Viral Hepatitis Prevention and Control

Executive Summary
Viral hepatitis refers to several different viruses that affect the liver: hepatitis A, B, C, D, and E.  All of these viruses cause acute, or short-term viral hepatitis. The hepatitis B and C viruses can also cause chronic or long-term hepatitis.
Each year, approximately 1,300 cases of acute and chronic hepatitis A, B, and C are reported to the Maine Department of Health and Human Services, Bureau of Health (BOH).  Chronic hepatitis C accounts for the majority of the reported cases and greatest burden of disease.  With an estimated 20,000 persons in Maine infected, fewer than 30 percent are aware of their hepatitis C infection status.  As a result, opportunities for preventive and therapeutic care that could slow or eliminate the progression of the disease are lost.  With the potential for outcomes such as cirrhosis, liver cancer, or death, earlier rather than later intervention is essential.
In 2003, the BOH received a grant from the Council of State and Territorial Epidemiologists (CSTE) to develop a state plan to address viral hepatitis A, B, and C in Maine.  During a one-day conference, stakeholders from around the state developed and prioritized feasible, specific and relevant goals and objectives for this Plan.  To help guide their efforts, the conference planning committee developed five broad topic areas for discussion in breakout workgroups:  Advocacy and Funding, General Public Education, Clinical and Medical, Priority Populations, and Care and Support.

A brief summary of the characteristics of the principle forms of viral hepatitis is located in Appendix A.  Details include:  transmission, signs and symptoms, prevention messages, risk groups, vaccine recommendations, treatment options, and burden of disease in Maine and the U.S.

This Plan is designed to:

•    Reduce the incidence and prevalence of viral hepatitis in Maine through primary and secondary prevention strategies.
•    Provide the history and current status of viral hepatitis activities in Maine and in the U.S.
•    Provide a framework for collaboration among agencies working with the same high-risk or priority populations.
•    Assist state and local agencies with identifying, adopting, and implementing specific goals and objectives identified by stakeholders.

This Plan can be used:

•    To support funding applications.
•    To identify how to enhance social services by integrating viral hepatitis activities.
•    To raise awareness among elected officials.
•    To help the people of Maine identify ways to make a difference locally.
•    To prioritize activities in an era of limited funding.
•    To heighten awareness in the general public about the significance of viral hepatitis.

Audience for this Plan:

•    Elected officials in Maine and at the national level
•    People working directly or indirectly with persons at high risk for viral hepatitis
•    Health professionals
•    Public health agencies
•    People infected or affected by viral hepatitis
•    Other states
•    Business leaders
•    Media
•    Health insurance companies

Guiding Principles

Core concepts to consider when implementing the objectives and action steps found in this Plan:

•    Integrate viral hepatitis services into existing prevention programs that serve persons at high risk for HIV, STD, and TB.
•    Build on what is already working well.
•    Ensure that education efforts are culturally, linguistically, and literacy level appropriate with a particular sensitivity to stigma and lack of awareness in the general public.
•    The public and private sectors share responsibility for hepatitis prevention.
•    Affected and infected persons should be included in the development and implementation of viral hepatitis activities.
•    Implementation of this Plan is not contingent upon funding.
•    Whenever possible, a comprehensive approach to HIV, STD, TB, and Viral Hepatitis should be included in both medical assessments and educational messages.

Goals and Objectives

It is important to note that although the need is great, there is currently no funding specifically designated to support the activities outlined in this Plan.

The following goals and objectives for the Plan are for a three-year timeframe: January 1, 2005-December 31, 2007.

Advocacy and Funding

Goal:  Maine will have a formally funded, structured, and institutionalized statewide advocacy network to support viral hepatitis activities.

Objective #1: Develop a State ombudsman program for viral hepatitis.

Objective #2: Create a statewide grassroots advocacy network for hepatitis C.

Objective #3: Create a statewide viral hepatitis coalition to increase funding for prevention, testing, and treatment.

General Public Education

Goal: The people of Maine will have, at minimum, a basic knowledge of viral hepatitis prevention, treatment, and resources.

Objective #1: Develop a statewide viral hepatitis media campaign.

Objective #2: Develop a pilot community health advisor program.

Objective #3: Educate persons working with middle and high school age children about viral hepatitis prevention, treatment, and resources.

Clinical and Medical

Goal #1: All Maine Health care providers, Social service providers, and Allied health workers (HSA) will have knowledge of viral hepatitis prevention, testing and counseling, diagnosis, treatment, and resources.

Objective #1: Assess Maine health care provider, social service provider, and allied health worker knowledge of viral hepatitis.

Objective #2: Develop and disseminate a comprehensive continuing education curriculum for HSA on viral hepatitis prevention, testing and counseling, diagnosis, treatment, and resources.

Objective #3: Provide accessible, user-friendly viral hepatitis resources for HSA that include current guidelines for an integrated approach to screening, patient education, and treatment.

Goal #2: Maine will have a comprehensive, integrated standard of care/clinical pathway for viral hepatitis.

Objective #1: Create a comprehensive patient risk assessment tool for use by HSA and emergency response personnel.

Objective #2: Create a clinical pathway that includes but is not limited to prevention, testing and counseling, diagnosis, treatment, support, and a comprehensive approach to services.

Objective #3: Create Regional Centers of Excellence (RCE) for primary health care providers to obtain clinical guidance on complex viral hepatitis cases (similar to the Virology Treatment Center at Maine Medical Center).

Priority Populations

Priority Populations are defined as people who practice (or have practiced) certain behaviors or have had other exposures that place them at an increased risk for viral hepatitis.  High-risk status is defined in guidelines published by the Centers for Disease Control and Prevention  (see Appendix A).

Goal #1: Decrease the incidence and prevalence of viral hepatitis in Priority Populations in Maine.

Objective #1: Educate Priority Populations about viral hepatitis.

Objective #2: Educate social service providers working with Priority Populations about viral hepatitis.

Objective #3:  Increase hepatitis C testing in Priority Populations.

Objective #4: Increase hepatitis A and B vaccination in Priority Populations.

Objective #5: Establish peer support groups designed for members of Priority Populations.

Objective #6: Educate primary health care providers to work more effectively with Priority Populations.

Care and Support

Goal:  Maine will have an Integrated, Coordinated, Comprehensive System (ICCS) of care and support available for people at risk for and/or infected with HCV.

Objective #1: Define the components of an ICCS for Maine.

Objective #2: Address the gaps of ICCS elements by region.

Objective #3: Plan for implementation of the ICCS system.

Purpose of the Plan

The purpose of Viral Hepatitis Prevention and Control: An Action Plan for Maine is to serve as a planning tool to address viral hepatitis A, B, and C in Maine. A brief summary of the characteristics of the principle forms of viral hepatitis is located in Appendix A.  Details include:  transmission, signs and symptoms, prevention messages, risk groups, vaccine recommendations, treatment options, and burden of disease in Maine and the U.S.

The Plan is designed to:

•    Reduce the incidence and prevalence of viral hepatitis in Maine through primary and secondary prevention strategies.
•    Provide the history and current status of viral hepatitis activities in Maine and in the U.S.
•    Provide a framework for collaboration among agencies working with the same high-risk or priority populations.
•    Assist state and local agencies with identifying, adopting, and implementing specific goals and objectives identified by stakeholders.

The Plan can be used:

•    To support funding applications.
•    To identify how to enhance social services by integrating viral hepatitis activities.
•    To raise awareness among elected officials.
•    To help the people of Maine identify ways to make a difference locally.
•    To prioritize activities in an era of limited funding.
•    To heighten awareness of the general public about the significance of viral hepatitis.

Audience for the Plan:

•    Elected officials in Maine and at the national level
•    People working directly or indirectly with persons at high risk for viral hepatitis
•    Health professionals
•    Public health agencies
•    People infected or affected by viral hepatitis
•    Other states
•    Business leaders
•    Media
•    Health insurance companies

Challenges and Strengths

Because Maine is a largely rural state with a low population density, several challenges exist in the effort to prevent and control viral hepatitis.  For example, there are very few local health departments in the State.  In Maine, local community organizations and individual health care providers with wide geographic coverage areas and limited resources deliver most health and social services.  The people of Maine living in areas outside of Bangor, Lewiston, and Portland have long distances to travel to reach the few specialists treating viral hepatitis and to access free State-sponsored services.  Other constraints include the lack of public transportation in most rural areas. Anecdotal evidence supports the presence of a hidden epidemic of injection drug use in the State, a behavior that facilitates viral hepatitis transmission.
Although the need for viral hepatitis prevention and control interventions is great, funding remains limited.  There is currently no funding specifically designated to support the activities outlined in this Plan.

Strengths to support implementation of a viral hepatitis plan include the considerable groundwork already laid by both the HIV community and viral hepatitis advocates (see Appendix B).  Experienced educators familiar with the multiple challenges facing public health programs provide the existing services reaching high-risk populations.  Opportunities for collaboration among agencies with similar missions exist and have already been implemented in some areas. The Bureau of Health has a CDC trained hepatitis C coordinator and a medical epidemiologist who holds a national leadership position focusing on viral hepatitis.  The Bureau of Health has surveillance systems to track the number of cases of viral hepatitis and trained experts to conduct investigation and outbreak response. The State has some funding and will continue to seek out resources to support Plan activities. The recent addition of a hepatitis B immunization requirement to the day care rules and the passage of hepatitis C legislation have helped to raise awareness and support for the issues.

Goals and Objectives

This Plan was conceived with the intent of creating feasible, specific and relevant goals and objectives.  Professional and community stakeholders working directly or indirectly with persons infected or affected by viral hepatitis developed and prioritized goals, objectives, and action steps. For more information on this process, see Appendix C.

In order to effectively prevent and control viral hepatitis in Maine, a variety of strategies and key collaborations are necessary.  This Plan is divided into five areas of concentration: Advocacy and Funding, General Public Education, Clinical and Medical, Priority Populations, and Care and Support. The goals and objectives for this Plan are for a three-year timeframe: January 1, 2005—December 31, 2007.   It is the hope of the stakeholders that all persons in a position to implement any part of this Plan will keep the following guiding principles in mind when implementing the strategies outlined in this road map.

Guiding Principles

Core concepts to consider when implementing the objectives and action steps found in this Plan:

•    Integrate viral hepatitis services into existing prevention programs that serve persons at high risk for HIV, STD, and TB.
•    Build on what is already working well.
•    Ensure that education efforts are culturally, linguistically, and literacy level appropriate with a particular sensitivity to stigma and lack of awareness in the general public.
•    The public and private sectors share responsibility for hepatitis prevention.
•    Affected and infected persons should be included in the development and implementation of viral hepatitis activities.

•    Implementation of this Plan is not contingent upon funding.
•    Whenever possible, a comprehensive approach to HIV, STD, TB, and Viral Hepatitis should be included in both medical assessments and educational messages.

Advocacy and Funding

Advocacy and Funding were identified as a priority issues for inclusion in this Plan for the following reasons:

•    There is currently no formal advocacy organization in the State of Maine that supports viral hepatitis issues.
•    The Bureau of Health hepatitis C coordinator has multiple competing responsibilities, which leaves a minimal amount of time to focus on advocacy and funding initiatives.
•    Organizations that have a similar mission (e.g. focus on other bloodborne pathogens) are not funded to focus on viral hepatitis and therefore unable to advocate for or raise awareness on a broad scale.
•    Due to a variety of reasons, perhaps including stigma or failing health, patient advocates have been unable to organize around the issues.
•    Funding for viral hepatitis at the national level and in Maine has been scarce.  To continue to expand viral hepatitis services in Maine, advocating for, identifying and securing consistent sources of funding is essential.

Goal:  Maine will have a formally funded, structured, and institutionalized statewide advocacy network to support viral hepatitis activities.

Objective #1: Develop a State ombudsman program for viral hepatitis.

Action Steps:

•    Identify natural allies and partners in the community to champion the development of a state-level viral hepatitis advocacy and funding program i.e.:

o    Health professionals
o    Elected officials
o    Media
o    Social service providers working with affected persons
o    General public
o    Employers
o    Persons infected/affected by viral hepatitis

•    Define the role of a viral hepatitis ombudsman–i.e. viral hepatitis advocacy/leadership position vs. someone responsible for investigating and resolving complaints from the public (which is a typical role for an ombudsman).
•    Examine the role of the Bureau of Health hepatitis C coordinator and how it complements and contrasts with the projected role of the viral hepatitis ombudsman.
•    Assess the capacity of State resources to develop a new hepatitis leadership position vs. enhancement of existing positions.
•    Investigate potential funding sources to support these initiatives.

Objective #2:  Create a grassroots statewide advocacy network for hepatitis C.

Action Steps:

•    Create a working list of hepatitis C contacts (e.g. professionals, persons infected/affected by hepatitis C, etc.).
•    Designate a facilitator for development of the advocacy network.
•    Research other hepatitis C or related advocacy networks that might serve as models.
•    Conduct strategic planning sessions with advocacy network participants to determine the mission and goals of the network.
•    Assess the skills and resources of network participants to aid in the network mission.
•    Schedule a predictable, ongoing forum for participants’ continued engagement e.g. regular meetings or annual conferences.
•    Assess the best mode of communication for the network participants (e.g. email list, conference call, telephone tree, or meetings).
•    Research, obtain, and/or develop advocacy literature for the network.

Objective #3: Create a statewide viral hepatitis coalition to increase funding for prevention, testing, and treatment.

Action Steps:

•    Convene state and local viral hepatitis partners and advocates to discuss the development of a funding strategy.
•    Research funding mechanisms and fundraising strategies used by non-profit organizations with similar public health missions.
•    Examine opportunities for partnership with nonprofit organizations that have similar public health missions.
•    Build relationships with volunteer and business organizations (e.g. chamber of commerce, large corporations, Elks Club, Rotary) to raise awareness about viral hepatitis, to provide a forum for raising donations, and to serve as partners in the statewide viral hepatitis coalition.
•    Research grants for application.
•    Identify potential grant writers.
•    Develop an educational packet for targeted funders.
•    Develop a list of priorities for funding.

General Public Education

General Public Education was prioritized for inclusion in this Plan for the following reasons:

•    The 2001 hepatitis C needs assessment, “At the Crossroads: Hepatitis C Infection in Maine” identified a significant need for increasing public awareness about hepatitis C.
•    To date, the only broad-based hepatitis C public awareness activities in Maine have been limited to a 4-month TV/radio public service announcement campaign and occasional publications of articles in local newspapers.
•    Public education about hepatitis B has been limited to child and adolescent immunization.
•    Public education about hepatitis A occurs only in the setting of disease outbreaks.
•    In Maine, and in the nation as a whole, confusion about the differences between hepatitis A, B, and C continues.

Goal: The people of Maine will have, at minimum, a basic knowledge of viral hepatitis prevention, treatment, and resources.

Objective #1: Develop a statewide viral hepatitis media campaign.

Action Steps:

•    Evaluate existing public service announcements for potential adaptation to Maine audiences.
•    As needed, create public service announcements (radio + TV) that provide information on viral hepatitis (prevention, transmission and resources) targeted to the people of Maine.
•    Develop a Maine specific brochure(s) on viral hepatitis.
•    Ensure that public service announcements and brochures are literacy and culturally appropriate.
•    Pilot test public service announcements and brochures with representatives from target groups and make adjustments based on feedback.
•    Disseminate radio and TV public service announcements statewide.
•    Create and implement an innovative plan to disseminate the brochures in places  “where the people are.”

Some examples of places to distribute educational information:
o    Newspapers (ads + inserts)
o    Libraries
o    Grocery stores
o    Laundromats
o    Doctors’ offices
o    Restaurants
o    Churches
o    Government agencies (Department of Motor Vehicle, post offices, DHHS regional offices)
o    Schools (college + high school)
•    Evaluate the media campaign.

Objective #2: Develop a pilot community health advisor program.

A community health advisor is a trusted individual who provides health information to members of the community. Most often, it is a local woman (or man) who shares cultural or ethnic characteristics with the target population.  A community health advisor provides support and health education to family, friends, neighbors and other community members in need of health improvement.

Action Steps:

•    Define the role of a community health advisor.
•    Identify health care providers and social service providers with the skills/knowledge to train local community health advisors about viral hepatitis prevention, treatment and resources.
•    Form a committee of community leaders to identify potential community health advisors.
•    Recruit community health advisors for a pilot program.
•    Train community health advisors to provide viral hepatitis education and referral in their communities in accordance with their language, cultural needs, and customs.
•    Evaluate the pilot program.

Objective #3: Educate persons working with middle and high school age children about viral hepatitis prevention, treatment, and resources.

Action Steps:

•    Enlist the support of the Maine Principals Association (or equivalent for Superintendents) to help highlight the importance of viral hepatitis education.
•    Work with the Department of Education to assess existing school health curricula (for the inclusion of viral hepatitis modules).
•    As needed, integrate viral hepatitis information into the school health curricula.
•    Evaluate the impact of integrating viral hepatitis into the school health curricula.
•    Assess school nurse, school health teacher, and youth social service provider knowledge of viral hepatitis prevention, treatment, and resources.
•    Provide comprehensive trainings in response to assessment results.
•    Evaluate the impact of the trainings.

Clinical and Medical

The decision to include a Clinical and Medical topic in this Plan was based on several key findings:

•    A survey of a sample of Maine primary care providers conducted in association with the 2001 hepatitis C needs assessment, “At the Crossroads: Hepatitis C Infection in Maine,” identified a significant need for accurate and up-to-date primary care provider education on risk assessment, diagnosis, and treatment of hepatitis C.
•    This finding is further supported by hepatitis C infected patients’ descriptions of encounters with medical providers unable to provide them with basic information about the virus.
•    To date, there has been no coordinated or comprehensive effort to educate primary health care providers, social service providers or allied health workers in Maine about viral hepatitis.
•    Less than 30% of people infected with hepatitis C in Maine are aware of their infection.  Given this circumstance, Maine primary health care providers will continue to serve a key role in identifying and diagnosing persons at risk for hepatitis C infection.

Although the numbers are relatively small in comparison to hepatitis C, hepatitis A and B are included in this section because of similarities in risk groups, transmission (in some cases), and because discussion about one of the hepatitis viruses often warrants discussion about the others.

Goal #1: All Maine Health care providers, Social service providers, and Allied health workers (HSA) will have knowledge of viral hepatitis prevention, testing and counseling, diagnosis, treatment, and resources.

Objective #1: Assess HSA knowledge of viral hepatitis.

Action Steps:

•    Research existing viral hepatitis knowledge survey tools.
•    Consult with local HSA representatives on the development/adaptation of a viral hepatitis survey.
o    Provide the survey tool in a variety of formats (e.g. electronic, paper, or web-based).
•    Conduct a pilot test of the survey with a sample of HSA.
•    Incorporate group feedback into the survey.
•    Distribute the survey to HSA.
•    Analyze survey data.
•    Share survey data results with participants and stakeholders.

Objective #2: Develop and disseminate a comprehensive continuing education curriculum for HSA on viral hepatitis prevention, testing and counseling, diagnosis, treatment, and resources.

Action Steps:

•    Research existing viral hepatitis curricula targeting HSA.
•    Consult with representatives from HSA and Priority Populations on the development of the curriculum.
•    Use HSA survey data to inform the development of the curriculum.
•    Create a curricula tailored to HSA that includes a variety to teaching approaches such as:
o    Presentations
o    Print
o    Training website
o    Teleconferencing/videoconferencing
o    Self-study modules (print or web)
o    CD-ROM
•    Develop corresponding evaluation measures for each module to determine achievement of objectives.
•    Apply for continuing education units (CEU) and continuing medical education (CME) hours.
•    Partner with respective professional organizations to develop strategies for reaching their members (e.g. conferences, grand rounds, training courses, seminars, etc.).
•    Evaluate the effectiveness of the training and recruitment strategy.

For more information about educating primary health care providers, see the Priority Populations section.

Objective #3: Provide accessible, user-friendly viral hepatitis resources for HSA that include current guidelines for an integrated approach to screening, diagnosis, patient education, and treatment of viral hepatitis.

Action Steps:

•    Assess existing resources available for HSA on viral hepatitis.
•    Survey HSA to determine best media for accessing resources.
•    Consult with representatives from HSA on the development of a comprehensive viral hepatitis tool kit that includes user-friendly educational materials (which may be adapted from the training curriculum) and patient resources.
•    Create a central location (such as a website) from which to access and disseminate basic hepatitis information, educational materials, and information on referrals and support groups in Maine.
•    Advertise and disseminate the tool kits by partnering with HSA professional organizations to learn the best strategies for reaching their members.

Goal #2: Maine will have a comprehensive, integrated standard of care/clinical pathway for viral hepatitis.

Objective #1: Create a comprehensive patient risk assessment tool for use by HSA and emergency response personnel.

Action Steps:

•    Research existing integrated risk assessment tools.
•    Create a committee of HSA stakeholders to provide input into the development of a risk assessment.
•    Develop a risk assessment tool that is practical and easy to use/administer
•    Recruit a small group of HSA to pilot test the risk assessment with their patients.
•    Provide training to HSA on how to use the risk assessment.
o    Include counseling information that is tailored to working with Priority Populations and uses a harm reduction approach.
•    Distribute the risk assessment to HSA and their respective professional organizations.
•    Evaluate the impact of using the risk assessment.

Objective #2: Create a clinical pathway that includes but is not limited to prevention, testing and
counseling, diagnosis, treatment, support, and a comprehensive approach to services.

Action Steps:

•    Create an expert viral hepatitis committee to develop a clinical pathway.
•    Research existing clinical pathway resources.
•    Draft a Maine specific clinical pathway that applies to multiple types of health care provider settings (private offices, Department of Corrections, substance abuse treatment centers, hospitals, etc.).
•    Build in a process for a periodic (e.g. annual) review of recommendations for any necessary modifications.
•    Distribute a draft of the clinical pathway to the expert viral hepatitis committee and external reviewers for feedback.
•    Disseminate to Maine health care providers.

Objective #3: Create Regional Centers of Excellence (RCE) for primary health care providers to obtain clinical guidance on complex viral hepatitis cases (similar to the Virology Treatment Center at Maine Medical Center).

Action Steps:

•    Recruit specialists treating viral hepatitis in Maine to serve on an education/consultation committee.
•    Investigate the feasibility of replicating the Virology Treatment Center model in other parts of the State.
•    Apply for funding to create Regional Centers of Excellence.


•    Develop an interim model or short-term consultation plan for use while Regional Centers of Excellence are in the development phase.
•    Ensure coordination with care and support systems (see Care and Support section).

Priority Populations

Priority Populations are defined as people who practice (or have practiced) certain behaviors or have had other exposures that place them at an increased risk for viral hepatitis.  High-risk status is defined in guidelines published by the Centers for Disease Control and Prevention  (see Appendix A).

Priority Populations warrant an entire section in this Plan for several reasons:
•    Because they have a demonstrated increased risk for viral hepatitis (based on participation in certain high-risk behaviors).
•    They have higher viral hepatitis infection rates than the general population and there is a high probability they are uninsured or underinsured and do not access healthcare services regularly.
•    Based on lessons learned from HIV prevention strategies, to reach Priority Populations, targeted health education messages and tailored outreach strategies are essential.
•    In addition, Priority Populations need comprehensive, coordinated services that are accessible and culturally competent.

Goal #1: Decrease incidence and prevalence of viral hepatitis in Priority Populations in Maine.

Objective #1: Educate Priority Populations about viral hepatitis.

Action Steps:

•    Choose one or more Priority Population on which to focus intervention efforts.
•    Conduct a materials review to gather information about pre-existing integrated educational tools that are easy to use, population based, credible, and use a harm reduction approach.
•    As needed, tailor educational materials to create Maine specific educational brochures, flyers, posters, etc.
•    Ensure that members of the targeted Priority Populations participate in the development and/or approval of materials.
•    Consult with members of the targeted Priority Populations to develop an outreach strategy and materials dissemination plan to reach peers  “where they are, when they are” i.e. bars, substance abuse clinics, shelters, emergency rooms, etc. Consider using “peer to peer” strategies.
•    Promote existing viral hepatitis resources to Priority Populations.
•    Evaluate the effectiveness of the outreach/dissemination strategy.

Objective #2: Educate social service providers working with Priority Populations about viral hepatitis.

Action Steps:

•    Gather information about existing trainings for social service providers that include medical/clinical aspects of the hepatitis viruses, cultural competence, training on how to conduct an accurate risk assessment, using a harm reduction model, interviewing skills, and a written manual.
•    Collaborate with state agencies (Bureau of Health, Department of Corrections, Office of Substance Abuse, and other relevant agencies) to ensure the trainings include concepts appropriate for each setting.
•    Create or adapt a standard viral hepatitis training manual for the State of Maine.
•    Recruit social service providers to attend the trainings (making sure to include continuing education credits for the training).
•    Implement trainings.
•    Establish an annual conference on viral hepatitis prevention and control for social service providers (make sure to include diverse speakers, and varied educational methods and topics).

Objective #3:  Increase hepatitis C testing in Priority Populations.

Action steps:

•    Evaluate existing state-funded HCV testing sites to assess the volume of high-risk patients, prevalence of disease, appropriateness of setting, and barriers to implementation (funding to provide testing, liability insurance, lack of phlebotomy training, etc.).
•    Assess consumer barriers to accessing HCV testing.
•    Make modifications based on the evaluation.
•    Re-evaluate the existing high-risk criteria for HCV testing in State-funded sites.
•    Investigate feasibility of offering testing in non-traditional, non-clinical settings   frequented by high-risk individuals (e.g. drug treatment facilities, jails, homeless shelters, recreational venues, etc.).
•    Research the availability of funding necessary to support the expansion of testing sites.
•    Implement testing programs in feasible “non-traditional testing sites.”
•    Provide continuing education to professionals working at sites that provide hepatitis C counseling, testing, and referral services.
•    Advertise viral hepatitis services to Priority Populations and to agencies that serve them.
•    Create a comprehensive viral hepatitis resource guide.

Objective #4: Increase hepatitis A and B vaccination in Priority Populations

(See Appendix A for a listing of persons recommended to receive hepatitis A/B vaccination)

Action Steps:

•    Evaluate existing State-funded hepatitis A and B vaccine sites to assess the volume of high-risk patients, appropriateness of setting, and barriers to implementation (funding to provide vaccine, liability insurance, lack of trained staff, etc.).
•    Assess barriers to vaccine acceptance.
•    Make modifications based on the evaluation.
•    Re-evaluate existing eligibility criteria for free hepatitis A and B vaccine (State funded sites).

Objective #5: Establish peer support groups designed for members of Priority Populations.

Action Steps:

•    Survey social service providers and health care providers to determine which communities are most in need of support groups.
•    Conduct a survey of a sample of members of Priority Populations to assess their needs for support groups.
•    Recruit and train support group facilitators.
•    Identify locations for support groups.
•    Advertise support group locations and promote the formation of new groups.
•    Assess barriers to attendance at support groups i.e.
o    Scheduling
o    Child care
o    Transportation
•    Work with support group members to identify ways to reduce barriers to participation.
•    Evaluate the impact of offering peer support groups.

Objective #6: Educate primary health care providers to work more effectively with Priority Populations.

Action Steps:

•    Identify professionals with experience caring for Priority Populations.
•    Identify existing trainings for health care providers on conducting risk assessments, cultural competence, harm reduction, and viral hepatitis.
•    Develop or adapt the curricula for Maine primary health care providers.
•    Provide training on how to conduct a risk assessment during a primary care visit (using a practical, easy-to-administer tool).
•    Provide training on cultural competence.
•    Provide training on harm reduction.
•    Educate health care providers about community-based viral hepatitis resources.

For more information about educating primary health care providers, see the Clinical and Medical section.

Care and Support

One of the most significant challenges for a person exposed to or diagnosed with hepatitis C is navigating the complex, expensive, disconnected, and often-incomplete web of services available in Maine. The 2001 hepatitis C needs assessment, “At the Crossroads: Hepatitis C Infection in Maine” recommended the creation of a comprehensive system of care, including, at minimum, medical, mental health, and substance abuse treatment services. Participants at the Viral Hepatitis Prevention and Control: An Action Plan for Maine conference reiterated this recommendation and suggested the strategy outlined in this section to help make a comprehensive system of care a reality.

Goal: Maine will have an Integrated, Coordinated, Comprehensive System (ICCS) of care and support available for people at risk for and/or infected with HCV.

Objective #1: Define components of an ICCS for Maine.  The ICCS must include the following elements:

o    Affordable and accessible counseling, testing, and referrals
o    An integrated approach to HIV, STD, TB, and Viral Hepatitis
o    Medical evaluation and treatment (HCV clinical pathway/standard of care)
o    Consultation/expert care services
o    Information and resources
o    Post-exposure prophylaxis
o    Case management (include standards that will help to decrease the number of people who “fall through the cracks”)
o    Pharmaceuticals access
o    Psychosocial support
o    Mental health services
o    Substance abuse treatment/counseling
o    Education for patients and providers
o    A plan to evaluate the system

Action steps:

•    Assess existing viral hepatitis ICCS elements/services in the State.
•    Examine the feasibility of offering regional ICCS systems.
•    Identify a coordinator in each region of the State for these activities.
•    Conduct a resource inventory of ICCS elements by region.
•    Conduct an analysis of the ICCS gaps in each region.
•    Assess patient barriers to prevention, testing, and treatment by a limited survey of diagnosed patients and their providers.

Objective #2: Address the gaps of ICCS elements by region.

Action steps:

•    Create a plan to develop resources to fill in the gaps identified in each region.
•    Identify activities that could be centralized to benefit the ICCS, i.e. create warmline/hotline model, in partnership with the Bureau of Health where patients can access basic information and referrals to Regional Centers of Excellence or clinics for testing, diagnostics, treatment, and support programs.
•    Partner with stakeholders in each region to devise a coordinated, multi-tiered approach–including minimum elements necessary for an ICCS system.

Objective #3:  Plan for implementation of the ICCS system.

Action Steps:

•    Using information gathered through the assessments and surveys conducted statewide, apply for funding to support the ICCS system.
•    Create a plan for implementation that includes a step-wise approach.
•    Work with Regional Centers of Excellence to begin implementation of the ICCS.

Glossary

Acute: A short-term, intense health effect. For purposes of this Plan, acute hepatitis A, B or C reflects newly acquired infection.
Advisory Committee on Immunization Practices (ACIP): A committee made up of 15 experts in fields associated with immunization who have been selected by the Secretary of the U. S. Department of Health and Human Services to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the most effective means to prevent vaccine-preventable diseases.
Allied Health Professional:  A person involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others. Allied health professionals, to name a few, include dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, registered nurses, radiographers, respiratory therapists, and speech language pathologists. See http://www.asahp.org/definition.html for more information.
Chronic: Term used to describe a disease of long duration.  For chronic hepatitis B and C, chronic is specified as persisting infection for 6 months or longer.

Community Health Advisor:  A community health advisor is a trusted individual who provides health information to members of the community. Most often, it is a local woman (or man) who shares cultural or ethnic characteristics with the target population.  A community health advisor provides support and health education to family, friends, neighbors and other community members in need of health improvement.

Consumer: A person in the community who receives services from a health or social service provider.

Council of State and Territorial Epidemiologists (CSTE): An organization for epidemiologists that promotes the effective use of epidemiologic data to guide public health practice and improve health.

Clinical pathway: A patient-focused tool, which describes the timeframe and sequencing of routine, predictable multidisciplinary interventions and expected patient outcomes for a group of patients with similar needs.

Epi-Gram:  A Maine Department of Health and Human Services, Bureau of Health, Division of Disease Control publication that contains timely and science-based information to guide Maine’s healthcare professionals in issues of public health and infectious disease importance and to promote statewide infectious disease surveillance.

Goal:  A broad, brief statement of intent that provides focus or direction for the work.  A goal is non-specific, non-measurable, and is rarely attainable.

Guiding Principles: Beliefs and values to keep in mind when implementing activities outlined in Viral Hepatitis Prevention and Control: An Action Plan for Maine.

Harm Reduction:  A set of practical strategies, including clean needle and syringe exchange, that reduce negative health consequences of drug use, incorporating a spectrum of approaches from safer use, to managed use, to abstinence.

Health care provider: An individual licensed to diagnose and treat disease such as a physician, a nurse practitioner or a physician assistant.  Primary health care providers and specialists are included in this category.

HSA: Abbreviation for Health care providers, Social service providers, and Allied health professionals.

ICCS: The Integrated, Coordinated, Comprehensive System of care and support described in the Care and Support section of this Plan.
Incidence: The number of new cases of a condition that occur in a given population over a period of time.
Integration: A comprehensive approach to providing multiple prevention services at a single client visit.  Prevention services may include counseling, testing, prevention education, immunization, and treatment services.  The similar modes of transmission of HIV, HCV, and HBV present a unique opportunity to provide integrated services.  Integration may also include prevention services for tuberculosis.
Objective:  A statement that provides realistic steps toward attaining a goal.  For this Plan, conference participants were asked to come up with specific, relevant, and feasible objectives.

Prevalence:  The number of infected individuals in a population at a given point in time.

Primary care provider:  A health care provider responsible for general/basic health care including practitioners in internal medicine, family practice, pediatrics, or OB/GYN.  This is  opposed to a specialist, such as a gastroenterologist, who does not provide general medical care.

Primary interventions: Strategies (such as providing educational materials and counseling) designed to prevent uninfected persons from becoming infected with a virus, in this case, the viruses that cause viral hepatitis.

Priority Populations: Priority Populations are defined as people who practice (or have practiced) certain behaviors or have had other exposures that place them at an increased risk for viral hepatitis.  High-risk status is defined in guidelines published by the Centers for Disease Control and Prevention  (see Appendix A).
Regional Center of Excellence (RCE):  A hospital-based center staffed by health care providers that have experience diagnosing and treating viral hepatitis (as described in the Clinical and Medical section of this plan).  The purpose of the center is to provide state-of-the-art care for patients and to offer primary health care providers with clinical guidance on complex viral hepatitis cases (similar to the Virology Treatment Center at Maine Medical Center).

 

ยาอึดทน หลั่งเร็วช้า

Posted on เมษายน 8, 2013, in บทความ. Bookmark the permalink. ใส่ความเห็น.

ใส่ความเห็น

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / เปลี่ยนแปลง )

Twitter picture

You are commenting using your Twitter account. Log Out / เปลี่ยนแปลง )

Facebook photo

You are commenting using your Facebook account. Log Out / เปลี่ยนแปลง )

Google+ photo

You are commenting using your Google+ account. Log Out / เปลี่ยนแปลง )

Connecting to %s

%d bloggers like this: