Is the integration of hepatitis prevention and care services an effective strategy to combat hepatitis C?

Approximately 40 000 individuals tested positive for hepatitis C (HCV) as identified through British Columbia’s Public Health Information System between 1992 and 2002. The majority are chronically infected and at-risk for sequelae such as cirrhosis, liver cancer, and liver transplantation. The number of individuals who received a medical assessment is unknown; however, about 650 cases per year receive antiviral therapy. The result is that 98% of chronically infected individuals live with HCV for decades. This problem has not been effectively addressed by our health care system. BC Hepatitis Services, a provincially funded program, was initiated at the BC Centre for Disease Control in January 2001 to coordinate a province-wide intersectoral strategy aimed at rapidly increasing both prevention and care services for those with or at-risk of HCV. This article highlights the early outcomes from two initiatives, professional education symposia, and integrated prevention and care demonstration projects, launched in partnership with the province’s six health authorities.

Through coordination, partnership building, and sharing of fiscal resources, BC Hepatitis Services facilitated collaboration with public health and personal health services. The analysis of multiple stakeholder-driven needs surveys identified the following two initial priorities for action: first, education of health care professionals, and second, development of locally accessible integrated prevention and care services.

A comprehensive 3-day interdisciplinary viral hepatitis education program was developed, provided, evaluated, and refined four times. Hepatitis experts presented the material using didactic and interactive sessions.

A demonstration project in each of the five regional health authorities was developed to provide integrated prevention and care services. Implementation was staged, with the first project started in July 2001 and the fifth in March 2003. The staging method and sharing of information and procedures between sites facilitated a rapid change/improvement process. Each site received $75 000 per year and is guided by a steering committee of multisector stakeholders. Demonstration project sites are managed and staffed mainly by public health nurses. The programs include hepatitis-focused prevention, community development, education, and clinical services. The clinical services provided by public health nurses include comprehensive health assessments, prevention and self-care education, chronic illness counseling for individuals and families, monitoring, and support of those on treatment. Addictions, mental health, and nutrition services are incorporated into the programs at most sites. In partnership with physician specialists, the sites organize medical clinics several times a month for patients who require specialized physician assessment and decisions regarding follow-up and treatment.

Thus far, four 3-day interdisciplinary educational workshops have been provided over the course of 2 years to 178 targeted health care providers. Evaluations demonstrated that educational needs were well met. Demonstration project staff subsequently provided presentations to local agencies or groups. Remarkably, one site provided a 1-day workshop attracting 16 physicians and 105 nurses and allied health care workers. Another site concentrated on youth education, developed and tested curricula, and provided sessions to 300 at-risk youth in 20 schools. Another site organized a comprehensive community response to the safe collection and disposal of discarded needles.

Referrals for clinic services average about 220 referrals per site per year. A major achievement for the program concerns patient accessibility to services, with specialist physician wait times being reduced from 12 to 14 months to 1 month. Approximately 25 patients per site undergo treatment annually. Compliance and adverse effects of treatment are closely monitored by nurses, and about 50% of patients have achieved a sustained viral response resulting in cure of their chronic HCV infection.

Building on public health’s strong foundation of prevention, health promotion, and community development, project sites are building capacity to improve the health status of those with or at-risk of HCV. The model of care has changed from an acute-care medical model to a chronic illness prevention and self-care management approach that integrates the strengths of both the public health and personal health systems. These projects are acting as catalysts for change in the system, and presently other service areas are adjusting their hepatitis services to reflect the new integrated model.

—G. Butt, MHSc
—W.D. Hill, PhD
—B. Paterson, PhD
—M. Krajden, MD, FRCP
British Columbia Centre for Disease Control