Acute Hepatitis C Infection in Young Persons Who Use Drugs

Scott Holmberg, MD


January 11, 2016

Editorial Collaboration

Medscape &

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I appreciate this opportunity to describe what we are calling the "emerging epidemic" of hepatitis C virus (HCV) infection among persons who inject drugs (PWIDs). After several years of plateaued HCV incidence—generally 800-1000 new reported cases of acute HCV infection every year from 2003 through 2009—CDC started noting an increasing rate of acute HCV infection in 2010 that essentially doubled the incidence to more than 2100 cases by 2013.[1] Because many people with acute HCV infection have no symptoms and may not be detected, evaluated, and subsequently reported to state health departments or CDC, we believe that these reports represent the tip of an iceberg and that almost 30,000 cases of acute HCV infection are now occurring yearly.[2] What has been fueling this worrisome increase?

Early investigation in Massachusetts of persons with any diagnosis of HCV—acute or chronic—showed that many were occurring in young persons, usually younger than 24 years old. An investigation of these young persons showed that almost all were non-Hispanic, white PWIDs living in rural or suburban communities.[3] Unlike the hepatitis C or HIV infections seen in injection-drug users in the past, these were almost as likely to be female as male. Perhaps the most notable feature was that most had started drug use by abusing oral prescription opioid drugs, such as oxycodone or OxyContin®, and then transitioned to often cheaper and more readily available injectable heroin. Subsequent CDC studies in Wisconsin, Michigan, and Ohio confirmed these same characteristics of the HCV epidemic in those states.[4] Newly or recently infected persons were generally young, usually white, living in nonurban communities, and of roughly equal gender distribution. In more than 400 interviews conducted to date, the average age of initial use of oral prescription opioids was 18 years, and followed by heroin use before age 20.[4] In several instances, injection drug use was a "family affair," with two or even three generations of injection-drug users living in the same household.

When rates of acute HCV infection reported to CDC were mapped for 2006 and 2012, increased infection rates were found in 30 states, with 15 states reporting more than a 200% increase in cases from 2006 to 2012. Those 15 states were heavily weighted east of the Mississippi, and county-level maps showed twofold or more increases in rural counties centered in Appalachia, specifically in Kentucky, Tennessee, Virginia, and West Virginia.[4,5] However, other substantial increases were seen in rural counties of Midwestern and New England states. Studies mapping where opioid overdose deaths were occurring corroborate that these same communities were suffering other sequelae of drug addiction. Also, although the greatest increases were seen in young people in rural areas, increases were also seen in persons older than age 30 years and in those living in urban communities.

As a practical matter, this emerging epidemic of HCV in young rural persons can be addressed only by rapid identification of these primarily marginalized youth, ensuring that they are tested for hepatitis C, HIV, and other diseases, and facilitating their access to care and treatment for both their drug use and HCV infection. To this end, CDC and other governmental and nongovernmental entities are performing demonstration projects to increase the number of PWID who are identified with HCV infection and are referred to appropriate care and treatment.

Thank you for your attention.

Web Resource

CDC Viral Hepatitis—Hepatitis C Information: Professional Resources

Scott Holmberg, MD, is the chief of the Epidemiology and Surveillance Branch, Division of Viral Hepatitis, CDC. His unit is responsible for national surveillance, outbreak investigations, and several studies of hepatitis A through E. Major current projects include the Chronic Hepatitis Cohort Study (CHeCS) involving 3500 patients with hepatitis B and 13,000 patients with hepatitis C at four urban healthcare systems; analysis of National Health and Nutrition Examination Survey data from > 5000 randomly selected households per year in the United States; the TIPS project, examining young rural injection drug users; and analyses of several large national data sets related to hepatitis morbidity and mortality.

Dr Holmberg's work with outbreaks started as a Peace Corps volunteer in Ethiopia (1971-1973) in the World Health Organization Smallpox Eradication Programme, after undergraduate studies at Harvard University. Thereafter, he attended Columbia University's College of Physicians and Surgeons (1975-1979); trained in internal medicine at Roger Williams Hospital, Providence, Rhode Island (1979-1982); and worked in CDC's Epidemic Intelligence Service (1982-1985). For 19 years (1986-2005), Dr Holmberg was chief of the Clinical Epidemiology Section in CDC's Division of HIV/AIDS Prevention, where he started and supervised many large studies of HIV/AIDS, including large cohort studies of HIV clinic patients generally (the HIV Outpatient Study [HOPS]), and of women, gay men, and injection drug users specifically.

Dr Holmberg has authored or coauthored over 250 medical journal articles and a book on scientific controversies in the HIV/AIDS epidemic, and he has received several high US Public Health Service and CDC awards.