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