HCV Killed Nearly 20,000 Americans in 2014

Diana Swift

May 06, 2016

In 2014, HCV deaths in the United States reached an all-time high of 19,659, according to surveillance data issued May 4 by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.

More than half of this rising mortality affected baby boomers, born 1945 to 1964, in the economically productive middle-aged category of 55 to 64 years old.

The CDC surveillance data also pointed to a recent HCV surge, with reported acute cases more than doubling from 850 in 2010 to 2194 in 2014. After adjusting for underascertainment and underreporting, an estimated 30,500 new HCV infections occurred in 2014. Those affected were predominantly young white drug users residing in rural and suburban areas in midwestern and eastern states and having previously used opioids such as oxycodone. Incidence markedly increased in Kentucky, Tennessee, Virginia, and West Virginia.

And in a second CDC analysis, which examined HCV mortality in 2013 and appeared in the May issue of Clinical Infectious Diseases, Kathleen N. Ly, MPH, and colleagues from the CDC's Division of Viral Hepatitis, found that from 2003 to 2013, HCV-associated deaths on death certificates rose from 11,051 to 19,368. Those rates dramatically outpaced total deaths from 60 other nationally notifiable infectious conditions combined, including HIV, tuberculosis, and pneumococcal disease.

The mortality burden represented an average increase of 865 deaths per year, for a mean annual increase of 6.2% (P < .05). Deaths associated with other nationally notifiable infectious conditions dropped from 24,745 in 2003 to 17,915 in 2013, for an average annual decrease of 3.4% (P < .05).

The figures, however, are probably based on underreporting. As Ly and coauthors point out, an analysis of some 1600 deceased patients with HCV found that only 19% had HCV listed anywhere on their death certificates, although 75% had substantial premortem liver disease. Moreover, among HCV-infected patients with a liver-related cause of death, 59% did not have HCV listed as a cause of death.

"Therefore, we believe these data greatly underestimate the true hepatitis C mortality burden," they write.

The number of HCV-related deaths (15,106) first exceeded the number of HIV/AIDS-related deaths (12,734) in 2007 and continued to increase, the CDC surveillance report notes.

Explaining this seemingly unaddressed epidemic, Ly and associates note that many HCV-infected individuals do not get antiviral therapy, with one study reporting only 19% of patients with HCV advancing to treatment, and just 13% completing it.

In a related CDC news release, Jonathan Mermin, MD, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, speculates that the mortality resulting from "this preventable, curable disease" is likely to decline over time in the United States.

"Once hepatitis C testing and treatment are as routine as they are for high cholesterol and colon cancer, we will see people living the long, healthy lives they deserve."

Approximately 3.5 million Americans are currently living with HCV, and approximately half of those do not realize they have the infection because of the long incubation period and often asymptomatic nature of the disease.

The CDC and the US Preventive Services Task Force joined forces in 2013 to recommend one-time HCV testing for all those born from 1945 to 1965, as well as regular testing for high-risk individuals.

"A key public health challenge is to increase the proportion of persons tested, and of those who are currently infected, increase the proportion referred for care and treatment," the CDC commentary states.

"Because hepatitis C often has few noticeable symptoms, the number of new cases is likely much higher than what is reported," said John W. Ward, MD, director of the Division of Viral Hepatitis, in the CDC news release. "We must act now to diagnose and treat hidden infections before they become deadly and to prevent new infections."

Reflecting on the underappreciation of HCV infection in the United States, Ly and coauthors also point to the virus's decades-long asymptomatic incubation period, as well as the lack of cohesive advocacy groups for patients who were often former injectable drug users, and "compassion fatigue" from HIV/AIDS and other acute public health issues. They also note a prevailing "therapeutic nihilism" about the perceived cost of antiviral therapy. "The unabated increasing trend in the number of hepatitis C–related deaths documented from 1999 to 2013, predominantly among middle-aged persons, underscores the urgency in finding, evaluating, and treating patients in the largest infectious disease epidemic in the United States," they write.

This study was supported by the CDC. The authors have disclosed no relevant financial relationships.

>Clin Infect Dis. 2016;62(10):1287-1288. Abstract

"Surveillance for Viral Hepatitis — United States, 2014." CDC. Published online May 4, 2016. Full text

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