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The Burden of H epatitis C Infection

The Burden of H epatitis C Infection. Monina Klevens, Iqbal K, Rizzo E, Thomas A, Vonderwahl C, Bryant T, Sweet K, Speers S, Sanchez M, Bornschlegel K, and Jiles R. Objectives. Describe relevant characteristics of hepatitis C Describe US burden of disease

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The Burden of H epatitis C Infection

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  1. The Burden of Hepatitis C Infection Monina Klevens, Iqbal K, Rizzo E, Thomas A, Vonderwahl C, Bryant T, Sweet K, Speers S, Sanchez M, Bornschlegel K, and Jiles R.

  2. Objectives Describe relevant characteristics of hepatitis C Describe US burden of disease Outline challenges to state specific burden measures

  3. Objectives Describe relevant characteristics of hepatitis C Describe US burden of disease Outline challenges to state specific burden measures

  4. Features of HCV Infection Transmission Blood Incubation period Average, 6–7 wk Range, 2–26 wk Acute illness (jaundice) Mild (20%–30%) Symptoms Non specific Immunity No protective antibody response identified

  5. Spectrum of Hepatitis C Infection • Elevated ALT • (75%) • Mild • Mod-severe Source: Marcellin J of Hepatology 1999;31:S9-16

  6. All Cause Mortality Rates of NHANES III Participants ≥17 Years, by Hepatitis C Status Deaths per 1000 person-years Source: El-Kamary CID 2011;53:150-7

  7. Treatment of Acute Hepatitis C Infection is Highly Effective Source: Jaeckel et al

  8. FDA Approved Treatments for Hepatitis C Infection 2011 http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/ucm151494.htm Accessed May 1, 2012

  9. Objectives Describe relevant characteristics of hepatitis C Describe US burden of disease Outline challenges to state specific burden measures

  10. Born ~1945-1965 Prevalence of Anti-HCV, United States, 1999-2002 (NHANES) Prevalence anti-HCV+ : 1.6% (4.1 million) Prevalence RNA+: 1.3% (3.2 million) Armstrong et al. Ann Intern Med, 2006.

  11. Forecasted Hepatitis C Mortality and Complications DECOMPENSATED CIRRHOSIS HEPATOCELLULAR CARCINOMA Source: Rein DB, et al. Dig Liver Dis (2010), doi:10.1016/j.dld.2010.05.006

  12. Annual Age-Adjusted Mortality Rates of Hepatitis B, C, and HIV as Underlying or Contributing Cause of Death, United States, 1999 – 2007 Source: Ly et al. Ann Intern Med 2012;156:271-278

  13. Objectives Describe relevant characteristics of hepatitis C Describe US burden of disease Outline challenges to state specific burden measures

  14. Challenges at the State Level • Number of prevalent cases • Resources • Insufficient for investigations or for preventive services • Incidence (as notifiable diseases) • Response rates for interview low • Supplemental sources of data • Seroprevalence - NYC • Healthcare utilization • Mortality

  15. 2010 Sites Reporting HCV Infection New York State + City* Oregon Minnesota Connecticut Colorado San Francisco* New Mexico *Past or present only Estimated population 31- 40 million

  16. Data Processing Hospital, Commercial Clinical Laboratories Health Care Providers • Maintain database • Investigate new cases • Classify • Analyze Local Health Departments State Health Department CDC

  17. HCV past or present • Acute hepatitis C • Clinical criteria • An acute illness with discrete onset of symptoms* and • Jaundice or elevated serum aminotransferase (ALT) levels >400 IU/L • Clinical criteria • Asymptomatic or mild-severe CLD • Laboratory criteria • Anti-HCV positive with predictive s/co • or • Positive HCV RIBA or HCV RNA (NAT) • and • IgM anti-HAV negative and • IgM anti-HBc negative • *unless seroconversion <6 months • Laboratory criteria • Anti-HCV positive and anti-HCV RIBA or NAT for HCV RNA, • or • Positive: RIBA, NAT, genotype • or • Anti-HCV positive with predictive s/co

  18. Evaluation of the HCV De-duplication Process Reports included 2180 68% - duplicate/match 5% - missing s/co 2% - tests negative 1% - missing demographics New cases 491 Source: Klevens et al, Emerg Infect Dis 2009; 15: 1499-1502

  19. Rate of Incident Acute HCV Infection in Funded US Sites, 2010 Rate per 100,000 population Site

  20. Rate of Newly Reported Cases of Past or Present HCV Infection in Funded US Sites, 2010 Rate per 100,000 population Overall Site Source: 2010 Surveillance Summary

  21. Conclusions • The burden of hepatitis C is significant but underappreciated in the United States. • State level measurement is challenging • New infections continue to be problematic • Complications among the 3.2 million chronically infected persons are of great concern

  22. Thank you.

  23. Objectives of surveillance for chronic HCV infection • Measure burden of disease • Estimate healthcare needs • Characterize population for secondary prevention • Evaluate prevention • Infected population in care • Receiving services

  24. Courtesy: T. Bryant

  25. Rates of Newly Reported Hepatitis C Virus Infection Among Persons <30 Years in 4 Communities, New York State, Nov 2004 - Apr 2007 Rate per 100,000 population

  26. Laboratory results used to classify cases of past or present HCV infection, 2006/2007, 6 sites conducting enhanced hepatitis surveillance

  27. [but 14% who denied IDU during exposure period reported prior injecting (6.7%) or intranasal (7.8%) drug use] Figure 2. Known and Potential Exposures during the 6 months Prior to Onset of Illness Reported by Patients with Acute Hepatitis C, Sentinel Counties, United States, 1994-2006 (n=270) Source: Williams et al. Arch Int Med 2011; 171:241-8

  28. Natural History of HCV Infection 100 People Time 15% 85% Resolve (15) Chronic (85) 80% 20% Stable (68) Cirrhosis (17) 75% 25% Stable (13) Mortality (4) Adapted from Seef

  29. HCV infection, past or present • Characteristics • No acute infection indicator lab test • Chronic infection asymptomatic for decades • High volume of anti-HCV tests • Past (resolved) • Present • Re-infection possible (2005) • Clinical criteria • Asymptomatic to mild-severe CLD • Laboratory criteria • Anti-HCV positive and a confirmatory test • or • Positive: RIBA, NAT, genotype • or • Anti-HCV positive with s/co predictive

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