March 18, 2015 The Honorable Thad Cochran Chairman Committee on Appropriations United States Senate Washington, DC 20510 The Honorable Barbara Mikulski Ranking Member Committee on Appropriations United States Senate Washington, DC 20510 The Honorable Harold Rogers Chairman Committee on Appropriations United States House of Representatives Washington, DC 20515 The Honorable Nita Lowey Ranking Member Committee on Appropriations United States House of Representatives Washington, DC 20515 Dear Chairman Cochran, Ranking Member Mikulski, Chairman Rogers, and Ranking Member Lowey: As you begin work on the Fiscal Year (FY) 2016 Labor, Health and Human Services, Education, and Related Agencies Appropriations bill, the Hepatitis Appropriations Partnership (HAP) respectfully requests an increase in appropriations for the Division of Viral Hepatitis (DVH) at the Centers for Disease Control and Prevention (CDC) by $31.5 million over FY2015 to total $62.8 million, consistent with the President’s budget request. The viral hepatitis community understands the challenge of budgeting additional resources in the current fiscal climate, yet the need for these programs continues to grow. In the United States, more than 5.3 million people live with chronic hepatitis B and/or hepatitis C, and at least 15,000 deaths annually are attributed to hepatitis-related liver disease or liver cancer. These figures are based on National Health and Nutrition Examination Survey (NHANES) data, which does not include homeless and unstably housed individuals, those living in nursing homes, the incarcerated, the military, or many immigrant and migrant populations – populations disproportionately affected by viral hepatitis. Worse, of the estimated 2.2 million people living with chronic HBV and 3.9 million people living with chronic HCV, 65-75% do not know their diagnosis and are not receiving the appropriate care and treatment. Without a confirmed diagnosis and linkage to and retention in care, 15-40% of those living with viral hepatitis will eventually develop liver cirrhosis and/or liver cancer. In 2012 alone, 40,599 cases of HBV and 145,762 cases of HCV were reported to the CDC. Unfortunately, due to the lack of adequate comprehensive and coordinated surveillance activities, these estimates are likely only the tip of the iceberg. Viral hepatitis disproportionately impacts several communities, particularly people who inject drugs (PWID), men who have sex with men, persons living with HIV, African immigrants and African Americans, Asian immigrants and Asian Americans, Pacific Islanders, Latinos, tribal communities, veterans, and residents of rural and remote areas with limited access to medical treatment or culturally and linguistically-appropriate services. “Baby Boomers,” persons born between 1945 through 1965 have the greatest risk for HCV-related morbidity and mortality – 1 in 33 people born in this time period are hepatitis C positive. Both CDC and the U.S. Preventive Task Force (USPSTF) recently released HBV and HCV screening guidelines recommending that providers offer a onetime screening of HCV to anyone in this birth cohort, and that anyone at high-risk for HBV should be screened. Additionally, recent alarming epidemiologic reports indicate a burgeoning epidemic of HCV infection among young people throughout the country. Some jurisdictions have even noted that the number of people ages 15 to 29 being diagnosed with HCV infection now exceeds the number of people diagnosed in all other age groups combined, representing 75 percent of new HCV cases. Alarmingly, 35 out of 41 responding states reported increases in persons newly infected with HCV from 2010-2012. Even with these challenges, the availability of effective new curative treatments for HCV, and an effective vaccine and good treatments to control HBV, brings the elimination of HCV and HBV in the United States within our reach, setting the stage for an enormous new public health victory. The elimination of HCV and HBV in the United States is possible – but not without increased investments in comprehensive, national viral hepatitis prevention, screening, linkage to care, education and surveillance programs. In FY2012, Congress demonstrated a commitment to increasing the federal response to the viral hepatitis epidemics with the creation of the first-ever viral hepatitis screening initiative through the Prevention and Public Health Fund (PPHF). This brought the total funding at DVH to an unprecedented $29.7 million in FY2012. The viral hepatitis community is appreciative that Congress recognized the importance of the identification and linkage to care of people living with viral hepatitis who are unaware of their status. While past increases have been helpful, these have only been small steps toward building a more comprehensive response to viral hepatitis. The CDC’s 2010 professional judgment (PJ) budget recommended $90.8 million each year from FY2011-FY2013, $170.3 million annually from FY2014-FY2017, and $306.3 million annually from FY2018-FY2020 for DVH in order to comprehensively address the hepatitis B and hepatitis C epidemics. HAP’s requested increase of $31.5 million is in line with the needs determined by that PJ and the goals of the Action Plan for the Prevention, Care, & Treatment of Viral Hepatitis (Viral Hepatitis Action Plan). HAP recommends that these funds be used on the following priority areas, allocated in proportion to HBV and HCV burden, using available epidemiological data. Screening and Linkage to Care At present, only 25-35 percent of people living with chronic viral hepatitis are aware of their infection. The Viral Hepatitis Action Plan established a goal of increasing the proportion of persons who are aware of their hepatitis infection to 66 percent for both HBV and HCV. In addition to identifying youth who are living with hepatitis C who are unaware of their status, DVH must also increase the percentage of Baby Boomers who are aware of their HCV status, and foreign-born and 2nd generation immigrants from Asian or African countries that have HBV infection rates of 10% or higher. These numbers continue to grow with an estimated 40,000 infected people entering the U.S. each year. This is why full implementation of the CDC and USPSTF recommendations for HBV and HCV testing and linkage to care by state Medicaid programs, Medicare, and private health systems and providers are so necessary. In the absence of a federal commitment to a nationwide awareness, testing and linkage to care initiative, we remain concerned about the ability of the federal government to meet the goals of the Viral Hepatitis Action Plan. Surveillance As testing and linkage to care activities increase and improve, strengthening local and state capacity to execute viral hepatitis monitoring and surveillance activities takes on an even greater importance. The CDC currently funds only 5 state health departments and 2 local health departments to conduct minimal surveillance in their jurisdictions. CDC also provides funds to state and local health departments, the cornerstone implementers of national public health policies, to coordinate prevention and surveillance efforts via the Viral Hepatitis Prevention Coordinator Program (VHPC). The VHPC program is the only national program dedicated to the prevention and control of the viral hepatitis epidemics. This program provides funding to support a coordinator position in each jurisdiction, but leaves little to no money for the provision of public health services, such as surveillance, public education and access to prevention services like testing and hepatitis A and B vaccinations, which must be cobbled together from other sources year-to-year. With increased investments in nationally coordinated surveillance activities, key stakeholders (states, health departments, policy makers, and providers) would be equipped with information that is critical to understanding the burden and impact of the hepatitis epidemics, identify and averts outbreaks, and that will allow for improved targeting of resources to the most impacted communities. Addressing the Emerging Hepatitis C Epidemic Among Young Persons at Risk HCV prevalence among PWIDs is as high as 70%, and between 20-30% of uninfected people who inject drugs acquires HCV each year. In recent years, state health departments have reported an alarming increase in new HCV cases among people under the age of 30 in many states, including but not limited to: Alabama, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Montana, New Mexico, North Carolina, Oregon, Tennessee, Washington and West Virginia. Unlike historical trends of HCV infections (i.e., concentration in larger, urban city centers), new HCV infections are increasingly found in suburban and rural settings, especially in Appalachia. This trend is largely due to the prescription opiate epidemic and the transition many young people have made from using opiate pills to injecting heroin. This increase makes the need to enhance and expand these prevention efforts all the more urgent and underscore the need to prioritize immediate support in the field, strengthening health department and community responses that target youth and young adults, specifically persons who injection drugs, persons under 30 years old, and persons living in rural areas. Elimination of Mother-to-Child Transmission of Hepatitis B Although we have made great strides in reducing the burden of HBV among newborns and young people, due in part to the success of the Perinatal Hepatitis B Coordinator program at CDC’s National Center for Immunization and Respiratory Diseases (NCIRD), between 800 to 1000 perinatal HBV transmissions occur each year. Further, one of the greatest remaining challenges for hepatitis A and B prevention is the vaccination of high-risk adults. Additional funding at NCIRD for an Adult HBV Vaccination Initiative is necessary to prevent the transmission of HBV, and especially perinatal HBV. High-risk adults account for more than 75 percent of all new cases of HBV infection each year and annually result in an estimated $658 million in medical costs and lost wages, despite the fact that HBV is preventable. Additional Hepatitis Related Priorities In addition to the above-recommended HHS funding priorities, the President’s FY2016 budget must also include robust funding for viral hepatitis activities within the Department of Veterans Affairs’ Veterans Health Administration. Approximately 175,000 veterans are diagnosed with HCV, at least 30,000 of whom have liver cirrhosis; and as many as 40,000 veterans may be infected with HCV and not know it. Hepatitis B testing and treatment rates are low among US veterans with only15% of US veterans having been tested for HBV infection, and among those who tested positive just 25% having received antiviral treatment. Therefore, HAP supports the President’s request for $690 million for the Veterans Health Administration to provide lifesaving treatment for veterans suffering from hepatitis B and hepatitis C, and requests the Committee appropriate this sum. Finally, we urge the Committee to end the ban on the use of federal funds for syringe services programs and to maintain language allowing the use of local funds for syringe services programs in the District of Columbia. Syringe exchange programs are one of the most effective ways to prevent transmission of blood borne pathogens, including HIV, hepatitis B, and hepatitis C, among people who inject drugs. Given the prescription opiate epidemic and the well-known trend in people transitioning from the use of pills to injecting heroin, it is critical that syringe exchange programs have appropriate support to provide life-saving services and to link participants to much-needed additional support, such as drug treatment, mental health services, and housing. The viral hepatitis community welcomes the opportunity to work with you and your staff on these very important and timely issues. HAP is a national coalition based in Washington, DC and includes community-based organizations, public health and provider associations, national hepatitis and HIV organizations, and diagnostic, pharmaceutical and biotechnology companies. HAP works with policy makers and public health officials to increase federal support for hepatitis prevention, testing, education, research and treatment. Should any questions arise or if you need additional information, please contact Mariah Johnson at (202) 434-8042 or [email protected]. We thank you for your leadership and look forward to your assistance in the fight against these silent epidemics. Sincerely, The Hepatitis Appropriations Partnership
© Copyright 2024