Addressing Viral Hepatitis at the Department of Veterans Affairs
Chronic viral hepatitis is a major public health problem in the United States because of the millions of persons who are chronically infected and because of the potential for untreated viral hepatitis to progress to cirrhosis, liver cancer, and other life-threatening conditions. Hepatitis C virus (HCV) and hepatitis B virus (HBV) are the major causes of chronic viral hepatitis in the U.S.
In the late 1990s, VA characterized HCV as a significant health problem requiring early detection and has taken a number of steps to address the issue. In 1998, the VA’s Under Secretary for Health issued an Information Letter outlining standards for provider evaluation and testing for HCV in the Veterans Health Administration (VHA). Subsequently, VA conducted a nationwide surveillance activity, testing over 26,000 Veterans for HCV in March 1999. The testing revealed a prevalence rate of 6.6% with a wide variation by geography and era of military service. In 2000, the VA’s Under Secretary for Health designated additional funding to be distributed across VHA for outreach, testing, counseling, and treating Veterans with hepatitis C.
By 2002, a VHA National Viral Hepatitis Program had been established, and HCV screening and testing guidelines were published. All Veterans were to be screened for risk factors for HCV and tested if they had a previous or ongoing risk, or if they simply asked to be tested. Testing was also offered to those who served during the Vietnam-era and to those with a history of alcohol abuse or dependence due to the high prevalence of HCV in these populations.
VHA's external peer review program data show that rates of testing at-risk patients are very high. In fiscal year 2005, based on a sample of 16,000 Veterans receiving care at VA medical facilities, 98% had been screened for HCV risk factors and 93% of the approximately 8,000 veterans with risk factors had been tested for HCV.
Since 2002, VHA’s National Viral Hepatitis Program has used a comprehensive population health-based approach to HCV care for Veterans, emphasizing access to high-quality clinical care and testing, counseling, patient and provider education, and quality improvement efforts. Clinical reminders in the electronic medical record have been found to be an effective way to trigger clinicians to screen Veterans for HCV risk and offer testing when appropriate. Clinical reminders were made widely available and have been successfully used to improve screening efforts.
The VA’s National Hepatitis C Program accomplishments have included extensive screening of at-risk Veterans, early and broad access to anti-viral therapy such as HCV protease inhibitors, and improvements in the management of other co-existing conditions such as depression, alcohol misuse and other substance use disorders.
VHA is the single largest HCV care provider in the U.S., with a seroprevalence rate three times that of the general U.S. population; currently there are over 170,000 Veterans in VHA care with confirmed chronic HCV. The gradual progression of HCV in affected Veterans over a period of decades has led to increasing numbers of patients with cirrhosis, end-stage liver disease, and liver cancer. Of note, over the last ten years, the number of HCV-infected Veterans in care diagnosed with cirrhosis has tripled to over 25,000, while over the same time period the cumulative number of HCV-infected Veterans diagnosed with liver cancer has increased by ten-fold.
It has also been recognized that Veterans are at higher risk for exposure to HBV than the general U.S. population. Current VHA recommendations for HBV screening are that at risk Veterans should be offered testing for HBV, and linked to care if found to be positive. Better understanding of the prevalence of HBV in the Veteran population, the number of Veterans who have been tested, and missed opportunities for testing, will help guide appropriate HBV screening/testing recommendations in the future.
VHA is committed to identifying Veterans at risk for viral hepatitis and linking those who are found to be positive to high quality care within our healthcare system. VHA will continue to work side by side with colleagues from HHS and other federal and non-federal partners to coordinate and implement a number of strategies to promote awareness around viral hepatitis and to ensure high quality of care to those who are living with these chronic diseases.Ms. Durfee is the Department of Veterans Affairs representative on the cross-agency work group coordinating implementation of the Action Plan for the Prevention Care and Treatment of Viral Hepatitis.