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Original Research |

Chronic Hepatitis C Virus Infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010

Maxine M. Denniston, MSPH; Ruth B. Jiles, PhD, MS, MPH; Jan Drobeniuc, MD, PhD; R. Monina Klevens, DDS, MPH; John W. Ward, MD; Geraldine M. McQuillan, PhD; and Scott D. Holmberg, MD, MPH
[+] Article and Author Information

From National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, and National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1133.

Reproducible Research Statement: Study protocol: Available at www.cdc.gov/nchs/nhanes/about_nhanes.htm. Statistical code: Available from Ms. Denniston (e-mail, mmd1@cdc.gov or mdennist@gmail.com). Data set: Available at www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.

Requests for Single Reprints: Scott D. Holmberg, MD, MPH, 1600 Clifton Road NE, Mail Stop G37, Atlanta, GA 30333; e-mail, sdh1@cdc.gov.

Current Author Addresses: Ms. Denniston and Drs. Jiles, Klevens, Ward, and Holmberg: 1600 Clifton Road NE, Mail Stop G37, Atlanta, GA 30333.

Dr. Drobeniuc: 1600 Clifton Road NE, Mail Stop A33, Atlanta, GA 30333.

Dr. McQuillan: 3311 Toledo Road, Room 4204, Hyattsville, MD 20782.

Maxine M. Denniston, MSPH; Ruth B. Jiles, PhD, MS, MPH; Jan Drobeniuc, MD, PhD; R. Monina Klevens, DDS, MPH; John W. Ward, MD; Geraldine M. McQuillan, PhD; and Scott D. Holmberg, MD, MPH

Author Contributions: Conception and design: M.M. Denniston, R.B. Jiles, J. Drobeniuc, M. Klevens, S.D. Holmberg.

Analysis and interpretation of the data: M.M. Denniston, R.B. Jiles, J. Drobeniuc, R.M. Klevens, G.M. McQuillan, S.D. Holmberg.

Drafting of the article: M.M. Denniston, J. Drobeniuc, S.D. Holmberg.

Critical revision of the article for important intellectual content: M.M. Denniston, R.B. Jiles, J. Drobeniuc, J.W. Ward, G.M. McQuillan, S.D. Holmberg.

Final approval of the article: M.M. Denniston, J. Drobeniuc, R.M. Klevens, J.W. Ward, G.M. McQuillan.

Provision of study materials or patients: G.M. McQuillan.

Statistical expertise: M.M. Denniston.

Obtaining of funding: J.W. Ward, S.D. Holmberg.

Administrative, technical, or logistic support: R.B. Jiles, J. Drobeniuc, R.M. Klevens, G.M. McQuillan, S.D. Holmberg.

Collection and assembly of data: J. Drobeniuc, G.M. McQuillan.


Ann Intern Med. 2014;160(5):293-300. doi:10.7326/M13-1133
Text Size: A A A

Background: Knowledge of the number of persons with chronic hepatitis C virus (HCV) infection in the United States is critical for public health and policy planning.

Objective: To estimate the prevalence of chronic HCV infection between 2003 and 2010 and to identify factors associated with this condition.

Design: Nationally representative household survey.

Setting: U.S. noninstitutionalized civilian population.

Participants: 30 074 NHANES (National Health and Nutrition Examination Survey) participants between 2003 and 2010.

Measurements: Interviews to ascertain demographic characteristics and possible risks and exposures for HCV infection. Serum samples from participants aged 6 years or older were tested for antibody to HCV; if results were positive or indeterminate, the samples were tested for HCV RNA, which indicates current chronic infection.

Results: Based on 273 participants who tested positive for HCV RNA, the estimated prevalence of HCV infection was 1.0% (95% CI, 0.8% to 1.2%), corresponding to 2.7 million chronically infected persons (CI, 2.2 to 3.2 million persons) in the U.S. noninstitutionalized civilian population. Infected persons were more likely to be aged 40 to 59 years, male, and non-Hispanic black and to have less education and lower family income. Factors significantly associated with chronic HCV infection were illicit drug use (including injection drugs) and receipt of a blood transfusion before 1992; 49% of persons with HCV infection did not report either risk factor.

Limitation: Incarcerated and homeless persons were not surveyed.

Conclusion: This analysis estimated that approximately 2.7 million U.S. residents in the population sampled by NHANES have chronic HCV infection, about 500 000 fewer than estimated in a similar analysis between 1999 and 2002. These data underscore the urgency of identifying the millions of persons who remain infected and linking them to appropriate care and treatment.

Primary Funding Source: None.

Figures

Grahic Jump Location
Figure.

Estimated prevalence of anti-HCV and HCV RNA in persons aged ≥6 y, according to NHANES III (1988–1994), NHANES 1999–2002, and NHANES 2003–2010.

Estimated persons infected are reported in millions. Anti-HCV = antibody to HCV; HCV = hepatitis C virus; NHANES = National Health and Nutrition Examination Survey.

Grahic Jump Location

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Comments

Submit a Comment
Prevalence of HCV infection in an imprisoned population
Posted on March 4, 2014
Donald Venes, MD
Pelican Bay State Prison
Conflict of Interest: None Declared
Prisoners and the homeless are not sampled in your survey. To gauge the prevalence of hepatitis C viral infection in an imprisoned population I reviewed the number of prisoners at Pelican Bay State Prison (Crescent City, California) who are known to be infected with hepatitis C. Five hundred thirty men (of a total prison population of ~2800) are known to be infected. Since not every prisoner has been tested for HCV antibodies, the prevalence rate in imprisoned populations may be 20 times as high as in the American population at large.
Using changes in the prevalence of anti-HCV and HCV RNA positivity to estimate the number of patients that were cured of HCV.
Posted on March 21, 2014
George N. Ioannou
Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle WA
Conflict of Interest: None Declared
The excellent data presented by Denniston et al.(1), provide an opportunity to estimate the number of HCV-infected patients successfully treated in the USA between the two NHANES studies.

The prevalence of chronic HCV infection (positive HCV RNA), declined from 3.2 million in 1999-2002 to 2.7 million in 2003-2010. Therefore:
3.2 – D(HCV) – C + I(HCV) = 2.7
Where:
D(HCV) = Deaths (in millions) among HCV-infected patients = 3.2 x Mortality in HCV-infected patients
C = Cures (in millions) of HCV infection
I(HCV) = Incident (new) infections, that occurred between the two studies.

The prevalence of Past (but not current) HCV Infection (anti-HCV positive - HCV RNA positive) was 0.9 million in both periods. Therefore:
0.9 - D(past HCV) + C + I(past HCV) = 0.9
Where:
D(past HCV) = Deaths (in millions) among patients with past HCV infection = 0.9 x Mortality in patients with past HCV infection
C = Cures (in millions) of HCV infection
I(past HCV) = Incident cases of past infection (i.e. new patients exposed to HCV who spontaneously clear the virus), that occur between the two studies.

We can assume that:
1. Incident HCV cases are 17,000/year (2), or 0.1 million cases during the 6-year period between the midpoint of 1999-2002 and the midpoint of 2003-2010.
2. Incident cases of HCV exposure without chronic infection are ≈ (0.9/3.2) x 0.1 = 0.028 million, where 0.9/3.2 is the ratio of HCV exposure without infection to chronic HCV infection in period 1999-2002.
3. Mortality among HCV infected patients should be equal to or greater than mortality among patients with past exposure without chronic infection.

Assuming that the mortality (m) is equal in both groups the two equations simplify to:
3.2 – 3.2m – C + 0.1=2.7
0.9 – 0.9m + C + 0.028 = 0.9

Solving these simultaneous equations yields C=0.1099 million or 109,900, which is 3.4% of the 3.2 million patients with chronic infection in 1999-2002. This would result in a mortality of 15.3% in both groups – corresponding to 489,600 deaths among the 3.2 million patients with chronic HCV infection in 1999-2002. If the mortality is greater in the group with chronic HCV infection than in the group with past infection, then the number of patients cured would be even smaller than 109,900, such that this is an upper limit estimate. For example if the mortality in patients with HCV infection is 16% (rather than 15.3%), solving the above equations yields only 88,000 patients cured and a mortality in those with past HCV infection of 12.9%.

Within the limits of the accuracy of the prevalence estimates presented by Denniston et al. (1), these calculations suggest that no more than 109,900 patients with chronic HCV were cured in the 6-year period between the midpoints of 1999-2002 and 2003-2010 in the United States representing <3.4% of the 3.2 million patients with chronic HCV infection in the United States between 1999-2002.








1. Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med 2014;160:293-300.
2. Wasley A, Grytdal S, Gallagher K, et al. Surveillance for acute viral hepatitis--United States, 2006. MMWR Surveill Summ 2008;57:1-24.

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