Spring 1999 Volume 4, Number 1		"Collaboration" is theme for 1999 National Hepatitis Coordinator Conference: Can three kingdoms join forces? Editor's Note: At the heart of hepatitis control in the U.S. is a corps of 77 hepatitis coordinators who are assigned to state, territorial, and large city health departments through grants from CDC. These people oversee hepatitis screening and vaccination programs, hepatitis case reporting and tracking, educational activities on viral hepatitis, and other essential tasks in hepatitis control. Their annual convention, the National Hepatitis Coordinator Conference is, we believe, the nation's best meeting on the practical prevention and control of viral hepatitis. This year's conference was held on May 24­27 in Tucson, Arizona. Nearly three hundred hepatitis coordinators, immunization workers, CDC staff, and representatives from private health organizations and manufacturers gathered to compare notes on the latest methods for preventing viral hepatitis. As in past years, the Hepatitis Control Report was there to bring you the highlights. (Tucson) The concept seems simple enough. You have three separate disease control programs working on sexually transmitted diseases. You have the same three programs working on diseases transmitted by intravenous drug abuse. The programs help each other out. They join forces. Right? Well, not necessarily. Working together is easy to say, but hard to do. The subject of collaboration ‹ how to join programmatic forces in the battle against viral hepatitis - was the theme of this year's National Hepatitis Coordinator Conference. A pre-conference survey of state hepatitis coordinators gave a glimpse of the dilemma. Seventy percent of coordinators admitted they do not actively collaborate with their own state's HIV department staff. Thirty percent said they do not collaborate with their own sexually transmitted disease (STD) staff. The sad reality is that many people working in hepatitis control have never even met key people working in HIV and STD. "We've got to start talking to one another. We can do better," said Dr. Harold S. Margolis, Chief of the Hepatitis Branch at CDC. Margolis told the conference that vaccination of high-risk adults against hepatitis B is still moving too slowly. Vaccination has not penetrated into populations of gay men, intravenous drug abusers, and persons with STDs and/or multiple sexual partners. "Unless we can find ways to vaccinate these groups, we will have to wait another 20 years to see a decrease in transmission in adults [until cohorts of vaccinated children grow into adulthood]. I don't want to wait 20 years," he said. One way to boost the hepatitis B vaccination rate in adults is to vaccinate them whenever and wherever they seek services, Margolis said. That means collaboration among programs. Margolis said that we must vaccinate adults in HIV counseling and testing centers, in STD clinics, in prisons, and at every other opportunity. "This is a concept whose time has come," he said. An ambassador from the Kingdom of HIV To highlight the need for collaboration, this year's conference featured workshops led by top staffers from CDC's HIV/AIDS and STD programs. Dr. T. Stephen Jones, a senior scientist at CDC's Division of HIV/AIDS Prevention, attended his first Coordinator Conference. In his remarks, he called himself an "ambassador from the Kingdom of HIV." "What we are doing now is too narrow," he said. "It makes sense that, if we work together, we can get more done." Jones said the national HIV counseling and testing program, which costs CDC about $100 million annually, should find ways to link with counseling and testing for HBV and HCV. "The goal should be to bring viral hepatitis prevention into the existing HIV counseling and testing system," he said. But, in a later interview, Jones agreed it will not be easy. "Our HIV programs were set up to focus on HIV, and we are good at it. The question is how can we adapt our programs to better serve clients who have risks for both HIV and viral hepatitis?" Jones said it could be difficult to mesh prevention messages, to collaborate on budgets, and to motivate HIV counselors about the importance of hepatitis vaccination. The biggest obstacle, he said, may be "the old bugaboo of public health, categorical funding. That will present a particular challenge." Yes, hepatitis B is an STD Another visiting ambassador came from the STD Kingdom. Dr. George Schmid, an epidemiologist at CDC's Division of STD Prevention, asked the crowd why people don't think of hepatitis B as an STD. At least half of all hepatitis B cases are acquired through sexual transmission, he said. Schmid pointed to a 1997 survey of 59 federal STD projects, representing 1,510 STD clinics around the country, which showed that only 22% of projects definitely did any hepatitis B education and only 24% offered hepatitis B vaccine to clients. The CDC Advisory Committee on Immunization Practices (ACIP) has recommended since 1990 that all persons seeking care for STDs be vaccinated against hepatitis B. In the same survey, only 47% of STD projects felt that it was their responsibility to vaccinate high-risk adults against hepatitis B. Only 25% said that all STD clinics should offer hepatitis B vaccine. Schmid said that hepatitis B vaccination needs to be better integrated into STD and other activities, such as corrections, adolescent health, drug treatment, school health, and family planning programs. Some states have legally classified hepatitis B as an STD, which allows minors to consent to their own vaccination, he said. The natural desire for compartments Privately, state hepatitis coordinators admit it is often difficult to collaborate with HIV, STD, and corrections programs. They identify such problems as physical distance (i.e., working in separate buildings), disparate organizational structures, distinct funding streams, and lack of time. Others point to cultural differences among people working in different programs. Still others say they already feel overwhelmed with work and have learned to survive psychologically by "compartmentalizing" their jobs and keeping a safe distance from other programs and their needs. But CDC is determined to find ways for programs to work together. Margolis predicted that collaboration will increase over the next few years. "We need to really work together if we expect to control viral hepatitis, especially in adults," he said.