The Institute’s Hepatitis Policy Project Launches New Website

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Sonia Canzater, Hepatitis Policy Associate, and Jeffrey S. Crowley, Program Director of Infectious Disease Initiatives, invite you to visit the Hepatitis Policy Project’s new policy-focused website on hepatitis C.

While there is already an abundance of general information available on the etiology, symptoms and transmission of HCV, this site is intended to provide the latest policy actions and most timely and relevant information related to the HCV crisis.

Content consists of links to relevant articles, study findings, features from thought leaders in the viral hepatitis space, and summaries of current policy issues written by the Policy Project team.

Our goal for the site is to fill a niche that is different than that of the CDC and other sites whose primary purpose is to provide information for the general public.

A highlight of our site is the Featured Expert Column that provides timely insights from leaders in viral hepatitis policy and advocacy.

Our inaugural expert column was authored by Dr. Rich Wolitski, Director, and Corinna Dan, Viral Hepatitis Policy Advisor, of the U.S. Dept. of Health and Human Service’s Office of HIV/AIDS and Infectious Disease Policy.

Please share the link to the site in your respective circles, and contact Sonia Canzater, Hepatitis Policy Project Associate, at sc1574@georgetown.edu with comments or inquiries.

Posted in Uncategorized;


The Truth Behind Home Health Aide Certification Requirements

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Home health aides (HHAs) play an important role in maintaining the health and well-being of the elderly, ill, and disabled.  This role varies from changing bandages and distributing medications, to grocery shopping and helping to pay bills.  Unlike other health care workers who are located in a health care facility, HHAs enter patient homes and thus have access to the most intimate parts of peoples’ lives and are often not supervised.  Because of this, it is imperative that HHAs are screened and that they go through a rigorous training process.

Home health aides usually work with patients who need more extensive physical and or medical care than a typical family can provide.  There is no formal education requirement (including a high school diploma) to secure a position as an HHA, although certificate and training courses are available from many postsecondary institutes.  Some HHA and hospice agencies, however, may require a high school diploma from their employees.

According to the US Bureau of Labor Statistics, HHA educational requirements vary depending on the employer.  Aides who work for organizations that receive funds from Medicare or Medicaid must complete formal training, while those who work for private companies are not required meet these obligations.  More experienced aides, such as certified nursing assistants (CNAs) and licensed practical or registered nurses, often provide on-the-job training for new aides.

Federal Requirements

Throughout the US any home health agency that accepts Medicare must employ certified home health aides.  Federal law states that HHAs working at a CMS (Centers for Medicare and Medicaid Services), must have 75 hours of training, including 16 hours of on-the-job training. This is the minimum number of required hours, and states can then choose if they want to license HHAs working in the state and if any additional training is needed.  However, it is important to distinguish facilities that accept CMS and those that do not.  Private companies that do not accept Medicare do not have certification requirements.

State Requirements

As mentioned above, HHA certification requirements vary greatly by state.  In Wyoming, there is no HHA specific training program or designation.  In order to work as an HHA, one must complete an approved CNA program.   The state of Wyoming then sets standards for how home health agencies train their home health aides. State law requires home health agencies to provide 16 hours of additional training upon being hired in the first two weeks.

In Wisconsin, potential HHAs must complete a CNA training program and then successfully complete an exam and a background check.  To be a CNA in Wisconsin requires a minimum of 120 total hours of training, including 32 clinical hours.

In Vermont, to work as an HHA an applicant must first be a Licensed Nursing Assistant (LNA).  The LNA training program includes 80 hours of total training, with 30 hours of clinical training.  After the training, all LNAs must pass a state exam and register with the state.

Washington, DC Requirements

Washington, DC only requires the bare minimum number of training hours (75), including 16 hours of on-the-job training.  Many states require more than this bare minimum and some states even require formal training such as a CNA or another nursing degree or certification to be an HHA.   In Washington, DC, in order to be certified, home health aides must successfully complete a training program, pass a competency exam issued by the District of Columbia Board of Nursing, pass a criminal background check, and submit an application along with a fee to the District of Columbia Board of Nursing.  However, for private companies that do not accept Medicare, these certification requirements do not apply.

The District of Columbia Home Health Aide certification by examination was established in July 2012 with the final publication of the Home Health Aide Regulations.   The regulations were derived from the revised Health Occupations Revisions Act of 2009, which place Nursing Assistive Personnel under the authority of the Board of Nursing.  The District of Columbia Home Health Aide Regulations were last revised and amended in September 29, 2017.

Many HHAs could be “waived in” or “grandfathered in” in the past, meaning they could waive the examination to be certified as an HHA. There are now four ways to be certified as an HHA in Washington, DC: (1) Certification by examination, (2) certification by endorsement, (3) certification by renewal, and (4) reactivation of certification.   The examination has 2 parts: a written section and a skills section.  HHA certifications expire October 31st of every odd numbered year.

There has been a history of fraudulent HHA applications in Washington, DC with HHA applicants submitting certification applications directly to the Board of Nursing themselves.  Many applicants have submitted fraudulent educational certificates and applications.  Because of this, the Board now requires applications to come directly from the HHA’s employers, and for those applying to take the HHA examination, the HHA schools must send lists of graduates to the processing unit.

Due to the nature of their responsibilities and the Importance of their roles, HHAs should be thoroughly trained and vetted, arguably more than health care workers who work in health care facilities.  However, this is not always the case due to relaxed training and education requirements that vary from state to state across the country.  This is especially worrisome in the nation’s capital, which has some of the least restrictive requirements for HHAs, and a history of loopholes, such as the grandfather clause, that allowed for unqualified and unverified HHAs to work in the District.

Posted in Health reform, National Healthcare; Tagged: , , , , , .


Actions Speak Louder than Words: Reclaiming Lost Ground in the Battles Against Viral Hepatitis

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Photo Credit: CDC.GOV

Expert Columnist post for the Hepatitis Policy Project at the O’Neill Institute for National and Global Health Law

Written by Richard J. Wolitski, PhD, Director, and Corinna Dan, RN, MPH, Viral Hepatitis Policy Advisor
Office of HIV/AIDS and Infectious Disease Policy, Office of the Assistant Secretary for Health,
Department of Health and Human Services

Viral hepatitis poses a serious threat to the health of millions of Americans from all walks of life. It accounts for more deaths in the United States than all other reportable infectious diseases combined. New infections are on the rise across the country as a result of injection drug use that has been driven by the opioid crisis that is gripping communities across the country. The severity of this problem was recognized by the editors of the American Journal of Public Health in what is certain to become an iconic cover. The February 2018 issue features an in-your-face cover image of a man injecting drugs into his scarred and scabbed arm. It is disturbing. It forces you to take notice, and it is not easy to forget.

Although the image is shocking for the cover of a journal, the editor’s choice to put this topic front and center is not. What is surprising is that has taken so long. New hepatitis C (HCV) infections have been increasing since 2009 and new hepatitis B (HBV) infections have remained stable or increased slightly after declining for more than three decades. The increase in new infections among young adults has resulted in increases in HCV transmission from pregnant women to their infants. Almost every one of these HCV infections could have been prevented; each new infection represents a failure of health care providers and health care systems.

We are losing ground in the battles against viral hepatitis despite the fact that we’ve made important scientific advances in prevention, care, and treatment. Vaccination against HBV infection is highly effective, but until recently required 3 doses. A new vaccine recently approved by the FDA can be delivered in two doses, which could increase the percentage of persons who are fully vaccinated against HBV. HCV can now be cured with an 8 to 12 week course of once daily oral medication that is more than 95% effective if taken as prescribed and has few the side effects. We cannot cure HBV infection at this time, but antiviral treatment can lower the amount of virus, prevent disease progression, and may prevent sexually transmission to others.

Why have we been backsliding in recent years, instead of moving forward? It’s not that we do not have the tools needed to get the job done. It’s not that we haven’t used these tools effectively. It’s not that we do not have a vision or a plan. We have had a national plan addressing viral hepatitis since 2011. CDC and other HHS agencies have put forward their own plans that are aligned with the National Viral Hepatitis Action Plan that include efforts to monitor, prevent, and treat new and existing cases. These plans also address the need to expand diagnosis, care, and treatment of viral hepatitis, especially among groups that have been most heavily affected. These plans lay out strong, science-based frameworks for mounting effective, comprehensive actions to combat viral hepatitis.

The National Academies of Science, Engineering, and Medicine (NASEM) convened a panel of experts from around the country to assess what it would take to eliminate viral hepatitis as a public health threat in the United States by 2030. Their 2016 and 2017 reports concluded that that viral hepatitis elimination is possible with existing prevention and treatment methods. It is important to keep at least two things in mind about their conclusions: (1) elimination is not the same as eradication of these infections—prevention, care and treatment would all still be needed for years to come, and (2) that achieving the goal of elimination will require “considerable will and resources.”

We strongly support the goal of eliminating viral hepatitis. It is the goal that we are all ultimately working to achieve.  We also believe it is important to set realistic expectations for policy makers and to set performance targets that are achievable. We must make the best possible use of available resources and leverage technology, partnerships, policy changes, and other approaches that have the potential to result in lasting, sustainable viral hepatitis programs that are not dependent on one type of funding for their survival.

A key to the long term success and sustainability of viral hepatitis efforts is greater integration into existing health care services in ways that support the client in making the best possible choices he or she can and having access to the most appropriate and most effective services and programs that will keep them healthy. We believe that this can be accomplished by taking a patient-centered approach- considering the health threats that each person faces and developing a plan that allows that client to access both preventive health care and treatment for existing illnesses.

But creating and sustaining change cannot stop there. The changes also have to make sense to the people who are footing the bill. They need a return on their investment such as reducing health care costs, serving more people in need, increasing profit, recognition of innovation, or feeling good about helping others. If a change is not reinforced by a resultant benefit, it doesn’t stand a chance of being sustained.

There are clear benefits of greater integration and colocation of HIV, viral hepatitis, STD, TB, substance use disorder treatment, overdose prevention, comprehensive syringe services, primary health care, housing and employment services. In many cases, behaviors place people in situations where they are at increased risk for multiple physical and mental health problems. Many of these problems do not occur independently of each other. They are often intertwined with each other and affect the social and economic well-being of individuals, families, and communities. Understanding the needs of the individual and what’s important to them can support a more holistic approach to health and wellness that meets people where they are at, addresses their most critical needs—the ones that most endanger their immediate health and well-being, and helps them identify their own lasting solutions in novel ways that are feasible, self-reinforcing, and habit forming.

Actions speak louder than words. Actions are the foundation of what’s required to turn around the negative viral hepatitis trends that we have been seeing in the data, in our communities, and too often within our own families and among our friends. We need to choose our actions wisely and focus on the things that are in our power to change or that can support others to take necessary actions when we cannot. Among the things we can influence, we need to choose those that will provide the greatest benefits to the greatest number of people.

A key objective for us is to promote an accurate understanding of the magnitude of the problem of viral hepatitis, its severity, the challenges, the solutions, and what it would take to achieve the vision of the National Viral Hepatitis Action Plan.

A goal without a plan (that is feasible and implemented) is just a wish.

— Antoine de Saint-Exupéry (paraphrased)

The opinions expressed in this blog are the writers’ own and do not necessarily represent the official policy of the Department of Health and Human Services.

Posted in Hepatitis C; Tagged: .


The Silent Epidemic of Hepatitis C in the United States

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This blog post was authored by Dr. Daniel Lising, Research Assistant for the O’Neill Institute’s Hepatitis Policy Project. Daniel is an LLM in Global Health student at Georgetown University Law Center.

In recent months, the spotlight has been trained on the alarming opioid crisis and even the President of the United States declaring it to be a health emergency after a report stated that drug overdoses killed approximately 64,000 people in the United States in 2016. However, very little has been said on silent killers that occurs because of needle exchange behavior which occurs with opioid abuse. Commonly associated with such practices is HIV but another one of such diseases is Hepatitis C.

Hepatitis C is a contagious liver disease caused by the Hepatitis C virus which affects an estimated 2.7 million to as high as 5 million people in the United States. It can manifest as a mild acute illness occurring within the first 6 months of exposure to the virus. Approximately 15-25% of these infected will recover from this infection but a majority would progress to chronic Hepatitis C.

A most alarming fact of this type infection is that approximately 70-80% of people with Acute Hepatitis C will manifest will be asymptomatic or be without symptoms. Moreover, chronic hepatitis C is asymptomatic as well thus leaving a person with no clue that he has already contracted a potentially fatal illness.

Chronic hepatitis C is a leading cause of chronic liver disease such as cirrhosis and liver cancer and nationally accounts for more than 30% of liver transplant indications among adults. These complications once in the end stage liver disease stage costs up to $59,995 annually in 2011 USD and which is 2.5 times more expensive than the early stages of stages of chronic liver disease. The economic costs are staggering given the number of people suffering from the disease.

Approximately three-fourths of patients suffering from the disease are adults born from 1945 to 1965 who have had blood transfusions, dialysis or organ transplants prior to 1992 when testing for the virus began and those who used injection drugs or used intranasal cocaine. However, men and women in the 20-29 age group has also been noted to have increasing number of infections. In California, rates of 55 percent for men and 37 percent among women in that age group has been noted. These data are consistent with increases in hepatitis C infection throughout the country.

These facts illustrate the importance of early diagnosis of hepatitis C positive individuals before their illness progresses to the more debilitating chronic liver disease. Of particular concern is the baby boomers which could potentially been infected for decades without symptoms ever coming about. Early diagnosis is of even greater importance now since the advent of new antiviral therapy that represents a significant improvement over earlier treatment protocols and has shown outcomes consistent with cure after treatment of approximately twelve weeks.

Despite these advances, hepatitis C is severely underfunded both federally and states-wide. Certain state legislatures like California have allocated funds for pilot projects to curb the rising tide of infections but these remain insufficient to dent the quandary of increasing hepatitis C infection.

Targeted mechanisms are needed for different at-risk populations so that there is increase awareness and so that behaviors may be changed to prevent the further spread of this once deadly illness. Such mechanisms can take the form of syringe service programs which exchanges used syringes for new ones. However, these kinds of programs must be implemented without the associated threat of incarceration for possession of illicit substances. Furthermore, capacity building of primary care facilities and health personnel is also essential so that vulnerable segments of the population can have access to testing and effective treatment.

The necessary first step for all these is the express recognition of the States and Federal government of the Hepatitis C “emergency”.

Posted in Hepatitis C, Hepatitis C Staff Insights;


Join a Global Conversation on a New Approach to Reducing Health Inequities

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The realities of health inequities may be too well known to shock us any longer. People in richer countries live longer than those in poorer countries. And within countries, people who are rich live longer than people who are poor, people with more education longer than people with little schooling. Practically everywhere, certain populations, like indigenous peoples, fair badly when it comes to the potential to live long, healthy lives.

Yet the tremendous nature of this injustice ought to shock us still. It ought to shock us that the residents of one mostly white suburb of St. Louis can expect to live to be over 91 years old – 35 years more than residents of another St. Louis suburb, where most residents are black. It ought to shock us that South Asian women who are among the poorest segment of the population are almost five times less likely to be attended by a skilled birth attendant – one of the most important interventions for reducing maternal mortality – than they would be if they were part of the wealthiest segment. And it ought to shock us that the TB incidence in Canada’s indigenous Inuit people is more than 270 times that of non-indigenous Canadians.

Such inequities coexist with a new political commitment to address them, as the world entered the Sustainable Development Goals era of Leave No One Behind several years ago. Redressing these health inequities is a momentous task, a challenge for our generation if Leave No One Behind is to avoid joining the ranks of Health for All by 2000 – the promise of the 1978 Alma-Ata Declaration on primary health care – as a noble promise that proved fatally empty. Indeed, even the Millennium Development Goals, lacking a focus on equity, failed to substantially and consistently reduce health inequities.

Certainly many efforts, from local to global initiatives, are underway to support the goal of leaving no one behind when it comes to health – and indeed, when it comes to life itself. The O’Neill Institute and a number of partners would like to add one more: that all countries develop National Health Equity Strategies. Through a partnership with Stop TB and USAID, and many others, we are developing a guide on National Health Equity Strategies.

What are National Health Equity Strategies? Some wealthier countries have these – if not quite as we propose. They delineate ways, in the health sector and beyond, to narrow health disparities, with particular attention and strategies to address health needs of certain marginalized populations.

Under National Health Equity Strategies as we are proposing, countries would tailor their responses to health inequities to the particular circumstances of all populations experiencing such inequities – not only some populations – and with extensive analysis to ensure that resulting strategies can address all major contributors to health inequities. The National Health Equity Strategy would include specific actions to take across populations and across the many causes of health inequities, seeking to narrow, and ultimately close entirely, these disparities – these injustices. The National Health Equity Strategy would not exist as a stand alone initiative. These actions should then be integrated into national strategies in health and other sectors.

Of course, good strategies alone cannot change the social and political dynamics that have led to persistent marginalization. Accordingly, the action plans would be backed by comprehensive accountability strategies. These would include regular monitoring and evaluation of measurable, time-bound targets; ongoing structures for continued, high-level political and community engagement in reviewing progress and recommending changes (these could build on existing structures), and; additional accountability strategies.

For example, targets might include reducing the proportion of migrants reporting mistreatment at health facilities by 50% within three years, narrowing the gap in life expectancy between indigenous and non-indigenous populations by four years within four years, reducing the number of people experiencing long-term homelessness by 80% within five years, reducing child marriages by 60% within five years, and reducing the number of people with mental disabilities in long-term mental health institutions by 100% within five years. Additional accountability strategies, meanwhile, could encompass human rights education and training, regular local and national health assemblies, legislation requiring public participation in health-related policymaking, and health equity impact assessments.

Integral to the concept of and proposal for these health equity strategies, linked to one of their central goals of empowering populations experiencing health inequities, members of marginalized populations would be in leadership positions in the process of developing the strategies and in follow-on structures. This would be at least one concrete opportunity for populations who are frequently sidelined from decision-making processes to instead be central to them.

Where are we in the process of developing this guide? An initial draft is nearly complete, with the assistance of a global Advisory Committee, with more than a dozen members. It includes people who are themselves members of marginalized communities, individuals who are work for international organizations, and a former minister of health, among others.

We believe it vital that our process of developing this guide be as broad and inclusive as possible. Accordingly, beginning in March and lasting for approximately two months, we will be holding an open, primarily online, consultation on the guide. Along with the opportunity to read and provide us feedback on the draft of the guide and related summary material, we plan to hold several webinars, and may have other means of engagement as well (such as possibly an online discussion group). We hope that you will participate.

Besides receiving feedback on the guide to improve its quality and accessibility, we aim to raise interest in putting this approach into practice, from governments that could spearhead these strategies to civil society organizations and communities experiencing health inequities that could advocate for them. Therefore, we would welcome your sharing information on the guide – such as this blog – with anyone whom you think might be interested in this initiative.

In addition, we would welcome your input in several areas:

  1. Statistics that demonstrate the extent of health equities in particular countries or for particular populations.
  2. Examples (particularly short examples or statistics) of improvements in health equity.
  3. For any marginalized population, what are successful strategies for improving health equity – whether initiatives within or beyond the health sector?
  4. Successful processes or mechanisms for engaging marginalized communities (in general or specific populations) in health-related decision-making.
  5. Are you aware of individuals in governments or international organizations that would likely be interested in developing or promoting these health equity strategies  that we should be in contact with?

If you have anything you would like to share in these areas, please email me (eaf74@law.georgetown.edu). And if you would like to participate, you can email me or have a look as March nears at the O’Neill Institute’s event page, which will provide more information on the timing and process for the consultation as soon as it is available. We look forward to your thoughts and participation.

Posted in Global Health, Human Rights, Resources; Tagged: , , , , , , , , , , .


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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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