Epidemiology and Outcomes of Hepatitis C Infection in Elderly US Veterans

H. B. El-Serag; J. Kramer; Z. Duan; F. Kanwal


J Viral Hepat. 2016;23(9):687-696. 

In This Article

Abstract and Introduction


The chronic hepatitis C (CHC) cohort in the United States is getting older. Elderly patients with CHC may be at a high risk of cirrhosis and hepatocellular carcinoma (HCC), but also other nonhepatic comorbidities that negatively impact their likelihood of receiving or responding to antiviral treatment. There is little information on the clinical epidemiology or outcomes of CHC and its treatment in the elderly. We conducted a retrospective cohort study of 1 61 744 patients with a positive Hepatitis C virus RNA in the Veterans Health Administration Hepatitis C Clinical Case Registry to examine the association between age subgroups (20–49, 50–64, 65–85 years) and risk of cirrhosis, HCC or death using Cox proportional hazards models. We also examined the effect of treatment with a sustained viral response (SVR) on these outcomes in each age subgroup. The age distribution was 36.8% 20- to 49-year-olds, 57.6% 50- to 64-year-olds and 5.6% 65- to 85-year-olds (i.e. elderly). Risk of cirrhosis, HCC and death was significantly elevated in elderly patients [HR cirrhosis = 1.14 (1.00–1.29), HR HCC = 2.44 (1.99–2.99); HR death 2.09 (1.98–2.22)] compared with younger patients. The incidence of HCC was than 8.4 per 1000 PY in the elderly compared with 2.6 per 1000 PY and 5.7 per 1000 PY, among the 20–49 and 50–64 age groups, respectively. Elderly patients were significantly less likely to receive antiviral treatment (3.8% vs 14.8% and 19.1%, P < 0.0001), but among those who received treatment SVR was not different among the age groups (33.5% vs 33.2% and 32.1%). In an analysis limited to those who received treatment, SVR compared to treatment receipt with no SVR was associated with a reduction in risk of developing cirrhosis (HR = 0.34; 0.18–0.66) and HCC (HR = 0.60; 0.22–1.61) and all-cause mortality risk (HR = 0.52, 0.33–0.82). Elderly patients with CHC are more likely to develop HCC than younger patients but have traditionally received less antiviral treatment than younger patients. However, receipt of curative treatment is associated with a benefit in reducing cirrhosis, HCC and overall mortality, irrespective of age.


Chronic hepatitis C (CHC) is a common and progressive condition. The current prevalence of CHC in the United States is estimated to be at least 3.5 million (range 2.5–4.7) individuals[1] and expected to decline to about half this number by 2030. Although the decline in overall hepatitis C infections is encouraging, other trends are of concern. CHC in the United States is typically thought of as a disease of young and middle-aged persons, but this age pattern is changing. Based on the known hepatitis C virus (HCV) acquisition time (i.e. 1960s–1980s) and age of acquisition (i.e. 20–40 years) of most infected persons in the United States, the proportion of elderly with CHC (i.e. 60 years and older) is expected to increase over time, especially as we head into the 21st century. Furthermore, it is estimated that at least one-third of patients with CHC will progress to advanced fibrosis and cirrhosis – a subset at high risk for subsequent complications, including hepatocellular cancer (HCC).[2,3]

The age of those with cirrhosis and its complications will also continue to rise. Because about 40 years elapse from the peak incidence years of HCV infection until the peak prevalence of cirrhosis and other complications, the group of persons aged 60–80 years will be most affected with complicated CHC. Indeed, emerging data support the contention of increasing CHC complications in a growing segment of elderly patients. Thabut and colleagues from France reported that cirrhosis was more prevalent in the elderly, of whom 14% presented with decompensation, compared with just 4% in persons younger than 65 years.[4] Furthermore, HCC in persons older than 65 years with CHC has doubled during the last several years.[5]

In addition to the rising CHC prevalence and its complications, the elderly with CHC constitutes a particularly vulnerable group. They may have a disproportionately high proportion of patients with nonhepatic comorbidities (e.g. cardiac and renal disease) and, thus, low likelihood of receiving HCV antiviral treatment, especially that containing interferon and ribavirin.[6] On the other hand, the elderly with CHC may have less alcohol and drug use and greater willingness or ability to start and adhere to antiviral treatment. Importantly, advancing age in itself is a consistent risk factor for progression to advanced stages of fibrosis and HCC in the presence of active viremia, and even after achieving treatment-related sustained virological response (SVR).

There is little information on the clinical epidemiology or outcomes of elderly with CHC or on the effect of antiviral treatment in this group. Older patients are underrepresented in clinical trials, and this has further limited our knowledge of effectiveness of HCV treatment (e.g. receipt, and viral clearance and associated outcomes) in this group. Additional information on CHC in the elderly is required for better planning and targeting of this group with the new directly acting antivirals. We examined the effect of age on outcomes (cirrhosis, HCC, death) with and without antiviral treatment in a large national cohort of CHC patients seen in Veterans Health Administration (VHA) facilities.