Hepatitis C in the United States: Emerging Trends in Incidence and Mortality

Over 3.2 million US residents have chronic hepatitis C virus (HCV) infection, and an estimated 30,000 new cases are acquired each year. As such, HCV is the largest ongoing infectious disease epidemic in the country.  The HCV epidemic is really two distinct “emerging” epidemics.  Among people with chronic cases of HCV infection, who typically acquired their infections decades ago, death rates are rapidly rising.  In 2014, over 18,000 death certificates noted HCV infection as an underlying cause of death, clearly supplanting HIV/AIDS deaths since 2007.  However, the situation is more serious in that only 20% of HCV-infected patients—even the 75% who have pre-mortem liver disease—have HCV recorded anywhere on their death certificate.  Public health actions, “secondary prevention” for already infected patients must intervene on a number of fronts along a “continuum of care” for HCV.   In terms of the continuum from testing to cure, it is estimated that 50% have been tested; 35% referred to an appropriate clinician; 12-23% evaluated for their stage of liver disease and treatment; 7-11% treated; and 5-6% cured.   Although effective curative therapies have been available for over a decade—and especially with the newer, short-term, all-oral therapies, that are prohibitively expensive for many—there are many obstacles beyond drug expensiveness.  Thus, CDC has recommended interventions at each step of the continuum to increase the numbers of persons evaluated and treated, such as the recent CDC recommendation for one-time screening of persons born from 1945-1965.  The other major “emerging” epidemic is among persons who inject drugs (PWIDs).  Increases of more than 100% in reported acute cases of HCV infection in recent years have occurred mainly in rural areas east of the Mississippi River.  The profile of these infected PWIDs is that they are young, often younger than aged 25 years; white; almost equally affecting females and males; living in rural and suburban communities; and highly mobile (and thus often difficult to locate).   Almost all started using oral prescription opioid drugs—such as oxycodone, ‘Oxycontin,’ and ‘Opana’—in their teens and then switched to heroin or dissolved prescription opioid drug injection.  The “primary prevention” for this epidemic emphasizes finding these young PWIDs and getting them into treatment for their drug addiction and HCV infection; education and outreach campaigns to dissuade young persons from using these drugs; provision of needle-and-syringe exchange (NSEP) and opioid substitution therapy (OST) programs; and identifying and closing “pill mills.”  These two HCV “epidemics” are hindered by attitudes that include continued downplaying of the seriousness of HCV infection and its extent.