February 21, 2012 — Hepatitis C viral infection (HCV) has surpassed HIV as a cause of mortality in the United States, according to a new study from the US Centers for Disease Control and Prevention (CDC), published in the February 21 issue of the Annals of Internal Medicine.
Termed the "silent epidemic," HCV is the most common blood-borne chronic viral infection. It affects about 3.2 million Americans and represents a leading cause of liver disease, cirrhosis, and death.
Using death certificate data from about 22 million decedents from between 1999 and 2007, investigators found that recorded deaths from HCV increased significantly, whereas those linked to HBV remained constant, and HIV-associated mortality decreased.
Almost 75% of HCV-related deaths occurred among baby boomers (individuals born between 1945 and 1964), who may have experimented with substances in their youth. Many are unaware of the infection, suggesting that the burden of disease will continue to rise unless policies for education, detection, and treatment are implemented in a manner similar to that used during the HIV epidemic.
"The decrease in deaths from HIV infection in the past decades reflects the availability and utilization of highly effective therapies, as well as effective national implementation of programs for prevention and care," write Kathleen N. Ly, MPH, from the Division of Viral Hepatitis, CDC, Atlanta, Georgia, and colleagues, noting that a similar approach to HCV might lead to similar reductions in mortality over time.
HCV Mortality Rate Exceeds That of HIV
For the study, investigators analyzed data from about 21.8 million death certificates (~2.4 million/year between 1999 and 2007) and found a significant increase in annual age-adjusted mortality rate resulting from HCV (0.18 deaths per 100,000 individuals; P = .002).
In contrast, the annual age-adjusted mortality rate for HBV-related deaths remained relatively constant, decreasing slightly by 0.02 deaths/100,000 individuals (P = 0.25), whereas that for deaths related to HIV infection decreased significantly by 0.21 deaths/100,000 individuals (P = .001).
By 2007, HCV infection was linked to an age-adjusted mortality rate significantly higher than that of HIV (4.58 deaths/100,000 individuals [95% confidence interval (CI), 4.50 - 4.67 deaths/100,000 individuals] vs 4.16 deaths/100,000 individuals [95% CI, 4.09 - 4.24 deaths/100,000 individuals]; actual deaths, 15,106 vs 12,734).
Moreover, the greatest proportion of HCV-related deaths occurred among baby boomers aged 45 to 64 years (73.4%). Frequently reported comorbid conditions included chronic liver disease (adjusted odds ratio [OR], 32.1; 95% CI, 31.0 - 33.3) and HBV coinfection (adjusted OR, 29.9; 95% CI, 26.5 - 33.6), followed by alcohol-related conditions (adjusted OR, 4.6; 95% CI, 4.4 - 4.8) and HIV infection (adjusted OR, 1.8; 95% CI, 1.6 - 2.0).
Though frightening, the data represent a fraction of the burden of disease and death associated with HCV, the authors write, noting that only 40% to 50% of infected individuals would have been diagnosed at the time of death. Left unaddressed, HCV-related mortality will only increase as the baby-boomer generation ages, they add.
Identification of Asymptomatic HCV Is Key
"It is estimated that 50% to 75% of persons with HCV are unaware of their HCV status," note Harvey J. Alter, MD, and T. Jake Liang, MD, from the National Institutes of Health in Bethesda, Maryland, in an accompanying editorial, noting that most are not addicts but simply people who experimented with drugs for a limited time in their youth.
The good news is that treatments for HCV are evolving so quickly that 5 years from now, interferon-free, oral, direct-acting antiviral regimens may achieve cure rates approaching 90% irrespective of viral genotypes and IL-28B status.
"What is currently lacking in this optimistic perspective is a national 'find-and-treat' policy aimed at achieving maximum identification of HCV carriers and providing new-generation therapies to a large proportion of those identified cases," Dr. Alter and Dr. Liang note.
Chronic Liver Disease Foundation Recommends New Screening Measures
The CDC currently recommends HCV screening only for people found to be at risk for infection, but it is evaluating the potential benefits of using a birth cohort based approach to HCV screening to help increase identification of HCV-positive patients.
The Chronic Liver Disease Foundation is supportive of the concept and has issued the following recommendations in support of the expansion of HCV screening efforts:
Routine screening for HCV among individuals born between 1945 and 1965.
Use of the OraQuick (OraSure) HCV rapid point-of-care test to expand testing opportunities and facilitate immediate care.
Educational programs aimed at primary care providers to increase awareness of HCV risk factors.
Testing for HCV in primary care setting with established linkages to HCV.
Creative ways to increase access to HCV testing and care for injection-drug users and other underserved populations.
Support for this study was provided by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.
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