to provide HCV testing through public health or private diagnostic laboratories; 4) identifying sources for appropriate medical referral of HCV positive persons; 5) ensuring appropriate surveillance for HCV infection; and 6) evaluating the effectiveness of HCV prevention activities.

Broad implementation of hepatitis C prevention activities has been greatly facilitated by the development of a State hepatitis C/viral hepatitis prevention plan. These plans have provided the road map for prioritizing development of prevention activities, integrating hepatitis prevention activities into existing public health programs, and obtaining resources to achieve implementation of prevention activities. A number of approaches have been used to develop such plans, including convening special commissions or consensus meetings, or using consultants. Key to development of a successful plan is inclusion of stakeholders and experts involved in viral hepatitis prevention and control from fields which include: public health, infectious disease, immunization, correctional health, drug and substance abuse treatment, HIV/AIDS counseling and testing, STD prevention and treatment, mental health, public health nursing, clinical medicine (primary care, hepatology, gastroenterology), laboratory medicine, patient support and advocacy, health communication and education, health care financing, and public health policy. Although a number of States have now developed such plans, technical assistance and resources are needed to assist those States without plans.

While prevention of all bloodborne virus infections (HIV, HCV, HBV) is a major goal of the National Hepatitis C Prevention Strategy, there is limited experience with the integration of hepatitis C and hepatitis B prevention activities into public health programs for persons at risk for bloodborne viral infections, including incarcerated persons⁷. Demonstration projects to examine the feasibility and operational aspects of integrating hepatitis C prevention into existing public health and correctional health programs were first funded by CDC in FY 1999, were expanded to include several county and city health departments in FY 2000, and should be further expanded to include state-wide projects. Demonstration projects include activities to prevent HCV, HBV, and HIV infection, such as counseling, testing, and medical referral for infected persons, and hepatitis B and hepatitis A immunization. Critical to the implementation of integrated prevention activities is funding for public health laboratories to provide HCV testing for persons served in the public sector and for immunization with hepatitis B and hepatitis A vaccines of at-risk persons.

CDC’s annual National Hepatitis Coordinator meeting, which previously has brought together persons involved with the prevention of HBV infection at the state and local levels (e.g., hepatitis B coordinators, state immunization directors, STD program managers), will be expanded to facilitate the sharing of information gained from federally and locally funded hepatitis C prevention activities.

Surveillance.   States that require reporting of persons who test HCV positive need resources to establish, maintain, and analyze information on infected persons for purposes of disease surveillance. These resources would support use of state surveillance databases to evaluate the effectiveness of prevention programs by determining: 1) the proportion of the population with hepatitis C that has been identified; 2) missed opportunities for identification of persons with selected risk factors for HCV infection; and 3) whether persons reported to state surveillance systems have received counseling, medical referral, and appropriate medical management. For states without HCV surveillance, CDC would offer assistance in establishing surveillance systems for evaluating the effectiveness of their hepatitis C prevention programs.

In addition to state-based surveillance, CDC must continue to maintain several other surveillance systems including: 1) the Sentinel Counties Study of Viral Hepatitis to determine trends in incidence of acute hepatitis C and other types of viral hepatitis, and risk factors for infection; 2) testing of participants in NHANES to determine age-specific trends in prevalence of HCV infection; and 3) sentinel surveillance for chronic liver disease to determine trends in chronic hepatitis C.

Epidemiologic and Laboratory Investigations. Research to answer questions which impact hepatitis C prevention and control is an important component of the National Hepatitis C Prevention Strategy and prevention of new HCV infections probably is the greatest challenge. The majority of new HCV infections occur among persons who inject illegal drugs and the risk of HCV infection among this group is several-fold greater than the risk of HIV infection. High priority must be given to studies that determine those activities among active injection drug users which facilitate HCV transmission and the development of interventions which interrupt transmission. In addition, prevention of HCV infection must become the marker of success of community-based interventions to prevent drug use among persons at high risk for this behavior.

Priority also must be given to studies which answer questions related to other risk factors for HCV infection in order to improve counseling messages and to devise effective prevention activities. These include studies to quantify risk for infection following sexual exposure, the risk of transmission from tattoos or body piercing obtained in various settings, risk from non-injection drug use (e.g., cocaine use), risk of infection following occupational needlestick exposure, and risk of perinatal HCV infection following obstetric interventions or complications. Laboratory tests that differentiate acute from chronic HCV infection or rapid diagnostic tests that could be used in outreach settings would greatly improve identification of persons with HCV infection and improve prevention and control activities.