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
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.
Death 2–4%/year
Cirrhosis 10%–20%
Decompensation3–6%/year
HCC1–4%/year
Acute Hepatitis C
Chronic Hepatitis 60%–85%
20–40 years
Prevalence of Chronic Hepatitis C Infection
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.
In the US, 2.7–3.9 million people are living
with chronic HCV infection;
75% are unaware they are infected
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.
Incarcerated
~ 330,000 to 860,000
(16–41%)1
Homeless
~ 175,000 (22%)7
Children
(6–18 years old)
~ 100,000 (0.1%)9
Living below poverty
level ~ 940,000
(3.2%)6
Injection drug users
~ 300,000
(80–90%)2,3
Alcoholics
~ 240,000
(11–36%)5
Veterans
~ 280,000 (4%)8
HIV-infected
~ 300,000
(30%)4
Male
63%37%
Female
Prevalence of HCV in Select Populations
Projected Cases of Hepatocellular Carcinoma
and Decompensated Cirrhosis Due to HCV
Davis GL, et al. Gastroenterology. 2010;138(2):513-521
1950 1960 1970 1980 1990 2000 2010 2020 2030
Year
Nu
mb
er
of
cases
160,000
0
140,000
120,000
100,000
80,000
60,000
40,000
20,000
Decompensated
cirrhosis
Hepatocellular cancer
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
• In 2012, 8% of liver cancer cases had chronic HBV,while 47% had chronic HCV
0
50
100
150
200
250
300
350
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
HCV (n=763)
HBV (n=196)
Not Hepatitis
Age and sex of cases of HCV-
associated liver cancer, 2008-12HCV-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
Categories of advanced liver disease in
patients with HCV-related
hospitalizations, Oregon, 2008-12,
(n=3,917)
75 76
22 15 30
1020304050607080
Perc
en
t o
f H
osp
itali
zati
on
s
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
Annual number of liver transplants
performed at OHSU by etiology,
2009–2013
2009 2010 2011 2012 2013
Other 15 7 22 13 15
HCV 16 19 18 21 17
HBV 1 2 2 1 0
05
1015202530354045
Nu
mb
er
of
Tra
nsp
lan
ts
34 transplants performed on average annually; 18 (53%) for HCV
Age-adjusted mortality from HCV and HIV in
Oregon and from HCV nationally,
1999-2013
15
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Ag
e-a
dju
ste
d R
ate
s p
er
10
0,0
00
Age-adjusted mortality rates
OR HCV US HCV OR HIV
• 83% of HCV-
related deaths
were in persons
aged 45-64 years
• Only 16% were >
65 years
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.
Hepatitis C Virus (HCV) in the US:
Gaps in Current Practice
Yehia BR, et al. PLoS One. 2014;9:e101554.
Pts
(%
)
n = 3,500,000 1,743,000 1,514,667 952,726 581,632 555,883 326,859
0
20
40
60
80
100
ChronicHCV Infected
Diagnosedand
Aware
Access to Outpatient
Care
HCV RNAConfirmed
UnderwentLiver
Biopsy
Prescribed HCV
Treatment
AchievedSustained Viral
Response
100%
50%
43%
27%
17% 16%9%
Primary Care Clinicians Have a Critical
Role in Hepatitis C Care
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]
US prevalence of hepatitis C
infection[1]
2%
1. Chak E, et al. Liver Int. 2011;31:1090-1101. 2. Ferrante JM, et al. Fam Med. 2008;40:345-351.
Hepatitis C Prevalence is Increased in
Baby Boomers
Iwasaki K, et al. ISPOR 2010. Abstract PG17.
Prevalence of Hepatitis C Antibody Positivity in US Population by Sex by Yr of
Birth (NHANES III)[1]
Screening
recommended
Pre
vale
nce o
f H
epatitis C
Positiv
e (
%)
0
2
4
6
8
10
1910-19 1920-29 1930-39 1940-49 1950-59 1960-69 1970-79 1980-89 1990-99
Yr of Birth
Male
Female
CDC, USPSTF, and AASLD/IDSA HCV Screening
RecommendationsPopulation 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
CDC. MMWR Morb Mortal Wkly Rep. 2013;62:362-365.
HCV
antibody test
Provide
care or
link to
care
Reactive
Nonreactive
Stop
HCV RNA
testDetect
ed
Not detected
No current
HCV
infection
Current HCV
infection
Additional testing as
appropriate