National Hepatitis C Prevention Strategy

2001
National Hepatitis C Prevention Strategy

A Comprehensive Strategy for the Prevention and Control of

Hepatitis C Virus Infection and its Consequences

Division of Viral Hepatitis

National Center for Infectious Diseases

Centers for Disease Control and Prevention 

Summer 2001
-1-

Table of Contents

Executive Summary 2

Hepatitis C Virus Infection in the United States 4

Prevention and Control 8

Surveillance and Research 13

Implementation of the National Hepatitis C Prevention Strategy 15
Executive Summary

On January 22, 1998, the Secretary of the Department of Health and Human Services concurred

with the Advisory Committee on Blood Safety and Availability and indicated that persons who

may have acquired hepatitis C virus (HCV) infection from blood transfusion be identified

through lookback notifications, and that other people at risk for HCV infection also should be

identified. The Secretary requested the Centers for Disease Control and Prevention (CDC) to

develop a comprehensive plan to address the prevention and control of HCV infection and its

consequences.

The National Hepatitis C Prevention Strategy is CDC’s response to this request, and includes

partnerships and coordination with the Agency for Healthcare Research and Quality (AHRQ),

Food and Drug Administration (FDA), Health Care Financing Administration (HCFA), Health

Resources and Services Administration (HRSA), National Institutes of Health (NIH), Substance

Abuse and Mental Health Services Administration (SAMHSA), and other federal, state, and

private sector agencies. This CDC strategy serves to protect the public’s health by preventing

and controlling HCV infection; enhancing health decisions by providing credible information on

hepatitis C; and promoting healthy living through strong partnerships with national, State, and

local organizations in both the public and private sectors. 

The goals of the National Hepatitis C Prevention Strategy are to lower the incidence of acute

hepatitis C in the United States and reduce the disease burden from chronic HCV infection. 

Achievement of these goals requires: 1) harm reduction programs directed at persons at

increased risk for infection to reduce the incidence of new HCV infections; 2) counseling,

testing, and medical evaluation and management of infected persons to control HCV-related

chronic liver disease; 3) surveillance to evaluate the effectiveness of prevention activities; and 4)

research to provide answers to questions pertinent to the prevention and control of hepatitis C.

The principle components of the National Hepatitis C Prevention Strategy are: 

• education of health care and public health professionals to improve the identification of

persons at risk for HCV infection and ensure appropriate counseling, diagnosis, medical

management, and treatment;

• education of the public and persons at risk for infection about risk factors for HCV

transmission, and the need for testing and medical evaluation; 

• clinical and public health activities to identify, counsel, and test persons at risk for HCV

infection, and medical evaluation or referral for those found to be infected; 

• outreach and community-based programs to prevent practices that put people at risk for

HCV infection, and to identify persons who need to get tested; 

• surveillance to monitor acute and chronic disease trends and evaluate the effectiveness of

prevention and medical care activities; and 

• research to better guide prevention efforts.

Hepatitis C prevention activities must be accessible to persons receiving health care services in

both the public and private sectors. The most effective means to prevent HCV infection and its

consequences is to integrate hepatitis C prevention activities into existing clinical services and

public health programs, such as those for the prevention and treatment of human
immunodeficiency virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), sexually

transmitted diseases (STDs) and drug abuse. Similar risk factors place persons at risk for

transmission of the major bloodborne viral infections – HIV, HCV, and hepatitis B virus (HBV). 

Effective implementation of the National Hepatitis C Prevention Strategy should reduce the

number of new HCV infections, further reduce other bloodborne virus infections, and prevent the

projected increase in chronic liver disease due to hepatitis C.
Figure 1.

Hepatitis C Virus Infection in the United States

Hepatitis C virus (HCV) infection is the most common chronic bloodborne viral infection in the

United States. First identified in 1988, HCV is the causative agent for what was formerly known

as non-A non-B hepatitis, and is estimated to have infected as many as 242,000 Americans

annually during the 1980's. Since 1989, the annual number of new infections has declined by

more than 80 percent to approximately 41,000 by 1998. A national survey (the third National

Health and Nutrition Examination Survey [NHANES III]) of the civilian, non-institutionalized

U.S. population found that 1.8 percent of Americans (3.9 million) have been infected with HCV,

of whom most (2.7 million) are chronically infected with HCV. These estimates of prevalence

are likely conservative, because the survey excluded incarcerated and homeless persons, groups

that have high prevalences of HCV infection. Most infected persons were aged 30-49 years

when the survey was done in the early 1990s (Figure 1). 

Many of these individuals are not aware of

their infection and are not clinically ill. 

However, the consequences of chronic liver

disease from hepatitis C do not become

apparent until 10 to 20 years after infection. 

Risk factors for infection. Individuals who

injected drugs, even if they did so on only one

occasion many years ago, are at highest risk

for HCV infection (Figure 2). HCV infection

is rapidly acquired following the initiation of

injection drug use and occurs from the sharing

of needles, syringes, or other equipment

associated with drug use. Of persons injecting drugs for at least 5 years, 60 percent to 80 percent

are infected with HCV compared to about 30 percent infected with HIV. The high rate of HCV

infection among injection drug users is also reflected in the high rates (15 percent to 40 percent)

of HCV infection found among incarcerated persons. More than 80 percent of the nation’s

estimated 1.7 million current injecting drug users have been incarcerated. 

Prior to the mid-1980's there was a 7 percent to 10 percent risk of non-A, non-B hepatitis

(hepatitis C) from blood transfusion. This risk declined by more than 50 percent between 1985

and 1990 as a result of implementation of blood donor screening for HIV and surrogate testing for

non-A, non-B hepatitis. In 1990, specific donor screening for HCV was implemented and by

1992 the risk of HCV infection from a unit of transfused blood was reduced to one in 100,000. 

As of 2001, the risk of HCV infection from a unit of transfused blood is less than one per million

transfused units. 

Clotting factor concentrates, which are plasma-derived products used to treat individuals with

hemophilia, posed a high risk for HCV infection prior to the use of virus inactivation procedures

that were introduced in 1985 and 1987. Except for one outbreak of hepatitis C from a single type
Figure 2.

of contaminated intravenous immunoglobulin,

other plasma-derived products, including

immune globulin for intramuscular

administration, have not been associated with the

transmission of HCV in the United States. 

Currently, all immune globulin products undergo

a virus inactivation procedure or test negative for

HCV prior to release. 

Sexual exposures account for about 15 percent of

cases of hepatitis C. Although the risk for

transmitting HCV infection through sexual

intercourse is low, sex is a common behavior in 

the general population, a substantial proportion of the adult population has had unprotected sex

with multiple partners, and there are a large number of persons with HCV infection. While other

types of exposures are more likely to transmit HCV (e.g., transfusion from an infected donor),

they account for a smaller proportion of infections because of the relatively small proportion of

the population in whom these exposures have occurred. 

HCV is most efficiently transmitted by exposures that involve 

direct passage of blood through the skin, i.e., a percutaneous exposure.

Exposures resulting from hemodialysis, employment in the health care field, and birth to an HCVinfected mother together account for about 5 percent of cases. About 10 percent of people with

HCV infection have no recognized source for their infection.

While it is possible for HCV to be transmitted from any percutaneous exposure to blood,

exposures such as tattooing, body piercing, or acupuncture have not been shown to place people

at increased risk for infection. Higher rates of HCV infection are not found among persons with

these exposures alone and these exposures are rarely reported among new cases of 

hepatitis C.

Consequences of HCV infection. About 15 percent to 25 percent of persons with acute hepatitis

C resolve their infection without further problems. The remainder develop a chronic infection

and about 60 percent to 70 percent of these persons develop chronic hepatitis. Cirrhosis of the

liver develops in 10 percent to 20 percent of persons with chronic hepatitis C over a period of 20-

30 years, and hepatocellular carcinoma (liver cancer) in 1 percent to 5 percent. For individuals

with cirrhosis, however, the rate of development of liver cancer might be as high as 1 percent to 4

percent per year. 

Lower rates of complications have been reported from studies of persons who acquired infection

as children. However, longer term follow-up studies are needed to assess lifetime consequences

of chronic HCV infection in different populations, especially among children.

Chronic liver disease is the tenth leading cause of death among adults in the United States. It is

estimated that 40 percent to 60 percent of chronic liver disease is due to hepatitis C and another
1 National Institutes of Health. (1997) Management of Hepatitis C. March 24-26;15(3):1-41.

http://odp.od.nih.gov/consensus/cons/105/105_statement.htm

10 percent to 15 percent is due to chronic hepatitis B. HCV-associated chronic liver disease is the

most frequent indication for liver transplantation

among adults. Additionally, because alcohol use is one of the most important contributing factors

to progression of chronic liver disease among persons with hepatitis C, it is important to identify

infected individuals as early as possible so that they can be counseled to limit alcohol

consumption and be offered treatment if appropriate. 

Treatment for hepatitis C. In 1997, an NIH Consensus Development Conference established

guidelines for the medical management of hepatitis C1, which have since been updated to reflect

the evolving nature of antiviral therapy. A combination of alpha-interferon and ribavirin

currently is the most effective therapy and achieves the sustained elimination of HCV infection

for at least 6 months in 30 percent to 40 percent of patients.

However, 10 percent to 20 percent of treated patients do not complete therapy because they

experience significant side effects. In addition, some patients may have conditions, such as severe

cirrhosis which prohibit treatment. Current antiviral therapy is not licensed for patients below age

18 years.

HCV-associated chronic liver disease is the most frequent indication for liver

transplantation among adults.

Persons with chronic hepatitis C who continue to abuse alcohol are at risk for ongoing liver injury

and antiviral therapy may be ineffective. In addition, interferon therapy can be associated with

relapse in people with a previous history of alcohol abuse; therefore, abstinence from alcohol is

recommended during antiviral therapy. Interferon therapy should be considered with caution for

patients who recently stopped alcohol abuse, and these patients require the support of alcohol

treatment programs. 

Patients with hepatitis C on methadone treatment have been successfully treated with interferon.

However, there is limited experience with treatment of persons who are recovered injection drug

users or who are active injection drug users. In addition, there is the concern that active injection

drug users are at risk for reinfection with HCV. When patients with past or continuing substance

abuse are considered for antiviral treatment, such patients should receive drug treatment or care

from substance abuse specialists or counselors. 

Drug treatment is an important adjunct to care for

many persons with hepatitis C.

Persons with HCV-related liver disease should be vaccinated against diseases that may produce

further complications or increase their risk of death. Susceptible persons with chronic liver

disease should receive hepatitis A vaccine since they are at increased risk of death from liver

failure if they get hepatitis A. All persons with chronic liver disease should be vaccinated
annually against influenza and should receive pneumoccocal vaccine. In addition, persons with

continued risk factors for HBV infection should receive hepatitis B vaccine. 

Co-infection. Coinfection with HCV, HIV and/or HBV is currently recognized as a serious

problem and is more likely to be found among injection drug users and persons treated for

hemophilia before the availability of inactivated clotting factor concentrates. Deaths from

chronic hepatitis C among patients with HIV are expected to increase as advances with

antiretroviral therapy extend the life span of these patients. Management of HIV infection in

HCV co-infected patients generally is similar to that for patients with HIV alone, although there

is some risk of liver toxicity from the antiretroviral drugs. HCV coinfected patients should be

evaluated to determine if they are candidates for antiviral treatment of 

their chronic liver disease. Because treatment and medical management of co-infected patients is

complicated and rapidly evolving, such patients are best managed by health care providers with

experience in treating both HIV and HCV infection. More research is needed to determine the

ideal management and treatment of co-infected individuals.

Deaths from chronic hepatitis C among patients co-infected with HIV are

expected to increase as antiretroviral therapy extends their life spans.
Persons for whom routine HCV testing is

recommended:

‚ Persons who ever injected illegal drugs,

including those who injected once or a

few times many years ago.

‚ Persons who received a blood transfusion

or organ transplant before July 1992.

‚ Persons who received clotting factor

concentrates produced before 1987.

‚ Persons who were ever on long-term

dialysis.

‚ Children born to HCV-positive women.

‚ Healthcare, emergency medical, and

public safety workers after needlesticks,

sharps, or mucosal exposures to HCVpositive blood.

Prevention and Control

The goals of hepatitis C prevention and control

efforts are: 1) to reduce the incidence of new

infections by reducing HCV transmission; and

2) to reduce the risk of chronic liver disease in

HCV-infected individuals through appropriate

medical management and counseling. 

These goals can be achieved by identifying

persons at risk for infection and providing them

with education, risk reduction counseling, HCV

testing, and appropriate medical services

including substance abuse treatment. Preventing

or changing behaviors and activities that place

persons at risk for HCV infection should reduce

disease transmission. Appropriate testing,

medical management and substance abuse

counseling and treatment should reduce the risk

of chronic liver disease. Implementation of the

following activities is required to achieve these

prevention goals. 

Identifying persons at risk for infection. Because of the large number of Americans infected

with HCV, identification of these persons through testing is a high priority. Testing should be

routinely offered to persons most likely to be infected with HCV. In addition, anyone who wishes

to know their HCV infection status should be provided the opportunity for testing. In all

instances, testing should be accompanied by appropriate counseling and referral for medical

follow-up. 

To identify persons who should be counseled and tested for HCV, health care professionals in

primary care, specialty, and public health settings should routinely question patients about risk

factors for infection, including history of injecting drug use. Current injecting drug users are

often not seen in primary care or other traditional health care settings. However, targeted

outreach in other settings may be particularly effective in reaching this population. These settings

include correctional institutions, drug treatment programs, programs for high risk youth, HIV

counseling and testing sites, and STD clinics.

Health care professionals in primary care, specialty, and public health settings

should routinely question patients about risk factors for HCV infection.

Persons infected with HCV because of medical risk factors (e.g., transfusion, hemophilia, chronic

hemodialysis) should be identified by health care professionals and through educational efforts

provided by patient organizations. Many of these persons have been tested for HCV and testing

should be encouraged for those not previously tested.
2 Centers for Disease Control and Prevention. (1998) Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and

HCV-Related Chronic Disease. MMWR;47 (No. RR-19). ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4719.pdf

Health Education and Communication. Achieving high levels of awareness concerning

hepatitis C prevention and maximizing the number of infected persons identified require

education and communication directed at health care and public health professionals, persons in

groups at risk for infection, and the general public. 

Health care professionals

Education of health care professionals requires:

• Continuing medical education programs such as found at www.cdc.gov/ncidod/diseases/hepatitis

and development of clinical and public health practice guidelines to facilitate the

incorporation of recommendations for the prevention of HCV infection and its consequences2

into clinical and public health practice. 

• Development and dissemination of materials to aid health care professionals in identifying

persons at risk for HCV infection during primary and specialty health care visits, at clinics

that provide public health services, in drug outreach and substance abuse treatment programs,

and in correctional health programs.

• Periodic updates of guidelines for the diagnosis, treatment and prevention of hepatitis C and

continuing medical education programs to disseminate this information at the local and

national level.

At-Risk Populations 

Development and distribution of educational messages for groups of persons at increased risk for

infection should include persons transfused prior to July 1992; incarcerated populations;

substance abusers including those in treatment and outreach programs; persons at risk for

HIV/AIDS and STDs; and persons attending other community health programs. 

HCV prevalence among prison inmates is 3-5 times greater

than in the general population. 

Recent data indicate that prevalence of HCV infection among incarcerated populations is 3-5

times greater than prevalence in the general population. In addition, messages need to be

developed for individuals who may have experimented with injecting drug use only in the distant

past, since these persons may not regard themselves as being at risk for infection because they

did not become long-term or habitual users. 

General Public

Culturally-sensitive, multimedia advertising and education in English, Spanish and other

languages are needed to increase public awareness about HCV infection; risk factors for
Figure 3: Public service messages directed to

persons at risk for HCV infection from a

transfusion.

infection; the need for counseling, testing, and medical management to prevent chronic liver

disease; and how to differentiate hepatitis C from other types of hepatitis. 

These include:

• Materials for use in clinic and other health care waiting rooms, correctional settings, drug

treatment and prevention programs, and outreach programs for persons at risk for HIV/AIDS.

• A full-time, national hepatitis hotline and information line (1-888-4HEP-CDC) that provides

both recorded information and interactive counseling.

• A web site (www.cdc.gov/hepatitis) that provides information about frequently asked

questions, patient and provider educational materials, and hyperlinks to other sites which

provide information on viral hepatitis.

• Regional or local sources that provide accurate

information to concerned persons or groups in a

culturally sensitive manner and in the language that

is best understood by the requestor.

Counseling, Testing, and Medical Referral. 

Identification of persons at risk for HCV infection

should initiate both counseling and testing, however,

counseling can be performed without testing. 

Counseling services must be available in a wide variety

of settings, including those that provide primary and

specialty health care services in the private and public

sectors. Because injection drug use is the primary risk

factor for infection, counseling and testing

must be available for clients of programs for the

prevention and treatment of substance abuse,

HIV/AIDS, and STDs and for persons in correctional

settings.

Individuals with ongoing risk factors for HCV infection

should receive client-centered education and counseling

which concentrates on changing behaviors that place them at risk for infection. These behaviors

include substance abuse, sharing of injection drug use equipment, and high risk sexual practices. 

In addition to risk reduction counseling, at-risk persons should be referred to appropriate harm

reduction programs, including treatment for substance abuse and syringe and 

needle exchange sites. In addition, these persons should receive hepatitis A and hepatitis B

vaccination.

At-risk persons should be immunized with hepatitis A and 

hepatitis B vaccine, as appropriate.
3

Association of Public Health Laboratories. (unpublished data)

HCV testing is required to identify infected persons at risk for chronic liver disease and for

transmitting HCV to others. When testing is performed, HCV positive individuals require: 1)

counseling to reduce the risk of HCV transmission to others; 2) medical referral to determine the

extent of their liver disease; and, if appropriate, 3) counseling to limit their alcohol intake,

antiviral treatment, immunization with hepatitis A, hepatitis B, pneumococcal and influenza

vaccines, and treatment for alcohol or drug abuse. HCV negative persons with ongoing risk

factors require counseling concerning ways to reduce their risk for infection, referral to

substance abuse treatment if appropriate, and immunization with hepatitis A and hepatitis B

vaccines. 

Hepatitis C counseling should be performed in a consistent, client-centered structure. 

Counseling materials are currently being developed and have not been extensively evaluated for

effectiveness. 

Integration of HCV counseling and testing into existing programs may enhance

identification of persons at risk for HIV and HBV infection.

Based on current experience in counseling persons at risk for HCV infection or with hepatitis C,

a wide variety of information must be available to the counselor. This includes information on

harm reduction for persons at continued risk for infection, the meaning of positive test results,

the importance of medical evaluation for chronic liver disease, the health outcomes of HCV

infection and hepatitis C, the risk of transmission to family members or other contacts, and

immunization to prevent infection with hepatitis A, hepatitis B, and other diseases.

Staff training is required for effective hepatitis C counseling and health education.While many

hepatitis C prevention messages are similar to those for HIV, several aspects of hepatitis C

prevention are different and must be integrated into counseling and testing activities to best meet

the needs of the client.

In addition, culturally appropriate health education materials will be required for use by health

care providers, and patient support groups.

While the capacity for HCV (antibody) testing exists in all blood banks and most hospital and

private diagnostic laboratories, a recent survey3

 showed that less than 50 percent of state and

local public health laboratories have the capacity to perform any type of HCV testing. As with

HIV testing, HCV antibody testing requires the laboratory capacity to perform supplemental

testing to

confirm that the initial test result represents a “true positive” and that the client does not receive

incorrect information concerning his or her HCV infection status. To determine whether a

person has chronic HCV infection requires nucleic acid testing for HCV RNA (‘PCR testing’). 

While this type of testing was only available in research laboratories several years ago, it is now

becoming better standardized and available in many diagnostic laboratories.
Less than 50 percent of state and local public health laboratories have the

capacity to perform HCV testing.

Counseling and testing sites should provide referral for the medical evaluation of persons who

test HCV-positive. The initial medical evaluation of an HCV positive individual does not

require a specialist (e.g., hepatologist, gastroenterologist). 

However, the referral physician should be familiar with the interpretation of the diagnostic workup required to ascertain whether a patient has chronic HCV infection and evidence of liver

disease. In addition, the physician should have contact with specialists expert in the treatment

and management of chronic hepatitis C.

Integration of Hepatitis C Prevention into Other Prevention Services. The similar modes of

transmission of HIV, HBV and HCV present a unique opportunity to provide prevention services

at a single client visit. Integration of services to prevent bloodborne viral infections is a

relatively new concept. There is limited experience with combining counseling, testing, 

prevention, immunization, and treatment services for these diseases in HIV/AIDS prevention

sites, STD clinics, drug treatment sites, and correctional health programs. However, data from

several demonstration projects indicate that integration of HCV counseling and testing into

existing public health programs is feasible and may enhance identification of persons with risk

behaviors for other bloodborne virus infections, such as HIV and HBV.
4

Alter MJ, Hadler SC, Judson FN, et al. (1990) Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C

virus antibody. JAMA; 264: 2231-2235.

Surveillance and Research 

Surveillance. Surveillance is essential to determine the effectiveness of national, state, and local

hepatitis C prevention efforts. However, surveillance for hepatitis C is complicated by the

absence of a laboratory test that can differentiate newly acquired infections from infections

acquired in the past. Although acute hepatitis (i.e., clinical illness) is reportable in all states,

only a few states conduct surveillance for acute cases of hepatitis C to monitor disease incidence. 

However, approximately 30 states have requirements for reporting of HCV positive laboratory

tests, most of which represent persons with resolved or chronic HCV infection.

The current challenge is to determine how to utilize HCV positive laboratory reports to monitor

trends in new infections, evaluate the effectiveness of testing and counseling efforts, and identify

missed opportunities for hepatitis C prevention. Only a few states maintain a database of

laboratory reports, and most do not collect patient-specific information concerning risk factors

for infection or medical follow-up.

The challenge is how to use laboratory-based reports of HCV to monitor disease

trends and the effectiveness of prevention programs.

Development and maintenance of confidential state databases of persons with HCV infection,

which contain information on risk factors for infection and medical follow-up, could provide a

means to determine the effectiveness of prevention programs. Such surveillance could determine

whether persons with certain risk factors for infection are more or less likely to be identified and

tested, and whether HCV positive persons have received counseling and medical referral. 

Making surveillance systems in all states comparable with respect to data quality and case

definitions would greatly facilitate targeting and assessment of prevention programs. 

National trends in new cases of infectious disease are monitored by CDC’s National Notifiable

Disease Surveillance System (NNDSS). However, for hepatitis C, the data reported by states are

not reliable because most reports to NNDSS represent persons with chronic or resolved HCV

infection and not acute disease. To determine national trends in disease incidence and risk

factors for infection, CDC has relied on intensive sentinel surveillance conducted in 6 counties4

 -

- the Sentinel Counties Study of Viral Hepatitis. Until such time that persons with acute HCV

infection can be identified either through a single diagnostic test or some combination of tests

(e.g., antibody testing and liver enzyme levels), estimates of HCV infection incidence will

primarily depend on data from the Sentinel Counties Study. 

CDC uses several other surveillance systems to monitor trends in HCV infection. NHANES III

identified the high prevalence of HCV infection in the United States and showed that AfricanAmericans had a higher prevalence of HCV infection than other racial/ethnic groups. Testing of

subsequent NHANES will be used to monitor infection prevalence in different populations of

Americans. Surveillance for chronic liver disease has been established in several of CDC’s

Emerging Infections Program sites. This chronic liver disease surveillance system will enhance
understanding of the natural history of HCV infection, monitor national trends in chronic

hepatitis C, and provide estimates of the contribution of HCV infection to chronic liver disease

in the United States. 

Epidemiologic and Laboratory Investigations. A number of unanswered questions

significantly impact the direction of hepatitis C prevention and control activities. Priority areas

in which studies are underway or in the planning stages include those that determine: 1)

incidence and risk factors for HCV transmission among household contacts of infected persons;

2) risk factors for transmission from mother to infant at birth; 3) risk of infection from intranasal

cocaine use, tattooing, and body-piercing; 4) prevalence and incidence of infection in

incarcerated populations; 5) risk of infection among steady heterosexual partners of HCVinfected persons; 6) risk factors for infection among persons on chronic hemodialysis; 7) risk for

infection among persons with occupational exposure to HCV and effectiveness of therapy during

acute infection; 8) the dynamics of HCV acquisition among injection drug users and the

effectiveness of harm reduction strategies in preventing infection; 9) the frequency and

consequences of infection with multiple HCV strains among injection drug users; and 10)

development and performance of rapid screening tests for HCV infection.
5

 Centers for Disease Control and Prevention. (2001) Recommendations for preventing transmission of infections among chronic hemodialysis

patients. MMWR;50 (No. RR-5): 28-29. http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf

Implementation of the National Hepatitis C Prevention Strategy

CDC’s implementation plan for the National Hepatitis C Prevention Strategy comprises the

following elements: 

• Communication of information about hepatitis C to health care and public health

professionals and education of the public and persons at risk for infection; 

• Integration of hepatitis C prevention and control activities into State and local public health

programs to identify, counsel, and test persons at risk for HCV infection; provide referral for

medical evaluation of those found to be infected; and conduct outreach and communitybased activities to address practices that put people at risk for HCV infection;

• Surveillance to monitor acute and chronic disease trends and evaluate the effectiveness of

prevention and medical care activities; and 

• Epidemiologic and laboratory investigations to better guide prevention efforts.

Timely implementation of these prevention activities at the national, state, and local levels can

be expected to achieve a reduction in hepatitis C mortality and morbidity.

Communication of Information about Hepatitis C. 

Education of health care professionals: Because hepatitis C was only recently described, health

care professionals are often not aware of current information concerning diagnosis, medical

management, and prevention of this disease. Education of health care professionals about

hepatitis C -- pathogenesis, diagnosis, medical management, epidemiology, and prevention --

was the first activity undertaken as part of the National Hepatitis C Prevention Strategy. 

Because knowledge about hepatitis C is complex and rapidly evolving, ongoing access to the

latest information must be provided and requires commitment of resources for development and

distribution of continuing education programs and materials for physicians, nurses, and other

health care professionals. A wide range of educational materials must continue to be developed

and distributed by CDC in partnership with other governmental, non-governmental, professional

and voluntary health organizations. These materials include brochures and monographs; articles

in professional journals; web-based and other distance learning formats; and symposia, grand

rounds, and workshops.

Good clinical and public health practice is based on the availability of recommendations and

guidelines from professional organizations, CDC, or other government agencies. Consultants

meetings will be held to develop and update recommendations for the prevention and

management of 

hepatitis C in various populations and settings, including correctional institutions, hemodialysis

units5

, and drug treatment and prevention programs. 

Because hepatitis C was only recently described, health care professionals 

often are not aware of current information concerning diagnosis, 

medical management, and prevention.

State-funded programs have requested technical assistance from CDC for materials to train
CDC Partners in Viral Hepatitis

Prevention, 1997-2001

American Liver Foundation

www.liverfoundation.org

American Social Health Association

www.ashastd.org

Council of State and Territorial

Epidemiologists

http://www.cste.org/

Health Care Education and Training

www.hcet.org

Hepatitis Foundation International

www.hepfi.org

Immunization Action Coalition

www.immunize.org

JSI Research & Training Institute

www.jsi.com

National Alliance of State/Territorial AIDS

Directors

www.nastad.org 

National Association of City/County Health

Officials

www.naccho.org

National Commission on Correctional

Health Care

www.ncchc.org

National Minority AIDS Council

www.nmac.org

Parents of Kids w/ Infectious Diseases

www.pkids.org

counselors. These materials are in the final

stages of development, along with a hepatitis

training curriculum for the national STD

Prevention and Training Center network. 

There is need for the further development and

distribution of a wide range of client-centered

counseling materials for use in settings where

persons at risk for HCV infection are identified

(e.g., HIV/AIDS counseling and testing sites,

STD clinics, drug treatment facilities,

correctional facilities).

Education of the general public and groups at

increased risk for infection: 

CDC has joined with a number of nongovernmental organizations to ensure

widespread distribution of hepatitis C health

education and prevention messages. 

Providing resources to these and other partners

will continue to ensure that health education

materials and messages consistent with CDC’s

recommendations are distributed to the public

as well as to persons in groups at increased risk

for infection. Public service advertising and

media outreach in various formats are needed to

increase public awareness of the importance of

hepatitis C prevention and control. Continued

formative research is needed to determine what

messages and formats might best reach

intended audiences, such as past and present

injecting drug users and individuals with high-risk sexual activity. Print materials and public

service advertising for persons at risk for transfusion-acquired HCV infection have been

developed and are being distributed, but their effectiveness remains to be evaluated. Education

and advertising materials and campaigns will be developed to reach persons in other risk groups. 

CDC’s hepatitis website regularly provides updated information for both health professionals

and the public and links with partners for additional information. In addition, CDC’s Hepatitis

Information Line and HotLine provide both “live” and recorded information in both English and

Spanish.

State-based Hepatitis C Prevention and Control Programs. Hepatitis C counseling and

testing programs need to be implemented at the state and local levels. Although a recent survey

of local health officers showed that 87 percent of city and county health departments provide

education about HIV/AIDS and 77 percent provide HIV testing, less than 50 percent provide
6 National Association of City and County Health Officers. (submitted for publication) Hepatitis C/HIV Needs Assessment. 

http://www.naccho.org/project4.htm

Figure 4.

hepatitis C counseling and only 23 percent provide HCV testing6. 

Currently, no federal funding is available to support nationwide establishment of 

hepatitis C counseling and testing services at the state or local level. In response to this lack of

federal funding, a number of state and local health departments have funded hepatitis C

counseling and testing projects.

Most of these local programs have relied heavily on technical support and materials developed

by CDC. However, prevention services need to be expanded, especially for disenfranchised

populations and populations with health disparities (e.g., African-Americans, Native Americans),

which can only be assured by a national program. 

Less than 50 percent of local health departments provide hepatitis C 

counseling and only 23 percent provide HCV testing.

A major goal of the National Hepatitis C Prevention Strategy is funding of a ‘Hepatitis C

Coordinator’ for every state and large metropolitan health department to meet the expressed

needs of state and local public health officials. The Hepatitis C Coordinator provides the

management, networking, and technical expertise required for successful integration of hepatitis

C prevention and control activities into existing public health programs (Figure 4). Coordinators

assist state or local health departments in: 1)

identifying public health and clinical activities in

which HCV counseling and testing should be

incorporated; 2) ensuring training of health care

professionals in effective hepatitis C prevention

activities; 3) developing the capacity to provide

HCV testing through public health or private

diagnostic laboratories; 4) identifying sources for

appropriate medical referral of HCV positive

persons; 5) ensuring appropriate surveillance for

HCV infection; and 6) evaluating the effectiveness

of HCV prevention activities.

Broad implementation of hepatitis C prevention activities has been greatly facilitated by the

development of a State hepatitis C/viral hepatitis prevention plan. These plans have provided the

road map for prioritizing development of prevention activities, integrating hepatitis prevention

activities into existing public health programs, and obtaining resources to achieve

implementation of prevention activities. A number of approaches have been used to develop

such plans, including convening special commissions or consensus meetings, or using

consultants. Key to development of a successful plan is inclusion of stakeholders and experts

involved in viral hepatitis prevention and control from fields which include: public health,

infectious disease, immunization, correctional health, drug and substance abuse treatment,

HIV/AIDS counseling and testing, STD prevention and treatment, mental health, public health

nursing, clinical medicine (primary care, hepatology, gastroenterology), laboratory medicine,
7

Association of State and Territorial Health Officers. (2000) Hepatitis C & Incarcerated Populations: The Next Wave for Correctional Health

Initiatives.

patient support and advocacy, health communication and education, health care financing, and

public health policy. Although a number of States have now developed such plans, technical

assistance and resources are needed to assist those States without plans.

While prevention of all bloodborne virus infections (HIV, HCV, HBV) is a major goal of the

National Hepatitis C Prevention Strategy, there is limited experience with the integration of

hepatitis C and hepatitis B prevention activities into public health programs for persons at risk

for bloodborne viral infections, including incarcerated persons7

. Demonstration projects to

examine the feasibility and operational aspects of integrating hepatitis C prevention into existing

public health and correctional health programs were first funded by CDC in FY 1999, were

expanded to include several county and city health departments in FY 2000, and should be

further expanded to include state-wide projects. Demonstration projects include activities to

prevent HCV, HBV, and HIV infection, such as counseling, testing, and medical referral for

infected persons, and hepatitis B and hepatitis A immunization. Critical to the implementation

of integrated prevention activities is funding for public health laboratories to provide HCV

testing for persons served in the public sector and for immunization with hepatitis B and

hepatitis A vaccines of at-risk persons.

 CDC’s annual National Hepatitis Coordinator meeting, which previously has brought together

persons involved with the prevention of HBV infection at the state and local levels (e.g, hepatitis

B coordinators, state immunization directors, STD program managers), will be expanded to

facilitate the sharing of information gained from federally and locally funded hepatitis C

prevention activities. 

Surveillance

States that require reporting of persons who test HCV positive need resources to establish,

maintain, and analyze information on infected persons for purposes of disease surveillance. 

These resources would support use of state surveillance databases to evaluate the effectiveness

of prevention programs by determining: 1) the proportion of the population with hepatitis C that

has been identified; 2) missed opportunities for identification of persons with selected risk

factors for HCV infection; and 3) whether persons reported to state surveillance systems have

received counseling, medical referral, and appropriate medical management. For states without

HCV surveillance, CDC would offer assistance in establishing surveillance systems for

evaluating the effectiveness of their hepatitis C prevention programs.

In addition to state-based surveillance, CDC must continue to maintain several other surveillance

systems including: 1) the Sentinel Counties Study of Viral Hepatitis to determine trends in

incidence of acute hepatitis C and other types of viral hepatitis, and risk factors for infection; 2)

testing of participants in NHANES to determine age-specific trends in prevalence of HCV

infection; and 3) sentinel surveillance for chronic liver disease to determine trends in chronic

hepatitis C.
Epidemiologic and Laboratory Investigations

Research to answer questions which impact hepatitis C prevention and control is an important

component of the National Hepatitis C Prevention Strategy and prevention of new HCV

infections probably is the greatest challenge. The majority of new HCV infections occur among

persons who inject illegal drugs and the risk of HCV infection among this group is several-fold

greater than the risk of HIV infection. High priority must be given to studies that determine

those activities among active injection drug users which facilitate HCV transmission and the

development of interventions which interrupt transmission. In addition, prevention of HCV

infection must become the marker of success of community-based interventions to prevent drug

use among persons at high risk for this behavior. 

Priority also must be given to studies which answer questions related to other risk factors for

HCV infection in order to improve counseling messages and to devise effective prevention

activities. These include studies to quantify risk for infection following sexual exposure, the risk

of transmission from tattoos or body piercing obtained in various settings, risk from noninjection drug use (e.g., cocaine use), risk of infection following occupational needlestick

exposure, and risk of perinatal HCV infection following obstetric interventions or complications. 

Laboratory tests that differentiate acute from chronic HCV infection or rapid diagnostic tests that

could be used in outreach settings would greatly improve identification of persons with HCV

infection and improve prevention and control activities.