Causes Of Liver Damage

mr. christopher bates: good afternoon andwelcome. we'd like to thank all of you for joining usthis afternoon for our webinar, what every woman needs to knowabout hepatitis b and c. we're very excited to have you join us withthis call this afternoon and webinar, and we'd like to make sure thatyou can hear videos that we have embedded in our presentation today. so, we would ask you to turn up the volumeon your phone or on your computer at this time, so that when we reachthose points in the presentation, you will be properly clued inand can hear and

appreciate the video. without further ado, i'm going to turn themic over to my colleague, dr. lydia martinez from the office ofwomen's health, and she is going to introduce our first speaker. dr. lydia martinez: hi, and welcome toeveryone to this important webinar on hepatitis and women. it is my honor tointroduce you to dr. nancy lee. dr. lee is the deputy assistantsecretary for health, women's health, and the director of the office on women'shealth in the office of the secretary at the u.s. department of healthand human services.

until this appointment, she worked for sevenyears as a private consultant in the areas of public health,epidemiology, and cancer control. prior to that time, dr. lee worked with the centers for disease control and preventionfor more than 22 years. for 10 of those years, she was at thedivision director or associate director level. she has extensive experience in women'shealth, cancer prevention and control, data analysis, epidemiology, andsurveillance systems. dr. lee received a b.a. from the universityof texas and an m.d.

from baylor college of medicine. please joinme in welcoming dr. nancy lee. dr. nancy lee: thank you so much, lydia, andwelcome. good afternoon. i want to welcome you alltoday to this webinar, what every woman needs to know abouthepatitis b and c. as people have said, i am nancy lee with thedirector of the office on women's health. we are proud to co-hostthis webinar, along with the office of hiv/aids andinfectious disease policy, and to be part of the team working toimplement the viral hepatitis action plan across the government.

this webinar is an important part of ourwork to raise awareness about viral hepatitis and the many ways wecan prevent new infections in women and their children, and help thoseaffected, and even cure people with hepatitis c. treatments also exist for hepatitis b, butmost people who are chronically infected are unaware of theirinfection. hepatitis b and c are the most commonblood-borne infections, but we have tools to address them -- a safe andeffective vaccine for

hepatitis b, and accurate blood tests forhepatitis b and c, as well as treatment, but we need you to help spreadthe word about these infections. so i'm going to do a call to action. thereis a lot of new activity in the field of viral hepatitis. what we have accomplishedthus far is a great start, but i am here today to urge all of you tolearn about what advances are on the horizon and to discuss what opportunitiesthere may be to make even greater impacts in this field. i ask all of you to identify opportunitiesto collaborate and partner to share the information you learntoday with coworkers in

your networks to provide viral hepatitisprevention, education, testing, and care. we can help the millions of people affectedby hepatitis b and c. only by working together can we addressviral hepatitis, and i look forward -- excuse me -- i look forward toworking with you all. thanks so much, and the webinar willcontinue now. christopher: okay, i am going to ask mycolleague, dr. martinez, to take us through the nextsection of this webinar. dr. martinez: thank you, chris. at thiswebinar today,

you will be hearing from christopher bates, who is the senior advisor to the director,and ms. corinna dan, the viral hepatitis policy advisor at theoffice of hiv/aids and infectious disease policy; and later on fromour distinguished presenter, ms. andi thomas,president of healthpro. today we will be addressing the significanceof viral hepatitis and its importance as a health issue for womenand their families. we all know that many women are the decisionmakers on health matters for their families.

so it is important for them and the peoplewho serve them to be aware and knowledgeable about viral hepatitis andits impact on their health and the health of their families. our hope is that women become messengers ofhealth and help spread the word among their families, friends, andcommunities. so, with that in mind, today's webinarobjectives are to increase the awareness and knowledge of viral hepatitisand its impact on women among owh grantees, partners, and allparticipants on today's presentation. our goal is that today's webinarparticipants will share this

information within the communities they workwith -- their partners, professional networks, families, andfriends. so, today we will share with you all anoverview on hepatitis b and c; online resources that are available toall; and we will also have a personal story that will make this topicreal. finally, we will conclude with a questionand answer segment. chris? christopher: hi. all of you should directyour attentions to the screen at this time. what we want to pointout to you is something that we are learning that a lot of peopledon't know,

and that is where the liver is located inthe body. [inaudible] a lot of people don't know that the liver is the largest organ that we have in ourbodies, and not only that -- i'm going to turn to my next slide -- the liveralso has 500 vital functions. here are just a few of those functions:immunity against infection; it regulates blood clotting; [inaudible] key for protein and cholesterol; clearsblood of drugs, chemicals, and alcohol; excretes waste via bile; and converts excessglucose to starch for

storage, excretes bile at digestion. the liver is very important, and it doesmany, many, many more functions that support our health. what is hepatitis? a lot of people don'tknow that hepatitis means inflammation of the liver. hepatitis is mostoften caused by a virus. at time of infection, a person is consideredacutely infected with hepatitis. if a person is infected for several monthsor years, the infection is classed as chronic. the most common types inthe united states of hepatitis are a, b, and c. however, today,our focus will be

heavily focused on b and c. and, last butnot least, heavy alcohol use, toxins, medications, and certain medicalconditions can cause hepatitis. here on this slide, we have the stages ofliver disease. in the left corner, lower, we see a normalliver. isn't that pretty? it almost reminds me of the liver thatpeople eat from the cow or pig or calf. however, on the left side, we see variousstages of liver disease being manifested, moving from chronichepatitis to sclerosis, and to hepatoid cellular carcinoma, which is justan advanced form of sclerosis, and liver cancer is what it'scommonly referred to as.

viral hepatitis in the united states isestimated at 4.5 million americans are living with this chroniccondition. about 15,000 people die from the diseaseeach year -- asian americans, african americans, and baby boomers sufferfrom this condition disproportionately. viral hepatitis is thenumber one blood-borne infection in the u.s. and the leading causeof liver cancer, resulting in chronic hepatitis is often called the silentdisease, because many people don't know they're infected untilthey're at severe liver damage. most chronically infected people are unawareof their infection,

roughly 65 to 75 percent. and lastly, blood tests can detect thevirus, but few get tested, and this is one of the points and importantaspects of today's presentation. what is hepatitis a? at this point, i'd liketo introduce to you my colleague, corinna dan, who will take usthrough hepatitis a, b, and c. corinna: great. thank you so much,christopher and lydia, and of course, nancy lee as well. and i'd like to echo the thanks for spendingpart of your afternoon with us today to talk about viral hepatitis,and i think christopher

laid out a really nice case for why we needto raise awareness about viral hepatitis with so many millions ofpeople affected, many people infected with hepatitis and unaware of theirinfection. so, hepatitis a is an infection that doesnot result in chronic infection. so people become infected with hepatitis a,they often get sick, and then the body fights off the infection andthey get better. hep a is primarily transmitted fecal-orally,or from contaminated poop or feces, from person-to-person, oroften through contaminated food or water.

the great news about hepatitis a is that itis vaccine-preventable. it's one of the most effective vaccines outthere. it is two doses of vaccine, and now, thesedays, currently, many of our children are being vaccinated forhepatitis a. they're recommended to get that at age 1,along with international travelers, who may be exposed when they aretraveling to countries that have high rates of hepatitis a, andothers who are at risk of hepatitis a infection. so hepatitis b is a contagious liver diseasethat results from

infection with the hepatitis b virus. i apologize -- at this time the slidesappear to be loading, but that should happen pretty soon, and i'm going tokeep on going here. hepatitis b is spread when blood, semen, orother body fluids from a person who is infected enter the body ofsomeone who is not infected, often happening through sexual contact orthrough exposure to blood via syringes, often when people areinjecting drugs. hepatitis b importantly can also be passedfrom an infected mother to her infant at the timeof birth.

the good news is that we can preventtransmission of hepatitis b. a few interesting facts about hepatitis b. it can be a very serious infection, it's 50to 100 times more infectious than hiv, and most people don'thave any symptoms. symptoms often develop over a really longperiod of time, up to even 30 years. hepatitis b is kind of a funny virus. when an infant is infected, almost all -- 9out of 10 -- infants who are infected become chronically infected,but adults, who have more mature immune systems, are often able tofight off that infection.

so when adults are newly infected withhepatitis b, only 10 percent of them become chronically infected. fifteen to twenty-five percent of people whobecome chronically infected with hepatitis b develop seriousliver problems like liver cancer, cirrhosis, liver failure. and many people do die of their hepatitis binfection. in 2010, approximately 2,000 people in theunited states died from hepatitis b-related liver disease. so we have a lot of people who arerecommended to be tested for

hepatitis b, and unfortunately, many peoplewho should be tested are not being tested. cdc recommends that anyoneborn in asia, africa, and other regions that have moderate or highrates of hepatitis b be tested for the infection, and i think cdc's website has areally wonderful map. if you are concerned about that, please dofollow up. unvaccinated people whose parents are fromplaces where there's a lot of hepatitis b should also be tested. hepatitis b is sexually transmitted, soanyone having sex with a person who has hepatitis b, and men who havesex with men, as well as

folks who have -- who even present at an stdclinic, or have other sexually transmitted infections, should betested for hepatitis b. hepatitis b has been known to be transmittedwithin households, so it's a good idea, if you're living withsomeone who has hepatitis b, to be tested. hepatitis b, as i saidearlier, very easily [inaudible] abuse, so anyone who has injected drugsshould be tested. pregnant women, because we know we canprevent new hepatitis b infections transmitted from a mother to herinfant at the time of

birth, we try to test all pregnant women toensure that they don't transmit that infection to their infant. people with hiv infection are also at higherrisk, as well as people on dialysis; and people who receivechemotherapy and other types of immunosuppressive therapy should be testedfor hepatitis b before they start those treatments, because if theyhad hepatitis b and it was undiagnosed, it could result in an acuteflare-up, and people have died because they didn't realize theyhad had hepatitis b in the past and they started on some of thosetherapies.

hepatitis b is diagnosed with a specificblood test. it's a fairly simple blood test, but it isnot a blood test that is usually done when your doctor says he'sgoing to check you for "everything." for acute hepatitis b cases,doctors usually recommend rest, adequate nutrition, and monitoring,but there is no treatment specifically for acute or a new hepatitis binfection; but for chronic hepatitis b, individuals should bemonitored regularly by a doctor, as with any chronic health problem,and also be evaluated for liver problems. there are treatmentsavailable for hepatitis b as well.

so, the great news about hepatitis b,similar to hepatitis a, is that we have a safe and effective vaccine. the entire series is needed, all three shotsover six months for long-term protection, and booster doses arenot currently recommended, so the good news on that frontis, if you've gotten all three doses of your hepatitis b vaccine,then you don't need to get any further shots. i am going to transition into hepatitis c. hepatitis c is acontagious liver disease.

it can result in infection with thehepatitis c virus. we know that about 15 to 25 percent ofpeople actually clear the virus without treatment for hepatitis c. however, 75 to 85 percent of people who getinfected with hepatitis c go on to develop a chronic or lifelonginfection, and over time, as we saw with chronic hepatitis b, liverdamage, cirrhosis, liver failure, and liver cancer can result. hepatitis c can be a very serious liverdisease. in the united states, an estimated 3.2million people have chronic

hepatitis c, and each year the cdc estimatesthat about 17,000 americans become newly infected. chronic hepatitis c can result in long-termhealth problems, and, again, cdc estimates that about 15,000people die every year from hepatitis c related. the graphic at the right-hand side kind ofillustrates the difference in magnitude comparing the number of peoplewho are infected with hiv, at about 1.1 million these days, withthe number of people who are chronically infected with hepatitis c,although we hear a lot

more about hiv, in large part because peoplein the early days of the hiv epidemic died very suddenly or veryquickly and a lot of energy and resources have been put into raisingawareness about hiv. the fact that many more people have chronichepatitis c infection is really a public health issue, and we areworking now to raise awareness about chronic hepatitis c and getpeople tested. because of the shared ways that hepatitis cis transmitted -- through blood exposure, occasionally through sexualexposure -- there are people who are co-infected with hiv andhepatitis c

overlapping circles in the diagram. spreads usually from an infected person tosomeone who is not infected. most people today are exposed other equipment to inject drugs; however,before 1992, we didn't have a test that could accurately identify thehepatitis c infection, and so before 1992, many people were exposed through theblood supply -- through blood transfusions, organ transplants, oroutbreaks from contaminated medical settings. who should get tested for hepatitis c?

current or former injection drug users, evenif they only injected one time or many years ago; anyone who wastreated for a blood clotting problem before 1987, which is whenwe started being able to ensure that blood clotting factors weresafe; anyone who got a blood transfusion or organ transplant before 1992;and anyone who has ever been on long-term hemodialysis. people who have abnormal liver tests shouldbe tested for hepatitis c, as well as anyone who has liver disease,to see if it may be the hepatitis c that's causing the abnormalliver test or the liver

disease; and just recently i spent some timewith some liver doctors who often hear, "oh, well, my liver enzymeswere only a little bit elevated, or they were just slightlyabnormal." but the liver doctors believe that there is no "only a little bitabnormal" and recommend that anyone who has any abnormal liverenzymes be tested for hepatitis c. the health care workers or public safetyworkers who are exposed to blood through needle sticks or other sharpobject injury. again, folks who are infected with hiv,because of the shared modes of transmission, should be tested forhepatitis b, and then just

recently last year in the summer, the cdccame out with new recommendations recommending thatindividuals born between 1945 through 1965 be tested for hepatitis c. this is because a good proportion of people about 75 percent of people chronicallyinfected with hepatitis c were identified to be in that age group ofindividuals born between 1945 and 1965. most of them don't have any symptoms ofinfection, and many of them don't have any rationale or reason tobelieve that they were exposed to hepatitis c. and so in order to reducethe number of people who are

walking around with undiagnosed hepatitis c,the cdc, as you saw in the video just recently, recommends now thatfolks born between 1945 and 1965 have a one-time test forhepatitis b. hepatitis c is diagnosed using a blood test. it is a two-step process to diagnose peoplewith hepatitis c test that looks for antibodies. antibodiesare proteins produced by your body when it's exposed to aninfection. and if that screening test is positive, thena different blood test is needed that actually measures hepatitis cvirus in the blood.

so it is a two-step process; however, it isrecommended that folks get the first test to see if they were everexposed, and then test for the actual virus itself to see ifthey're still infected. as you may remember in a previous slide, imentioned that 15 percent or so of people who are infected withhepatitis c actually are able to clear the infection, and so there is achance, even if the antibody test is positive, that a personcould have resolved that infection and no longer be chronicallyinfected. so the other good news about hepatitis c isthat we have treatments

that can cure it. so, we've had hepatitis ctreatments that resulted in a cure for a fairly small numberof people who took them for over a decade. however, those treatmentsare rapidly changing. they've already begun to change, but we'revery excited about the new treatments that are coming down the line. so for the past little over a decade, we'vehad pegylated interferon were effective in a little less than half ofpeople in actually resulting in a cure for hepatitis c.unfortunately, those two medications taken together have some very serious sideeffects, and many people

weren't able to even tolerate or take thosemedications at all. so there are some new direct actinganti-viral drugs that have improved cure rates up to 75 percent, andsome people are even able to take those for shorter time periods thanthe previous treatments. and our pharmaceutical industry partnershave been working along with researchers from the national institutes ofhealth to develop new drugs that are even more effective that canhelp cure many more people. two of these new medications areexpected to be on the market starting just next month, and there are, youknow, more than 20 new

drugs in the pipeline that will be -- startbecoming available starting in 2014 and 2015, and i'm sure wellbeyond that. so we are looking at being able to cure morethan 90 percent of people, in the coming years, of theirchronic hepatitis c infection. and again, this is so important, then, toidentify individuals before they develop serious liver disease or livercancer, because we can save lives. i'm going to turn it back over. christopher: thank you, corinna. in 2010, the institute of medicine publisheda report, hepatitis and

liver cancer: a national strategy forprevention and control of hepatitis b and c. this report led the department of health andhuman services, under the direction of assistant secretary forhealth dr. howard koh, to develop a national viralhepatitis action plan. the action plan was a three-year plan for2011 through 2013. that plan had six goals to accomplish, andthey're on the screen in front of you: educating providers incommunities to reduce health disparities; strengthening surveillance todetect viral hepatitis

transmission and disease; eliminatingtransmission of vaccine-preventable viral hepatitis;reducing viral hepatitis cases caused by drug use behavior; protectingpatients and workers from health care-associated viral hepatitis; andimproving testing, care, and treatment to prevent liver disease andcancer. it was further decided that since this planwould be ending this year, and there was still groundwork to becompleted from the original plan and agencies and departmentsacross the country -- i'm sorry, across the government involved inviral hepatitis response,

decided that it was important that wecontinue our work. and so now we are entering into a new plan,which will be released in the late winter of next year. renewing the action plan hopefully may 2013,assistant secretary for health howard koh announced the renewal ofthis viral hepatitis plan, then, to run 2014 through 2016. the renewal gives us all the chance to jointogether to eliminate perinatal hepatitis b and increase awarenessof who should be tested, identify new collaborative partners andprograms, and identify

opportunities with the affordable care act. also, this new plan will be constructed suchthat it will be far more user friendly to the general public and toyou, our listening audience today, to help you become strongerpartners with us in addressing this national health issue. one thing that we get as a question from alot of our colleagues across the country is, "what resources areavailable to help us in promoting public awareness and educationabout viral hepatitis?" i am glad to say that the cdc has been veryengaged, in its division of

viral hepatitis, to develop tools andinstruments to help us educate the public and to keep the public aware ofthe importance of viral hepatitis screening as well as viralhepatitis testing, and hopefully those who are infected with hepatitis b or care connected to vital care and treatment services. on the screen now, you see what we believeis one of our most important tools that the cdc developed. itis their hepatitis risk assessment. you can go online and access this riskassessment tool, and it can

give you a very generalized understanding ofwhether or not you are at risk for hepatitis. we recommend to you that you take theinformation derived from taking this test and discuss it with your doctor,and hopefully you and your physician can decide that a hepatitis test for you, and that at this time, you'll learnabout your status. other tools on the cdc website are badgesand posters and brochures, and also we have pens for people to wear, tohave them serve as ambassadors of education for viralhepatitis.

and you become an immediate partner of thedepartment in doing so. furthermore, there are fact sheets, veryimportant fact sheets, on the website that are targeted to racial andethnic groups, and then to expected mothers, and also looking atissues of subpopulations like men who have sex with men, substanceabusers, and so forth. there is a broad dearth of informationonline available to the general public. in addition, there are resources online toacquaint physicians and clinical people about the importance ofthis, a response to viral hepatitis, as well as tools to furthereducate them about treatment

care of patients who come to them forservices. at this time, and -- it's my pleasure tointroduce our guest speaker this afternoon. our guest speaker is andithomas. she is president of healthpro. she is thefounding partner of a group called the support partnership, and if youturn to this slide on your screen, you will see that there is a hepatitishotline, which andi will talk a little bit about in her presentation. it gives me great pleasure at this time tointroduce you to andi thomas. andi thomas: thank you so much christopher,and i am delighted to be

here. and thank you to the office of women'shealth, the office of hiv/aids, corinna dan, dr. koh, dr.valdiserri, and all of the otherdignitaries. it is unusual for me to speak from apersonal level, so in my comfort zone i'm going to start by tellingyou how i got to where i am, and then i'm going to share some deeplypersonal information with you. when i first found out about hepatitis c, ihad -- this was 17 years ago -- i had an unusual blood test, and ihad a need to have a colonoscopy. so i was referred to a gastroenterologist,and he noted the abnormal liver enzymes, and just totally scared me,freaked me out, telling me

everything about hepatitis c and the drugsthat were worse than the cure and so on and so forth, and we neverfollowed up with that conversation with the blood test thatparticular visit. when i went to follow up with him a yearlater, we actually -- i reminded him about the blood test, and wedid it. now, three or four weeks later, after voicemail tag, i finally received a call back from him about my testresults, both the follow-up colonoscopy as well as the bloodtest. and i was standing in the lunch room at alarge employer, where

there's probably 50, 55 people at lunch. and i'm in the corner with the phone tryingto be discreet, and i got a "good news, bad news" phone call. the good news was that my colon was fine. the bad news was that i tested positive forhepatitis c. and i huddled in the corner with my handcupped over the mouthpiece and asked him, "what does this mean? am i infectious? what about my husband? what about my children?" and his responsewas, "just don't bleed on

your kids." that was 17 years ago. i would love to say that globally,throughout the u.s., that gastroenterologists have gotten a bettermessage, but that's not necessarily the case. but it's gettingbetter. but my personal experience that one moment,and when i went home and pulled this up on the internet, and way backwhen, 17 years ago, there were very few websites about hepatitisc. i thought i was going to die, absolutely wasconvinced, to the point of starting to call family members and tellthem goodbye.

and then, as i educated myself further, itbecame very clear that wasn't the case -- that there was a hugevariability in disease progression, and there was no absolute deathsentence associated with this, and that really pissed me off. so i went on treatment, because i wanted tonot be infected, and while i was on treatment i'm having thiscompletely upper-middle-class suburbian thing, wherei'm laying in the pool, the husband's grilling steaks on the grill, andit occurred to me that i needed to do something about this, that icould actually quit my day

job and do this full-time. somebody had to. so i did. the husband said okay, by the way.so i did. i started health -- sorry, hep-c alert,which was founded in 1997, and originally our major program was a nationalcounseling and referral helpline, 877-helpforhep. this model wasn't a traditional passivehelpline where we'd receive a call and do some counseling, maybe mail outmaterials, but instead was a helpline where we made an initialconnection, and then followed up with those individuals over the course oftime as they moved

through the stages of care access andtreatment and health decision-making. i'm really happy to say that, despite thechanges in the non-profit situation that i'm working in, that helplinestill exists. but this all started with a pissed offwoman, and i always say, it's like, "how do you start a non-profit? you make a woman angry." my needs ultimatelygot met because i've worked in the medical field and in anadministrative capacity, and it was really easy for me to make my waythrough this information, but for those individuals who weren't asfortunate as i to be able to

synthesize all of the information out thereand search it out and make sense of it and apply it to decisions,that's was really was the driving force. hep-c alert ultimately moved. our office moved into a medicallyunderserved, low-income minority community in north miami, and it becameclear that hepatitis c was not a primary concern for this community. and it was at that point that theorganization began expanding its roster of services to include all viralhepatitis screening, vaccination, hiv testing, and as well aschlamydia, gonorrhea,

and syphilis testing. and then, ultimately,we added cholesterol, blood pressure, and obesity screening. so we became a preventive health home with apopulation of primarily, like i said, medically underserved minorityyoung adults. it was wildly popular, and we had -- theconcept was so well accepted. we didn't advertise, but in the course offour years, as we had expanded our roster of service andintegrated them into a single visit, we increased our volume by 900percent. we used to see 60 people a month, and i hadpanicked because i

thought, "oh my gosh, we'll never keep thedoors open if we only have 60 people a month come in," to over 600people a month. it was an amazing transition, and thisintegrated service model over the course of eight years was tweaked andadjusted and responsive to the feedback that we got from the communitythat made it incredibly successful. unfortunately, with the funding issues --with funding issues, let's just say that -- hep-c alert, which wasrenamed alert heath to better represent the integrated service model, hadto close in july of 2011. and healthpro -- i formed health pro not asa direct consumer service

organization, but rather to assist otherorganizations expand their services and look at the service integrationmodel and spread the word. so, it's giving away the program. what i am happiest about is that help forhep, 877-helpforhep, continues on. so the very first program that was startedwith hep-c alert -- not pepsi, hep-c -- alert 17 years ago lives on;but it lives on not run by a single organization, but rather as apartnership. one of the passions that i have is to --peer linkage, but i think the peak of this is ensuring that people aretested, and as corinna

was going through the risk factors fortesting, for the criteria for hepatitis c testing, when i first read therisk factor list from cdc, personally i didn't fit into any of thoserisk factors. i was not an injecting drug user. i didn't have a blood transfusion. i didn't have a needle stick from aninfected source, no kidney dialysis, so on and so forth. i did over the years have intermittingly,mildly abnormal liver enzymes, which my primary care physician hadattributed to alcohol

consumption, social drinking, and it wasignored. and it was just amazing to me, the day thati got the phone call in the lunch room, that i could have beeninfected for what i estimate to be 18 years, done everything that i wassupposed to be doing -- you know, you get a job, you get married, youhave children, so on and so forth, i'm beat bopping through life feelinghealthy and well -- to find out that i'm infected with the virus,and i don't meet any of the criteria for ever having been screened,even with the abnormal liver enzymes. i am happy about the cdc's recommendation,as well as the adoption

of this recommendation by the united statespreventive services task force, to make it a b recommendation, whichmeans it is recommended -- hepatitis c screening is recommended for thebaby boomer population. and i want to say, a one-time test -- onetest, one time. as a call to action, if the only thing youtake away from this call is to speak with the people in the highestprevalence population -- baby boomers, people that look like me,maybe don't look like me, but they're in my age group -- one test, onetime. then you can put it to bed. if the test is positive, there are betterresources and more

information today than there ever has beenin the past. and with the viral hepatitis action plan,and the interagency cooperation within health and human servicesas well as other governmental agencies, and the miraculouschange in the treatment paradigm, from something that -- fromtreatment that was incredibly difficult to tolerate, to an all-oralregimen or an interferon-based regimen with oral medications that make itmore powerful. this is such an exciting and empowering timein hepatitis c advocacy. i want to share a couple things with youabout finding out i was

infected, because i'm going to speak as awoman hopefully to all the women that are on the call, and men, pleasebear with me. when i was diagnosed, it was -- i feltdirty. i felt contaminated, infected; it was an "ohmy god" moment. how could this happen to me? one of the things that was, amongst several,one of the things that was hardest to cope with was menstruation. i make a joke of this, but it wasn't funny,and it really still isn't, but, being diagnosed with a viralinfection that's transmitted

through blood, when you menstruate, it'slike my crotch was a bio-hazardous waste dump, and all thesanitary products associated with it had to be treated accordingly. it was as if this one part of my body was nolonger okay for general consumption, if you get my drift. it took me many, many months to adjust, andi know this happens with women with hepatitis b, as well as those whohave been diagnosed with hiv. it's a very personal thing for women. and it doesn't -- it's not spoken of veryoften, but in counseling and

supporting women, it's something to bring upas part of the adjustment and towards coping. it's important for counseling women with ablood-borne communicable infection in the management and disposal oftheir sanitary products. just -- i needed to put that out there. i'm pretty sure nobody else will ever saythis to you. but i really, i think the other take-awaywas about having infected my children, and thank god both of mychildren and my husband tested negative, but as a mother, not knowing thati was infected when i

became pregnant and had my children, findingout years later when they were old enough to realize thatsomething was up, but that was a real challenge for me to adjust to as well. and again, i'm sharing this because it's animportant part of the counseling, coping, and acceptance, and aswell as a recommendation for the children of women who have hepatitisb and hepatitis c to be screened as well. so i'd like to close by reading you a poemthat i have read out loud now three times.

i wrote the poem after i went throughtreatment, and i did go through treatment -- the old-fashioned treatmentwith the injection and the pills; that was very difficult, and i don'tknow if you know how difficult it is or if you've known anybodywho's gone through it, but it's tough. it's doable, but very difficult to getthrough. but every time i've read this poem, i'vecried, but it was a poem that was that was in me and i would like toshare it with you as i close. the poem is titled "get it out." when i first heard the news, i was shockedand dismayed.

me have hepatitis c? i thought i'd beenplayed. because when my doc told me, "just don'tbleed on your kids," i lost all control and my life hit the skids. that one single moment, it changed my wholeview. my thoughts filled with pain -- my lifenever the same, and this refrain kept repeating as my soul shoutedout, "there is a virus inside me. get it out! get it out!" i drew my kids close to tell them my fate,and i said my goodbyes, and "please live without hate," because eventhough i'd be dead in a

matter of years, and they might be infected-- my greatest of fears. and after damaging them for life with thisdramatic goodbye, i called my husband on the phone and i started tocry. i told him, "divorce me. i am infectious and sickly, and john, iinsist, get away from me quickly." that one single moment, it changedtheir whole view, their thoughts full of terror hoping there wassome error. the refrain kept repeating as their soulsshouted out, "there is a virus inside her. oh my god, get it out!" druggies and whores, that's who gets thisinfection, not

middle-class moms who live in perfection. but i confessed and explained that i wasn'treally a junky or whatever, but their stares became chilly,like i was a leper to avoid at all cost, and when my friends shunned me,that's when i got lost. that one single moment, they changed theirwhole view. their eyes filled with accusation and abunch of fascination. the refrain kept repeating, my thoughtsclouded now, "i'm really not contagious, but i'll manage somehow." poison medicine injected until out my hairfell, needles and pills

daily, and living in hell. dropping 30 pounds on a drug-induced diet iswhen curious folks started acting real quiet, spreading rumorsthat i had aids, or that i was going crazy, and i let them believe itbecause that kept them busy. that one single moment, they changed theirwhole view, rumors rife with suspicion and not even one ounce ofcontrition. the refrain kept repeating as my mouthsnapped shut, "it's a virus, for christ's sakes. why don't you shut thehell up?" my family embraced me with true love andprotection.

i didn't have to ask, they just gave meconnection. loved me unconditionally through angrydepression, through poison, through treatment, they never questioned mychoices or my secrets or my past or my tears; instead gave me loveand shared in my fears. that one single moment, i changed my wholeview. i felt my whole family rally around me. the refrain kept repeating as my heartshouted out, "there's a virus inside us? then we're getting it out." i failed the first round for the drugs --they failed me, but a

second chance came round to become virusfree. so i asked my kids who were leaving the nestin a hurry, if they'd prefer that i wait so that they wouldn'thave worry, and they both said, "no, mom, we want to be near. in case you need help, we'll all be righthere." so even though i did "i'm going to die" drama, they've shownme how much they love me, their not-perfect mamma. that one single moment, we changed our wholeview. our hearts became joyful because the drugswere so powerful.

the refrain kept repeating, one voice unitedin shout, "there's no more virus inside us. we got it out. we gotit out." thank you. christopher: wow, andi, i cannot thank youenough for sharing with us your very heartfelt story, your personalexperience, and also giving us the history of the organizationyou founded, and telling us about the work you continue to do. we appreciate you very much, and i'm surethat the hundreds of people who are online with us now join me inthanking you very much for your participation in our webinar today.

andi: now i'm going to go and have a goodcry. christopehr: but you can't go too soon,because we're going to move into our q&a section, and i'm sure there maybe some questions in this portion of our program this afternoon,that you may a get a question or two from our listeningparticipants. michael richardson: yes, this is michaelrichardson. i was wondering, andi thomas, when you wastalking about your menses, what education did you give the women on howto get rid of the waste? andi: great question. well, i had youngerkids, and i wanted to

make sure they weren't, you know, goingthrough my trash. what i did is i -- well, in my bathroom,obviously, wrapped the products in towels, and then i sealed theminto a plastic bag, and they went into the regular trash can; but idid educate the children both for my menstrual, you know, to, "don'tgo into this," but also, not to share my toothbrushes. my daughter had just started shaving herlegs, and not to share my razors. and in our kitchen, you know, where the momcuts herself regularly, we actually put a -- this is a great trick,whether it is hiv,

hepatitis b, or hepatitis c -- a kind ofdo-it-yourself blood clean-up kit. we had gauze, you know, like a first aidkit, with a lot of gauze and cellophane that you could wrap around thegauze to contain whatever was bleeding; and then in there we had maxipads to soak up any blood that had gotten on hard surfaces or on anysurfaces. so, but it was important that i wrapeverything up, that it wasn't just -- that the sanitary products weren'tjust, kind of just wrapped in toilet paper and put into my little trashcan. blair kermin: thank you. i would like to know ifsomeone could

elaborate on the current treatments for hepc. corinna: sure. this is corinna dan. the current treatment for hepatitis cactually depends on a number of factors. there are six known genotypes, or differentstrains, of hepatitis c, and so depending on the genotype, then, thespecialist or the doctor that is taking care of the patient wouldrecommend different treatments. however, in the united states, about 75percent of people have genotype 1, and the current standard of carefor genotype 1 is pegylated interferon, which is an injectiongiven once per week,

along with ribavirin which are pills givenusually twice a day by mouth, and they usually add a third directacting agent. currently there are two available --boceprevir and telaprevir -- and those are both given along with thepegylated interferon and ribavirin. so that treatment lasts between six monthsand one year, and the length of treatment depends, again, on somepatient factors and on how the person responds to the early part oftreatment. so, it's a fairly complex treatment, andthat is, as i said earlier, going to be evolving and hopefully becomingmuch simpler over time,

but currently most people will get the shotsonce a week and the pills by mouth daily. blair: how long have these treatments beenavailable? corinna: so the pegylated interferon hasbeen available since 2001. prior to that time, there was a short-actinginterferon that people had to take three times a week, alsoinjected. and so the peg-interferon and ribavirin hasbeen around since 2001, but the other two drugs were only approvedin 2011. i did just attend the big liver meetingwhich just ended earlier this

week, and all signs are that the newermedications that are more effective, they're still for patients withgenotype i, they're still paired with pegylated interferon andribavirin, but they'll result in a cure for 75 and upwards percent of peoplewho take them. and those we hope will be, or anticipatethat they'll be approved at the end of november and december. so there are two new drugs that are expectedto be out later this year. blair: okay. i would like to know if you are going to goup on the map with this

information so i can print it out. corinna: i think the easiest way to handlefollow-up would probably be to please contact christopher bates,whose contact information was on the registration. and we'll put up the slide now that has ourcontact information. but if you could follow up with us, then wecan share additional information. thanks. blair: superb. thanks so very much. judy hardy: okay. my name is judy hardy and i am acd nurse in

wake county, raleigh, north carolina. how iseverybody? panel: great. we're good. judy: well, good. my question is for andi. and i really appreciate her personal storyand being so honest and real with what she had to say to us today,and if i missed this, i apologize, but andi, i didn't hear you -- idon't recall hearing you say if any sources, or did you ever identifya potential risk or sources where you can track to the hepatitisc? being a cd nurse, you know, we want to doinvestigation and find out

the answers. so that's why i asked thatquestion. thank you. andi: thanks, and the question -- i wasexpecting the question. so the list that corinna had gone down,obviously i said i didn't fall into those risk factors, but i was amedical assistant for many, many years, and little nicks and cuts, andwe used to do in-office surgeries. so i'd scrub the tools without gloves, andthis really, terribly nasty toothbrush, and then put them in coldsoak. so there was medical -- potentialoccupational exposure, but the second risk factor for me is that i grew upin south florida in the

'70s, and i put things in my nose. christopher: [laughter] andi: neither of which -- that was, like, asdiscreet as i could be. i experimented with intranasal drugs, andthose are the risk factors that i have. which fall out, fall really kind of firmlyoutside of the risk factors that had been published for so manyyears, which is why the recommendation from cdc and the unitedstates preventive services task force is so exciting, that it movesaway from -- for this

population of people born between 1945 and1965, it moves away from risk-based assessment to population-based. it's age-based, because there are so manyways that i could have contracted this. those are the two that fall into riskfactors, or potential risk factors, but who knows? all of this was, you know, all of us --that's it. who knows? we just know that the highest prevalence ofchronic hepatitis c, the 75 percent of people with chronic hepatitisc, fall within this birth

cohort, this age range, and being able tomove away from the risk-based assessment for this populationreally helps move people into screening. christopher: thank you, caller. karen wooden: yes, good afternoon. andi: good afternoon. karen: a question for the panel, certainlywith getting the word out for 1945 to 1965 for testing one time, thequestion of cost may come into the picture here in regards to coverageby health plans or now

under the affordable care act, medicare, andmedicaid. what types of responses might one have toprovide some feedback when fielded with those questions for testing? corinna: sure. that's a great question. so,a couple of answers. one piece of good news -- we learned earlierthis year, actually in response to the change in the u.s. preventive services task forcerecommendation, and also some efforts by advocates in the community, the centersfor medicare have begun the process of determining whether hepatitisc will be covered

nationally for individuals born between 1945and 1965. so they have opened a national testingdetermination analysis, and they'll come up within the next year or so,we're told, that medicare will make a decision about sort of a blanketpayment for tests for hepatitis c. so that's one piece of what youasked for. the other component that we understand isthat the affordable care act does have preventive services included,and those preventive services include any u.s. preventive services task forcerecommendation that is an a or a b

grade, and so it is part of the law, then,that payers will have to cover the test for anyone that has a riskfactor, as well as anyone born between 1945 and 1965 for hepatitis c. karen: okay, that's good news. anotherquestion. i deal with a number of insulin-dependentdiabetic patients. so, therefore, exposure to needle sticks,whether it's children, adults, family members being around,injectable supplies. corinna: sure. karen: so that would be a good targetedaudience for this type of

discussion, getting the testing. corinna: absolutely. the cdc just, i believe it was the end of2011, came up with an expanded recommendation for hepatitis bvaccination for anyone who is a diabetic. they should be tested first and thenvaccinated for hepatitis b, because they actually -- cdc identified anumber of outbreaks related to people who had shared the glucose-testingequipment, from the monitors to lancets -- the whole range ofsupplies.

so, in order - we have a safe and effectivevaccine for hepatitis b. we should be using it in allinsulin-dependent diabetics. but for hepatitis c, certainly, it's a goodidea, especially if there has been cross-contamination or potentialexposure of the patient. they should be tested, but additionally,you're absolutely right that education of insulin-dependent diabeticsabout the need to store their -- dispose of their sharps safely andnot share their equipment. and even, because hepatitis b and c arepotentially hardier than some other infections, they could even live onsurfaces.

so making sure that table tops and othersurfaces are clean is another important message to get out there. karen: great. and one final question inregards to public health policy, particularly in hospitals environment, andas the accountable care organizations expand because of aca, thepolicy of one-time testing or perhaps annual testing for those healthcare providers who are continually being exposed and at risk. corinna: yes, you make a good point. i know that the cdc has a very long list ofpolicies and analyses to

inform the policies that they need to do,but among them, certainly, near the top of the list is to review andrevise policies around hepatitis c for health care professionals. last year, last summer, they released newrecommendations for the management of hepatitis b-infected healthcare professionals and students. so folks in the health professions who arechronically infected with hepatitis b. however, it is on our radar that we do needthose updated guidelines

for individual health care professionals whoare infected with hepatitis c as well. so, i'll share your feedback with mycolleagues, and i appreciate your recommendations. karen: thank you. michael richardson: yes, this is michael. on hepatitis b, how long will that live on asurface? also, hepatitis c? and what cleaning solutions do you allrecommend? corinna: so, hepatitis b is extremely hardyand can live for up to

seven days, even in dried blood. hepatitis c is not that hardy. it can live, estimates are about three daysoutside the body. that would depend on the environment. if it were, for example, in a syringe or awater bottle, it may live longer than out and exposed to air. i'm not an expert on bio-hazardous wastecleanup, so i do not know that i -- certainly using gloves, and, youknow, using some kind of cleaning product that kills viruses.

many of them are available on the market. but i don't think -- my office doesn't haveany specific recommendations for that, and i wouldimagine that the cdc and/or osha would be very good resources if youneed additional information. michael: do you recommend bleach, usingbleach to clean with? corinna: bleach? you know, i have to say i'mnot as expert on this infection as i probably should have been. i'm sorry, i not prepared to give anabsolute yes or no. i think it's -- bleach has been used in thepast, but i haven't seen

the data on how effective it is. i'm sorry. michael: and then one more question whilei'm on the line. in new mexico, we don't test pregnant womenfor hep c. do you see that coming nationwide? corinna: well, that is a really goodquestion. so, the thing about -- the reason that wetest pregnant women for hepatitis b is because we can interrupttransmission. we have the vaccine for hepatitis b. we also have immune globulins for hepatitisb.

and for infants born to women who havechronic hepatitis b, if you give those two things together, you are morethan 90 percent likely to prevent the hepatitis b beingtransmitted. however, we don't have a vaccine forhepatitis c, and we don't use immune globulin in that way for hepatitis c,either. and we don't really have any way to stoptransmission. but this a very quickly evolving field, andi mentioned earlier that i was at the liver meeting, and there issome research being done on the transmission of hepatitis c frominfected mothers to their infants.

so i believe that we'll start hearing moreabout that over the coming years. at this time, i think if a woman has a riskfactor, it's a very good idea. it's a wonderful time to intervene, whenshe's pregnant, to get her tested and diagnosed, but it's not yetconsidered standard of care to test women for hepatitis c just because ofpregnancy. michael: one other question. do we stilltest at 18 months if it's a pregnant woman that delivers ababy? corinna: the infant should be tested at 18months after the infant has completed that series of three hepatitisb vaccines.

so, yes, the recommendations is that theinfant receive the hepatitis b vaccine and the immune globulin at birth,and then that infant should also receive the second shot onschedule and the third shot of the hepatitis b vaccine on schedule; andthen they test the infants at 18 months to ensure that that vaccineworked. and then we have, that's considered asuccess story, when the infant didn't get infected and has become immune tohepatitis b. so, yes, that's currently the standard ofcare. clara singh: hi, this is clara singh fromarizona.

my question was about the development of ahepatitis c vaccine. is there any news or research going on withthat? corinna: yes, there are clinical trialsongoing currently testing a potential hepatitis c vaccine. we're fairly early in the process of theclinical trials. so i believe that it's only being tested inone or two small studies, but we're very hopeful, because we reallyrecognize the need for a hepatitis c vaccine. and so, we have one fora and b. we've seen wonderful -- amazing reductionsin new infections for

hepatitis a and b, and so we're very, veryhopeful that there will be a hepatitis c vaccine. however, i can tell you that it is a numberof years away. i would say likely more than five years, atleast, down the line. andi: corinna, i'd like to add to that thedistinction between the a and b virus, and the c virus is, hepatitis cis an rna virus, as is hiv. dna viruses, when they make copies ofthemselves, make good copies. so, it's easy to develop a vaccine. rna viruses, it's like a seventh-generationfax copy.

you know how that gets skewed and whateverelse. it's much more of a moving target. so the hepatitis c vaccine development willfollow more along the lines of hiv vaccine development, from whati understand. is that, corinna, is that correct? corinna: absolutely. the hepatitis c virusitself is very diverse. it makes a lot of mutant copies of itself. and so, that has been one of the bigchallenges in developing a vaccine, is that there are so many genotypesof the infection, and

it's been really challenging for researchersto even develop a vaccine to start with. andi: so that is where prevention comes intoplace. andi: yes. aretha jones: yes, good afternoon. panel: good afternoon. aretha: my question is, and i'm going to saythat i have aids. i was diagnosed in 2009 after contracting aviral infection. with that said, i became homeless, and i'vebeen segregated to a

congregated environment and housing. and my question is, what is my -- or, ishould say, for my own protection with people, my exposure of thehepatitis b or c? like, if, because i know i'm around a lot ofpeople who cough, who do have liver diseases, who are still usingdrugs and alcohol, which i don't. and i'm concerned about -- i took the threeinjections, but that was when i was in my teens. so now, what do i do as far as keepingmyself safe from such exposure? corinna: sure. well, the most important wayyou can protect yourself is to not

expose yourself to other people's blood. you already mentioned that you aren'tinjecting drugs, so that's a very, very important way to preventexposure; but any blood exposure, and that can be if there's fighting andfolks are bleeding, tattoos could eventually lead to exposure hepatitisc and b infection, but hepatitis c and b are not spread throughcoughing, or vomit, or urine, or feces. so it's really, i think, focusing on notexposing yourself to other people's blood. and then, hepatitis b, certainly, andhepatitis c to a lesser extent, may be sexually transmitted.

so you would want to make sure that youprotected yourself during any kind of sexual encounter as well. andi: in short, this is andi, i always say,"don't share stuff." toothbrushes, razors, so on and so forth. tattooing, tattoo needles -- don't sharestuff. corinna: right. in the hiv prevention arena,i think early on they identified that toothbrushes and razors weren't really waysthat hiv could be spread, but because hep c and hep b are hardierviruses, we want to make sure that folks aren't sharing those, either,because if someone's gums

are bleeding, and another person comes alongbehind them and uses the toothbrush, then there could be bloodexposure there. aretha: okay. and is that also as well assaliva, like say if someone is spitting? it's a lot of that also that goes on. i seepeople spat a lot. corinna: well, so, again, i think oftenlikely folks aren't always, they're not taking very good care of theiroral hygiene, and so if they have bleeding gums, or a sore in theirmouth, there is a slight chance that there is blood in their saliva. so it's all about -- this comes back toblood.

i would avoid saliva, or if somebody spitssomething out, i would avoid that myself, because of the potentialfor blood exposure there. but, generally, hepatitis b is not spreadthrough saliva. aretha: okay. all right, thank you verymuch. christopher: thank you for your call. aretha: you're welcome. chrisotpher: operator, it seems like we'vegotten to the top of our hour here. this has been an exciting eventfor us here at the u.s. department of health and human services.

i did get one question, possibly two via theinternet, and i just want to raise it with all of our listenerswho are still online, and that is, as soon as we have a web addressand can secure a copy of the audio recording of this event, we willtry to post it for people. so all of those who participated orregistered for the call, we will send that information to you. we've also had some specific requests frompeople for copies of the slide presentation today, and that, too, wewill make available for those who wish to have a copy.

our information is still online. please jot it down, but you can also referto the announcement that led you to this call today and this webinar,and that information there on the announcement definitely can beused to connect with me, and hopefully you can do that in the nearfuture. the last thing that i'd like to say is thankyou to andi for stepping up and sharing her most personalstory. we would also like to thank dr. lee for joining us and opening up ourmeeting, i'm sorry, our webinar

this afternoon; and last but not least, we'dlike to thank all of you for joining us, and we appreciate yourparticipation. your show of interest in this particularwebinar encourages us to move forward and hopefully hold otherwebinars like this in the near future. so, good afternoon, and good day to you. panel: thank you.