Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination 2021–2025 Toolkit Additional Messages

Why does the nation need this Viral Hepatitis Plan?

• Viral hepatitis is a significant public health threat that puts people who are infected at an increased risk for serious disease and death. The Viral Hepatitis Plan is necessary as the nation faces unprecedented hepatitis A outbreaks, progress on preventing hepatitis B has stalled, hepatitis C rates nearly tripled from 2011 to 2018, and, as of 2016, an estimated 3.3 million people were chronically infected with hepatitis B and hepatitis C. Viral hepatitis is associated with substantial health consequences, stigma, and discrimination. It takes a large toll on individuals as well as communities, many of which are disproportionately impacted. Collectively, viral hepatitis costs people, health systems, states, and the federal government billions of dollars each year.
• Despite the availability of effective clinical interventions, including vaccines, diagnostic tests and therapeutics, new or acute viral hepatitis infections have increased in recent years.
  • From 2014 to 2018, the rate of new hepatitis A cases increased by 850%, the rate of acute hepatitis B increased by 11%, and the rate of acute hepatitis C cases increased by 71%.
  • As of 2016, nearly 3.3 million people in the United States were living with chronic viral hepatitis—an estimated 862,000 with hepatitis B and 2.4 million with hepatitis C.
• Surveillance data collected by the Centers for Disease Control and Prevention (CDC) reveal the following trends:
  • Hepatitis A: The hepatitis A incidence rate decreased by greater than 95% from 1996 to 2011. However, the rate of new cases increased by 850% from 2014 (0.4 cases per 100,000) to 2018 (3.8 cases per 100,000) primarily because of large person-to-person outbreaks among people who use drugs and people experiencing homelessness. Hepatitis A is preventable by a safe and effective vaccine.
  • Hepatitis B: Despite the availability of a safe and effective vaccine, the rate of acute hepatitis B cases increased 11% from 2014 (0.9 per 100,000) to 2018 (1.0 per 100,000). The rate of infection increased even more dramatically in states hardest hit by the opioid crisis. Injection drug use (IDU) and sexual transmission are risk factors associated with rising acute hepatitis B cases in the United States.
  • Hepatitis C: The rate of acute hepatitis C cases increased 71% from 2014 (0.7 per 100,000) to 2018 (1.2 per 100,000), with two-thirds of cases occurring among persons aged 20–39 years, the age group most impacted by the opioid crisis.
• All three viral hepatitis infections disproportionately impact certain populations, many of which experience other significant health and social disparities. The escalation of hepatitis B and hepatitis C infections is correlated with an increase in substance use disorders and injection drug use.
• The year 2020 marks the 10th year of implementing prior iterations of a national viral hepatitis strategic plan. The Viral Hepatitis Plan builds on three prior National Viral Hepatitis Action Plans, which covered the periods of 2011–2013, 2014–2016 and 2017–2020. The Viral Hepatitis National Strategic Plan: A Roadmap to Elimination 2021­–2025 is the first Plan to aim for elimination of viral hepatitis as a public health threat in the United States.

What does the viral hepatitis epidemic look like in the United States?

• New hepatitis A and hepatitis C infections have increased dramatically in recent years, little progress has been made on preventing hepatitis B infections and, as of 2016, an estimated 3.3 million people were chronically infected with hepatitis B and hepatitis C. Collectively, viral hepatitis costs people, health systems, states, and the federal government billions of dollars each year.
• Safe and effective vaccines to prevent hepatitis A and hepatitis B are available. Infants and children are recommended to be routinely vaccinated for both hepatitis A and hepatitis B, and childhood vaccination efforts have resulted in relatively high rates of coverage.
  • However, in 2017, 26% of infants did not receive the recommended hepatitis B vaccine at birth, and 40% of children aged 19–35 months did not receive the recommended two doses of hepatitis A vaccine.
• More than one-half of new hepatitis A and acute hepatitis B infections in 2018 were among persons aged 30–49, who were born before infant vaccination was recommended.
• Utilizing data from 2013 to 2016, only 32% of people living with hepatitis B and 60% of people living with hepatitis C are aware of their status; this is likely because hepatitis B and hepatitis C often do not cause symptoms.
• Although viral hepatitis affects millions of Americans nationwide from all social, economic, and racial and ethnic groups, it disproportionately impacts certain populations and communities. Viral hepatitis prevention and treatment efforts can be more efficient and effective by identifying and focusing efforts on those populations that bear a disproportionately higher burden of infection and disease, referred to in the Viral Hepatitis Plan as priority populations.
• The Plan uses nationwide surveillance data to determine the priority populations. Focusing on the priority populations will reduce health disparities and put the nation on the path toward elimination of viral hepatitis. This approach should not diminish efforts to increase awareness, prevention, treatment, and integration of viral hepatitis efforts more generally, for all populations.

How does this plan help to strengthen the nation’s response to the viral hepatitis epidemics and aim for elimination of viral hepatitis as a public health threat?

• The Viral Hepatitis Plan lays out a clear vision for how the United States will be a place where new viral hepatitis infections are prevented, every person knows their status, and every person with viral hepatitis has high-quality health care and treatment and lives free from stigma and discrimination.
• This vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, disability, geographical location, or socioeconomic circumstance.
• To meet this vision, the Plan provides a roadmap for all stakeholders at all levels to guide development of policies, initiatives, and actions for viral hepatitis prevention, screening, and treatment to eliminate viral hepatitis as a public health threat in this nation.
• Stakeholders are encouraged to use the Viral Hepatitis Plan to build their own roadmap to reduce viral hepatitis and viral hepatitis-related health disparities and inequities, and to eliminate the viral hepatitis epidemics among the populations and communities they serve.
• The plan includes five goals to guide those efforts:
  • Goal 1: Prevent new viral hepatitis infections.
  • Goal 2: Improve viral hepatitis-related health outcomes of people with viral hepatitis.
  • Goal 3: Reduce viral hepatitis-related disparities and health inequities.
  • Goal 4: Improve viral hepatitis surveillance and data use.
  • Goal 5: Achieve integrated, coordinated efforts that address the viral hepatitis epidemics among all partners and stakeholders.
• The Viral Hepatitis Plan sets forth objectives for each goal, and strategies for each objective. These objectives and strategies will help guide federal partners and other stakeholders in achieving the goals of the Plan. The objectives for each goal set an overarching directional course. The strategies specify approaches or methods to help achieve the objectives.
• The Viral Hepatitis Plan is an elimination plan, with the overarching goal of eliminating hepatitis as a public health threat in the United States by 2030. Elimination is defined by the World Health Organization (WHO) as a 90% reduction in new chronic infections and a 65% reduction in mortality, compared to a 2015 baseline.
• The Viral Hepatitis Plan identifies disproportionately impacted populations with higher rates of viral hepatitis incidence, prevalence, and mortality (i.e., priority populations) so that federal agencies and other stakeholders can focus their resources to realize the greatest impact and to reduce disparities.
• The Plan identifies indicators to track progress toward each goal and quantitative targets for each indicator. Although this is a 5-year plan, it sets 10-year quantitative targets for each indicator—aligning with global WHO elimination efforts and reflecting the reality that it will take more than 5 years to eliminate viral hepatitis as a public health threat.
• The Viral Hepatitis Plan emphasizes viral hepatitis as part of a syndemic, which occurs when health-related problems—such as viral hepatitis, HIV, sexually transmitted infections (STIs), substance use disorders (SUDs)—cluster by person, place, or time and interact synergistically. The syndemic also intersects with mental health, stigma, discrimination, and social determinants of health. This complex, multifactorial environment must be addressed to eliminate viral hepatitis in the United States.
• The Plan provides a roadmap to integrate prevention, screening, and linkage to care for all components of the syndemic, to avoid missed opportunities and meet people where they are, with no wrong point of entry to health care and related systems.
• The Viral Hepatitis Plan focuses on opportunities to expand research and development of a hepatitis C vaccine, point of care testing and improved diagnostics and therapeutics. The Plan also focuses on implementation research to put into practice evidence-based interventions, as effective interventions to improve prevention, testing, and treatment are identified.
• The Plan aims to improve viral hepatitis surveillance data collection, management, and analysis, including interoperability of data and data sharing, to understand the true scope, level of public health threat, and opportunities to address viral hepatitis.

Why is the Viral Hepatitis Plan important to me and my organization?

• Utilizing a whole-of-nation approach, the Viral Hepatitis Plan requires the active participation of national, state, local, and tribal health departments and organizations, health plans and health care providers, community-based and faith-based organizations, scientists, researchers, and the public in this effort.
• The Plan provides goal-oriented objectives and strategies that can be implemented by a broad mix of stakeholders at all levels and across many sectors, both public and private. It serves as a mechanism to identify and leverage areas of synergy and resources and to avoid duplication of efforts.
• The Viral Hepatitis Plan encourages achieving integrated, coordinated efforts that address the viral hepatitis epidemics among all partners and stakeholders by integrating programs to address the syndemic of viral hepatitis, HIV, STIs and substance use disorders.
• Further, the Plan uses national-level data to provide stakeholders with a method to focus limited resources for the greatest impact. As more stakeholders establish hepatitis monitoring and reporting and contextualize efforts as contributing to national elimination efforts, the U.S. viral hepatitis elimination efforts will become more streamlined and effective and the nation will be able to eliminate viral hepatitis as a public health threat.

How will the Plan be implemented?

• The Viral Hepatitis Plan is a whole-of-nation plan. It is intended to serve as a roadmap for federal and other stakeholders to reverse the rates of viral hepatitis, prevent new infections, improve care and treatment, and ultimately eliminate viral hepatitis as a public health threat in the United States.
• The success of the Viral Hepatitis Plan depends on the active participation and coordinated action of national, state, tribal, territorial, and local governments; community-based and faith-based organizations; health plans, healthcare providers and other health-related organizations; private industry; nongovernmental organizations; foundations; researchers; and patients and their partners.
• Its success also depends on a holistic approach to the various parts of the syndemic, including HIV, STIs, SUD, mental health disorders, stigma, discrimination, and social determinants of health.
• In 2021, federal partners will collaborate to develop an Implementation Plan. The Implementation Plan will set forth federal partners’ commitments to policies, initiatives, and activities to meet the goals and objectives of the Viral Hepatitis Plan and will be published for transparency and accountability.
• Federal agency partners have committed to serve on a viral hepatitis implementation working group. This working group will meet regularly to coordinate activities across agencies and departments, including with other components of the syndemic, implement lessons learned from epidemiological data and research findings, monitor progress toward the indicator targets, course correct as needed, and report on national progress.
• Stakeholders are encouraged to use the Viral Hepatitis Plan to build their own roadmap to reduce viral hepatitis and viral hepatitis-related health disparities and inequities, and to eliminate the viral hepatitis epidemics among the populations and communities they serve. Stakeholders should consider adopting the vision and goals of the Viral Hepatitis Plan, examining challenges from a health equity lens, implementing the objectives and strategies relevant to their role, population(s), and community(ies), applying other evidence-based objectives and strategies, using available data to identify where their resources will have the most impact, and identifying indicators and targets to measure their progress.

How will progress be measured?

• The Viral Hepatitis Plan establishes indicators, as well as baseline measures and quantitative targets, to help measure progress toward the Plan’s goals. Eight core indicators will be used to measure progress on preventing new infections and improving viral hepatitis-related health outcomes of people with viral hepatitis. Five of the core indicators are stratified by one or more of the priority populations to measure progress toward reducing disparities.
• The core indicators were selected because they represent the best way to measure national progress on viral hepatitis elimination with the available data. Indicators were selected using the following criteria. Each indicator must:
• Relate to at least one of the Plan’s goals
• Reflect current viral hepatitis science, policy, and medical screening guidelines
• Represent measurements of outcomes that, if changed for the positive, would be an indication of better viral hepatitis health for the nation
• Have data from a nationally representative data source, which:
  • Is provided on a routine basis, enabling cross-year comparisons
  • Allows for stratification by age, geographic region, race, ethnicity, and sex (and transmission category if available)
• Have a national impact
• For each indicator, the Viral Hepatitis Plan identifies baseline measurements and establishes annual targets through 2030. Establishing 2030 targets aligns with other national plans such as Healthy People 2030, the HIV Plan, the STI Plan, and global targets established by WHO. This approach also recognizes that it will likely take more than the 5-year duration of the Plan to achieve its goal of eliminating viral hepatitis in this nation.
• To better measure progress, the Plan recommends development of five additional indicators—referred to as developmental indicators. Nationally representative data for these developmental indicators are not currently collected and doing so would fill critical gaps in measuring the nation’s efforts to eliminate the viral hepatitis epidemic.