Underascertainment of acute hepatitis C virus infections in the U.S. surveillance system: a case series and chart review.

BACKGROUND: In 2010, the incidence of hepatitis C virus (HCV) infection in the United States was estimated to be 17 000 cases annually, based on 850 acute HCV cases reported to the Centers for Disease Control and Prevention by local public health authorities. Absence of symptomatic disease and lack of a specific laboratory test for acute infection complicates diagnosis and surveillance. OBJECTIVE: To validate estimates of the incidence of acute HCV infection by determining the reporting rate of clinical diagnoses of acute infection to the Massachusetts Department of Public Health (MDPH) and Centers for Disease Control and Prevention. DESIGN: Case series and chart review. SETTING: Two hospitals and the state correctional health care system in Massachusetts. PATIENTS: 183 patients clinically diagnosed with acute HCV infection from 2001 to 2011 and participating in a research study. MEASUREMENTS: Rate of electronic case reporting of acute HCV infection to the MDPH and rate of subsequent confirmation according to national case definitions. RESULTS: 149 of 183 (81.4%) clinical cases of acute HCV infection were reported to the MDPH for surveillance classification. The MDPH investigated 43 of these reports as potential acute cases of HCV infection based on their surveillance requirements; ultimately, only 1 met the national case definition and was counted in nationwide statistics published by the Centers for Disease Control and Prevention. Discordance in clinical and surveillance classification was often related to missing clinical or laboratory data at the MDPH as well as restrictive definitions, including requirements for negative hepatitis A and B laboratory results. LIMITATION: Findings may not apply to other jurisdictions because of differences in resources for surveillance. CONCLUSION: Clinical diagnoses of acute HCV infection were grossly underascertained by formal surveillance reporting. Incomplete clinician reporting, problematic case definitions, limitations of diagnostic testing, and imperfect data capture remain major limitations to accurate case ascertainment despite automated electronic laboratory reporting. These findings may have implications for national estimates of the incidence of HCV infection. PRIMARY FUNDING SOURCE: National Institutes of Health.

Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012.

BACKGROUND: Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the US epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). METHODS: We examined trends in incidence of acute hepatitis C among young persons reported to the Centers for Disease Control and Prevention (CDC) during 2006-2012 by state, county, and urbanicity. Sociodemographic and behavioral characteristics of HCV-infected young persons newly reported from 2011 to 2012 were analyzed from case interviews and provider follow-up at 6 jurisdictions. RESULTS: From 2006 to 2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in nonurban counties (P = .003) vs 5% annually in urban counties (P = .028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in nonurban counties east of the Mississippi River. Of 1202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. CONCLUSIONS: These data indicate an emerging US epidemic of HCV infection among young nonurban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in nonurban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention.

An epidemiologic update on hepatitis C infection in persons living with or at risk of HIV infection.

Due to shared routes of transmission, coinfection with both human immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV) is relatively common and results in accelerated liver disease, driving morbidity and mortality. Deaths related to HCV now exceed deaths related to HIV in the United States, and co-infected patients bear a significant proportion of that mortality. This burden may be addressed by novel antiviral therapies that promise increased rates of cure or by enhanced access to liver transplantation, but these are costly interventions. Ultimately, the future burden of coinfection is addressed by greater understanding of who is at risk for development of each infection, thus guiding preventive efforts. Key recent reports regarding the US burden of morbidity and mortality due to HCV and groups at risk for coinfection are reviewed, with a focus on recently described HCV occurring among young injection drug users and men who have sex with men. Given the lack of available vaccine against HCV, enhanced detection and surveillance is a vital component of our public health strategy to combat HCV.

Enhancing surveillance for hepatitis C through public health informatics.

Disease surveillance for hepatitis C in the United States is limited by the occult nature of many of these infections, the large volume of cases, and limited public health resources. Through a series of discrete processes, the Massachusetts Department of Public Health modified its surveillance system in an attempt to improve timeliness and completeness of reporting and case follow-up of hepatitis C. These processes included clinician-based reporting, electronic laboratory reporting, deployment of a Web-based disease surveillance system, automated triage of pertinent data, and automated character recognition software for case-report processing. These changes have resulted in an increase in the timeliness of reporting.

Debunking the myth: low knowledge levels of HBV infection among Asian American college students.

OBJECTIVE: To examine the hepatitis B virus (HBV)-related knowledge among Asian American college students and to determine whether there are significant differences in the level of HBV knowledge among Asian American subgroups. METHODS: A cross-sectional survey was self-administered to assess a sample of 258 Asian American students' knowledge about HBV at the campus of the research site. RESULTS: Knowledge regarding transmission and consequences of HBV infection was poor. Of a possible knowledge score of 14, the median number of correct answers was eight. There were no significant differences between the subgroups of Asian American college students in total knowledge of HBV infection. CONCLUSION: The findings of this study point to the fact that the lack of knowledge and awareness is not limited to community settings only but also includes higher education environment. This finding brings to the forefront the importance of HBV education for Asian American college students.

The Massachusetts HIV, hepatitis, addiction services integration (HHASI) experience: responding to the comprehensive needs of individuals with co-occurring risks and conditions.

Categorical funding mechanisms traditionally used to fund public health programs are a challenge to providers serving individuals with complex needs that often span multiple service areas. Integration--a formalized, collaborative process among service systems--responds to the challenge by decreasing fragmentation of care and improving coordination. In 2000, the Massachusetts Department of Public Health (MDPH) received a one-year planning grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to evaluate opportunities for integrating HIV/AIDS programs and substance abuse treatment programs. The project was later expanded to include viral hepatitis programming. Outcomes include the development of a strategic plan, joint procurement initiatives, and an ongoing commitment to sustain inter-bureau integration efforts, even in the face of substantial budget reductions. Integrated approaches can promote greater efficiency, improving communication and coordination among clients, providers, and government funding agencies.

Hepatitis B virus infection and immunizations among Asian American college students: infection, exposure, and immunity rates.

OBJECTIVES: To evaluate the prevalence of hepatitis B virus (HBV) infection, exposure, and immunity among Asian American college students as a basis for evaluating HBV screening and vaccination policy. PARTICIPANTS AND METHODS: Self-identified Asian American college students aged 18 years or older were examined. Serological tests of HBV surface antigens, antibodies to HBV core antigens (anti-HBc), and antibodies to HBV surface antigens (anti-HBs) were used to determine HBV infection and immunization prevalence. RESULTS: Among US-born students (n = 66), none was infected with HBV, 68% (n = 45) had immunity from vaccination, and 1 student had evidence of past exposure to HBV. Among foreign-born students (n = 142), 4% (n = 5) had evidence of chronic HBV infection, 62% (n = 88) had immunity from vaccination, and 19% (n = 27) had results indicating past exposure to HBV. Asian American college students showed very little knowledge of HBV vaccination; 43% reported that they had received vaccination, whereas 50% did not know whether they had received it or not. CONCLUSIONS: The prevalence of current and past HBV infection among foreign-born Asian American college students is significantly higher (p < .01), than US-born students. The lack of awareness of their HBV-infected status points out the importance of routine HBV screening of high-risk populations such as Asian students.

Hepatitis C prevention with nurses.

A state campaign to educate nurses about hepatitis C and encourage nurses to fight the epidemic provided an opportunity to assess the relationship between information and safety practices. Baseline and follow-up surveys were sent to random, representative samples (n = 6000) of licensed nurses in Massachusetts, USA. Responses received by 42% (n = 2443) at baseline and 37% (n = 2167) at follow-up were compared to explore the relationship between receiving information and propensity to counsel patients or use safety equipment. Only data from nurses in direct patient care were analyzed. Although few changes were observed, the assessment provided further evidence that more than a single intervention is needed to achieve health behavior change. The number of nurses who never used safety equipment did decrease slightly, from 13.3% (191) to 8.2% (132), and nurses who received information were more likely to talk to patients about the virus: 49% (414) compared to 21% (120). Hepatitis information aimed at nurses may help control this emerging epidemic.