Evaluation of Acute Hepatitis C Infection Surveillance — United States, 2008

RM Klevens, DDS; RA Tohme, MD

Disclosures

Morbidity and Mortality Weekly Report. 2010;59(43):1407-1410. 

In This Article

Editorial Note

The findings in this report show that the quality of data from NNDSS is not on par with data reported from EIP surveillance sites. Clinical and risk factor information for a substantial proportion of the cases was missing from NNDSS. As shown in previous studies, NNDSS had a substantial proportion of cases with missing data on race and ethnicity.[4,5] Hepatitis C disproportionately affects non-Hispanic blacks compared with persons of other races.[1] Therefore, surveillance data should include race and ethnicity information to reduce disparities through targeted prevention programs.[4] In addition, because of limited resources, several states are not able to handle the volume of laboratory case reports received, which affects timeliness of reporting. In 2009, a total of 27 jurisdictions had backlogs of HCV data, with an average of 6,200 reports that needed to be entered.[3] Accurate, timely, and complete surveillance data are needed to identify and respond to outbreaks in a timely fashion, to guide and evaluate prevention strategies, and to allow for the early initiation of treatment, leading to an ultimate decrease in health-care costs.

Health departments using EIP enhanced surveillance have shown its effectiveness in identifying clusters or outbreaks of hepatitis C infection. For example, the New York State Department of Health detected a cluster of 20 hepatitis C infections among young injection-drug users by conducting enhanced surveillance of HCV infections reported among persons aged <30 years.[6] Similarly, EIP enhanced surveillance of acute hepatitis C infections allowed the identification of health-care–associated acute hepatitis C outbreaks.

Early identification of acute hepatitis C infection is essential to prevent chronic infections and subsequent liver cancer and associated health-care costs. In fact, early treatment of hepatitis C prevents chronic disease in more than 90% of persons treated during the acute phase of the infection[7,8] and more than doubles the chance of achieving a sustained virologic response (absence of HCV RNA 24 weeks after discontinuation of therapy reflecting absence of viremia and normal liver function), compared with that achievable by treating chronic hepatitis C infection.[9] The rate of achieving a sustained virologic response is inversely associated with time from acute HCV infection diagnosis.[9] In addition, early treatment contributes to lower health-care costs compared with later treatment.[8]

The findings in this report are subject to at least four limitations. First, the data for timeliness calculation were missing from the majority of NNDSS cases, and this might have led to an overestimation of timeliness in NNDSS. Second, estimates of timeliness would have been improved if CDC had been able to assess the duration between diagnosis and reporting to the local rather than the state health department. However, this information was not available from NETSS. Third, the states where enhanced reporting of acute hepatitis C was implemented were not selected at random; consequently, the observed differences between the performances of the NNDSS and EIP surveillance systems might not all be attributable to differences between the surveillance systems themselves. Finally, this report could not assess the proportion of missed diagnoses of acute HCV infections at the provider level, which would contribute to underreporting of cases to both NNDSS and EIP.

The comparison of NNDSS (a passive surveillance system) with EIP (an enhanced surveillance system) indicates that accuracy and timeliness of reporting for acute HCV infections were improved through enhanced surveillance. Expanding enhanced surveillance for acute hepatitis C to the national level would detect an estimated additional 22% of acute hepatitis C cases. However, because of budget constraints, enhanced surveillance for acute HCV infections is not implemented nationwide.

The Institute of Medicine report recommended a surveillance system comparable to that of human immunodeficiency virus (HIV) surveillance.[3] HCV and HIV infections are similar in that many of the cases are asymptomatic and early identification and initiation of treatment would prevent transmission, complications, and deaths. However, although HIV case ascertainment requires a single laboratory test, ascertainment of a single case of acute HCV infection requires an average of four laboratory reports.[10] Based on the findings described in this report, additional resources for acute hepatitis C surveillance could enhance substantially the quality of the data on which prevention interventions are based, and in turn, could reduce morbidity and mortality associated with HCV infection. Nonetheless, a cost-benefit analysis to assess the usefulness of implementing EIP enhanced surveillance for acute hepatitis C at the national level is needed.

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