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C. Everett Koop, M.D., SC. D.

Former U.S. Surgeon General
Statement on Hepatitis C

Mr. Chairman and Members of the Committee:

My name is C. Everett Koop, M.D. I am the former Surgeon-General of the United States. During my tenure in the Reagan and Bush Administrations, I spearheaded the campaign to increase public awareness of the AIDS epidemic and encourage a comprehensive federal response to prevention, detection, and treatment of the disease. Now, over a decade later, the federal government is dedicating substantial resources to this disease, including public education, research on transmission, prevention, and treatment itself. While more than 700,000 Americans are infected with HIV, new cases of AIDS are thankfully declining. Nevertheless, despite the billions spent on AIDS research, there is still no cure for AIDS.

Mr. Chairman, I would like to thank you for extending to me an invitation to appear before you. I commend you and the Committee for your leadership on blood safety issues and in particular for your attention to the disease we are discussing today - hepatitis C.

We are at the edge of a very significant public health challenge - not unlike the AIDS epidemic. We have an infectious disease that is an undisputed threat to the public health. It is a viral disease that millions of people harbor without knowing they have it. It is a disease these millions will carry for a decade or more - possibly spreading to others - while it develops into a serious threat to their health. We can treat the disease during this quiescent period and we can eliminate the infection for a large portion of the infected, preventing progression to serious disease.

But we in the public health community have done practically nothing about it to date. We are starting with a blank slate, and we have a long way to go very quickly if we are to prevent the very serious public health consequences of this disease.

We call hepatitis C the "silent epidemic" because so many Americans have the disease (over 4.5 million), so few know they have it (only 225,000 or 5%), and such a small portion (40,000 or 1%) have had treatment for it.

Hepatitis C is a particularly insidious disease. It is a blood borne infection, easily transmitted through blood-to-blood contact. Those who are exposed usually get the disease. It rarely, however, appears as an acute infection. Instead, it develops into a chronic disease with few symptoms and lingers for 10 to 30 years before it results in permanent liver damage and, in many cases, liver cancer or liver failure. The disease is insidious for several reasons:

1. The vast majority of people infected with HCV do not know it. Most of the 4.5 million Americans infected with the hepatitis C virus are not aware of their risk for the disease, nor do they experience any acute symptoms. Any symptoms they may have are often mistaken for the flu. Their first awareness may come years later with liver dysfunction.

2. There is a sizable pool of HCV infected people - with over 4 million HCV-infected Americans unaware of their infection, there is a danger of unwitting spread of the disease.

3. There is no vaccine for hepatitis C - unlike hepatitis A and B, there is no vaccine effective against C, and there is little chance that one can be developed.

4. Much is still unknown about HCV - Ten years ago we knew practically

nothing about this disease. Effective tests for hepatitis C only became available in this decade. As a result, there is still much that medical researchers do not know about how this disease is transmitted or how it progresses in an infected individual. We cannot, therefore, be assured that the means of transmission are clearly understood.

5. Many with HCV have no reason to suspect they are infected - many of those at high risk are average people - middle-aged housewives who had a caesarean section delivery, young adults who had transfusions as high risk babies, or middle-aged men who served in Vietnam. The focus of the public health effort to date, however, has been on marginal populations (e.g. IV drug users, people with tattoos or body piercing). As a result, many average Americans with HCV infection do not suspect it and many may be discouraged from seeking medical attention if a stigma is attached to HCV infection.

In interrupting the epidemic of hepatitis C, a public safety net must be provided to help the most needy in the country. Our present health care climate makes it desirable to include the poor, disadvantaged and uninsured who have chronic hepatitis C. For those who have access to federally funded health care programs, it is important to assure that patients infected with HCV are managed in the manner recommended by the NIH Consensus Development Conference. This would include Medicare and Medicaid as well as the health care programs of the Department of Veterans Affairs and the Department of Defense. In March of 1997, the NIH sponsored a consensus development conference on the management of hepatitis C. The report of that conference expressed grave concern about the large number of Americans infected with the virus, noting: hepatitis C leads to cirrhosis of the liver in 20% of cases, is the leading reason for liver transplantation in this country, and is associated with increased risk