Prevalence and Challenges of Liver Diseases in Patients with Chronic Hepatitis C Virus Infection

Ira M. JAcobson; Gary L. Davis; Hashem El–Serag; Francesco Negro; Christian trépo

Disclosures

Clin Gastroenterol Hepatol. 2010;8(11):924-933. 

In This Article

Prevalence, Identification of at-risk Individuals, and Effects on Life Expectancy

Various estimates of HCV prevalence in the US population place the number of infected individuals (as defined by anti-HCV antibody positivity) at between 4.1 and 5 million. Of these, 3.2–3.4 million are chronically infected.[17,18] During the first 10–20 years of infection HCV-infected individuals generally experience asymptomatic or mild illness,[19] which explains why an estimated 75% of infections remain undiagnosed in the United States.[15,20] Despite a decline in the number of new US cases of HCV infection from a peak of an estimated 262,000/year in 1986 to 17,000/year in 2007,[21] the prevalence of individuals infected with HCV for more than 20 years is expected to continue to increase until 2015.[22] In the National Health and Nutrition Examination Survey (NHANES; 1999–2002), patients aged 40–49 years accounted for 66% of American HCVinfected patients, and the prevalence of HCV infection in the United States was 2.7 times higher among 40- to 49-year-olds than the general population (Figure 1).[17] This "baby boomer" generation is particularly susceptible to blood-borne HCV transmission as a result of an increased lifetime risk of injection drug use (IDU), blood transfusion before 1992, or sexual activity with ≥20 partners, compared with older or younger patients.[23,24] The prevalence of HCV infection varies by age, sex, and race/ethnicity, and early identification of at-risk individuals through routine questioning by clinicians is critical, because management options are limited in late-stage disease.[24]

Figure 1.

Prevalence of HCV antibodies by age group (A) and year of birth (B) in the 1988–1994 and 1999–2002 NHANES. Vertical bars, 95% confidence intervals. Adapted with permission from Armstrong et al 2006.17

After 30 years of infection, an estimated 15%–35% of patients will develop cirrhosis (5-year survival, 75%–80%);[6] after 40 years, up to 60% could have cirrhosis. Given the high prevalence of HCV infection among 40- to 49-year-olds[17] and that Americans are now expected to live into their mid-70s or beyond, the incidence of complications of HCV infections can be expected to further increase in coming years. In fact, from 1995–2004, US HCV-related mortality already increased 123% from 1.09/100,000 to 2.44/100,000 persons, although this study has some limitations.[25] Furthermore, the proportion of CHC patients in the United States with cirrhosis is projected to rise from 25% in 2010 to 45% in 2030.[8] Projections also estimate that without effective treatment, the annual number of US patients with cirrhosis, hepatic decompensation, or HCC will roughly double by 2020, and liver-related deaths will almost triple (Table 1).[26] Although not all data agree with these estimates,[5] several studies have suggested that HCV infection could have a deleterious effect on population mortality rates and life expectancy.[27,28] HCV increased the risk of death in several analyses, irrespective of comorbidities such as coinfection with human immunodeficiency virus (HIV)[29] or hepatitis B virus (HBV)[30,31] and even after adjustment for alcohol consumption.[32] Furthermore, numerous studies[33–37] and a Cochrane review[38] indicated that achievement of an SVR through effective antiviral therapy can significantly reduce mortality in patients with chronic HCV. If all HCV-infected patients were treated with currently available treatment in 2010, liver-related HCV-associated deaths could be reduced by 36% by 2020,[8] whereas antiviral treatment rates are currently declining. Improvements in diagnosis and treatment are therefore necessary to reduce the associated public health burden.[15,39]

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