BACKGROUND: Injection drug use (IDU) is a major contributor to the syndemic of viral hepatitis, human immunodeficiency virus, and drug overdose. However, information on IDU is frequently missing in national viral hepatitis surveillance data, which limits our understanding of the full extent of IDU-associated infections. Multiple imputation by chained equations (MICE) has become a popular approach to address missing data, but its application for IDU imputation is less studied. METHODS: Using the 2019-2021 National Notifiable Diseases Surveillance System acute hepatitis C case data and publicly available county-level measures, we evaluated listwise deletion (LD) and 3 models imputing missing IDU data through MICE: parametric logistic regression, semi-parametric predictive mean matching (PMM), and nonparametric random forest (RF) (both standard RF [sRF] and fast implementation of RF [fRF]). RESULTS: The estimated IDU prevalence among acute hepatitis C cases increased from 63.5% by LD to 65.1% by logistic regression, 66.9% by PMM, 76.0% by sRF, and 85.1% by fRF. Evaluation studies showed that RF-based MICE imputation, especially fRF, has the highest accuracy (as measured by smallest raw bias, percent bias, and root mean square error) and highest efficiency (as measured by smallest 95% confidence interval width) compared to LD and other models. Sensitivity analyses indicated that fRF remained robust when data were missing not at random. CONCLUSION: Our analysis suggested that RF-based MICE imputation, especially fRF, could be a valuable approach for addressing missing IDU data in the context of population-based surveillance systems like National Notifiable Diseases Surveillance System. The inclusion of imputed IDU data may enhance the effectiveness of future surveillance and prevention efforts for the IDU-driven syndemic.

BACKGROUND AIMS: The National Health and Nutrition Examination Survey (NHANES) underestimates the true prevalence of hepatitis C virus (HCV) infection. By accounting for populations inadequately represented in NHANES, we created two models to estimate the national hepatitis C prevalence among US adults during 2017-2020. APPROACH RESULTS: The first approach (NHANES+) replicated previous methodology by supplementing hepatitis C prevalence estimates among the US noninstitutionalized civilian population with a literature review and meta-analysis of hepatitis C prevalence among populations not included in the NHANES sampling frame. In the second approach (persons who inject drugs [PWID] adjustment), we developed a model to account for underrepresentation of PWID in NHANES by incorporating the estimated number of adult PWID in the United States and applying PWID-specific hepatitis C prevalence estimates. Using the NHANES+ model, we estimated HCV RNA prevalence of 1.0% (95% confidence interval [CI]: 0.5%-1.4%) among US adults in 2017-2020, corresponding to 2,463,700 (95% CI: 1,321,700-3,629,400) current HCV infections. Using the PWID adjustment model, we estimated HCV RNA prevalence of 1.6% (95% CI: 0.9%-2.2%), corresponding to 4,043,200 (95% CI: 2,401,800-5,607,100) current HCV infections. CONCLUSIONS: Despite years of an effective cure, estimated prevalence of hepatitis C in 2017-2020 remains unchanged from 2013-2016 when using comparable methodology. When accounting for increased injection drug use, estimated prevalence of hepatitis C is substantially higher than previously reported. National action is urgently needed to expand testing, increase access to treatment, and improve surveillance, especially among medically underserved populations, to support hepatitis C elimination goals.

During 2017-March 2020, approximately 2.2 million noninstitutionalized civilian U.S. adults had hepatitis C; one-third were unaware of their infection. Prevalence was substantially higher among persons who were uninsured or experiencing poverty. Unrestricted access to testing and curative treatment is urgently needed to reduce disparities and achieve 2030 elimination goals.

INTRODUCTION: Hepatitis C is a leading cause of death from liver disease in the United States. Acute hepatitis C infection is often asymptomatic, and >50% of cases will progress to chronic infection, which can be life-threatening. Hepatitis C can be diagnosed with a blood test and is curable, yet new cases of this preventable disease are increasing. METHODS: National Notifiable Diseases Surveillance System data were analyzed to determine the rate of acute hepatitis C cases reported to CDC by age group and year during 2009-2018 and the number and rate of newly reported chronic cases in 2018 by sex and age. The proportion of adults aged >/=20 years with hepatitis C who reported having ever been told that they had hepatitis C was estimated with 2015-2018 National Health and Nutrition Examination Survey data. RESULTS: During 2018, a total of 3,621 cases of acute hepatitis C were reported, representing an estimated 50,300 cases (95% confidence interval [CI] = 39,800-171,600). The annual rate of reported acute hepatitis C cases per 100,000 population increased threefold, from 0.3 in 2009 to 1.2 in 2018, and was highest among persons aged 20-29 (3.1) and 30-39 years (2.6) in 2018. A bimodal distribution of newly reported chronic hepatitis C cases in 2018 was observed, with the highest proportions among persons aged 20-39 years and 50-69 years. Only 60.6% (95% CI = 46.1%-73.9%) of adults with hepatitis C reported having been told that they were infected. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Increasing rates of acute hepatitis C among young adults, including reproductive-aged persons, have put multiple generations at risk for chronic hepatitis C. The number of newly reported chronic infections was approximately equal among younger and older adults in 2018. The new CDC hepatitis C testing recommendations advise screening all adults and pregnant women, not just persons born during 1945-1965, and those with risk factors.

We appreciate Dr. Spaulding and colleagues’ thoughtful commentary on our article. We used national data to provide the most accurate estimate possible of the prevalence of hepatitis C among adults in the United States, but our estimate was dependent on the quality and completeness of the available data. We corrected for the omission of several high-prevalence populations from the National Health and Nutrition Examination Survey (NHANES), but no nationally representative studies of these populations exist. Spaulding and her colleagues raise a number of reasons why our study may underestimate the true prevalence of hepatitis C among incarcerated persons, but unfortunately, no nationwide data exist to assess the magnitude of these potential biases. According to 2016 Bureau of Justice Statistics data, most people arrested are detained in jails for short periods of time(1); thus, most of the number of persons cited in Dr. Spaulding’s reply would be eligible for NHANES sampling. We could not further adjust estimates for potential nonresponse bias beyond those addressed through standard NHANES sample weights without risk of double-counting prevalent cases. | | Varan et al.(2) data were excluded because we decided a priori to include only articles published more recently than those included in the incarcerated prevalence analysis from the Edlin et al. 2015(3) national hepatitis C virus prevalence estimate. With respect to the differential treatment of North Carolina and South Carolina from Schoenbachler et al. (4) (“study 6”), South Carolina data were excluded because “Initially, the South Carolina program targeted detainees…who had obtained tattoos in non-professional or unregulated settings.” Although testing was eventually expanded to include other detainees, Shoenbachler et al. did not indicate at what point that transition occurred or whether the expansion applied to all four South Carolina jails in the study or just one.(4) We determined that the targeted risk-based screening employed met our “sampling higher-risk subpopulations selectively” exclusion criteria, and consequently only included North Carolina data from Schoenbachler et al. in our analysis. | | Incarcerated populations bear a large and disproportionate hepatitis C burden, and incarceration provides an important opportunity to identify cases, provide life-saving curative treatment, and prevent transmission. The Centers for Disease Control and Prevention (CDC) is looking to other systems to collect data for prevention planning and providing more support to traditional and nontraditional surveillance systems both within and outside correctional facilities. Regardless of the exact number, prevention, testing, care, and treatment of incarcerated persons with or at risk for hepatitis C is an important priority for CDC and the nation.

Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged >/=18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.

Background: Mother-to-child transmission of hepatitis B can be prevented with vaccination and screening. Foreign-born women living in the United States may have lower vaccination coverage and greater lifetime exposure to hepatitis B virus than US-born women. Objective: To determine if self-reported hepatitis B vaccination and screening differ between US-born and foreign-born women of reproductive age and examine predictors. Methods: National Health Interview Survey data from 2013-2015 were pooled to estimate prevalence of lifetime history of hepatitis B vaccination and screening self-reported by women aged 18-44 years who were born in the United States or elsewhere (foreign-born). Significance of world region of birth, birth cohort, and immigration-related characteristics were considered. Results: Among women of reproductive age (n= 24,216), reported hepatitis B vaccination was 33% lower for foreign-born (27.3%) than US-born (40.9%) women (t-test P < .05). Vaccination coverage was low for women who were born in Mexico and other parts of Central America, including the Caribbean islands (18.4%), South America (25.3%), and the Indian subcontinent (31.7%). Factors associated with vaccination in both groups included education, income, and health insurance coverage. Screening was reported by 28.5% of foreign-born vs. 31.9% of US-born women (t-test P < .05). The lowest reported screening prevalence occurred among foreign-born Hispanic or Latina Mexican (21.0%) and Puerto Rican (21.9%) women. Factors associated with screening prevalence among foreign-born women included English fluency, recent US residency, and citizenship. Conclusions: Foreign-born women of reproductive age had lower hepatitis B vaccination and screening coverage compared to US-born women of reproductive age.

To inform selection of a control range around the Public Health Service's recommended 0.7 mg/L drinking water fluoride concentration to prevent tooth decay, the Centers for Disease Control and Prevention's Water Fluoridation Reporting System data for 2006-2010 and 2015 were analyzed. Monthly average concentration data from 4,251 fluoride-adjusted community water systems for 191,266 of 255,060 system-months (2006-2010) were compared with control ranges 0.6 mg/L to 0.2 mg/L wide. Percentages of system-months within control ranges ≥0.4 mg/L wide (e.g., +/-0.2 mg/L) were >83% versus 68% for 0.2 mg/L wide (+/-0.1 mg/L). In 2015, 70% of adjusted systems maintained averages within +/-0.1 mg/L of their system's annual average for nine of 12 months, 67% used the 0.7 mg/L target and 45% used it with a +/-0.1 mg/L control range. Adoption of the 0.7 mg/L target was underway but not completed in 2015. Control ranges narrower than +/-0.2 mg/L may be feasible for monthly average fluoride concentration.

OBJECTIVE: We examined the association between utilization of care for a dental problem (utilization-DP) and parent-reported dental problem (DP) urgency among children with DP by type of health care insurance coverage. METHODS: We used weighted 2008 National Health Interview Survey data from 2,834 children, aged 2-17 years with at least one DP within the 6 months preceding survey. Explanatory variables were selected based on Andersen's model of healthcare utilization. Need was considered urgent if DP included toothache, bleeding gums, broken or missing teeth, broken or missing filling, or decayed teeth and otherwise as non-urgent. The primary enabling variable, insurance, had four categories: none, private health no dental coverage (PHND), private health and dental (PHD), or Medicaid/State Children's Health Insurance Program (SCHIP). Predisposing variables included sociodemographic characteristics. We used bivariate and multivariate analyses to identify explanatory variables' association with utilization-DP. Using logistic regression, we obtained adjusted estimates of utilization-DP by urgency for each insurance category. RESULTS: In bivariate analyses, utilization-DP was associated with both insurance and urgency. In multivariate analyses, the difference in percent utilizing care for an urgent versus non-urgent DP among children covered by Medicaid/SCHIP was 32 percentage points; PHD, 25 percentage points; PHND, 12 percentage points; and no insurance, 14 percentage points. The difference in utilization by DP urgency was higher for children with Medicaid/SCHIP compared with either PHND or uninsured children. CONCLUSION: Expansion of Medicaid/SCHIP may permit children to receive care for urgent DPs who otherwise may not, due to lack of dental insurance.

Tooth decay is one of the most common chronic conditions among children. Approximately 23% of children aged 2-11 years have at least one primary tooth with untreated decay and 20% of adolescents aged 12-19 years have at least one permanent tooth with untreated decay. Tooth decay, if left untreated, can cause pain and infection, and can lead to problems with eating, speaking, and learning. Risk factors for tooth decay include recent history of cavities, low fluoride exposure, and living in a low-income household. Prevalence of untreated decay in primary or permanent teeth among children from lower-income households is more than twice that among children from higher-income households. Prevalence of untreated tooth decay is also higher among Mexican-American children and non-Hispanic black children than among white non-Hispanic children. By age 15, approximately 60% of all adolescents will have experienced tooth decay. An estimated 51.7 million school hours are missed annually by school-aged children because of a dental problem or visit.

The oral health component for the National Health and Nutrition Examination Survey (NHANES) was changed in 2005 from an examination conducted by dentists to an oral health screening conducted by health technologists rather than dental professionals. The oral health screening included a person-based assessment for dental caries, restorations, and sealants. This report provides oral health content information and presents results of data quality analyses that include dental examiner reliability statistics for data collected during NHANES 2005-08. Oral health data are available on 15,342 persons aged 5 years and older representing the civilian, noninstitutionalized population of the United States who participated in NHANES 2005-08. Overall, interrater reliability findings indicate that health technologist performance was excellent with concordance between examination teams and the survey reference examiner being almost perfect for a number of assessments. Concordance for dental caries and sealants (kappa statistics) between health technologists and the survey reference examiner ranged from 0.82 to 0.90 for the combined 4-year period. These findings support the use of health technologists in the assessment of person-based estimators of dental caries and sealant prevalence as part of an oral health surveillance system.

This paper applies a Bayesian approach to ecological-type inference in matched-pair studies because traditional methods that assume parallel tables are not directly applicable. The proposed procedure is based on a hierarchical Bayes structure which models information about the within-pair association. The proposed algorithm relies on Markov chain Monte Carlo simulation, recovers the full table, and reports its accuracy in terms of credible sets for the cell counts. This methodology is motivated and illustrated with examples from split-mouth designs assessing the effectiveness of dental sealant materials and cross-over trials comparing two forms of insulin. Published in 2011 by John Wiley & Sons, Ltd.

BACKGROUND: Oral and dental diseases may be associated with other chronic diseases. METHODS: Using data from the National Health and Nutrition Examination Survey 1999-2004, the authors calculated the prevalence of untreated dental diseases, self-reported poor oral health and the number of missing teeth for adults in the United States who had certain chronic diseases. The authors used multivariate analysis to determine whether these diseases were associated with indicators of dental disease after controlling for common risk factors. RESULTS: Participants with rheumatoid arthritis, diabetes or a liver condition were twice as likely to have an urgent need for dental treatment as were participants who did not have these diseases. After controlling for common risk factors, the authors found that arthritis, cardiovascular disease, diabetes, emphysema, hepatitis C virus, obesity and stroke still were associated with dental disease. CONCLUSIONS: The authors found a high burden of unmet dental care needs among participants with chronic diseases. This association held in the multivariate analysis, suggesting that some chronic diseases may increase the risk of developing dental disease, decrease utilization of dental care or both. CLINICAL IMPLICATIONS: Dental and medical care providers should work together to ensure that adults with chronic diseases receive regular dental care.