An updated assessment of hepatitis delta prevalence among adults in Canada: A meta-analysis.

Foreign-born (FB) persons represent a large proportion of adults with chronic hepatitis B (CHB) in Canada due to higher prevalence rates in countries of birth for FB persons. Suboptimal awareness and low rates of hepatitis delta virus (HDV) testing contribute to underdiagnosis and gaps in accurate estimates of Canada HDV prevalence. We aim to provide an assessment of CHB and HDV prevalence in Canada using a comprehensive literature review and meta-analysis. A comprehensive literature review of articles reporting HBsAg seroprevalence and anti-HDV prevalence was conducted to calculate country-specific rates and pooled prevalence of CHB and HDV using meta-analyses. Country-specific CHB and HDV rate estimates were combined with number of FB persons in Canada in 2021 from Statistics Canada to estimate total numbers of FB with CHB and HDV, respectively. These estimates were combined with estimates of Canada-born persons with CHB and HDV to yield the total number of persons with CHB and HDV. In 2021, we estimated 0.550 million (M) (95% CI 0.488-0.615) persons with CHB; 0.344 M (95% CI 0.288-0.401) were FB and 0.206 M (95% CI: 0.200-0.214) were Canada-born. The weighted average HDV prevalence among FB persons in Canada was 5.19% (17,848 [95% CI 9611-26,052] persons), among whom 50% emigrated from Asia and 31% from Africa. When combined with estimates of Canada-born persons with HDV, we estimate 35,059 (95% CI: 18,744-52,083) persons with HDV in Canada. In conclusion, we estimate 0.550 M and 35,059 persons living with CHB and HDV, respectively, in Canada in 2021.

Hepatitis C Elimination in Rwanda: Progress, Feasibility, and Economic Evaluation.

OBJECTIVES: In 2018, Rwanda launched a national program to eliminate the hepatitis C virus (HCV). We aim to assess the impact of the program to date and identify strategies to achieve the World Health Organization's HCV elimination goals by 2030. METHODS: We developed a microsimulation model to simulate Rwanda's HCV epidemic from 2015 through 2050 and evaluated temporal trends in HCV infection, prevalence, mortality, and the total cost of care for scenarios that could achieve HCV elimination by 2030. RESULTS: Between 2018 and 2022, over 7 million people were screened for HCV, and 60 000 were treated. The study projected that Rwanda could achieve HCV elimination as early as 2027. A feasible strategy of an annual screening rate of 15% and a treatment rate of 100% would achieve all World Health Organization elimination goals by 2028, requiring screening an additional 4 million people and treating 23 900 patients by 2030. The elimination strategy costs $25 million for screening and diagnosis and $21 million for treatment from 2015 to 2050. The national program would avert 4900 hepatocellular carcinoma cases and 6700 HCV-related deaths and save the health system $25.33 million from 2015 to 2050. CONCLUSIONS: Rwanda is poised to become one of the first countries in the world to eliminate HCV. Rwanda's program serves as a blueprint for other countries in the African region. By rapid screening and treatment scale-up (eg, by leveraging HIV platforms) and by drug price negotiations, HCV elimination is not only feasible but can be cost-saving in low-income settings.

Interactions between the sex of the clinician grader and the sex of the chiropractic student intern on spinal manipulation assessment grade.

OBJECTIVE: The purpose of this project was to determine if there was any relationship between the sex of the clinician grader and the sex of the chiropractic student intern on student spinal manipulation assessment grades. METHODS: Twelve thousand six hundred and thirty-one supervised patient adjustments by student interns were analyzed over a 3-year data collection window. Student interns were assessed by multiple male and female clinicians in a teaching clinic using a modified Dreyfus model scoring system on a 1-4 scale (1 = novice, 4 = proficient). A Mann-Whitney U test was used to compare the relationship between grader sex and student grade as well as student sex and student grade. RESULTS: Sex of the grader had a statistically significant effect on spinal manipulation assessment grade, p < .001, with male clinician graders assigning average scores of 2.81 ± 0.39 (mean ± SD) and female clinician graders scores of 3.01 ± 0.52, r = .18. Sex of the student had a statistically significant but negligible (r = .08) effect on spinal manipulation assessment grade, p < .001, with male students averaging slightly higher scores (2.93 ± 0.47) than females (2.86 ± 0.44) on the modified Dreyfus scale. CONCLUSION: Male clinicians tended to assign lower grades on spinal manipulation assessments than female clinicians. Male students on average received slightly higher scores than female students on spinal manipulation assessments.

An Assessment of National Strategic Action Plans for Viral Hepatitis Elimination, 2016-2021.

In 2016, the World Health Organization (WHO) released the Global Health Sector Strategy (GHSS) setting goals for global hepatitis elimination. To inform new or revised viral hepatitis national strategic action plans (NSAPs) for 2022-2030, NSAPs developed during 2016-2021 were assessed for alignment with the WHO GHSS. Country NSAPs were assessed to determine if they included components in the 2016 GHSS. Of 55 country NSAPs, 19 (35%) did not include hepatitis B and C virus elimination goals, only 18 (33%) included targets for needles and syringes for persons who inject drugs, and 21 (38%) had a national budget or financing plan for hepatitis activities. Gaps identified indicate need for technical support in NSAP development.

Hepatitis C Elimination in Moldova Is Feasible and Cost-Saving: A Modeling Study.

BACKGROUND: Moldova, an upper-middle-income country in Eastern Europe, is facing a high burden of hepatitis C virus (HCV). Our objective was to assist the National Agency of Public Health of Moldova in planning to achieve the World Health Organization's HCV elimination goals by 2030. METHODS: This study adapted a previously developed microsimulation model to simulate the HCV epidemic in Moldova from 2004 to 2050. Model outcomes included temporal trends in HCV infection, prevalence, mortality, and total cost of care, including screening and treatment. We evaluated scenarios that could eliminate HCV by 2030. RESULTS: Multiple strategies could lead to HCV elimination in Moldova by 2030. A realistic scenario of a 20% annual screening and 80% treatment rate would require 2.75 million individuals to be screened and 65 000 treated by 2030. Compared to 2015, this program will reduce HCV incidence by 98% and HCV-related deaths by 72% in 2030. Between 2022 and 2030, this strategy would cost $17.5 million for HCV screening and treatment. However, by 2050, the health system would save >$85 million compared to no investment in elimination efforts. CONCLUSIONS: HCV elimination in Moldova is feasible and can be cost saving, but requires resources to scale HCV screening and treatment.

Overcome Health Inequities to Eliminate Viral Hepatitis.

This Viewpoint outlines the progress made toward eliminating hepatitis B and C but emphasizes the work that remains to prioritize diagnosis and treatment of populations disproportionately affected by viral hepatitis, including ensuring that there are systems in place to treat those infected and care for those at risk.

A nationwide cross-sectional review of in-hospital hepatitis B virus testing and disease burden estimation in Ghana, 2016 - 2021.

BACKGROUND AND AIMS: Data are needed to inform hepatitis B virus (HBV) testing and treatment policies in Ghana to make progress towards achieving the 2030 WHO elimination targets. This study investigated testing patterns for HBV and described the age, sex, and region-specific prevalence of HBV infection in Ghana using hospital data. METHODS: A nationwide multi-centre cross-sectional study was performed where hospital-based registers were reviewed. These included review of 139,966 laboratory, 169,048 blood bank, and 83,920 delivery register entries from 22 healthcare institutions in Ghana. Frequencies and proportions, and crude and pooled estimates reported. Chi squared test was used for tests of independence. Logistic regression was used to identify factors associated with a positive test result. RESULTS: The crude HBsAg seroprevalence was 8.48% (95%CI 8.25-8.57%) with pooled estimate of 11.40% (95%CI 10.44-12.35). HBsAg seroprevalence among children under 5 years was 1.87% (95%CI 1.07-3.27) and highest age-specific seroprevalence was in those 40-49 years. The highest region-specific seroprevalences was in the Savannah (22.7%). Predictors of a positive HBsAg RDT test included female sex (OR 0.81 95% CI 0.74-0.88), and age (OR 1.005 95%CI 1.002-1.007). The proportion of parturient women receiving HBsAg testing increased between 2017 (87.2%) and 2020 (94.3%) (p < 0.001). The crude HBsAg seroprevalence in parturient women was 6.14% (95% CI 5.97-6.31). Among blood donors the crude HBsAg seroprevalence was 5.69% (95%CI 5.58-5.80). Data from 2 teaching hospitals indicated that in 2020, although 1500 HBsAg positive tests were recorded only 746 serological profile and 804 HBV DNA tests were performed. HBV e antigen seroprevalence was 6.28% (95%CI 4.73-7.84). CONCLUSION AND RECOMMENDATIONS: Ghana remains a country with high HBV burden. There is an unequal distribution, with higher HBsAg seroprevalence in the north of the country. Furthermore, PCR testing is not widely available outside of large teaching hospitals, which limits diagnostic work-up. Hepatitis reporting systems and registers should be improved to facilitate data capture of indicators and standardised across the country to allow for comparability. Furthermore, where gains have been made in testing among pregnant women, there is a need for linkage to appropriate care.

Evaluation of Oncology Hospital at Home: Unplanned Health Care Utilization and Costs in the Huntsman at Home Real-World Trial.

PURPOSE: Patients with cancer experience high rates of morbidity and unplanned health care utilization and may benefit from new models of care. We evaluated an adult oncology hospital at home program's rate of unplanned hospitalizations and health care costs and secondarily, emergency department (ED) use, length of hospital stays, and intensive care unit (ICU) admissions during the 30 days after enrollment. METHODS: We conducted a prospective, nonrandomized, real-world cohort comparison of 367 hospitalized patients with cancer-169 patients consecutively admitted after hospital discharge to Huntsman at Home (HH), a hospital-at-home program, compared with 198 usual care patients concurrently identified at hospital discharge. All patients met clinical criteria for HH admission, but those in usual care lived outside the HH service area. Primary outcomes were the number of unplanned hospitalizations and costs during the 30 days after enrollment. Secondary outcomes included length of hospital stays, ICU admissions, and ED visits during the 30 days after enrollment. RESULTS: Groups were comparable except that more women received HH care. In propensity-weighted analyses, the odds of unplanned hospitalizations was reduced in the HH group by 55% (odds ratio, 0.45, 95% CI, 0.29 to 0.70; P < .001) and health care costs were 47% lower (mean cost ratio, 0.53; 95% CI, 0.39 to 0.72; P < .001) over the 30-day period. Secondary outcomes also favored HH. Total hospital stay days were reduced by 1.1 days (P = .004) and ED visits were reduced by 45% (odds ratio, 0.55; 95% CI, 0.33 to 0.92; P = .022). There was no evidence of a difference in ICU admissions (P = .972). CONCLUSION: This oncology hospital at home program shows initial promise as a model for oncology care that may lower unplanned health care utilization and health care costs.

An Updated Assessment of Chronic Hepatitis B Prevalence Among Foreign-Born Persons Living in the United States.

BACKGROUND AND AIMS: Although prevalence of chronic hepatitis B (CHB) in the USA includes 0.42 million (range, 0.28-0.67) U.S.-born persons, foreign-born (FB) persons contribute a substantially larger number to the burden of CHB in the USA. Over the past decade, patterns of U.S. immigration have changed and many countries have implemented HBV prevention programs. This study aims to estimate the number of FB persons with CHB in the USA by country of origin, updating our 2011 study. APPROACH AND RESULTS: We performed systematic searches for articles published in 2009-2019 reporting HBsAg seroprevalence in emigrants and in-country populations of 117 countries. Data meeting inclusion criteria were combined with data from our 2011 study to calculate pooled prevalence estimates for 99 countries using meta-analyses (total 2,800 surveys involving 112 million subjects). Combining country-specific CHB rate estimates with the number of FB in the USA in 2018, by country of origin from the U.S. Census Bureau, we estimate that the number of FB with CHB in the USA in 2018 was 1.47 million (95% CI, 1.21-1.73), substantially higher than previously reported. The weighted average CHB prevalence for all FB in the USA in 2018 was 3.07%. Approximately 59% of FB with CHB in the USA in 2018 emigrated from Asia, 19% from the Americas, and 15% from Africa. Subgroup analyses found that for many countries, CHB rates are higher in males than females and have declined over the past three decades, but no consistent pattern is observed between emigrant and in-country rates. CONCLUSIONS: Including FB and U.S.-born persons, the total prevalence of CHB in the USA may be as high as 2.4 million.

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs.

AIMS: To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States. DESIGN: HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective. SETTING: Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings. PARTICIPANTS: PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies. INTERVENTIONS AND COMPARATOR: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID. MEASUREMENTS: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs). FINDINGS: For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis. CONCLUSIONS: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

Estimated cost of comprehensive syringe service program in the United States.

OBJECTIVE: To estimate the cost of establishing and operating a comprehensive syringe service program (SSP) free to clients in the United States. METHODS: We identified the major cost components of a comprehensive SSP: (one-time start-up cost, and annual costs associated with personnel, operations, and prevention/medical services) and estimated the anticipated total costs (2016 US dollars) based on program size (number of clients served each year) and geographic location of the service (rural, suburban, and urban). RESULTS: The estimated costs ranged from $0.4 million for a small rural SSP (serving 250 clients) to $1.9 million for a large urban SSP (serving 2,500 clients), of which 1.6% and 0.8% is the start-up cost of a small rural and large urban SSP, respectively. Cost per syringe distributed varied from $3 (small urban SSP) to $1 (large rural SSP), and cost per client per year varied from $2000 (small urban SSP) to $700 (large rural SSP). CONCLUSIONS: Estimates of the cost of SSPs in the United States vary by number of clients served and geographic location of service. Accurate costing can be useful for planning programs, developing policy, allocating funds for establishing and supporting SSPs, and providing data for economic evaluation of SSPs.

The global campaign to eliminate HBV and HCV infection: International Viral Hepatitis Elimination Meeting and core indicators for development towards the 2030 elimination goals.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) affect more than 320 million people worldwide, which is more than HIV, tuberculosis (TB) and malaria combined. Elimination of HBV and HCV will, therefore, produce substantial public health and economic benefits and, most importantly, the prevention of 1.2 million deaths per year. In 2016, member states of the World Health Assembly unanimously adopted a resolution declaring that viral hepatitis should be eliminated by 2030. Currently, few countries have elimination programmes in place and even though the tools to achieve elimination are available, the right resources, commitments and allocations are lacking. During the fifth International Viral Hepatitis Elimination Meeting (IVHEM), 7-8 December 2018, Amsterdam, the Netherlands, an expert panel of clinicians, virologists and public health specialists discussed the current status of viral hepatitis elimination programmes across multiple countries, challenges in achieving elimination and the core indicators for monitoring progress, approaches that have failed and successful elimination plans.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission.

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

Cost Effectiveness of Universal Screening for Hepatitis C Virus Infection in the Era of Direct-Acting, Pangenotypic Treatment Regimens.

BACKGROUND & AIMS: Most persons infected with hepatitis C virus (HCV) in the United States were born from 1945 through 1965; testing is recommended for this cohort. However, HCV incidence is increasing among younger persons in many parts of the country and treatment is recommended for all adults with HCV infection. We aimed to estimate the cost effectiveness of universal 1-time screening for HCV infection in all adults living in the United States and to determine the prevalence of HCV antibody above which HCV testing is cost effective. METHODS: We developed a Markov state transition model to estimate the effects of universal 1-time screening of adults 18 years or older in the United States, compared with the current guideline-based strategy of screening adults born from 1945 through 1965. We compared potential outcomes of 1-time universal screening of adults or birth cohort screening followed by antiviral treatment of those with HCV infection vs no screening. We measured effectiveness with quality-adjusted life-years (QALY), and costs with 2017 US dollars. RESULTS: Based on our model, universal 1-time screening of US residents with a general population prevalence of HCV antibody greater than 0.07% cost less than $50,000/QALY compared with a strategy of no screening. Compared with 1-time birth cohort screening, universal 1-time screening and treatment cost $11,378/QALY gained. Universal screening was cost effective compared with birth cohort screening when the prevalence of HCV antibody positivity was greater than 0.07% among adults not in the cohort born from 1945 through 1965. CONCLUSIONS: Using a Markov state transition model, we found a strategy of universal 1-time screening for chronic HCV infection to be cost effective compared with either no screening or birth cohort-based screening alone.

Cost and efficacy comparison of five prostate biopsy modalities: a platform for integrating cost into novel-platform comparative research.

BACKGROUND: The cornerstone of prostate cancer diagnosis remains the transrectal ultrasound-guided biopsy (TRUS-BX), which most frequently occurs in the office setting under local anesthesia. However, there are now other techniques of prostate biopsy aimed at improving outcomes such as patient comfort, significant cancer detection, and infectious complications. The purpose of the present study is to compare the cost and efficacy outcomes of five different approaches. METHODS: We compared the comprehensive costs of a random sample size of 20-30 cases from each of the following: (1) local anesthesia TRUS-BX (reference), (2) sedation TRUS-BX, (3) general anesthesia transperineal template biopsy (TP), (4) sedation MRI-TRUS fusion biopsy (FB), and (5) sedation in-bore MRI biopsy (IB-MRI). Cost categories included pre-procedure, anesthesia pharmacy and recovery, and the technical/professional costs from urology, radiology, and pathology services. For procedure outcomes, we compared the larger cohorts of TRUS-BX, TP, and FB in terms of indication, cancer yield, and downstream decision impact. RESULTS: Compared with standard TRUS-BX, the total costs of sedation TRUS-BX, TP, FB, and IB-MRI increased significantly ×1.9 (90%), ×2.5 (153%), ×2.5 (150%), and ×2.2 (125%), respectively (p < 0.001). Although there was no statistical difference between the total costs of TP, FB, and IB-MRI, these costs were significantly higher than those of TRUS-BX under either local anesthesia or sedation (p < 0.05). The cost of TRUS-BX under sedation was significantly higher than that of TRUS-BX under local anesthesia (p < 0.001). Compared to TRUS-BX, more significant cancers were detected in FB (16% vs. 36%) and TP (16% vs. 34%) groups (p < 0.001). CONCLUSIONS: Compared with standard TRUS-BX, the additions of imaging, sedation anesthesia, and transperineal template increase costs significantly, and can be considered along with known improvements in accuracy and side effects. Ongoing efforts to combine imaging and transperineal biopsy, especially in an outpatient/local anesthesia setting may lead to a higher cost/benefit.

Population-level Outcomes and Cost-Effectiveness of Expanding the Recommendation for Age-based Hepatitis C Testing in the United States.

Background: The US Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born 1945-1965 and targeted testing for high-risk persons. This strategy targets HCV testing to a prevalent population at high risk for HCV morbidity and mortality, but does not include younger populations with high incidence. To address this gap and improve access to HCV testing, age-based strategies should be considered. Methods: We used a simulation of HCV to estimate the effectiveness and cost-effectiveness of HCV testing strategies: 1) standard of care (SOC) - recommendation for one-time testing for all persons born 1945-1965, 2) recommendation for one-time testing for adults ≥40 years (≥40 strategy), 3) ≥30 years (≥30 strategy), and 4) ≥18 years (≥18 strategy). All strategies assumed targeted testing of high-risk persons. Inputs were derived from national databases, observational cohorts and clinical trials. Outcomes included quality-adjusted life expectancy, costs, and cost-effectiveness. Results: Expanded age-based testing strategies increased US population lifetime case identification and cure rates. Greatest increases were observed in the ≥18 strategy. Compared to the SOC, this strategy resulted in an estimated 256,000 additional infected persons identified and 280,000 additional cures at the lowest cost per QALY gained (ICER = $28,000/QALY). Conclusions: In addition to risk-based testing, one-time HCV testing of persons 18 and older appears to be cost-effective, leads to improved clinical outcomes and identifies more persons with HCV than the current birth cohort recommendations. These findings could be considered for future recommendation revisions.

State HCV Incidence and Policies Related to HCV Preventive and Treatment Services for Persons Who Inject Drugs - United States, 2015-2016.

Hepatitis C is associated with more deaths in the United States than 60 other infectious diseases reported to CDC combined. Despite curative hepatitis C virus (HCV) therapies and known preventive measures to interrupt transmission, new HCV infections have increased in recent years (1,2). Injection drug use is the primary risk factor for new HCV infections (2). One potential strategy to decrease the prevalence of HCV is to create and strengthen public health laws and policies aimed specifically at reducing transmission risks among persons who inject drugs. To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease.

County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs, United States.

OBJECTIVE: A recent HIV outbreak in a rural network of persons who inject drugs (PWID) underscored the intersection of the expanding epidemics of opioid abuse, unsterile injection drug use (IDU), and associated increases in hepatitis C virus (HCV) infections. We sought to identify US communities potentially vulnerable to rapid spread of HIV, if introduced, and new or continuing high rates of HCV infections among PWID. DESIGN: We conducted a multistep analysis to identify indicator variables highly associated with IDU. We then used these indicator values to calculate vulnerability scores for each county to identify which were most vulnerable. METHODS: We used confirmed cases of acute HCV infection reported to the National Notifiable Disease Surveillance System, 2012-2013, as a proxy outcome for IDU, and 15 county-level indicators available nationally in Poisson regression models to identify indicators associated with higher county acute HCV infection rates. Using these indicators, we calculated composite index scores to rank each county's vulnerability. RESULTS: A parsimonious set of 6 indicators were associated with acute HCV infection rates (proxy for IDU): drug-overdose deaths, prescription opioid sales, per capita income, white, non-Hispanic race/ethnicity, unemployment, and buprenorphine prescribing potential by waiver. Based on these indicators, we identified 220 counties in 26 states within the 95th percentile of most vulnerable. CONCLUSIONS: Our analysis highlights US counties potentially vulnerable to HIV and HCV infections among PWID in the context of the national opioid epidemic. State and local health departments will need to further explore vulnerability and target interventions to prevent transmission.