Epidemiology and Screening for Hepatitis C Infection Atif Zaman, MD MPH Oregon Health & Science University Professor of Medicine Division of Gastroenterology and Hepatology
Epidemiology/Screening for Hepatitis C Natural History of HCV infection Trends in HCV transmission, disease, mortality Health benefits of HCV Testing, care and treatment Testing algorithms/strategies to screen patients for HCV infection (CDC cohort)
The Natural History of HCV Infection Acute Hepatitis C Chronic Hepatitis 60% 85% Cirrhosis 10% 20% 20 40 years Decompensation 3 6%/year HCC 1 4%/year Death 2 4%/year NIH Consensus Development Panel. Gastroenterology. 2002;123:2082-2099; Serfaty L, et al. Hepatology. 1998;27:1435-1440; Fattovich G, et al. Gastroenterology. 1997;112:463-472.
Prevalence of Chronic Hepatitis C Infection In the US, 2.7 3.9 million people are living with chronic HCV infection; 75% are unaware they are infected Centers for Disease Control and Prevention. Hepatitis C FAQs for Health Professionals. Available at: http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed January 6, 2011. Institute of Medicine. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C; 2010.
Prevalence of HCV in Select Populations Incarcerated ~ 330,000 to 860,000 (16 41%) 1 Injection drug users ~ 300,000 Alcoholics (80 90%) 2,3 ~ 240,000 (11 36%) 5 HIV-infected ~ 300,000 (30%) 4 Male 63% Female 37% Homeless ~ 175,000 (22%) 7 Veterans ~ 280,000 (4%) 8 Living below poverty level ~ 940,000 (3.2%) 6 Children (6 18 years old) ~ 100,000 (0.1%) 9 Adapted from: 1. CDC. MMWR. 2003;52(RR-1):1-33; 2. Edlin B. Hepatol. 2002;36(5 suppl 1):S210-S219; 3. NHSDA Report 2003; 4. Poles M, et al. Clin Infect Dis. 2000;31:154-161; 5. LaBrecque D, et al. Hepatitis C Choices. 2002:7-15; 6. Alter M, et al. N Engl J Med. 1999;341:556-562; 7. Nyamathi A, et al. J Gen Intern Med. 2002;17:134-143; 8. Dominitz J, et al. Hepatology. 2005;41:88-96; 9. Jonas M. Hepatol. 2002;36(5 suppl 1):S173-S178.
Number of cases Projected Cases of Hepatocellular Carcinoma and Decompensated Cirrhosis Due to HCV 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 Decompensated cirrhosis Hepatocellular cancer 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 Year Davis GL, et al. Gastroenterology. 2010;138(2):513-521
Incidence of chronic HCV by county, Oregon, 2009-13 (cases/100,000) 7
Total reported cases of chronic HCV By 2013, 47,435 cases were reported to Oregon s HCV registry Assuming that at least 50% of Oregonians with HCV are unaware of their diagnosis, the actual number is probably closer to 95,000
Chronic viral hepatitis cases by year of liver cancer diagnosis, Oregon, 1996-2012 350 300 250 200 150 HCV (n=763) HBV (n=196) Not Hepatitis 100 50 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 In 2012, 8% of liver cancer cases had chronic HBV, while 47% had chronic HCV
Age and sex of cases of HCVassociated liver cancer, 2008-12 HCV-associated liver cancer (n=611) Age Group No. (%) 0-29 years 2 (0.4) 30-39 years 0 (0) 40-49 years 42 (7) 50-59 years 321 (53) 60-69 years 201 (33) 70 and older 45 (7) Sex Male 475 (78) Female 136 (22)
HCV-associated hospitalizations Oregon, 2008-12 (n=3,917) Characteristic Finding Age 83% aged 45-64 years only 8% were > 65 years Sex 2/3 male Payer 30% Medicare 32% Medicaid
Percent of Hospitalizations Categories of advanced liver disease in patients with HCV-related hospitalizations, Oregon, 2008-12, (n=3,917) 80 70 60 50 40 30 20 10 0 75 76 22 15 3
Mean length of stay and healthcare charges per admission, HCV-related hospitalizations Oregon, 2008-12 (n= 3,917) Condition Mean length of hospital stay in days Mean healthcare charges per admission Cirrhosis (n=2,919) 4.4 $23,942 Decompensated Cirrhosis (n=2,969) 4.9 $27,234 Other chronic liver disease (849) 4.4 $22,230 Liver cancer (N=597) 5.1 $34,281 Liver Transplant (n=103) 6.9 $52,245 Average charges per hospitalization were $26,961 and the total average charges per year were $21,149,111
Number of Transplants Annual number of liver transplants performed at OHSU by etiology, 2009 2013 45 40 35 30 25 20 15 10 5 0 2009 2010 2011 2012 2013 Other 15 7 22 13 15 HCV 16 19 18 21 17 HBV 1 2 2 1 0 34 transplants performed on average annually; 18 (53%) for HCV
Age-adjusted Rates per 100,000 Age-adjusted mortality from HCV and HIV in Oregon and from HCV nationally, 1999-2013 Age-adjusted mortality rates 12.00 10.00 8.00 6.00 4.00 83% of HCVrelated deaths were in persons aged 45-64 years Only 16% were > 65 years 2.00 0.00 OR HCV US HCV OR HIV 15
The Majority of Patients are Asymptomatic Symptoms of HCV may include: Fatigue Nausea Poor appetite/weight loss Muscle and joint pains/weakness Jaundice Abdominal pain or swelling Dark urine Itching Fluid retention Some patients may not have any symptoms for up to 20 years, and yet have liver disease progression CDC. http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed June 2011.
Pts (%) Hepatitis C Virus (HCV) in the US: Gaps in Current Practice 100 100% 80 60 50% 43% 40 27% 20 17% 16% 9% 0 Chronic Diagnosed HCV Infected and Aware Access to Outpatient Care HCV RNA Confirmed Underwent Liver Biopsy Prescribed HCV Treatment Achieved Sustained Viral Response n = 3,500,000 1,743,000 1,514,667 952,726 581,632 555,883 326,859 Yehia BR, et al. PLoS One. 2014;9:e101554.
Primary Care Clinicians Have a Critical Role in Hepatitis C Care US prevalence of hepatitis C infection [1] 2% Average pt load for primary care clinician [2] x 2000 pts Average primary care clinician has 40 pts with hepatitis C infection in his/her practice [2] 1. Chak E, et al. Liver Int. 2011;31:1090-1101. 2. Ferrante JM, et al. Fam Med. 2008;40:345-351.
Prevalence of Hepatitis C Positive (%) Hepatitis C Prevalence is Increased in Baby Boomers Prevalence of Hepatitis C Antibody Positivity in US Population by Sex by Yr of Birth (NHANES III) [1] 10 8 6 4 2 Screening recommended Male Female 0 1910-19 1920-29 1930-39 1940-49 1950-59 1960-69 1970-79 1980-89 1990-99 Yr of Birth Iwasaki K, et al. ISPOR 2010. Abstract PG17.
CDC, USPSTF, and AASLD/IDSA HCV Screening Recommendations Population Recommendation Age One-time screening is recommended for persons born between 1945 and 1965, without ascertainment of HCV risk [1-3] Risk One-time screening is recommended for persons with these risk factors [1,3] : History of illicit injection drug use (IDU) or intranasal illicit drug use History of long-term hemodialysis Receiving a tattoo in an unregulated facility/setting Healthcare workers upon accidental exposure Children born to anti-hcv positive mothers History of transfusion with blood or organ transplantation Were ever in prison HIV infection Chronic liver disease/hepatitis with unknown cause, including elevated liver enzymes Annual screening is recommended for current IDUs and HIV-infected MSM [3] 1. Smith BD, et al. MMWR Recomm Rep. 2012;61(RR-4):1-32. 2. US Preventive Services Task Force. HCV Screening Guidelines 2013. 3. AASLD-IDSA. HCV Guidelines 2016.
Recommended Testing Sequence for Identifying Current HCV Infection HCV antibody test Reactive HCV RNA test Detect ed Current HCV infection Provide care or link to care Nonreactive Not detected Stop No current HCV infection Additional testing as appropriate CDC. MMWR Morb Mortal Wkly Rep. 2013;62:362-365.