Texas Legislature to Address Issues on Viral Hepatitis

By S. Van McCrary, Health Law & Policy Institute

Texas has an opportunity this year to become one of the leading states in the fight against viral hepatitis. A number of bills have been filed during the 76th Session of the Texas Legislature to deal with this serious problem.

Background, Cost, and Public Health Implications

Viral hepatitis refers to several common diseases caused by viruses that can lead to inflammation of the liver. Hepatitis A virus (HAV), which infects an estimated 150,000 people in the United States annually, is typically contracted by eating food or drinking water that has been contaminated with human excrement. Hepatitis A usually resolves itself within 6 months and does not develop into a chronic disease.

In contrast, hepatitis B and C can lead to serious, permanent liver damage. Hepatitis B virus (HBV) is much more prevalent than HIV (the virus that causes AIDS) and is also much more infectious than HIV. HBV is transmitted through exposure to blood or other body fluids of an infected person, typically through sharp instruments contaminated with infectious material or unprotected sexual intercourse, but it can also be transmitted from mother to baby at birth. Hepatitis B may develop into a chronic disease in up to 10% of the 200,000 newly infected people each year. If left untreated, the risk of developing cirrhosis (scarring of the liver) and liver cancer is significantly increased in patients with chronic hepatitis B. Hepatitis B is responsible for 5,000 deaths annually. Currently there is only one approved treatment for hepatitis B called interferon alpha 2-b. About 15%-20% of those treated will have a lasting response.

Hepatitis C virus (HCV) develops into a chronic infection in up to 85% of the 150,000 newly infected people each year. HCV is transmitted in the same manner as HBV. Liver failure due to chronic hepatitis C infection is the leading cause of liver transplants in the United States. 12,000 people in the U.S. die of hepatitis C each year. The drugs interferon alpha-2b and interferon alpha-2a have been approved for the treatment of chronic hepatitis C. However, only 10-15% of patients treated with interferon have a lasting response.

Because of their frequent exposure to blood and blood products, health care providers face an elevated risk of HBV and HCV.

Total cost at non-Federal hospitals for liver diseases in 1994 was $9 billion. 22,287 people were admitted to non-Federal hospitals with hepatitis B, and another 36,697 for hepatitis C in 1994. Total charges for these persons were $618,695,723. 3,653 liver transplants were performed in 1994. Because of the shortage of organs, especially for children, it is estimated that 558 prospective recipients died in 1992 while waiting for a transplant. Estimated cost for a transplant and related costs range from $225,000 to $302,000. Treatment of HBV or HCV with interferon is also extremely costly.

This information suggests that hepatitis B and C are both very difficult and expensive to treat. Currently, there are a large number of cases and that number is growing. Thus, preventing infection is vital for optimal public health outcomes and reducing expenditures on treatment. Both vaccination (for HBV and HAV) and education can be effective ways of controlling viral hepatitis. However, in order to evaluate results, accurate information on the prevalence of the diseases in the population is necessary.

The Bills

Senate Bill (SB) 905 and House Bill (HB) 1646 would add to the Texas Health and Safety Code a statewide plan for control of bloodborne pathogens (including HBV and HCV) among health care providers in governmental facilities. State laws regarding bloodborne pathogens, including viral hepatitis, are highly fragmented and incomplete. At least one other state has developed a comprehensive worker-protection plan applicable to bloodborne diseases (See, e.g., West's Ann. Cal. Labor Code § 144.7; and Cal. Admin. Code. tit. 8, § 5193).

SB 519 and HB 2036 would amend existing statutory requirements that pregnant women, during gestation or at delivery of an infant, shall be tested for HIV and syphilis, by adding HBV to the list of required tests. At least eight other states currently have similar statutes (See Ark. Code Ann. § 20-16-507; Haw. Rev. Stat. § 325-92; Kan. Stat. Ann. § 65-153-f; Ky. Rev. Stat. Ann. § 214.160; Mich. Stat. Ann. § 333.5123; Mo. Rev. Stat. ' 210.030; N.Y. Pub. Health Law ch. 45, ' 2500-e; and Tenn. Code Ann. § 68-5-602).

HB 1652 would establish a Texas program for education about, and surveillance and prevention of, hepatitis C. Given the lack of effective treatments for HBV and HCV, prevention and surveillance appears to be strongly indicated from a public health perspective.

SB 99 would allow testing of a hospital patient for HBV or HCV without the patient's informed consent in cases where a health care provider has been accidentally exposed to the patient's blood. A similar provision allowing HIV testing currently exists in Texas (See Texas Health and Safety Code § 81.107). At least three other states allow testing for hepatitis where health care providers may have been exposed, either allowing a facility to test the patient's blood regardless of consent or deeming consent in such cases (See S.C. Code Ann. § 44-29-230; Tenn. Code Ann. § 68-11-222; and Va. Code Ann. § 32.1-45.1). Some states allow testing of patients even where there is a specific refusal of consent, in cases where certain individuals have been potentially exposed, e.g., firefighters, EMS technicians, law enforcement officers, and correctional officers (See Fla. Stat. Ann. § 112.181; and Va. Code Ann. § 32.1-45.2).

HB 1725 would amend a section of the Texas Education Code, which currently requires student immunization against specified diseases, to require immunization against hepatitis A for residents of counties within 60 miles of the Texas-Mexico border, where the risk of HAV is higher than in other areas of Texas. Requiring immunization for hepatitis A in areas where there is an elevated risk of this disease (like the border area) is consistent with the State's interest in promoting public health in Texas.

All these bills appear to support broad based public health interests in terms of either improving treatment of viral hepatitis and/or improving prevention efforts and surveillance. The Texas Legislature's consideration of these bills is a timely response to a serious and growing public health threat in Texas.

For more information on hepatitis and other liver diseases, visit the American Liver Foundation's web site.