Gregory L. Armstrong, MD; Annemarie Wasley, ScD; Edgar P. Simard, MPH; Geraldine M. McQuillan, PhD; Wendi L. Kuhnert, PhD; Miriam J. Alter, PhD
Grant Support: None.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Gregory L. Armstrong, MD, Division of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop G-37, 1600 Clifton Road NE, Atlanta, GA 30333; e-mail, GArmstrong@cdc.gov.
Current Author Addresses: Drs. Armstrong and Wasley and Mr. Simard: Division of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop G-37, 1600 Clifton Road NE, Atlanta, GA 30333.
Dr. McQuillan: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health and Nutrition Examination Surveys, 3311 Toledo Road, Room 4204, Hyattsville, MD 20782.
Dr. Kuhnert: Division of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop A-33, 1600 Clifton Road NE, Atlanta, GA 30333.
Dr. Alter: Division of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop D-66, 1600 Clifton Road NE, Atlanta, GA 30333.
Author Contributions: Conception and design: G.L. Armstrong, G.M. McQuillan, M.J. Alter.
Analysis and interpretation of the data: G.L. Armstrong, A. Wasley, E.P. Simard, G.M. McQuillan, W.L. Kuhnert, M.J. Alter.
Drafting of the article: G.L. Armstrong, G.M. McQuillan.
Critical revision of the article for important intellectual content: G.L. Armstrong, A. Wasley, E.P. Simard, G.M. McQuillan, M.J. Alter.
Final approval of the article: G.L. Armstrong, A. Wasley, E.P. Simard, G.M. McQuillan, M.J. Alter.
Provision of study materials or patients: G.M. McQuillan.
Statistical expertise: G.L. Armstrong.
Obtaining of funding: M.J. Alter.
Administrative, technical, or logistic support: W.L. Kuhnert.
Collection and assembly of data: A. Wasley, E.P. Simard, G.M. McQuillan.
Defining the primary characteristics of persons infected with hepatitis C virus (HCV) enables physicians to more easily identify persons who are most likely to benefit from testing for the disease.
To describe the HCV-infected population in the United States.
Nationally representative household survey.
U.S. civilian, noninstitutionalized population.
15 079 participants in the National Health and Nutrition Examination Survey between 1999 and 2002.
All participants provided medical histories, and those who were 20 to 59 years of age provided histories of drug use and sexual practices. Participants were tested for antibodies to HCV (anti-HCV) and HCV RNA, and their serum alanine aminotransferase (ALT) levels were measured.
The prevalence of anti-HCV in the United States was 1.6% (95% CI, 1.3% to 1.9%), equating to an estimated 4.1 million (CI, 3.4 million to 4.9 million) anti-HCV–positive persons nationwide; 1.3% or 3.2 million (CI, 2.7 million to 3.9 million) persons had chronic HCV infection. Peak prevalence of anti-HCV (4.3%) was observed among persons 40 to 49 years of age. A total of 48.4% of anti-HCV–positive persons between 20 and 59 years of age reported a history of injection drug use, the strongest risk factor for HCV infection. Of all persons reporting such a history, 83.3% had not used injection drugs for at least 1 year before the survey. Other significant risk factors included 20 or more lifetime sex partners and blood transfusion before 1992. Abnormal serum ALT levels were found in 58.7% of HCV RNA–positive persons. Three characteristics (abnormal serum ALT level, any history of injection drug use, and history of blood transfusion before 1992) identified 85.1% of HCV RNA–positive participants between 20 and 59 years of age.
Incarcerated and homeless persons were not included in the survey.
Many Americans are infected with HCV. Most were born between 1945 and 1964 and can be identified with current screening criteria. History of injection drug use is the strongest risk factor for infection.
The Third National Health and Nutrition Examination Survey (NHANES III), conducted between 1988 and 1994, indicated that 1.8% of people in the United States had been infected with hepatitis C virus (HCV), 70% of whom had chronic infection. Most anti-HCV–positive individuals were between 30 and 49 years of age.
Data from the recent NHANES (1999–2002) show little change in anti-HCV prevalence, but peak prevalence has shifted to individuals between 40 and 49 years of age. More than 85% of HCV RNA–positive individuals may be identified through targeted testing of 18% of adults between 20 and 59 years of age: persons with abnormal serum alanine aminotransferase levels, those who have used injection drugs, and those who received blood transfusions before 1992.
Incarcerated and homeless people were not included in the survey.
Despite a decrease in new HCV infections, aging of chronically infected individuals may presage an imminent increase in complications.
Table 1. Prevalence of Antibody to Hepatitis C Virus by Demographic Characteristics and Potential Risk Factors
Prevalence of antibodies to hepatitis C virus (HCV) by ethnicity, age, and sex.
Prevalence of antibodies to hepatitis C virus (HCV) by age group (A) and year of birth (B) in the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and the current NHANES (1999–2002).
Table 2. Adjusted Relative Odds of the Presence of Antibody to Hepatitis C Virus among Participants 20 to 59 Years of Age
Table 3. Adjusted Relative Odds of the Presence of Antibody to Hepatitis C Virus among Participants 60 Years of Age and Older
Table 4. Relationship between Alcohol Use and Abnormal Serum Alanine Aminotransferase Level
Table 5. Evaluation of Potential Screening Criteria for Hepatitis C Virus Infection
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Mark H. Kuniholm
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
June 13, 2006
The prevalence of hepatitis C virus infection: high in the US but higher in many other countries
TO THE EDITOR:
We were encouraged by the recent article by Armstrong et al. (1) that reported both a decline in the overall prevalence of antibody to hepatitis C virus (anti-HCV) in the United States as well as a lower prevalence of anti-HCV among younger compared to older adults. While very good news, it is important to note that the HCV epidemic is a global health problem and the blood supplies of many developing countries are not routinely screened for HCV. In addition, programs to treat injection drug users and educate them about the dangers of needle sharing have had limited impact outside of a few countries in the industrialized world.
In Russia and other countries of the former Soviet Union epidemics of hepatitis C and HIV are expanding rapidly and needle sharing among injection drug users is widely believed to be the major risk factor. We recently conducted a population-based survey in Georgia, a small country in the Caucuses region, using survey methodology not dissimilar to that used for the NHANES series of surveys (2). In a random sample of 2000 adults, we found that 6.7% were anti-HCV positive, and 8.1% had injected illicit drugs during their lifetimes. Over 85% of individuals who had injected illicit drugs had shared needles with others. While Armstrong et al. found that most HCV-infected Americans were born between 1945 and 1964, we found that most HCV-infected Georgians were born between 1974 and 1977.
The United States has learned hard lessons from the now diminishing hepatitis C epidemic, and will reap the "˜bitter harvest' for many years to come (3). Similarly, hepatitis C is poised to cause more morbidity and mortality than any other infectious disease in a number of developing countries. Fortunately, there has been some recognition of the seriousness of this global health problem, and WHO, the SOROS foundation, and governmental entities have invested considerable resources to combat this problem. However, the global epidemics of HCV and illicit drug use will continue to expand unless more effective collective interventions, including injection drug user harm reduction and hepatitis C research and care strategies, are implemented.
From the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 and the Emory University School of Medicine, Atlanta, GA 30322
(1) Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-14.
(2) Stvilia K, Tsertsvadze T, Sharvadze L, Aladashvili M, del Rio C, Kuniholm MH et al. Prevalence of hepatitis C, HIV, and risk behaviors for blood-borne infections: a population-based survey of the adult population of T'bilisi, Republic of Georgia. J Urban Health. 2006;83:289-98.
(3) Dienstag JL. Hepatitis C: a bitter harvest. Ann Intern Med. 2006;144:770-771.
Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The Prevalence of Hepatitis C Virus Infection in the United States, 1999 through 2002. Ann Intern Med. ;144:705–714. doi: 10.7326/0003-4819-144-10-200605160-00004
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Published: Ann Intern Med. 2006;144(10):705-714.
Gastroenterology/Hepatology, Infectious Disease, Liver Disease, Viral Hepatitis.
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