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97–775 PDF 2004

STALKING A FURTIVE KILLER: A REVIEW OF THE

FEDERAL GOVERNMENT’S EFFORTS TO COMBAT

HEPATITIS C

HEARING

BEFORE THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

DECEMBER 14, 2004

Serial No. 108–275

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform
(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

DOUG OSE, California

RON LEWIS, Kentucky

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

NATHAN DEAL, Georgia

CANDICE S. MILLER, Michigan

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

PATRICK J. TIBERI, Ohio

KATHERINE HARRIS, Florida

MICHAEL C. BURGESS, Texas

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

JIM COOPER, Tennessee

BETTY MCCOLLUM, Minnesota

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel
(III)

C O N T E N T S

Page

Hearing held on December 14, 2004 ...................................................................... 1

Statement of:

Khabbaz, Rima, M.D., Associate Director of Epidemiologic Science, National Center for Infectious Diseases, Center for Disease Control and

Prevention, accompanied by Eric Mast, M.D., Acting Director of the

Division of Viral Hepatitis; Jay Hoofnagle, M.D., Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National

Institute of Diabetes and Digestive Kidney Diseases, National Institutes of Health; and Lawrence Deyton, MSPH, M.D., Chief Consultant,

Public Health Strategic Healthcare Group, Department of Veterans

Affairs, accompanied by Michael Rigsby, M.D, Director of the National

Program Office for HIV and hepatitis C, Veterans Health Administration ................................................................................................................. 15

Rudman, Michael, M.D., founder, Frederick County Hepatitis Clinic, Inc.;

Ann Jesse, founding executive director, HEP C Connection; John

Niemiec, first vice president, Fairfax County Professional Fire Fighters

and Paramedics; and Erika Stein, Robinson Secondary School DECA

student (father has hepatitis C) .................................................................. 74

Letters, statements, etc., submitted for the record by:

Cummings, Hon. Elijah E., a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 120

Davis, Chairman Tom, a Representative in Congress from the State of

Virginia, prepared statement of ................................................................... 4

Deyton, Lawrence, MSPH, M.D., Chief Consultant, Public Health Strategic Healthcare Group, Department of Veterans Affairs, prepared statement of ........................................................................................................... 43

Hoofnagle, Jay, M.D., Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive Kidney Diseases, National Institutes of Health, prepared statement of ........................................................................................................... 29

Jackson Lee, Hon. Sheila, a Representative in Congress from the State

of Texas, prepared statement of .................................................................. 128

Jesse, Ann, founding executive director, HEP C Connection, prepared

statement of ................................................................................................... 85

Khabbaz, Rima, M.D., Associate Director of Epidemiologic Science, National Center for Infectious Diseases, Center for Disease Control and

Prevention, prepared statement of .............................................................. 18

Niemiec, John, first vice president, Fairfax County Professional Fire

Fighters and Paramedics, prepared statement of ...................................... 97

Ros-Lehtinen, Hon. Ileana, a Representative in Congress from the State

of Florida, prepared statement of ................................................................ 124

Rudman, Michael, M.D., founder, Frederick County Hepatitis Clinic, Inc.,

prepared statement of ................................................................................... 77

Souder, Hon. Mark E., a Representative in Congress from the State

of Indiana, prepared statement of ............................................................... 111

Stein, Erika, Robinson Secondary School DECA student (father has hepatitis C), prepared statement of ..................................................................... 101

Waxman, Hon. Henry A., a Representative in Congress from the State

of California:

Letter dated October 7, 2004 .................................................................... 63

Prepared statement of ............................................................................... 9

Wilson, Hon. Heather, a Representative in Congress from the State of

New Mexico, prepared statement of ............................................................ 125

(1)

STALKING A FURTIVE KILLER: A REVIEW OF

THE FEDERAL GOVERNMENT’S EFFORTS TO

COMBAT HEPATITIS C

TUESDAY, DECEMBER 14, 2004

HOUSE OF REPRESENTATIVES,

COMMITTEE ON GOVERNMENT REFORM,

Washington, DC.

The committee met, pursuant to notice, at 2 p.m., in room 2154,

Rayburn House Office Building, Hon. Tom Davis (chairman of the

committee) presiding.

Present: Representatives Tom Davis, Waxman, Towns and Norton.

Staff present: David Marin, deputy staff director/communications

director; Robert White, press secretary; Drew Crockett, deputy director of communications; Susie Schulte, professional staff member;

Teresa Austin, chief clerk; Sarah Dorsie, deputy clerk; Corinne

Zaccagnini, chief information officer; Bill Womack, legislative director; Amy Westmoreland, legislative assistant, Karen Lightfoot, minority communications director/senior policy advisor; Sarah

Despres, minority counsel; Josh Sharfstein, minority professional

staff member; Earley Green, minority chief clerk; and Jean Gosa,

minority assistant clerk.

Chairman TOM DAVIS. With a quorum being present, the Committee on Government Reform will come to order; and I want to

welcome everybody to today’s oversight hearing on the significant

public health threat posed by hepatitis C.

Most people probably don’t realize that hepatitis C is now the

most common blood-borne viral infection in the United States, affecting nearly 4 million Americans. Hepatitis C is also a leading

cause of chronic liver disease, now the 10th leading cause of death

among adults in the United States.

In 1998, this committee held a hearing on the need to improve

the Nation’s response to hepatitis C. At that hearing, several specific points of action were recommended. Today, we will examine

what progress has been made in responding to the hepatitis C epidemic. We also hope to identify areas for improvement.

Hepatitis C was only identified 15 years ago, so we still have a

lot to learn about this disease. We have learned that significant obstacles to fighting hepatitis C exists. There is currently no vaccine

to shield against hepatitis C virus. There are vaccines against hepatitis A and B; however, the structure of the hepatitis C virus has

proved a difficult puzzle for medical researchers to solve.
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Today, we will hear from NIH whether it’s reasonable to expect

availability of a hepatitis C vaccine in the near future. Pharmaceutical treatments are available but only successful about 50 percent of the time under ideal conditions. They are also attended by

side effects, sometimes so devastating they often are not an option

for many patients with hepatitis C infection.

Second, infection with hepatitis C virus generally carries no

symptoms but gradually damages the liver over the course of many

years or even decades. It’s discovered only after a patient exhibits

signs of serious liver disease, such as cirrhosis or liver cancer.

Since the virus lasts for such a long period of time, it is possible

for infected persons to disassociate or even forget about long-ago instances of drug use or other high-risk behavior. Thus, the individual doesn’t address their own illness, nor do they take steps to

stem the spread of the virus to others.

A final obstacle is that hepatitis C, while a serious public health

issue, remains relatively unknown to the general public. Those affected often come from marginalized populations, intravenous drug

users and prisoners, for example, lacking the political organization

to effectively raise public awareness about the disease.

Public health officials face the challenge of informing, rather

than panicking, the public about hepatitis C, a task made even

more difficult given our still-evolving knowledge base. It seems to

me that there is a misperception that hepatitis C is a disease affecting, ‘‘somebody else.’’ However, social strata provide no prophylaxis. This misperception underscores the need to establish effective programs to educate both health care providers and the public

at large about the dangers of hepatitis C and the high-risk activities that tend to spread it.

This hearing sets the stage to review our Nation’s response to

hepatitis C. Several questions we would like answered today include: How well are hepatitis C prevention strategies working? Are

we screening enough people to identify persons at risk for infection? What progress has been made in the last 5 years toward the

quest for vaccine and developing better and more effective treatments for hepatitis C? How well do the Federal agencies share information among themselves and with State health departments?

The current epidemic has challenged our public health system’s

capabilities and provides us with a chance to evaluate existing prevention, screening and treatment programs. The Department of

Veterans Affairs [VA], has an excellent hepatitis C program and

has taken the leading role in managing infection. I am pleased we

have a witness on our first panel to discuss the proactive education, screening, treatment, counseling and surveillance measures

taken by the VA over the past few years. We will take a look at

how these programs are being implemented and what lessons can

be provided to the general public health community.

In addition to the testimony from several medical and public

health experts, we will hear the personal story of a teenage girl

from Fairfax County whose father has hepatitis C. Erika Stein has

helped lead a marketing program at her high school to raise awareness and get more Federal resources allocated for prevention and

research for the disease. We look forward to her testimony.
3

The committee hopes to learn from the experiences of those who

feel the effects of hepatitis C infection every day. I understand

some of our witnesses this morning will express concerns about the

success of current hepatitis C prevention efforts and identify areas

where improvement is still needed. I look forward to a constructive

dialog on these concerns. I know we all share the same goal at the

end of the day, a public health system that can adequately respond

to the hepatitis C epidemic.

We have an excellent roster of witnesses today. I want to thank

all of them for appearing before the committee. I look forward to

their testimony.

[The prepared statement of Chairman Tom Davis follows:]
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Chairman TOM DAVIS. I would now like to yield to Ms. Norton

for her opening statement and then go to Mr. Waxman.

Ms. NORTON. Thank you very much, Mr. Chairman.

Chairman Davis, I think you are performing a public service, an

unusually important public service, with today’s hearing. Of course,

every hearing is a service to the public. But I must say the first

question that came to me as I prepared for this hearing is why is

this disease such a mystery to me and why is it, I believe, such a

mystery to most of the people in this country? And I couldn’t help

but wonder whether we were simply sitting on a problem where

you have a highly contagious disease like this which has no vaccine

and no cure. Where is the public health campaign and public

health outcry about this disease? Why am I sitting here, a Member

of Congress, probably as ignorant about it as the average American? That is very troubling.

You consider the consequences, the contagion, when you don’t

know about a disease, that you can then pass on through intravenous drug use, you really are creating a public health menace,

that alarms should be raised about it. People should be put on notice. Today’s hearing for me is an opportunity to understand why

and what we can do about it. Very dangerous disease. Most of the

people who have it don’t have any symptoms. Here you are passing

along a terrible disease and don’t know you have it and nobody is

telling the public about it.

Here we are sitting in the most advanced country in the world

when it comes to health matters, except when it comes to making,

of course, health care available to everybody. Why is it that we

aren’t doing more about this disease?

Consider some of the consequences. This is one of the diseases

that leads to terrible liver disease, and people who have liver disease need transplants. And about the most expensive way to deal

with the disease is to take an organ out and put another one in.

Yet there was a fivefold increase in liver transplants in the 1990’s.

I wonder whether it is the nature of the disease and the people

who have the disease that account for why we know so little about

it and have done so little about the disease. Do we need a Ryan

White to get the country’s understanding, to get CDC’s attention?

Because that is what it took, frankly, with the AIDS crisis. If so,

shame on us.

The fact that those who get this disease often are people who use

drugs, people who are in prison, I should say nothing about the attention we pay to the disease. Unless there is another explanation,

I’m going to have to start with a presumption that it’s who gets the

disease is responsible for why we haven’t done more, about why we

haven’t done more about this disease.

Mr. Chairman, you are doing a great deal about it by having this

hearing today that may start us on the way to truly raising the

consciousness of the American people about hepatitis C.

Chairman TOM DAVIS. Thank you very much.

I now recognize the ranking member, Mr. Waxman.

Mr. WAXMAN. Thank you, Chairman Davis, for calling this hearing today on an important but often overlooked problem.

Inside the human body, the hepatitis C virus acts with unusual

stealth. Infected individuals may feel fine for years and even dec-
7

ades and then, without warning, hepatitis C can awaken and cause

irreversible cirrhosis, liver failure and death.

The stealth of the hepatitis C virus also has been evident in the

body politic. Over the past 2 decades, our government has missed

opportunities to take action to combat hepatitis C and to alert the

public to a growing threat. Now we find ourselves facing a chronic

blood-borne infection that affects 3 million Americans and kills

8,000 each year. We must first ask what went wrong, and then we

must be clear about the opportunities we are missing even today

to defeat hepatitis C.

By 1981, it was known that hundreds of thousands of patients

were contracting chronic hepatitis C from blood transfusions. Even

through the specific virus causing hepatitis had yet to be identified

and there was no specific screening test, blood banks could have

taken action to protect the public, because, at the time, research

showed that by screening blood for evidence of liver disease in the

donor thousands of cases of transfusion-associated hepatitis could

be prevented. Such screening, however, was not required by the

Food and Drug Administration, and it was not adopted widely by

blood banks until 1987.

Two years later, in 1989, the hepatitis C virus was discovered at

a specific screening test. Blood banks and hospitals could have

looked back and identified people who had been transfused with infected blood, but FDA decided against requiring such a review.

The issue was revisited in the mid-1990’s. Under the leadership

of HHS Secretary Donna Shalala, the Food and Drug Administration oversaw notification of Americans transfused with tainted

blood after 1992. In 1999, FDA proposed extending the notification

back to individuals transfused prior to 1992, but the current administration has resisted finalizing this potentially life-saving rule.

There is a moral issue here. The government has neither required notification of people who did receive tainted blood nor conducted a broad public education campaign informing anyone about

who needs to get tested. The result is that many people have no

idea of the risks they face.

In 2000, Surgeon General David Satcher sought to write a letter

to every American’s home about the threat of hepatitis C. His effort

was never funded.

In 2001, a national hepatitis C strategy was developed. While

CDC has begun to pursue important parts of this strategy, many

of its elements have yet to be fully funded and implemented. As a

consequence, millions of Americans at risk remain unaware of the

problem. Many who can benefit from treatment never get it. And

even today many infections that can be prevented are not.

According to the Centers for Disease Control, 60 percent of the

new hepatitis C infections are transmitted by intravenous drug

use. Yet, across our country, many thousands of people who want

to get into drug treatment programs, programs that are proven to

work, can find no space available to them.

Scientific evidence also demonstrates that even those who continue to use drugs can be kept safe from hepatitis C. Two years

ago, a consensus panel on hepatitis C convened by the National Institutes of Health recommended, ‘‘providing access to sterile syringes through needle exchange, physician prescription and phar-
8

macy sales.’’ The panel advised that physicians and pharmacists

should be educated to recognize that providing intravenous drug

users with access to sterile syringes and education and safe infection practices may be lifesaving. Yet, since then, not much progress

in this area has been made.

This is an area where right-wing ideology conflicts with sound

public health practices. Everyone wants to stop illegal drug use,

but because we know that some addicts will continue to use drugs,

it is essential to support needle exchange and other life-saving

measures. Those who oppose needle exchanges are like those who

oppose comprehensive sex education for teenagers, which also has

proven to be effective. Public health policy needs to recognize reality and be based on facts and science.

The infections that we fail to prevent today may not create problems for tomorrow, but, as the years and decades pass, our society

will suffer the economic social burden of hepatitis C infections that

were entirely preventable. This is a terrible legacy to our children.

It’s a terrible tragedy for those involved.

I hope this hearing will shed light on the dangers of the hepatitis

C virus. We must work together to generate momentum for legislation to address hepatitis C and to expand access through drug

treatment.

I thank the witnesses who are going to be here today and am

looking forward to their testimony.

Chairman TOM DAVIS. Thank you very much.

[The prepared statement of Hon. Henry A. Waxman follows:]
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Chairman TOM DAVIS. Mr. Towns, any opening statement?

Mr. TOWNS. Thank you very much. I want to thank you, Mr.

Chairman, for holding this hearing.

Beginning in 1995, Representative Chris Shays of Connecticut

and I held a series of hearings on blood-borne illnesses and hepatitis C. Our concerns for the safety of the blood supply and the possible transmission of disease through transfusion led us to ask

hard questions about the Federal policy.

During those hearings, we heard the moving testimony of the

Honorable Joe Moakley, former Chair of the Rules Committee, from

Massachusetts, who had contracted hepatitis C through a blood

transfusion. Unfortunately, he died from the disease within a few

years of those hearings. His death showed that hepatitis C can

happen to anyone. It made me aware of the fact that education and

prevention could not be solid components of the Federal public

strategy.

As a result of those hearings, the Centers for Disease Control

and Prevention agreed to engage in the first-ever public education

campaign on hepatitis C, which included a requirement that the

CDC take the unprecedented step of notifying those people who

may have been infected through blood transfusions. Some public

health officials are warning us that the number of deaths from this

disease will triple in the next decade, from the estimate of 8,000

to 10,000 deaths per year to an incredible 24,000 to 30,000 deaths

per year. Because the disease can be dormant for several years and

only 30 percent of those who are infected have any symptoms of the

disease, these estimates may be an understatement. But I’m hopeful we will not see such an explosion before we take action.

That is why I join with my colleague, Heather Wilson, to introduce H.R. 3539, the Hepatitis C Epidemic Control and Prevention

Act. This bipartisan bill will direct the Secretary of Health and

Human Services to establish, promote and support a comprehensive prevention, research and medical management referral program. For persons suffering from the hepatitis C virus, if passed,

this bill will represent the first Federal effort to provide a strategic

approach to combat this disease by requiring the development and

implementation of a plan for public education, early detection, testing and counseling of patients. Mr. Chairman, I know that you are

a supporter of this bill, and I want to thank you so much for that.

In March 2004, the U.S. Preventive Services Task Force, a panel

called together by an agency of the Department of Health and

Human Services, published recommendations which advised

against hepatitis C screening in people who are not in current

high-risk categories for the disease. The published recommendations appear to indicate neutrality on whether adults who are high

risk should be screened. These recommendations directly contradicted recommendations of the NIH and the current accepted practice in the medical community. Mr. Chairman, may I suggest that

we have a hearing on the apparent contradiction within the Federal Government on the issue of hepatitis C screening.

On that note, let me thank you again for holding this hearing;

and I would like to thank the witnesses as well for being here and

to say to you that, with you, I hope we can make certain that there

is a serious and strategic Federal response to hepatitis C. Mr.
15

Chairman, we need to stay on this issue. This is a very serious

problem.

Chairman TOM DAVIS. Thank you very much for your leadership

on this as well, Mr. Towns; and I’m proud to be a co-sponsor of

your bill.

We are going to move to our first panel of witnesses who will discuss efforts being taken at the Federal level to manage the hepatitis C epidemic. They will also describe their efforts to coordinate,

educate, screen, treat, counsel and survey measures.

We have Dr. Rima Khabbaz, the Associate Director of Epidemiologic Science for the National Center for Infectious Diseases. She’ll

be providing testimony on behalf of the CDC. Dr. Eric Mast, the

Acting Director of the Division of Viral Hepatitis at CDC, accompanies Dr. Khabbaz and is available to answer questions. So when

we swear in witnesses we will have both of them sworn in.

Dr. Jay Hoofnagle of the Liver Disease Research Branch at NIH

will provide testimony regarding research efforts in search of a vaccine and more effective treatment options; and Dr. Lawrence

Deyton, the Chief Consultant of the Public Health Strategic

Healthcare Group at the Department of Veterans Affairs, will discuss the VA’s excellent hepatitis C program. He’s accompanied by

Dr. Michael Rigsby, who is the Director of the National Program

Office for HIV and Hepatitis C at the Veterans Health Administration. Dr. Rigsby will also be available to answer questions posed by

Members, so he’ll be sworn as well.

Would you please rise with me and raise your right hands.

[Witnesses sworn.]

Chairman TOM DAVIS. It’s our policy that we swear you in before

you testify.

Dr. Khabbaz, I think I’ll start with you—we will move straight

on down the line—and I thank you for your efforts in this area and

thank you for being with us today. We try to keep our 5-minute

presentation. Your entire testimony is in the record. So thank you.

STATEMENTS OF RIMA KHABBAZ, M.D., ASSOCIATE DIRECTOR

OF EPIDEMIOLOGIC SCIENCE, NATIONAL CENTER FOR INFECTIOUS DISEASES, CENTER FOR DISEASE CONTROL AND

PREVENTION, ACCOMPANIED BY ERIC MAST, M.D., ACTING

DIRECTOR OF THE DIVISION OF VIRAL HEPATITIS; JAY

HOOFNAGLE, M.D., LIVER DISEASE RESEARCH BRANCH, DIVISION OF DIGESTIVE DISEASES AND NUTRITION, NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE KIDNEY

DISEASES, NATIONAL INSTITUTES OF HEALTH; AND LAWRENCE DEYTON, MSPH, M.D., CHIEF CONSULTANT, PUBLIC

HEALTH STRATEGIC HEALTHCARE GROUP, DEPARTMENT

OF VETERANS AFFAIRS, ACCOMPANIED BY MICHAEL

RIGSBY, M.D, DIRECTOR OF THE NATIONAL PROGRAM OFFICE FOR HIV AND HEPATITIS C, VETERANS HEALTH ADMINISTRATION

Dr. KHABBAZ. Good afternoon, Mr. Chairman and members of the

committee. I am Dr. Rima Khabbaz, Associate Director for Epidemiologic Science at the National Center for Infectious Diseases

at the CDC; and I’m accompanied today by Dr. Eric Mast, the Acting Director of the Division of Viral Hepatitis. We are pleased to
16

be here, and we thank you for the opportunity to describe the activities that CDC has undertaken with our partners to implement

the National Hepatitis C Prevention Strategy, which this committee was instrumental in initiating in 1999.

Hepatitis C virus [HCV], is indeed a very serious concern, as it

is today the most common cause of chronic liver disease in the

United States. It is the most common chronic blood-borne infection.

About 4 million Americans have already been infected, and approximately 3 million are chronically infected, and about 30,000

Americans become newly infected each year. Unlike hepatitis A

and B, there is no vaccine to prevent infection with HCV. Because

the consequences of chronic liver disease from HCV may not become apparent for 10 to 20 years, many infected persons are not

aware of their infection.

The two major objectives of the National Hepatitis C Prevention

Strategy are identification of infected persons and prevention of

new infections. These objectives are paramount to reducing the impact of HCV on the public.

Identification of HCV-infected persons as well as persons at risk

of HCV infection is best achieved through the integration of hepatitis prevention services into community-based clinical and public

health programs that serve at-risk persons. Because the majority

of persons with hepatitis C do not have symptoms of liver disease,

their identification requires that testing be done on persons with

risk factors for infection.

CDC has conducted a number of community-based demonstration

projects called Viral Hepatitis Integration Projects which have

shown the feasibility and the effectiveness of including hepatitis

prevention services in a variety of clinical and public health settings.

I would now like to take a few moments to highlight some specific components of the National Hepatitis C Prevention Strategy.

First, as it relates to health communications, CDC has developed

evidence-based guidelines for identification and testing of persons

at risk of hepatitis C. CDC has also provided a broad range of materials about hepatitis C for health care professionals and the public. These include Web-based, continuing medical education programs for health care professionals, a Hepatitis C Toolkit for primary care providers and their patients. We have brought with us

samples of these materials on the table here and there for those

interested, and it can also be found on CDC’s Web site. CDC has

also funded academic centers, health departments and nongovernmental organizations to carry viral hepatitis education and training

activities.

Second, with regard to community-based prevention programs,

currently, CDC funds 53 hepatitis C coordinators in States, large

metropolitan areas and in the Indian Health Service. These coordinators work to accelerate the integration of hepatitis C testing,

counseling and referral for medical evaluation into communitybased programs that provide clinical and Public Health Services.

Among the many activities in which the coordinators engage is the

development of comprehensive State hepatitis C prevention plans,

and at least 23 States have such a plan at this time.
17

Surveillance is another important component of the prevention

strategy because it allows us to monitor trends as well as the effectiveness of prevention efforts. CDC continues to work to develop

and maintain enhanced national surveillance systems for hepatitis

C. Since 2003, chronic HCV infection has become reportable to

CDC; and CDC has developed surveillance guidelines for case investigation and followup of persons of chronic HCV infection.

As there continues to remain a number of an unanswered questions concerning the epidemiology and the natural history of HCV

infection, CDC has a number of studies under way or planned.

In conclusion, since 1998, CDC and its partners have made considerable progress in raising awareness about the prevention of

hepatitis C both among health care providers and the public. In addition, many States have initiated hepatitis C prevention programs, which are being facilitated by the federally funded hepatitis

C coordinators. However, our job is far from complete and much

more remains to be done.

Thank you for your attention and for the opportunity to increase

awareness about hepatitis C for this hearing, and I will be happy

to answer any questions you may have.

Chairman TOM DAVIS. Thank you very much.

[The prepared statement of Dr. Khabbaz follows:]
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Chairman TOM DAVIS. Dr. Hoofnagle, thank you for being with

us. It is a pleasure to have you. One of my staff members told me

that your efforts, at least she thinks, helped save her life a couple

of years ago, so thank you very much.

Dr. HOOFNAGLE. Thank you very much, Mr. Chairman and members of the committee.

My name is Jay Hoofnagle, and I’m the Director of the Liver Disease Research Branch for the National Institute of Diabetes and

Digestive and Kidney Diseases, one of the Institutes at the National Institutes of Health. I’m pleased to be asked to present testimony today on behalf of the NIH and its commitment to research

on hepatitis C.

As you have heard from Dr. Khabbaz, hepatitis C is a very important cause of liver disease. Between 1 and 2 percent of Americans are chronically infected with hepatitis C. Hepatitis C is now

the most common cause of chronic liver disease and most common

cause of cirrhosis and the major single cause for liver transplantation in adults, and it has become the most common cause of liver

cancer in this country and most of the western world.

But, also important, hepatitis C is due to a virus and, as such,

this is a potentially preventable, potentially treatable disease. That

means that control of this virus will go a long way to the control

of cirrhosis in this country.

We believe, Mr. Chairman, that the greatest promise for ultimate

control of hepatitis C will come through advances in biomedical

science and biomedical research, advances in the means of diagnosis and evaluation and treatment and prevention of this disease.

Indeed, there are few areas of biomedical research at present that

are more likely to result in immediate and tangible improvements

in the health of Americans than research on hepatitis C.

As you know, the mission of the NIH is to advance biomedical

research and thereby reduce the burden of disease and improve

health of Americans. Hepatitis C is a shared interest at the NIH,

not just by my Institute but also by the National Institute of Allergy and Infectious Diseases, the National Institute on Drug

Abuse, the National Cancer Institute, the National Heart, Lung

and Blood Institute, and the National Institute on Alcohol Abuse

and Alcoholism.

The activities of the Institutes are coordinated through multiple

committees, so that in fiscal year 2004 that was just completed the

estimated total amount of NIH research on hepatitis C was $118

million. Importantly, this figure is a major increase from what was

funded 5 and 10 years ago. For instance, between 1998 and 2003,

the Congress allocated funding that allowed for the doubling of the

NIH budget. During this same time, the budget specific for hepatitis C increased almost five-fold, stressing the importance of this

research area and the ability of the NIH to allocate funding to

emerging conditions of importance.

This hearing actually occurs at a special time for liver disease research in that the NIH has just completed a trans-NIH action plan

for liver disease research. This is the result of a year of work and

input from over 250 investigators, physicians and lay persons. It

covers all of the diseases, but hepatitis C is a major focus of this

action plan. The action plan outlines some goals and visions for the
27

next 5 to 10 years of research on liver disease, and some of my testimony will address the goals outlined in that plan. So in this brief

introduction I want to discuss two areas of importance and research. The first is treatment and the second, prevention.

As to treatment: The first treatment for hepatitis C was licensed

in 1991, and it is alfa interferons, given by injection for 6 to 12

months. As originally formulated, this regimen of therapy gave us

sustained response in only 10 to 20 percent of patients at most.

During the last 5 years, we have been fortunate to see several

advances in therapy of hepatitis C, the first, the introduction of the

anti-viral drug ribavirin, and, the second, the development of longacting interferons that are given once a week rather than daily or

every other day and that are more effective. So that the currently

recommended regimen for hepatitis C, the combination of

peginterferon and ribavirin, is effective in 55 percent of patients

with hepatitis C who have no other problems with their health. Indeed, in subgroups of patients, patients who have different strains

of hepatitis C, strain 2 and 3, the response rate is greater than 80

percent. These results are heartening.

Also heartening is the fact that what we call sustained response

is now shown to be durable and long lasting, and it appears to be

a cure of this viral infection. Well, that’s nice in a way, but remember that for 55 percent of these people that respond, there are 45

percent who did not. This treatment is difficult, and it’s expensive

and has many side effects. Clearly, new approaches of treatment

are needed.

A major proportion of our portfolio now in funding research on

hepatitis C is directed at improving therapy, and industry is also

involved in this to a major degree. There have been more than 50

patent applications for new therapies of hepatitis C, and at least

six of them are in early human trials. These are not ready for licensure or approval, but I can assure you that they look very promising. It is our hope that in the next 5 to 10 years, we will have therapy for this disease that will be effective in more than 90 percent

of patients and will extend to those difficult-to-treat populations

that are a problem at present.

Finally, as to prevention, as you have heard from the CDC, currently, there are recommendations toward prevention based on

public health measures. Since the discovery of the virus in 1987,

there has been an 80 percent drop of new cases of hepatitis C. It

is quite heartening. But since the 1990’s, this level of infection has

stayed stable, and there has been very little further decrease. What

is needed? Clearly, specific means of treatment are needed, vaccines and globulins that are effective against exposure to hepatitis

C.

In this regard, major efforts are being made in this area, stimulated through workshops, initiatives, added funding, to request of

applications for basic research on development of tissue culture,

animal models and candidate vaccines. Phase one studies of experimental vaccines have been funded, and with the advances and

knowledge about the immune system and with the focus on this

issue, we believe that a vaccine against this disease will ultimately

be available.
28

Mr. Chairman, let me conclude by thanking you for having this

hearing highlighting this very important disease and express the

gratitude of the basic and clinical research community in general

for the confidence and trust that the U.S. Congress has put into us

through continued support of the National Institutes of Health and

their mission. We believe that real progress can be made in the

control of hepatitis C, and I will be glad to answer any questions

that you have of me on the issue.

Chairman TOM DAVIS. Thank you very much.

[The prepared statement of Dr. Hoofnagle follows:]
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Chairman TOM DAVIS. Dr. Deyton.

Dr. DEYTON. Thank you, Mr. Chairman and committee members.

We appreciate the opportunity to be here today.

Hepatitis C has been and continues to be a high priority for the

Department of Veterans Affairs. Veterans who use VA for health

care are affected by hepatitis C in greater proportion than the Nation as a whole, and VA cares for more people with hepatitis C

than any other medical system in the country. VA has established

a comprehensive approach to hepatitis C similar to that recommended by former Surgeon General Dr. Koop and others in testimony before this committee 6 years ago.

VA’s public health approach to hepatitis C contains five integrated components that I will highlight: No. 1, screening and testing; No. 2, patient and provider education; No. 3, access to excellent clinical care; No. 4, data-based quality improvement; and, No.

5, research.

First in the area of screening and testing, it is VA policy to provide screening for hepatitis C risk factors for all veterans who receive VA health care and to offer testing for those with risk or anyone who desires to be tested. Since 1999, Mr. Chairman, over 4 million veterans in VA care have been screened for hepatitis C risk

factors, and over 200,000 have been diagnosed with hepatitis C infection. A recent external review of over 50,000 medical records

showed that over 98 percent of VA patients have been screened for

risk factors, and over 90 percent of those at risk have been tested

for hepatitis C.

VA leads the Nation in testing for hepatitis C. Our success in

screening and testing has its foundation in the second component

of our public health approach, that is, an aggressive program of patient and provider education. We’ve provided to your staff examples

of our education program, including copies of 29 single-topic patient

education brochures on hepatitis. We distributed literally millions

of these brochures throughout the VA health care system in order

to inform veterans about hepatitis C. We have partnered with veterans’ service organizations and various advocacy groups to promote hepatitis C awareness. We have also conducted an aggressive

provider education program, including giving grand round lectures

on hepatitis C at nearly every VA hospital in the Nation. We have

held national education conferences attended by nearly 1,000 VA

health care providers. We have developed recommendations on hepatitis C treatments and distributed them in print and electronic

form, on pocket cards and by software downloadable into provider’s

handheld PDAs. In addition, we’ve identified a lead hepatitis C clinician in every VA hospital in the country. These are our main

points of contact to transmit education and treatment updates.

Identification of veterans infected with hepatitis C who use VA

health care system necessitates the third component of our public

health approach, and that is excellent clinical care. Excellent clinical care for hepatitis C includes, one, careful medical assessment

of liver function; two, identification of and treatment of important

co-morbidities of especially mental health, substance abuse disorders and HIV infection. The third area is providing anti-viral

drug therapy when indicated, with close medical monitoring during

the 6 to 12 months of therapy and treatment of its frequent side
41

effects, which Dr. Hoofnagle mentioned. The fourth area is management and prevention of complications associated with cirrhosis and

end-stage liver disease when they occur and, finally, liver transplantation when no other option exists.

The VA’s hepatitis C resource centers program works to improve

clinical care, including regular updating of our anti-viral treatment

recommendations, expanding the population of patients who can be

safely treated for hepatitis C, increasing skills of our liver specialists in managing the psychiatric complications of hepatitis C treatment, and in managing cirrhosis and end-stage liver disease, and

expanding the cadre of health care providers trained to deliver hepatitis C care beyond liver specialists, who are in very short supply,

to include primary care providers, mid-level practitioners and clinical pharmacists as well as development of guidelines for establishing hepatitis C patient and family support groups so important in

successful care.

Anti-viral therapy is not recommended for all hepatitis C patients, and some who are eligible turn it down because of the potentially severe side effects, long duration of therapy and relatively

poor success rates of the currently available drugs. Recently, VA

has treated approximately 9,000 veterans each year with anti-viral

medications for their hepatitis C infection.

In addition, VA has an active liver transplant program. Last

year, over 400 veterans were evaluated for possible liver transplant, and VA performed 87 liver transplants.

VA’s national electronic medical records system allows us the

unique opportunity to undertake the fourth component of our public health program for hepatitis C, that is data-based quality improvement. In 2000, we established the National VA Hepatitis C

Case Registry. This registry tracks, in a confidential manner, the

detailed medical data on VA patients who have tested for or have

been diagnosed with hepatitis C. This information helps both our

national program and our local clinicians improve the quality of patient care. Through the end of fiscal 2004, over 273,000 veterans

have been added to that registry. This is the largest organized prospective collection of clinical data on persons with hepatitis C in

the world.

The final component of the VA public health program in hepatitis

C is to promote and support research to improve the health of veterans living with hepatitis C. In fiscal 2003, VA funded 15 projects

at a cost of more than $2.4 million, and VA investigators leveraged

over $4.1 million in non-VA funding to support 104 different hepatitis C research projects.

In conclusion, VA’s comprehensive public health approach to hepatitis C has been successful in achieving the goals outlined to this

committee 6 years ago. VA’s approach to hepatitis C has elements

that may be useful for other large health care systems, for health

insurance companies, employers, public health departments, private practitioners and the public at large.

While proud of these accomplishments, we recognize much remains to be done to identify veterans with hepatitis C and provide
42

them with the best medical care possible. That is our commitment

to serve the men and women who have served our Nation so nobly.

This concludes my remarks. Dr. Rigsby and I would be happy to

answer any questions about the VA program.

[The prepared statement of Dr. Deyton follows:]
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Chairman TOM DAVIS. I want to thank all of you for your testimony and your work in this area.

Dr. Khabbaz, let me start. When HIV-AIDS was emerging, as

was noted before, and this is true with other diseases, a lot more

information and publicity were available about the disease that

seems to be lacking in this instance despite some efforts on your

part and others to try to increase awareness of this and some of

the preventive measures that people can take. What do you attribute that to and do you have any thoughts about how we change

it?

Dr. KHABBAZ. Thank you, Congressman, for the question.

HCV is, by and large, thought of as being a silent epidemic in

terms of a large number of people with asymptomatic infections in

the acute phase of the infection. And 75 to 85 percent of those go

on to develop chronic infection, and there’s a subset that develop

chronic disease. So it has been around with us for a long time undetected.

As part of the National Hepatitis C Prevention Strategy, identification of infected persons, prevention of the disease, part of that

strategy is putting information out. And CDC has been working to

put such information out. I mentioned the brochures and the fact

sheets, and we have worked with partners as well to develop educational materials both for health care providers and for the public.

Chairman TOM DAVIS. Do you think there are thousands of people walking around that are infected now and have no idea because

the symptoms haven’t appeared yet?

Dr. KHABBAZ. That is one element out there, but, as I alluded to

in my remarks, the best approach to reaching those people is integration of prevention programs, hepatitis prevention programs into

existing health and public programs, and we have initiated that.

Chairman TOM DAVIS. And only 23 States have comprehensive

hepatitis C prevention plans today. That is a good way to get at

it, is to get the States involved. We had trouble to get a State medical officer here today to testify. I know they are handling a lot of

different emergencies and so on, but that is a problem and that is

something we can look at from this area in trying to put some incentive or stick in the hands of these States so that they wake up.

Would that be helpful?

Dr. KHABBAZ. As I mentioned in my remarks, I think there is

more to be done. CDC has funded hepatitis C coordinators, 53 of

them in State health departments, and we have one with Indian

Health Service. And one important function of these coordinators

is to develop prevention plans, comprehensive prevention plans.

Correct, 23 States have those plans, and 5 other States are developing plans. CDC also provides assistance to States and some of

the plans are shared, available on the Web site and shared with

States to develop their own plans. More needs to be done.

Chairman TOM DAVIS. Dr. Hoofnagle, currently, there is no vaccine against hepatitis C. Why in the age of preventive medicine is

it so hard to develop an effective hepatitis C vaccine? Do you think

it is realistic to expect a vaccine in the next 5 to 10 years? What

can we do to help that along? Is it a funding issue? What are some

of the variables?
55

Dr. HOOFNAGLE. The problem is with the virus and how you respond to it. The difficulty is that if you are one of those lucky people who recover from hepatitis C, you are not protected against reinfection. The antibody in hepatitis C—this is nature and not something we did—is not very protective. If nature can’t do it, how can

we come along and do better?

Well, one clue is that 30 percent of people recover. Why do they

recover? It appears to be not just antibody. The usual thing, that

we stimulate with a vaccine like hepatitis A or B vaccine, you get

antibody. Maybe you also have to stimulate T cells or other forms

of the immune system to clear the virus. This is the kind of new

information that’s arising, that perhaps you can’t get sterilizing immunity, but you can induce parts of the immune system so that the

person who gets exposed and gets infected will recover on their

own.

And I’m a little optimistic about a vaccine being available. I

think it might not be the typical type of vaccine, like hepatitis A

or B vaccine, but it would be a vaccine that promotes recovery, and

that might be almost as good as a regular vaccine.

Chairman TOM DAVIS. Thank you very much.

Mr. Waxman.

Mr. WAXMAN. Thank you, Mr. Chairman.

We are dealing with a disease that people wouldn’t realize they

had for years, maybe even decades, is that right?

Dr. HOOFNAGLE. That’s correct.

Mr. WAXMAN. And it suddenly would take hold? How would it

manifest itself if somebody had a reactivated hepatitis C?

Dr. HOOFNAGLE. Hepatitis C is a long-drawn-out disease and

causes inflammation and damage to the liver. You don’t feel your

liver very much with inflammation. It is not like a sore throat or

a skin rash. You don’t see it until the liver is fairly badly damaged;

and, at that point, it may be a little bit late to do something or to

treat. So if we wait for symptoms to appear, we are waiting for the

point that the liver is starting to fail; and you need to do something

about this disease while there is just inflammation and a little bit

of damage to the liver. There are blood tests that show that the

liver is inflamed and ways to screen tests for those.

Mr. WAXMAN. So the obvious public health matter before us is to

try to get to the people who may have hepatitis C and get them

in to be tested and get them into treatment before the symptoms

manifest themselves.

Dr. Khabbaz, there was a group of people who had blood transfusions prior to 1992. It is a discrete group. We know who had

blood transfusions prior to 1992. I guess the FDA did not recommend a look back to notify those people who had those blood

transfusions prior to 1992. Many of them are infected and don’t realize it. From a medical standpoint, wouldn’t it be valuable to let

these people know that they have hepatitis C and that they should

do something about it?

Dr. KHABBAZ. Yes. As I mentioned, part of the hepatitis C prevention strategy and an important component is identifying people

who are infected. And you are correct. Limited look-back was initiated. However, the thought was that it was difficult to reach people, most of the people, infected in terms of when you look at blood
56

transfusion basically before the mid-1980’s when a nonspecific test

was introduced. Before that, there was quite a bit of transmission

via blood. And in 1992, when the specific hepatitis C test was introduced, is when the transmission dropped to less than one in a million. To reach those people and reach the other groups at risk, one

of the important things is to make sure that clinicians, health care

providers routinely ask about risk factors, transfusion and others,

and then offer the test, as you have alluded to.

Mr. WAXMAN. I suppose when people came in for medical care

they might get this routine test as part of their physical examination. But, as I understand it, most of the people who now have hepatitis C are IV drug users. Sixty percent of the people have hepatitis C. I doubt many of them come in for medical care.

I know CDC is trying to reach people and inform them. If you

have a group that could be contacted directly, it seems to me there

is a moral argument to contact them. If you don’t do that, the

strong argument then is to have a public education campaign. If

CDC had more money, would you be putting money into trying to

inform the public of the risks that they may be having with hepatitis C and get them in for the tests?

Dr. KHABBAZ. Let me make a few comments.

In terms of reaching people and reaching the groups that we

know of for hepatitis C, you know, we feel that people do see providers for a number of reasons. So, basically, the approach to educate health care providers not just in the private sector but the

public sector as well and the demonstration projects that we have

had, the viral hepatitis integration projects to provide care, you

know, screening and testing and then forward patients for management and all that sort of thing within the context of programs that

provide care, a comprehensive approach has been shown to be feasible and effective. That is one component. There is public education material that we put out. Thirty thousand separate materials are requested from the CDC.

Mr. WAXMAN. Let me interrupt you, because the light is on. I

have time for one more question, and I wanted to ask Dr.

Hoofnagle a question.

It seems to me one of the strategies ought to be, especially if we

have all these IV drug users, we ought to discourage them from

using drugs, which means get them into treatment programs. But,

second, if they are not going to be into a treatment program because the program is not available, wouldn’t it be wise for us to

have them use clean syringes and have the government make that

available? That was one of the recommendations that was given by

the National Institutes of Health group that looked at this whole

problem. Don’t you think that would make sense from a public

health point of view?

Dr. HOOFNAGLE. I have to defer to my CDC people about public

health issues. The consensus conference was not officially the Federal Government. They are an independent panel the Federal Government calls together.

Mr. WAXMAN. That make it even more credible, doesn’t it?

Dr. HOOFNAGLE. It does.
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Mr. WAXMAN. And they recommended we have a clean syringe

program. Doctor, do you want to respond to that in the time that

I don’t have available to me?

Dr. KHABBAZ. In terms of drug treatment centers, this is a good

place for primary and secondary prevention for hepatitis and other

blood-borne infections. In my understanding, in terms of the harm

reduction interventions, while they make sense, it has been shown

to be effective for HIV but are lacking for HCV. There are some differences in the epidemiology when you look at drug users in terms

of, even though they are all blood-borne infections, but in terms of

who gets them there and how, there are some differences out there.

Quickly after starting drug use, people get them, and it takes a

long time.

Mr. WAXMAN. Wouldn’t sterile syringes and safe injection practices decrease the public health problem for HIV and hepatitis C?

Dr. KHABBAZ. Strategies and prevention programs to drug users

would seem to make a difference, I would think.

Mr. WAXMAN. Thank you.

Chairman TOM DAVIS. Thank you.

Ms. Norton.

Ms. NORTON. I have a great respect for science in this country,

and I’m bothered we can’t get a straight answer on Mr. Waxman’s

question. If something can be transmitted by dirty needles, the

question is you say to a scientist, you say to a doctor, would it be

better to have an exchange of clean needles?

I want to quote from the NIH consensus panel: Urge the government to institute measures to reduce transmission of hepatitis C

virus among intravenous drug users, including providing access to

sterile syringes through needle exchange, physician prescription

and pharmacy sales. May I just ask both of you, do you agree with

that recommendation of the NIH consensus panel? I’m asking you

as doctors, do you agree with that or are you in disagreement with

what this panel has said?

Dr. HOOFNAGLE. No, I’m in agreement that would be a good policy.

Ms. NORTON. Dr. Khabbaz, are you in agreement or disagreement with what these experts in this field have said?

Dr. KHABBAZ. Again, I don’t disagree, as I told Congressman

Waxman, that those and other harm reduction interventions make

sense and it would be helpful. I don’t, for hepatitis C specifically—

and Dr. Mast can add to my comments—I’m not aware that it

shows it is effective.

Ms. NORTON. This is what this panel has said. The reason I ask

is because it is very bothersome. The one set of people I expect to

get straight answers are people that base their information on

science. I’m not asking whether you are for it or against it. I’m asking you whether this is a way of preventing the spread of what you

yourself have said is a silent killer. I’m asking you as a doctor and

as a scientist. And Dr. Mast, if you want him to——

Chairman TOM DAVIS. Will the gentlelady yield? I would like to

throw something in the mix. I ask unanimous consent that the

gentlelady from the District be given an additional minute, and I

will just intervene to opine a question.
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This is an issue we have fought over up here, needle exchange

programs, and argued about, particularly with the District of Columbia. I have always had some concern that if you are a veteran

and go to a veterans hospital we charge you for a needle. If you

are an average Joe, you go to a hospital, they charge you for a needle. If you are on Medicare, they charge you for a needle. But if

you are using illegal drugs, they give you a free needle and what

are the policy implications of that.

We understand that using a clean needle is better for you than

using a dirty needle, and we agonize over this, and in different

parts of the country, jurisdictions react differently. I think the way

we have dealt with it in the District is we decided they could do

what they wanted to do with their own money and not use Federal

money, and it seemed to work itself out but not without a lot of

debate.

The gist of the question is—and maybe you are not in a position

overall to say what the ramifications are to the message of giving

out free needles when you are trying to get people to stop using

drugs altogether. But, clearly, a clean needle is better than a dirty

needle. We argued about this, too, because we have competing policy goals.

Dr. KHABBAZ. I don’t disagree. I agree.

Ms. NORTON. I’m looking for a way to get at the silent killer. I

was interested in the testimony from you, Dr. Khabbaz: Current

anti-viral treatment completely eliminates the infection in 50 to 55

percent of selected patients, with 95 percent of those remaining

free for—virus free for 5 years. That would seem to put a premium

on getting some people before this progressive liver disease and all

the attending consequences.

I’m looking for signs of a national campaign, and I have spoken

of my ignorance of this disease. I think it’s your testimony, Dr.

Hoofnagle, about outreach and public education efforts, and the

testimony at page 7 talks about coordinating focus provided by the

National Digestive Diseases Information Clearinghouse—I kind of

don’t understand that, but perhaps you could explain why that is

a clearinghouse. I don’t much care, but that’s interesting. I didn’t

think of this as a digestive disease. But, moving right along, including the involvement of multiple NIH agencies, other Federal agencies, professional lay organizations. And online you have two NIH

Web sites. I can’t find a focus for this disease. I can’t find somewhere in NIH or in CDC, somewhere in the Federal Government

where somebody regards it as his mission to educate the public

that millions are walking around with this silent disease or to tell

people that we actually can do a great deal if you get to us early,

as your testimony has indicated.

So I am looking for who it is who is in charge of helping us to

spread the word to eliminate the disease, to get people into treatment, and the rest of it.

Dr. HOOFNAGLE. Well, what you are referring to there is the

NAIAD Digestive Disease Clearinghouse, which is the mechanism

we use to provide information to people, to physicians, doctors, interested in the diseases that we are involved in as far as research.

It is not mandated as an educational program to go out to all
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Americans. It’s largely a mechanism that we use to get out information.

Ms. NORTON. Who is it that is in charge of getting the word out

to average Joes like people on this panel?

Dr. HOOFNAGLE. Well, I would turn to my colleagues here at the

CDC again about that.

Dr. KHABBAZ. I’ve alluded to the efforts that we have in the

health communication arena. Let me just expand. I’ve already mentioned we have the brochures and posters and pamphlets and information on hepatitis C for health care providers and for the public,

are available and have been translated into Spanish and Russian,

and about 30,000 separate pieces of such educational material are

actually distributed each month on request to the public and doctors. There’s also a tool kit that was developed for physicians and

their patients and about 143,000 providers have received this tool

kit. There’s a hotline. The CDC funds cooperative agreements with

nongovernmental organizations, academic centers, and health departments to develop training and education materials and to

evaluate them. And so there’s a lot of material being developed by

CDC and by partners and others.

I would also mention the roundtable that CDC has initiated to

bring together all the partners working in this arena, governmental

and nongovernmental organizations, to make sure that we are all

coordinated in terms of information and approach to prevention.

Chairman TOM DAVIS. Thank you. This is the last question. Go

ahead and answer if you want to.

Dr. MAST. Ms. Norton, we agree with you that health education

and communication is a major component of the National Hepatitis

C Prevention Strategy, and CDC has developed a broad range of

materials both for the general public, for persons at risk, and for

health care providers. We’ve done our best to make those materials

accessible to people and will continue to do our best to make those

materials accessible to people.

Chairman TOM DAVIS. Thank you very much. Mr. Towns.

Mr. TOWNS. Thank you very much, Mr. Chairman. Let me begin

with you, Dr. Khabbaz. Why is it that CDC does not require all

States to provide surveillance on hepatitis C?

Dr. KHABBAZ. That is an important question. Actually surveillance for hepatitis C has a number of components. With regard to

acute hepatitis, acute hepatitis C, it is reportable actually, and the

organization that makes the disease reportable is not CDC. It’s the

Council of State and Territorial Epidemiologists that actually have

representatives of State epidemiologists, the ones who decide on a

disease being reportable, and then States adopt its recommendation. So acute hepatitis C has been reportable for many years, and

so we gather and put out reports and follow trends of disease. And

in 2003 actually, working with the Council and State Territorial

Epidemiologists [CSTE], chronic hepatitis C viral infection has also

become reportable, and 19 States have actually provided reports.

There are challenges to doing chronic hepatitis C surveillance in

terms of gathering——

Mr. TOWNS. Nineteen States.

Dr. KHABBAZ [continuing]. And verifying these reports and clearly more States need to come on board, and that work is going on
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to train and to provide investigation material and all. So we have

made progress but there’s more to do, as I mentioned earlier.

Mr. TOWNS. You know, let me just say I don’t feel there’s a sense

of urgency here. I hate to say that but just sort of casually 19

States out of the 50, maybe next year there will be 20, and this

just sort of casual kind of thing, that really bothers me, because

we’re talking about a life and death issue. And I’m disturbed by it.

Let me ask again, in your testimony you note that States have

initiated hepatitis C prevention programs and that these programs

use Federal funds. Let me ask this: The number of States that

have such programs, you indicated, the amount of Federal funds allocated per program, could you tell me that, the amount of money

allocated?

Dr. KHABBAZ. I don’t have the numbers with me but will be glad

to give you those numbers.

Mr. TOWNS. Mr. Chairman, could we leave the record open to receive that information?

Chairman TOM DAVIS. Could you try to get that to the committee, and we’ll keep the record open for that. Thank you.

Mr. TOWNS. The other question is do States have to match these

funds?

Dr. KHABBAZ. My understanding, and Dr. Mast may want to

elaborate some more, is that these funds are made available

through cooperative agreement. So States do not have to match

funds. Funds are made available to support programs in prevention, State coordinators, education and surveillance. Now, many

States have actually put in funds and supplemented those Federal

resources to carry out hepatitis C prevention activities, but they’re

not mandated to do so.

Dr. MAST. The basic concept is we fund a single hepatitis C coordinator in every State and their responsibility is to integrate hepatitis C activities into existing State programs. So they work with

other communicable disease programs, with STD, HIV programs to

integrate hepatitis C activities into existing State programs. So

that’s the concept that we’re promoting.

Mr. TOWNS. The reason why I’m asking is I’m trying to figure out

why every State would not want to have one.

Dr. MAST. We offered funding to all States to have a hepatitis C

coordinator, and all but two States have requested and are currently funded.

Chairman TOM DAVIS. Can I just ask which two States haven’t

asked?

Mr. TOWNS. Yes. Which two States?

Dr. MAST. The two States that currently don’t are Kentucky and

South Dakota.

Mr. TOWNS. Let me get Dr. Hoofnagle. Can you tell us about the

Federal Interagency Working Group? I need to know a little bit

more about that hepatitis C working group.

Dr. HOOFNAGLE. The hepatitis C working group is an informal

group of people from each of the institutes that funds research on

hepatitis C that get together to coordinate our initiatives, if we

have a new idea like, say, put together a workshop to see which

other institutes would be interested in contributing.
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Mr. TOWNS. I see my time has expired, Mr. Chairman. So thank

you very much.

Chairman TOM DAVIS. Thank you very much. Let me just thank

this panel. We’ve got another panel we are going to go to and hear

from them, some of the personal stories, but I want to just thank

you all for——

Ms. NORTON. Mr. Chairman, could I ask one moment——

Chairman TOM DAVIS. Without objection, Ms. Norton, you can

ask another question.

Ms. NORTON. The reason I asked about a national campaign, it

has to do with statistics that show that 60 percent of those infected

are intravenous drug users. I hope that you will take back to CDC,

particularly given your answer on what kind of campaign you’re

conducting, posters and the rest of it, and, you know, a lot of these

people are in jail. They will come home to communities like the

District of Columbia. They’re going to come home to the big cities

and spread this disease, and we don’t know anything about this

disease in this city. Their own Congresswoman doesn’t know anything about it, and I would imagine that I’m like many other Members of Congress and many other people who run cities, and I am

going to ask you, based on your testimony today, whether you

would take back to CDC the need to do a real national campaign

so that we can apparently make available treatment which could

keep this disease from progressing.

You have testified it’s a preventable disease, and I have to tell

you I don’t think you’re doing anything to help us prevent this disease, which even those of us who ought to know better don’t know,

and we need a campaign to reach people who are in jail, to reach

people who are inclined to take drugs, and campaigns about posters

and the rest of it clearly are not doing the job as these figures go

up, and I just have to leave you with that message and hope you

will take it back and try to come forward with a campaign.

Chairman TOM DAVIS. Let me ask, Dr. Deyton, we didn’t get

really into the success you have had at VA on this, but what elements of VA’s hepatitis C program could be exported to the general

public do you think?

Dr. DEYTON. Certainly, Chairman Davis, the educational materials that we’ve developed and distributed throughout the VAs

around the country for both patients, their families, and providers

are publicly available. They’re on our Web site, and we’re happy to

make them available to anyone else.

Chairman TOM DAVIS. So we don’t have to reinvent the wheel on

this case?

Dr. DEYTON. No, sir. No, sir. And these materials are already

being used by CDC and NIH. It’s just a matter of getting it in the

right hands. And I have to say that I think that the VA’s success,

and we’ve still got a ways to go, but the VA’s success is—it’s a

multicomponent issue. It’s the screening and testing, it’s the education, it’s the care, but it’s a partnership, Mr. Chairman, between

the health care system and the public and our national leadership

and advocacy groups. We in the VA have been very lucky that this

is an issue that the veterans service organizations, Vietnam Veterans of America, and specific advocacy groups around this issue,

some of which are here in this room today, have been passionate
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about for some time, and it’s given us a lot of external support to

do what we knew we needed to do. So I think it’s a marriage, sir,

and many components, including leadership from communities,

from Governors, from health directors, health department directors,

etc., are very important to get this important disease into the

public’s mind.

Chairman TOM DAVIS. Thank you.

Mr. Waxman.

Mr. WAXMAN. Mr. Chairman, Dr. Deyton’s point I think is well

taken, but I would point out that the veterans health system is an

integrated approach to screening, diagnosis, and treatment, and for

people who are not part of the VA, it doesn’t work like a system.

Others with hepatitis C, even if they have health insurance, often

struggle to get the care they need. We don’t often find ourselves in

an integrated health care model.

I would like to ask two things for the record. Dr. Khabbaz, there

was a National Hepatitis C Strategy, and I’d like to have you supply for us what elements of the strategy have not yet been implemented because I assume that everything has not yet been implemented; otherwise we wouldn’t be holding a hearing today about

how this problem is still a major concern.

Chairman TOM DAVIS. You can followup on that and we’ll put it

in the record.

Mr. WAXMAN. Yes. So this will be furnished to us for the record

of those elements of the strategy that have not yet been fully implemented or funded.

And third, Mr. Chairman, Congressman Cummings and I recently wrote NIH Director Dr. Zerhouni about harm reduction, and

I would ask that his response on the effectiveness of harm reduction be placed into the record for today’s hearing.

Chairman TOM DAVIS. Without objection.

[The information referred to follows:]
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Mr. WAXMAN. Thank you very much.

Mr. TOWNS. Let me ask for the record as well, of the $118 million, Dr. Hoofnagle, how much was actually spent, for the record?

You don’t have to tell me today. For the record. And what kind of

correlation exists between NIDDK and the other agencies and institutes within NIH that are doing hepatitis C research? How are

these research dollars being used? Can you give me some percentage on the amount devoted to basic research, the amount devoted

to treatment, the amount devoted to the vaccine? I’d be delighted

if you would submit that for the record.

Chairman TOM DAVIS. We will try to get that as well. Any other

comments you would like to make? If not, you don’t have to.

Dr. KHABBAZ. I just wanted to thank you for bringing visibility

to hepatitis C, and I want to thank Miss Stein for her interest and

for bringing us here today.

Chairman TOM DAVIS. She has been great. We’re going to hear

her on the next panel, what she and a group at Robinson High

School are trying to do.

Thank you all very much, and we’ll take a 3-minute break and

then move to the next panel.

[Recess.]

Chairman TOM DAVIS. We’re ready to move to the second panel.

I want to thank our witnesses for appearing. Invited to join us on

our second panel is Dr. Michael Rudman, the founder of the Frederick County Hepatitis Clinic. Dr. Rudman will provide the committee with an assessment of current Federal efforts to combat

hepatitis C. Ms. Ann Jessie, the Founding Executive Director of the

Hep C Connection, she’s here to discuss the potential costs of an

inadequate response to hepatitis C and support systems available

to people living with the disease. Captain John Niemiec, the first

vice president of the Fairfax County Professional Fire Fighters and

Paramedics, is here to discuss the risks posed to first responders

and the necessity of education about the disease. And last but certainly not least, Ms. Erika Stein, from Robinson Secondary School,

is with us today to tell us her personal story of her efforts to raise

awareness and increase funding of prevention and research of hepatitis C, and we have some of her Robinson classmates here with

you today.

Could we have you stand up, and just say thank you very much.

We waited until 2 p.m. for the hearings so they could get in a full

day of class ahead of time.

Dr. Rudman, why don’t we start with you and we’ll move on

down. Thank you for being with us.

Dr. RUDMAN. Thank you, Chairman Davis, for giving me the opportunity to share with you something of what it’s like to provide

medical care for people with hepatitis C and to share with you my

assessments of the effectiveness of the current Federal efforts

to——

Chairman TOM DAVIS. Dr. Rudman, I’ve just been reminded I

need to swear all of you.

[Witnesses sworn.]

Chairman TOM DAVIS. You can proceed.
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STATEMENTS OF MICHAEL RUDMAN, M.D., FOUNDER, FREDERICK COUNTY HEPATITIS CLINIC, INC.; ANN JESSE, FOUNDING EXECUTIVE DIRECTOR, HEP C CONNECTION; JOHN

NIEMIEC, FIRST VICE PRESIDENT, FAIRFAX COUNTY PROFESSIONAL FIRE FIGHTERS AND PARAMEDICS; AND ERIKA

STEIN, ROBINSON SECONDARY SCHOOL DECA STUDENT (FATHER HAS HEPATITIS C)

Dr. RUDMAN. Since March 2000 I’ve been the Medical Director of

the Frederick County Hepatitis Clinic. This is a small not-for-profit

community-based organization in central Maryland that has provided comprehensive medical care to victims of hepatitis C, care

without regard to insurance or financial status. We have now treated over 1,000 patients for hepatitis C, most of them coming from

marginalized populations that have no other access to care.

Our patients come from as far away as Colorado, Florida, Tennessee, Louisiana, Pennsylvania, West Virginia, and the extremes

of Maryland. They come because they’re sick or because they are

afraid, or both, and they come to us because they have nowhere

else to go.

The majority of people with hepatitis C will not suffer serious effects from the disease; however, a significant minority will. Dr. JB

Wong and others have projected that in the decade of 2010 to 2019,

190,000 Americans will die of this disease and this will represent

a loss of 1.83 million years of human life under the age of 65. Dr.

Wong’s group modeled the economic cost of the epidemic and put

it at $75 billion in health care and societal costs. Now, that’s for

the decade to come. This decade will be almost that high. Twenty

percent of the people with chronic hepatitis will get cirrhosis. That

represents 540,000 Americans. Reducing the disability and death

from HCV is the goal of our clinic. Each number represents a

human life, a world full of sensibilities and possibilities.

It seems like everyone I talk to sees this as a question of money

or the lack of it. Let me tell you what our clinic in Frederick County has done with an annual budget of $60,000 to $70,000 with one

full-time employee, with a few part-timers and a bunch of hardworking volunteers.

Last year, thanks to our strategic partners, including Frederick

County physicians, the Frederick Memorial Hospital, Frederick

County Health Department, Schering Plough, Roche, and other

pharmaceutical companies, and a grant from our Board of County

Commissioners, our clinic distributed $1.5 million in goods and

services to our target populations. As small and as fragile as we

are, the clinic is now one of Maryland’s largest hepatitis providers

and is the only source of comprehensive hepatitis care dedicated to

Maryland’s uninsured and underinsured. Imagine what could be

done with adequate funding.

Most federally funded HCV studies have not carefully examined

how the disease is expressed in marginalized populations. Indeed,

many of these people were excluded from the NHANES survey

upon which our current estimates of disease prevalence are based.

These people are truly invisible both to the Federal Government

and to academia. They’re also where the burden of this disease, its

prevalence, disability, and mortality, is concentrated. Our clinic

targets these special populations infected with hepatitis C, the poor
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and working poor, the chemically dependent, the mentally ill, and

HIV coinfected. They comprise a little over half of our clientele and

our experience in dealing with special populations suggests that

HCV tends to be especially virulent in them; that is, more likely

to produce disability and death. Effective interventions such as

screening, education, vaccination and treatment, may reap even

larger benefits in this population than in the general public.

When each client first arrives at our clinic, we do a comprehensive health assessment. One of every 16 people arrives at their first

visit with end-stage liver disease, too late for much of anything except comfort measures, transplantation, or death. Our goal is to

prevent this from happening in the other 15. We educate, counsel

and support our clients. People who are headed for cirrhosis get

antiviral therapy.

Of the clients that our clinic selects for treatment, 48 percent

have the most severe stages of viral hepatitis, stage III and stage

IV fibrosis. This is an important indication of just how sick this invisible population is. There are hundreds of thousands of people all

over the country with stage III and stage IV liver disease right now

that are not getting any counseling, not getting any treatment. Our

clients often have a history of substance abuse and/or psychiatric

problems, and we have to optimize treatment for these co-occurring

illnesses prior to, during, and after treatment. This is the challenge

and the dividend of treating HCV, its special populations. The way

we look at it, helping our patients to become healthy means more

than just curing hepatitis C.

Because antiviral treatment can be difficult, we provide a lot of

support for our clients, and the result is that 85 percent of those

who start therapy finish it and the majority of them who finish it

eliminate the virus permanently. For them treatment is a once and

done deal. Today HCV is the only chronic viral infection that can

be called curable.

Chairman Davis, you asked for our comments on the Federal efforts to combat this disease. Your Honor, if I could use your combat

metaphor, let me describe the situation from the point of a view of

a lowly platoon leader in the battlefield of HCV. Sir, our troops are

getting hammered. The battle plans that have been drawn up in

the form of NIH consensus statements and CDC guidelines have

not been implemented. The few units that remain in action must

scrounge for food and ammunition in the wilderness. Let me illustrate these points from my experience as a Maryland physician.

The State of Maryland, mind you, is not a poor State. We are national leaders in biomedical research and in medical education. Our

Governor, Robert Ehrlich, a distinguished former Member of the

House of Representatives, is Maryland’s first Governor to begin addressing hepatitis C, and we’re very excited about this. However,

let me share with you a few surprising facts about the past,

present, and future of HCV in Maryland, a state of affairs which

our Governor inherited.

I serve as a current member on Governor Ehrlich’s Hepatitis Advisory Council, and I have learned a lot about how Maryland sees

this epidemic. HCV is Maryland’s second most commonly reported

infectious disease. It already has affected 100,000 Marylanders, of

which or whom at least 20,000 will develop cirrhosis and 5,000 will
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die. It will cost the State over $2 billion in health care and societal

costs over the coming years.

Yet Maryland’s Department of Health and Mental Hygiene, following the Federal Government’s lead on HCV, has not one person

in the entire government designated to work on HCV, not one. We

do not have a hepatitis coordinator. In the 16 years since the virus

has been identified, the State of Maryland has yet to spend $1 for

HCV control or HCV education. Maryland presently denies 90 percent of its 8,000 to 10,000 HCV infected prisoners access to any

screening, any education, or treatment for HCV. Maryland does get

Federal funds to treat HCV and co-infected patients; that is, patients with HIV. You see, HCV is a major cause of death in HIV

patients and the Federal Government provides funding for HIV and

some of that could be used to treat HCV, but only if you have HIV.

HCV patients who don’t have HIV get nothing. They have the right

to remain permanently silent, the right to die of a treatable disease.

Congress can improve its efforts in combating HCV and other infectious diseases by addressing the process by which health care

funding is allocated, making certain that the diseases that are the

most prevalent, costly, lethal, and responsive to intervention receive priority funding. However, effective HCV intervention will require a lot more than Federal funds. It will require a degree of cooperation between mental health, addictionology, prison, and public

health, and infectious disease disciplines that have never before

been achieved. It will require the development of fully integrated

cross-cutting teams that work well together instead of competing at

the Federal trough for funds, and unless this type of platform for

cooperation is crafted into the wording of funding proposal goals

and objectives, the results will be suboptimal.

Congress may want to look at allocating funds for HCV training

programs and primary care teaching settings. Family practice, internal medicine, nurse practitioner, and physicians’ assistant training programs can easily integrate HCV treatment into existing inhouse substance abuse, STD, HIV, and mental illness programs to

provide the total package necessary for optimizing clinical outcomes, and graduates for these programs will then go out into the

community and provide good service for years to come.

On behalf of all the people with HCV and their families and their

friends and the doctors who struggle to treat it, I respectfully implore you, Congressmen, please help us. We need your help, not

just Federal funds but Federal leadership, and we need it now.

Thanks for your attention.

[The prepared statement of Dr. Rudman follows:]
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Chairman TOM DAVIS. Thank you very much.

Ms. Jesse.

Ms. JESSE. My name is Ann Jesse. I’m both the founding member

of the National Hepatitis C Advocacy Council, a national coalition

of hepatitis C advocacy organizations, and also the Founding Director of Hep C Connection, a national nonprofit network support system for people living with hepatitis C. I thank you, Mr. Chairman,

for the opportunity to once again address this grave public health

threat before the Government Reform Committee.

I remember well when shortly after my hepatitis C diagnosis in

1994, former Surgeon General Dr. C. Everett Koop described the

hepatitis C epidemic as one of the most significant preventable and

treatable public health problems facing our Nation. At that time he

said it was a graver threat than the AIDS crisis. Despite the ominous warnings of experts like Dr. Koop and his successor, Dr.

David Satcher, the general public and many people in the health

care and public health communities still remain uninformed about

the threat imposed by the current hepatitis C crisis.

As early as 1991, Dr. Miriam Alter of the Centers for Disease

Control and Prevention warned us that hepatitis C was a sleeping

giant. Although others soon realized the far reaching personal and

societal threats posed by this sleeping giant, the warnings were not

acted upon with sufficient rigor to contain a problem of such magnitude. So today we are faced with a public health crisis that is

growing day by day. This crisis will continue to grow in destructive

capacity for the foreseeable future until we meet this foe with sufficient funds and the rigor to control it.

To be sure, the alarm must be sounded. Based on incidence and

prevalence data and our current knowledge about the clinical

course of hepatitis C, we can expect that of the 5 million people estimated to be infected, at least 1.25 million will develop cirrhosis

and 125,000 will require liver transplantation for liver failure and/

or liver cancer. To give you some frame of reference to comprehend

the magnitude of these figures, think of the number of people in

a city the size of New Orleans, Los Angeles, or San Antonio, TX.

Now try to imagine that every man, woman, and child in the city

is suffering from hepatitis C-related cirrhosis of the liver. That is

what this treacherous giant called hepatitis C has in store for us

unless we act immediately to intervene in the public health crises.

Another way to comprehend the magnitude of the problem is to

consider how the number of people infected with hepatitis C compares to other well-publicized health problems with which we are

very familiar.

We have the sign over here. HIV is notably absent from this

graphic over to my right. The reason is that because of the way

HIV/AIDS is reported, it is currently not possible to determine how

many new infections occur each year. However, according to the

CDC, an estimated 570,000 people in the United States were living

with HIV/AIDS in 2003 compared to an estimated 3 to 5 million

people living with chronic hepatitis C. I think this statistic is always amazing and alarming to the general public.

We must take control of the crisis and look at integration into

preexisting programs, but this alone is not adequate. The National

Hepatitis C Advocacy Council appreciates the fact that there are
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several individuals in the Department of Health and Human Services who understand the magnitude of the hepatitis C crisis and

are willing to dedicate the efforts needed to intervene effectively.

However, those of us who understand the urgency of the crisis have

been stymied because the response at the Federal level to this crisis has thus far been starkly insufficient to deal with the magnitude of the problem. We feel strongly that an effective disease

control and prevention program must be tailored to fit the specific

characteristics of the disease being targeted.

In other words, effective programs are disease specific and take

into account the characteristics of the disease, such as how it is

transmitted, the national course of the disease, the population at

risk, and available treatment options. Herein is the foundational

problem with the current DHHS plan which attempts to address

the hepatitis C crisis solely by integrating Hep C prevention control into preexisting HIV/AIDS and sexually transmitted disease

programs. Although HCV and HIV have some shared routes of

transmission, they are distinctly different viruses and diseases. The

risk groups and relative risks of acquiring these two very different

viruses from certain activities are simply not the same. An integration-only approach we feel is doomed to failure.

Should HCV prevention and control efforts be integrated into existing HIV/AIDS and STD programs? Of course. But HCV prevention and control efforts must go far beyond integration if we hope

to bring this crisis under control. In terms of the potential costs of

the inadequate response, I can assure you that the hepatitis C crisis grows more seriously each day.

A landmark study published recently by Dr. John Wong, to

whom Dr. Rudman referred, laid forth the dire consequences of the

currently unchecked hepatitis C crisis. He predicted several devastating personal, societal, and fiscal developments, and I believe

we have that to our right again. The accuracy of Dr. Wong’s predictions are already declaring themselves in the rising rates of

chronic liver disease, increased incidence of liver cancer, and increasing demand for liver transplantation. We are only at the beginning of this devastating course. It will grow far worse unless we

take immediate action to change the current tide.

The good news is that we have not yet squandered our opportunity to change the ultimate outcome of this public health crisis.

In the past decade great advances have been made in the treatment of hepatitis C, and with the appropriate therapy nearly 50

percent of those treated for their disease are able to successfully

clear the virus and halt further disease progression. If we act now

and successfully identify and treat those at greatest risk for the development of liver failure and/or liver cancer, we can save lives,

salvage productivity and ultimately decrease the burden of this disease.

Unlike HIV, which requires life-long antiviral therapy, the treatment for HCV is limited. A successful course of therapy is completed in 24 to 48 weeks. For those who clear the virus know that

additional antiviral therapy is required. For all intents and purposes these patients have been cured of chronic hepatitis C.

The bottom line is that identifying and treating hepatitis C is

clearly cost effective, and we have those figures again to the right.
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Hepatitis C national advocacy and community-based organizations have put forth heroic efforts to try to provide much needed

intervention and control services. Funded virtually exclusively by

private fundraising and small nonFederal grants, the organizations

of the National Hepatitis C Advisory Council have conducted local

screening, counseling and testing programs, worked with corrections facilities to improve Hep C efforts for the incarcerated population, collaborated with harm reduction programs to provide Hep

C education to at-risk populations, authored a comprehensive patient-oriented book about Hep C, and countless other daily efforts

by a legion of unsung heroes across the land. We are doing the best

we can on what amounts to a wing and a prayer and a passionate

commitment to those afflicted with this disease, but we are sadly

aware that our efforts are barely scratching the surface of what

needs to be done to address the crisis.

We, the DHHS agencies, the State and local health departments

and the Hepatitis C advocacy organizations, must have funding to

do the work we know must be done and that we are fully prepared

to do. Hepatitis C is everyone’s disease. Many of the millions of

Americans infected with HCV are average citizens just like you and

me, our family members and friends: Middle-aged working class

men and women who may have had a blood transfusion due to surgery, injury, or childbirth; young adults who had transfusions as

premature babies; military veterans of Vietnam, Desert Storm and

the young men and women coming home from Afghanistan and

Iraq; hard-working productive men and women who experimented

briefly with drugs in the folly of their youth and are now paying

the price.

Unlike most viral diseases from the common cold to influenza to

AIDS, HCV is a treatable illness. In other words, unlike many

other afflictions, we have the opportunity to intervene in this crisis

with a potential to achieve a viral cure in approximately half of

those treated. We have a rare opportunity with HCV, and we must

not squander it.

I am one of the many faces of hepatitis C and I stand before you

today as one of the lucky ones. Not only am I a treatment veteran

but I am also a successful responder to treatment for this insidious

disease. Unlike so many unsuspecting people infected with hepatitis C, I was fortunate enough to get tested, and unlike many people currently struggling with hepatitis C, I had adequate insurance

coverage and was thus able to afford treatment. Above all, I was

fortunate to have successfully cleared the virus and remain virusfree 6 years later.

In gratitude for my good fortune, the misfortune of the millions

of others infected with hepatitis C, not to mention the more than

2 million Americans who are not aware they are infected, that misfortune is never far from my mind. I cannot forget about them and

neither should you. Just as I pled for attention before this same

congressional committee in March 1998, I repeat my plea with even

greater passion today. We have a moral, professional, and fiscal responsibility to the American people to act now to implement a fed-
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erally funded comprehensive hepatitis C prevention and control

program. It is not only our responsibility, it is the only humane option possible.

Thank you for your time and attention.

[The prepared statement of Ms. Jesse follows:]
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Chairman TOM DAVIS. Thank you very much, Ms. Jessie.

Mr. Niemiec, thanks for being with us.

Mr. NIEMIEC. Good afternoon, Mr. Chairman. My name is John

Niemiec, and I’m a captain with the Fairfax County Fire and Rescue Department. I appear before you today on behalf of my department and the Fairfax County Professional Fire Fighters and Paramedics-International Association of Fire Fighters Local 2068, and

my colleagues from the Fairfax County Sheriff’s office.

I would like to thank you, Congressman Davis, and the committee for holding this important hearing today, and I commend you

for shining a spotlight on a public health issue that is of vital concern to the Nation’s fire fighters.

I would also like to thank Mr. Jay Walker, the students from

Robinson High School, DECA, and especially Erika Stein for their

unselfish campaign in promoting hepatitis C awareness and future

legislation.

I am here today because Hep C is a real concern for first responders. Because hepatitis C is transmitted blood to blood, first

responders face an increased risk of exposure to the virus. Hep C

can be a lethal virus that is five times more prevalent here in the

States population compared to the HIV virus, and yet, the American people receive little information as it relates to the hepatitis

C virus. The Centers for Disease Control and Prevention estimate

that approximately 1 out of every 50 Americans, that is 1 out of

every 50 Americans, is infected with hepatitis C virus. Individuals

who are Hep C infected can be asymptomatic up to 20 to 30 years.

Often by the time the disease is even diagnosed, the disease has

already progressed to cirrhosis, liver cancer, end-stage liver disease, or the need for a liver transplant. In those cases, if it had

been caught earlier, there may have been a chance to slow the progression of the disease with behavior changes, such as limiting alcohol consumption.

Currently there is no vaccine for hepatitis C. Often individuals

who were administered the hepatitis A and/or the hepatitis B vaccine believe they are protected against hepatitis C. This is not the

case and these misperceptions show that we need a better public

education campaign about the disease. Because the virus consistently mutates, there are six genotypes and over 80 subtypes, manufacturing a vaccine for hepatitis C is problematic.

Typically the treatment regimen is 6 to 12 months of injections

and oral medications. While treatment has advanced over the last

10 years, more needs to be done. In about 50 percent of the patients, current treatment does not eliminate the disease. Also,

treatment for Hep C can cause significant physical and mental side

effects, which means the patient receiving treatment may require

additional support from medical providers and patient support

groups to optimize their treatment outcome.

As mentioned, first responders face an increased risk of exposure

to the disease. Hep C has not only infected but also has affected

a number of first responders within the fire service and law enforcement arenas. Fairfax County Fire and Rescue currently has 10

fire fighters infected with the virus while the city of Philadelphia

Fire Department has over 200 fire service personnel stricken by
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this disease. On a personal note, I have a younger sibling infected

with this virus.

The time to educate, prevent, and screen the at-risk population

is now. Medical experts with knowledge about this virus continue

to echo the urgent need to screen at-risk populations such as first

responders and individuals who had blood transfusions prior to

1992. Therefore, I urge all congressional leaders to embrace, promote, and fund the Hepatitis C Epidemic Control and Prevention

Act not only for first responders but for the American people as

well.

Thank you for your time and consideration, and I’d be happy to

answer any and all questions.

[The prepared statement of Mr. Niemiec follows:]
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Chairman TOM DAVIS. Thank you very much.

Erika, thanks for being here with us. You’re a cleanup hitter

here.

Ms. STEIN. Thank you. First of all, I would like to thank you,

Congressman Davis, for everything you have done for us and, Congressman Towns, for everything that you also have done for us.

Thank you.

I was 5 years old when my father was first diagnosed with hepatitis C. At the time I really didn’t understand what this meant but

I could tell that my mother seemed to be very concerned and I

sensed that something was gravely wrong. By the time I was in

fourth grade my father’s physician started him on a course of

interferon in hopes of ridding him of the virus. My dad had to give

himself painful injections of the drug several times a day and the

drug caused him to become seriously ill. I can remember vividly my

dad lying on the couch with a fever of 102 and shivering as if he

had a bad case of the flu.

During the time my dad was on interferon he became depressed

and seemed like a completely different person to me. The smallest

event could cause my dad to literally go ballistic, almost like he

had changed into the Incredible Hulk. Our family experienced a

great deal of stress and turmoil throughout the interferon treatment and we were all thankful to reach its end.

Although he went through nearly 6 months of sheer torture, the

interferon treatment had no effect on his hepatitis C virus. Needless to say, we were all heart broken at the failure of the treatment.

Several years later my dad became a patient of the Halt C study

and was started on a course of Pegylated interferon with Ribavirin

at the National Institutes of Health. Before beginning the treatment, he was given a liver biopsy and they discovered he had cirrhosis of the liver. He finished the less painful course of the

interferon treatment only to find out once again that it had no effect on the virus. My dad felt as if he had failed the treatment, but

in truth the treatment failed him.

In the fall of 2003, I was in my advanced marketing class and

we were deciding what we should focus on as a public relations

project for the school year. I introduced the idea of doing a project

on hepatitis C because it was real life for me and our Robinson

DECA chapter has always dealt with serious issues that impact the

lives of people who are greatly loved. We discovered that a bill had

been introduced in May 2003 that would allot $90 million for research and education on the hepatitis C virus.

As you know, Congressman Davis, our DECA chapter takes on

tough issues. We’ve worked on the Ricky Ray Hemophilia Relief

Fund Act, the Good Samaritan law which protects users of

automative defibrillators, and most recently the Dirty Diamond

Act. I learned that Senator Kay Bailey Hutchison had introduced

bill S. 1143; so I immediately contacted her office to see what we

could do to help. I was then put into contact with Sharon Phillips,

president of the Hepatitis C Advocacy Network based in Texas, and

she was instantly by our side. She and Lorren Sandt of the Hepatitis C Caring Ambassadors Program flew to Virginia and came to

educate our advanced marketing class. After Lorren and Sharon’s
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powerful visit, where we learned that 4 million Americans were infected with hepatitis C and 10,000 Americans die each year of the

virus, our chapter unanimously decided that hepatitis C would be

our public relations project.

Since October 2003, nearly 500 marketing students from Robinson Secondary School have been working on Capitol Hill, visiting

congressional offices and persuading health legislative assistants to

encourage their members to co-sign the Wilson-Towns Hepatitis C

Epidemic Control and Prevention Act, H.R. 3539. We have letters,

phone calls, and e-mails of encouragement from hundreds of hepatitis C patients across the country.

I have a story to tell you concerning some of the frustrations that

come along with explaining hepatitis C to the public. A year ago

this month, 80 Robinson marketing students went to New York

City for our annual marketing field study. We planned a side trip

at 5 a.m. to visit Rockefeller Center and be a part of the studio audience of the Today Show. Of course being good marketing students, we couldn’t miss the opportunity to promote our five fruits

and vegetables a day campaign, our child safety civic consciousness

project, and of course the hepatitis C public relations campaign.

Each student was manned with a poster, except only five posters

out of the 80 were allowed into the Today Show fenced-in area. We

were told that ‘‘the Today Show has a family audience and the sexually oriented hepatitis C thing would not be appropriate for the

audience.’’ Security literally threw away our posters because they

thought hepatitis C is a sexually transmitted, dirty disease.

Chairman Davis, when we began this project a year ago, no one

wanted to talk about hepatitis C. Even a congressional aide told

one of our students that the number of recorded deaths from his

State who are infected with hepatitis C was not enough to pass the

bill. Just one death is too many. The American people have the

right to know about this silent epidemic. Our government needs to

be proactive so we are not caught off guard like we were with the

HIV/AIDS virus in the 1980’s.

In this audience today are representatives from the hemophiliac

community who know all too well about viruses that are spread

through our blood supply. Our DECA chapter spent 7 years working on the Ricky Ray bill with hemophiliacs like Ellis Sulser and

Dana Kuhn, who are currently co-infected with hepatitis C and

HIV. Will our generation have a chance to survive hepatitis C? The

answer is yes, Chairman Davis, if we can stimulate research and

education during the 109th session of Congress.

Chairman Davis, as I close my speech I would like to say I know

you’re here representing your constituents and we believe you care

about Americans like my father, Gene Stein. If we don’t provide

some funding for research and education for hepatitis C, it will impact each and every one of our lives.

Thank you.

[The prepared statement of Ms. Stein follows:]
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Chairman TOM DAVIS. Erika, thank you very much. I’m going to

start with Ms. Norton.

Ms. NORTON. Thank you very much, Mr. Chairman. I think probably this question is best offered to Dr. Rudman. I’m trying to find

evidence of some Federal involvement commensurate with this disease. Your clinic—is it a clinic—has an annual budget of $60,000

to $70,000 a year and you have one full-time employee, etc. How

much of that is Federal funding?

Dr. RUDMAN. We have no Federal funding. We have no State

funding. The only funding that we have on a governmental level is

local from our Board of County Commissioners.

Ms. NORTON. How is that, no Federal funding and no State?

Have you tried to get funding from either of these two entities?

Dr. RUDMAN. Yes. Actually, our little clinic got together with

RJO and our STD clinic and our sexually transmitted disease clinic

and our hospital and our mental health programs and our emergency room and our in-patient psychiatric ward and Johns Hopkins

University’s top scientists and we came up with a grant proposal

for a $447,000 viral integration project. And it turns out that we

were actually awarded a $447,000 grant, but then the funding for

that project was cut.

Ms. NORTON. Grant from whom?

Dr. RUDMAN. CDC.

Ms. NORTON. When was that?

Dr. RUDMAN. Earlier this year.

Ms. NORTON. The entire grant?

Dr. RUDMAN. It was a $3.5 million grant and they advertised it

for seven programs. We were one of the seven programs that was

approved. Then what happened, the funding was cut in half and we

were cut in the final cuts.

Ms. NORTON. Was this for treatment, for surveillance?

Dr. RUDMAN. For prevention of hepatitis A and B in at risk populations and hepatitis C. We were also screening for HIV, but we

would have been probably the only program that offered treatment

for hepatitis C. So that made us kind of special.

Ms. NORTON. Do any of you know of any programs in Maryland

and Virginia? I know of none in the District of Columbia, private

or public, which are geared toward this population who may get or

who have hepatitis C?

Dr. RUDMAN. That’s the point I’ve tried to make.

Ms. NORTON. Are you the only program in Maryland?

Dr. RUDMAN. I’m afraid so. And that is a very sad thing.

Ms. NORTON. Any program that you know of in Virginia? Mr.

Chairman, I was just trying to find traces of public health involvement in what turns out to be a public health menace that you have

uncovered with this hearing. We have heard today that 60 percent

of the HIV—60 percent of those with hepatitis C are HIV drug

users. We have heard testimony that many of them are in prison.

And we have heard testimony that the outreach consists of things

like going on-line and posters. I’m afraid that the problem here is

not the disease but perhaps who gets the disease. This is exactly

the problem with HIV/AIDS, precisely the problem with HIV/AIDS.

Until a little boy, a little white boy and a wonderful poster child

got HIV/AIDS, we didn’t wake America up to what now everybody
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embraces, that whoever has the disease deserves our help. And if

you don’t believe that, do you understand that you are not going

to quarantine them from society, and we learned that the hard way

as AIDS got into our blood supply. And now, of course, nobody

identifies AIDS with gay people. It’s all across the aboard. And

that’s exactly what’s going to happen here. It’s not going to be identified with people who have been in jail or people who are drug

users. And I don’t think we should have to wait for a poster child

to deal with the disease.

We have zero funding in this tri-State area on the part of public

health funding. I think what we are dealing with here, Mr. Chairman, is a second-class disease. And I say so because I was shocked

until your staff told me why it could possibly be that you had to

have HIV/AIDS in order to get treated for hepatitis C. It is

counterintuitive, not true, she said, but it’s probably because the

funding stream is available only for HIV, and nobody has put a red

cent into separately funding hepatitis C. We have to do something

about it. I’m pleased that we can get some money from someplace.

So, Mr. Chairman, I can’t thank you enough for your leadership.

You have awakened my consciousness by having this hearing. I

hope what you have uncovered in this hearing, we will resolve to

do for hepatitis C what the country has done for HIV/AIDS.

Chairman TOM DAVIS. I thank you very much. I think the people

before us today have done more than we have. They have brought

it—I think keyed it up for us in terms of how we can follow

through, what legislation we can pass and what we can do in terms

of awareness. Mr. Towns has been a leader and has been the head

of the pack, and you are recognized for questions.

Mr. TOWNS. Thank you very much, Mr. Chairman. Thank you for

your kind words.

Dr. Rudman, the panel before you said that every State had a

coordinator except I think South Dakota and Kentucky. They didn’t

say Maryland didn’t have one.

Dr. RUDMAN. Well, that may be because he didn’t know Maryland—Maryland did have one, but she was fired, I think for doing

a good job. You see, not every State wants a hepatitis C coordinator, because that’s going to make people want to spend State dollars to take care of disease in local communities and people who

run budgets say, we will have to take money away from other

projects or we will have to raise taxes. So we don’t want people to

know about this disease. And that’s what we’re running into. It’s

almost as if it’s a secret they don’t want to get out.

And so our Department of Health does not have one person

working, one person in the entire State Health Department working on hepatitis C. And there is some discouragement, I think, in

talking about it, because they’ll say well, we can’t do anything

about this anyway, we don’t have any money. So it’s a nice thing

to have good projects. And the State plans—I have looked at State

plans all over the country, which is what I do for the State of

Maryland. Having a plan doesn’t mean anything unless you have

the funds to implement them. And that’s the problem. We have a

plan in Maryland and we have 39 action points on it, and we have

implemented 6 of them, and those 6 we would have had to implement for other reasons anyway. So we have actually implemented
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zero hepatitis C action plans. And I think other States are having

the same problem.

You know, we need clear guidelines that are ethical and legally

defensible and scientifically sound, but we also need funds to implement them, and the States are strapped.

Mr. TOWNS. Thank you very much, Dr. Rudman. Let me say, I

really appreciate the testimony of all of you. I really do, but I just

want to single Erika out, because you know, we feel about—and

people talk about young people not doing anything positive. But

Erika, I want you to know you touched me, the fact that you are

involved in this issue and the fashion that you are involved in it.

I wish the media was fair. Tonight you would be the leading thing

on every news station throughout the United States of America because of what you are doing in such a positive way. I salute you

and I thank you for your support of our legislation. I appreciate

that as well. So continue to do so. And eventually, I think that if

enough people hear us that somebody is going to get the message.

I think that my son said to me and I think it’s appropriate to comment on here, he said, sometimes it takes some people 21⁄2 hours

to watch 60 Minutes. That means they can’t watch it. It takes them

a lot longer. It takes our country a lot longer to understand where

we need to go and what we need to be about.

I thank you all for coming here today and say to you, do you

have any suggestions or recommendations for us, the Members of

Congress, that we might be able to pursue? I would just like to

spend my last few seconds hearing from you on that issue.

Ms. STEIN. I would really say that encouraging other Members

of Congress to co-sign on the bill, and even on the Senate side, to

get them to sign onto the bill. As you can see, it’s vital that we

have the funding to do the things that we need to do. And I think

the biggest problem here is the American public isn’t aware of this.

Something needs to be done about this. I don’t know what you have

to do, but I don’t think it’s going to be effective by doing posters

and brochures. Something more needs to be done. And I don’t think

it should be necessary that we need a poster child for it to go along

with the disease. It shouldn’t be that way. When you see that an

average American is being diagnosed with this—my father has no

idea how he contracted it. He never used drugs, and the only reason he found out he had it is because he was getting a new life insurance policy. People need to be aware of it. It’s not fair to the

American public that they don’t know what’s going on. People need

to know what it is and how you can get it.

Mr. NIEMIEC. I didn’t hear anyone testify that about 40 percent

of the HIV infected individuals are co-infected with hepatitis C,

about 40 percent. Within our arena of emergency care, in that very

chaotic, unsterile, uncontrolled environment where a fire fighter,

EMT, EMS person sustains a dirty needle stick, the current stats

out there are that individual has anywhere from a zero to 7 percent

risk of now contracting hepatitis C, and bear in mind that currently there is no post-exposure prophylaxis for HCV. If I have a

dirty needle stick, there are medications out there called the HIV

cocktail. And as long as I get the cocktail on board within a certain

amount of time, it is not 100 percent efficacious but it’s going to

reduce my chances of contracting HIV. I have seen nothing as it
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relates to a fire fighter, or EMS personnel sustaining a dirty needle

stick. There are no recommendations from CDC. If I have a dirty

needle stick and if I reside in the State that is fortunate to have

implied consent; in other words, I have access to that source patient’s blood, I may not know whether or not that patient is infected with hepatitis C. And if I do find out that the individual is

serial positive for hep C, there is nothing to do about it but sit and

wait. So a lot needs to be done.

Dr. RUDMAN. I think this goes to the educational problems. Most

doctors don’t know this, but if you have acute hepatitis C, that is

new onset hepatitis C, you could treat it with 6 months of

interferon alone and current studies indicate that up to 97 percent

of the cases will be cured. This comes from Stephen Mann’s work

out in Germany where 43 out of 44 patients were cured, and we

are presently doing that with our acute cases. With the needle stick

injury, that may be one of the only situations where you are going

to identify an acute hepatitis C case. So if you watch carefully and

signs of hepatitis occur and they don’t resolve by themselves, then

there should be a post-exposure treatment program in place.

Ms. JESSE. If I could just urge you to get behind us passionate

advocates, try to get the public aware of this disease to make them

aware that it is everybody’s disease that can affect you and your

friends and people like me and try to break the stigma. And another thing that I constantly work with in my organization is to try

to make people aware that there are possibly 5 million people infected in the United States and more than half of them are aware

of this. And so help us get risk factors distributed so people can

start self-identifying, because if you are infected, you need to press

on with this. So do what you can to help us with education and

help us get the funding to move on with this very important work.

Chairman TOM DAVIS. Let me ask just a couple of questions. If

you don’t stop it, though, and it keeps spreading, it becomes much

more difficult further down the road. Erika, when you discuss hepatitis C with the average person, what’s the reaction you get?

Ms. STEIN. A lot of them don’t know what it is. When we introduced it to our class, kids had said they had their vaccine for it.

There is no vaccine for it. And it is very common you come across

people who have no idea what it is or they can’t decipher between

hepatitis A, B and C and they have no idea how serious it is and

how easily it can be contracted.

Chairman TOM DAVIS. And you would be the last person to stand

up here and make this the Erika Stein Show. You have a team behind, you. Your classmates at Robinson have been so active in this.

And they have been all over Capitol Hill and everything else, and

it makes a difference. Legislation moves very slowly sometimes. I

have been working on some bills since I got here 10 years ago, but

we don’t give up. I think this next session we have a shot of doing

some. But time runs out on this one, because we hear more people

getting infected.

Dr. Rudman, do you feel people who come to you that if you can

get ahold of them and have the resources, that you can get a pretty

high cure rate out of it?

Dr. RUDMAN. That is interesting and perhaps sad because the

people I see are really sick. And when you look at some of the clean
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studies that are done, 16 or 13 percent of the people have severe

liver disease when they are entered into random trials. I’m running

48 percent. So our people are a lot sicker, and yet our cure rates,

even with all of that fibrosis, are as high as what they get in those

clean studies. So if you have a team that motivates patients and

cares about them, even these tough patients, you can get them

cured. And we are able, thanks to Sharon, to get free drugs for

these people. But you have to have all the other support available

to give them the drugs. And that’s what we were able to do in our

community.

Chairman TOM DAVIS. We ought to let more people know about

this and replicate it.

Dr. RUDMAN. We designed it to be a model. That is one of the

reasons we are here, to get the word out that this can be treated

at the local level and communities. And we certainly do need more

Federal support and funding.

Chairman TOM DAVIS. NIH has stayed here and I know they are

interested in responding. They want to help. Our job is to make

sure they have some resources along the way.

Captain Niemiec, you mentioned that 10 people in Fairfax County Fire and Rescue have hepatitis C and other departments across

the country have similar numbers. Is this on the rise?

Mr. NIEMIEC. It is unfortunate, chairman, that law enforcement

and fire service arenas are not doing any testing, aren’t doing anything. A lot of that is because of education, awareness, funding, but

moreover, if that fire fighter, if that police officer is now hepatitis

C infected, who takes care of him or her? Whose problem? This is

one of the things I have heard echoed over and over and over

again. We don’t want to screen, we don’t want to test, because if

that fire fighter or that police officer comes up hep C positive,

whose problem does he or she become?

Chairman TOM DAVIS. Do you think that is because this is job

related for the most part?

Mr. NIEMIEC. That’s correct.

Chairman TOM DAVIS. You may want to run down to the legislature, like you do with heart and lung, to make sure it is taken care

of.

Mr. NIEMIEC. We are very unique. Latter part of 1999 through

2000, we did a comprehensive screening process with 1,200-plus of

our fire fighters. And of those fire fighters, we had 10 who came

up hepatitis C positive. Every year we are doing our work required

under OSHA, blood-borne pathogen training. It is disquieting and

most chilling that a lot of departments out there, a lot of the first

responders, are not receiving this training, nor are they getting any

type of screening. And we know that they are at risk every single

day he or she puts on that uniform and goes out to the streets.

Chairman TOM DAVIS. You give me a lot of ideas just hearing

about the seriousness of this. And as we start monitoring this nationally, this has been fairly recently monitored, and we can check

the rise, but hopefully we can take some actions that can curb that.

I thank all of you for being here. You add a lot. This has been

televised today on C–SPAN. But more importantly, our committee

will followup with the appropriate reports. We have to work with

other committees of jurisdiction on funding and the like. I know
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Mr. Towns isn’t discouraged. He is going to keep trying and we will

be looking for new ways and hopefully we made a small difference

here today. Thank you for taking time to be here, and for all of the

Robinson kids. This is one of series of different causes that they

have adopted through time, and they weren’t here for Ricky Ray

and several of the other issues that took several years, but I appreciate their can-do spirit and it’s contagious. So we appreciate it,

and thank you for your continued advocacy. Hearing is adjourned.

[Whereupon, at 4:20 p.m., the committee was adjourned.]

[The prepared statements of Hon. Mark E. Souder, Hon. Elijah

E. Cummings, Hon. Ileana Ros-Lehtinen, Hon. Heather Wilson,

and Hon. Sheila Jackson Lee, and additional information submitted

for the hearing record follow:]
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