BACKGROUND AND AIMS: In the United States, hepatitis C virus (HCV) infection occurs primarily through injection drug use (IDU), but transmission also occurs through other ways. This study examined HCV prevalence and disparities among US residents aged 12-59 years with no IDU history. METHODS: We analysed 2013-March 2020 National Health and Nutrition Examination Survey data to calculate the HCV prevalence among people with no drug use history and only a non-IDU history, collectively referred to as no IDU history. These estimates were compared to those with an IDU history and stratified by sociodemographic and hepatitis A and hepatitis B serologic characteristics. RESULTS: The current HCV infection prevalence among people aged 12-59 was .7% overall, and specifically 17.2% among people with an IDU history, .9% among people with a non-IDU history and .2% among people with no drug use history. These rates represented 1.4 million people with current HCV infection, of whom, 730 000 had an IDU history, 262 000 had a non-IDU history and 309 000 had no drug use history. Among people with no drug use history, current HCV infection prevalence was higher for people born during 1954-1965 versus after 1965, had completed high school or less versus at least some college and had past/present hepatitis B versus vaccinated for hepatitis B. CONCLUSION: While the HCV infection burden was highest among people with an IDU history, we found a sizeable burden among people without such a history. These findings support policies and practices aimed at addressing disparities among people needing treatment.

OBJECTIVES: Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. We assessed trends in HCV testing, infection, and surveillance cases among US adults. METHODS: We used Quest Diagnostics data from 2013-2021 to assess trends in the numbers tested for HCV antibody and proportion of positivity for HCV antibody and HCV RNA. We also assessed National Notifiable Diseases Surveillance System 2013-2020 data for trends in the number and proportion of hepatitis C cases. We applied joinpoint regression for trends testing. RESULTS: Annual HCV antibody testing increased from 1.7 million to 4.8 million from 2013 to 2021, and the positivity proportion declined (average, 0.2% per year) from 5.5% to 3.7%. The greatest percentage-point increase in HCV antibody testing occurred in hospitals and substance use disorder treatment facilities and among addiction medicine providers. HCV RNA positivity was stable at about 60% in 2013-2015 and declined to 41.0% in 2021 (2015-2021 average, -3.2% per year). Age-specific HCV RNA positivity was highest among people aged 40-59 years during 2013-2015 and among people aged 18-39 years during 2016-2021. The number of reported hepatitis C cases (acute and chronic) declined from 179 341 in 2015 to 105 504 in 2020 (average decline, -13 177 per year). The proportion of hepatitis C cases among those aged 18-39 years increased by an average of 1.4% per year during 2013-2020; among individuals aged 40-59 years, it decreased by an average of 2.3% per year during 2013-2018. CONCLUSIONS: HCV testing increased, suggesting improved universal screening. Various data sources are valuable for monitoring elimination progress.

Hepatitis B virus (HBV) causes acute and chronic infection of the liver leading to substantial morbidity and mortality. In the United States, since 1996, a total of 29 outbreaks of HBV infection in one or multiple long-term-care (LTC) facilities, including nursing homes and assisted-living facilities, were reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood glucose monitoring. These outbreaks prompted the Hepatitis Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) to evaluate the risk for HBV infection among all adults with diagnosed diabetes. The Work Group reviewed HBV infection-related morbidity and mortality and the effectiveness of implementing infection prevention and control measures. The strength of scientific evidence regarding protection was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology,* and safety, values, and cost-effectiveness were incorporated into a recommendation using the GRADE system. Based on the Work Group findings, on October 25, 2011, ACIP recommended that all previously unvaccinated adults aged 19 through 59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made (recommendation category A). Data on the risk for hepatitis B among adults aged ≥60 years are less robust. Therefore, ACIP recommended that unvaccinated adults aged ≥60 years with diabetes may be vaccinated at the discretion of the treating clinician after assessing their risk and the likelihood of an adequate immune response to vaccination (recommendation category B). This report summarizes these recommendations and provides the rationale used by ACIP to inform their decision making.

BACKGROUND: Despite national immunization efforts, including universal childhood hepatitis A (HepA) vaccination recommendations in 2006, hepatitis A virus (HAV)-associated outbreaks have increased in the United States. Unvaccinated or previously uninfected persons are susceptible to HAV infection, yet the susceptibility in the U.S. population is not well known. METHODS: Using National Health and Nutrition Examination Survey 2007-2016 data, we estimated HAV susceptibility prevalence (total HAV antibody negative) among persons aged >/=2 years. Among U.S.-born adults aged >/=20 years, we examined prevalence, predictors, and age-adjusted trends of HAV susceptibility by sociodemographic characteristics. We assessed HAV susceptibility and self-reported non-vaccination to HepA among risk groups and the "immunization cohort" (those born in or after 2004). RESULTS: Among U.S.-born adults aged >/=20 years, HAV susceptibility prevalence was 74.1% (95% CI: 72.9-75.3%) during 2007-2016. Predictors of HAV susceptibility were age group 30-49 years, non-Hispanic white/black, 130% above the poverty level, and no health insurance. Prevalences of HAV susceptibility and non-vaccination to HepA, respectively, were 72.9% and 73.1% among persons who reported injection drug use, 67.5% and 65.2% among men who had sex with men, 55.2% and 75.1% among persons with hepatitis B or hepatitis C, and 22.6% and 25.9% among the immunization cohort. Susceptibility and non-vaccination decreased over time among the immunization cohort, but remained stable among risk groups. CONCLUSION: During 2007-2016, approximately three-fourths of U.S.-born adults remained HAV susceptible. Enhanced vaccination efforts are critically needed, particularly targeting adults at highest risk for HAV infection, to mitigate the current outbreaks.

BACKGROUND: Hepatitis C virus (HCV)-associated mortality is well-documented nationally, but examination across regions and jurisdictions may inform healthcare planning. METHODS: To document HCV-associated deaths sub-nationally, we calculated age-adjusted HCV-associated death rates, compared death rate ratios (DRR) for ten US regions, 50 states, and District of Columbia (DC) with the national rate and described rate changes between 2016 and 2017 to determine variability. We examined mean age at HCV-associated death and rates and proportions by sex, race/ethnicity, and birth year. RESULTS: In 2017, there were 17,253 HCV-associated deaths, representing 4.13 (95% CI, 4.07-4.20) deaths/100,000 standard population, a significant 6.56% rate decline from 4.42 in 2016. Age-adjusted death rates significantly surpassed the US rate for the following jurisdictions: Oklahoma, DC, Oregon, New Mexico, Louisiana, Texas, Colorado, California, Kentucky, Tennessee, Arizona, and Washington (DRR, 2.87, 2.77, 2.24, 1.62, 1.57, 1.46, 1.36, 1.35, 1.35, 1.35, 1.32, 1.32, respectively) (P<0.05). Death rates ranged from a low of 1.60 (95% CI, 1.07-2.29) in Maine to a high of 11.84 (95% CI, 10.82-12.85) in Oklahoma. Death rates were highest among non-Hispanic American Indians/Alaska Natives and non-Hispanic blacks nationally and regionally. Mean age at death was 61.4 years (range, 56.6 years in West Virginia to 64.1 years in DC); 78.6% of deaths were born during 1945-1965. CONCLUSION: In 2016-2017, national HCV-associated mortality declined but remained high in western and southern regions, DC, non-Hispanic American Indians/Alaska Natives, non-Hispanic blacks, and Baby Boomers. These data can inform local prevention and control programs to reduce the HCV mortality burden.

OBJECTIVE: Emergency departments (EDs) are critical settings for hepatitis C care in the United States. We assessed trends and characteristics of hepatitis C-associated ED visits during 2006-2014. METHODS: We used data from the 2006-2014 Nationwide Emergency Department Sample to estimate numbers, rates, and costs of hepatitis C-associated ED visits, defined by either first-listed diagnosis of hepatitis C or all-listed diagnosis of hepatitis C. We assessed trends by demographic characteristics, liver disease severity, and patients' disposition by using joinpoint analysis, and we calculated the average annual percentage change (AAPC) from 2006 to 2014. RESULTS: During 2006-2014, the rate per 100 000 visits of first-listed and all-listed hepatitis C-associated ED visits increased significantly from 10.1 to 25.4 (AAPC = 13.0%; P < .001) and from 484.4 to 631.6 (AAPC = 3.4%; P < .001), respectively. Approximately 70% of these visits were made by persons born during 1945-1965 (baby boomers); 30% of visits were made by Medicare beneficiaries and 40% by Medicaid beneficiaries. Significant rate increases were among visits by baby boomers (first-listed: AAPC = 13.8%; all-listed: AAPC = 2.6%), persons born after 1965 (first-listed: AAPC = 14.3%; all-listed: AAPC = 9.2%), Medicare beneficiaries (first-listed: AAPC = 18.0%; all-listed: AAPC = 3.9%), and persons hospitalized after ED visits (first-listed: AAPC = 20.0%; all-listed: AAPC = 2.3%; all P < .001). Increasing proportions of compensated cirrhosis were among visits by baby boomers (first-listed: AAPC = 11.5%; all-listed: AAPC = 6.3%). Annual hepatitis C-associated total ED costs increased by 400.0% (first-listed) and 192.0% (all-listed) during 2006-2014. CONCLUSION: Public health efforts are needed to address the growing burden of hepatitis C care in the ED.

BACKGROUND: Hepatitis B virus (HBV) can transmit through needle sharing. National HBV infection prevalence in persons who inject drugs remains ill-defined. We estimated the prevalence of total HBV core antibody (anti-HBc) positivity, indicating previous or ongoing HBV infection, among adults aged 20-59 years with injection drug use (IDU) history. We compared select characteristics by anti-HBc status. METHODS: Using 2001-2016 National Health and Nutrition Examination Survey data, we calculated anti-HBc+ prevalence among adults with IDU history and among the general US population. For adults with IDU history, we compared sex, age group, birth cohort, race/ethnicity, health insurance coverage, and hepatitis A immunity by anti-HBc status. Using marginal structural models, we calculated model-adjusted prevalence rates and ratios to determine characteristics associated with anti-HBc positivity among adults with IDU history. RESULTS: From 2001-2016, anti-HBc+ prevalence was 19.7% (95% CI, 16.0%-24.0%) among those with IDU history compared with 4.6% (95% CI, 4.3%-5.0%) in the general population. HBsAg+ prevalence was 0.4% (95% CI, 0.3%-0.5%) in the general population. Among adults with IDU history, 19.8% reported past year IDU and 28.5% had hepatitis A immunity. CONCLUSION: One-fifth of adults with IDU history had previous or ongoing HBV infection, which was over four times higher than the prevalence in the general population. One-fifth of adults with IDU history reported past year use. Programs promoting safe IDU practices, drug treatment, and hepatitis A and B vaccination should be key components of viral hepatitis prevention.

BACKGROUND: Chronic hepatitis C (CHC) is a leading cause of morbidity and mortality and has imposed a high health care burden in the United States. Direct-acting antiviral (DAA) regimens are well tolerated and highly effective for CHC therapy but were initially marketed at a high price. Studies of their real-world use with a nationwide population are limited. OBJECTIVE: To examine patient characteristics, treatment adherence, effectiveness, and health care costs in a large U.S. population with commercial and Medicare supplemental insurance plans who received simeprevir (SIM), sofosbuvir (SOF), or ledipasvir/sofosbuvir (LED/SOF) during the years 2013-2015. METHODS: Patients with at least 1 diagnosis code for CHC and at least 1 claim for SIM, SOF, or LED/SOF prescriptions were selected. The date of the first claim for SIM, SOF, or LED/SOF was defined as the index date. Analyses were stratified by 4 regimens: SOF + SIM +/- ribavirin (RBV), SOF + peginterferon alpha-2a or 2b (PEG) + RBV, SOF + RBV, and LED/SOF +/- RBV. Adherence was defined by the proportion of days covered (PDC) >/= 80%. Sustained virologic response (SVR12) was defined as a hepatitis C virus (HCV) RNA load of </= 25 IU/mL measured at >/= 12 weeks following the end of the days supply of the last DAA refill. Health care costs such as DAA drug costs and medical costs (inpatient costs plus outpatient costs) were described. RESULTS: Of 10,808 CHC patients, approximately two thirds were male, and mean age was 55 years. The proportion of patients with compensated cirrhosis among each regimen ranged from 7.4% in LED/SOF +/- RBV to 13.8% in SOF + SIM +/- RBV, and the proportion of patients with decompensated cirrhosis ranged from 3.9% in LED/SOF +/- RBV to 10.7% in SOF + SIM +/- RBV. The majority of patients (89.0%) used the newer regimen LED/SOF +/- RBV in 2015. Adherence rates were estimated at 80.5%, 81.5%, 85.7%, and 91.4% for SOF + SIM +/- RBV (n = 1,761); SOF + PEG + RBV (n = 1,314); SOF + RBV (n = 1,994); and LED/SOF +/- RBV (n = 5,739), respectively. Regimen-specific adherence predictors included sex, age group, payer type, health plan, and treatment option with RBV. Being born during 1945-1965, liver disease severity, and Charlson Comorbidity Index levels did not predict adherence in any regimen. Overall SVR12 was 92.6% in 203 patients with available HCV RNA results: 100% (41/41) in SOF + SIM +/- RBV; 83.3% (25/30) in SOF + PEG + RBV; 90.6% (29/32) in SOF + RBV; and 93% (93/100) in LED/SOF +/- RBV. While the drug costs for these DAA regimens were initially high, they had decreased 18.9% (P < 0.001) during 2013-2015. Medical costs decreased 9.2% (P < 0.001) 1 year after the index dates. CONCLUSIONS: These results indicate that DAA drug costs decreased steadily during 2013-2015 and that 89% of patients on SOF-based DAA regimens took newer, lower-cost regimens with adherence rates above 80%. Available data show that SVR12 rates were close to those obtained in clinical studies. Medical costs also significantly decreased 1 year after the index dates. DISCLOSURES: No outside funding supported this study. All authors are U.S. federal employees of the Centers for Disease Control and Prevention. The authors declare that they have no competing interests. The findings and conclusions in this research are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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.

Background: In the United States, hepatitis C virus (HCV) infection has increased among young persons who inject drugs, but the extent of this epidemic among reproductive-aged women and their children is unknown. Objective: To estimate numbers and describe characteristics of reproductive-aged women with HCV infection and of their offspring. Design: Analysis of the National Notifiable Diseases Surveillance System (NNDSS) from 2006 to 2014 and the Quest Diagnostics Health Trends national database from 2011 to 2014. Setting: United States. Participants: 171 801 women (aged 15 to 44 years) and 1859 children (aged 2 and 13 years) with HCV infection reported to the NNDSS; 2.1 million reproductive-aged women and 56 684 children who had HCV testing by Quest Diagnostics. Measurements: NNDSS HCV case reports and Quest laboratory data regarding unique reproductive-aged women and children who were tested for HCV infection. Results: The number of reproductive-aged women with acute and past or present HCV infection in the NNDSS doubled, from 15 550 in 2006 to 31 039 in 2014. Of 581 255 pregnant women tested by Quest from 2011 to 2014, 4232 (0.73% [95% CI, 0.71% to 0.75%]) had HCV infection. Of children tested by Quest, 0.76% (CI, 0.69% to 0.83%) had HCV infection, but the percentage was 3.2-fold higher among children aged 2 to 3 years (1.62% [CI, 1.34% to 1.96%]) than those aged 12 to 13 years (0.50% [CI, 0.41% to 0.62%]). Applying the Quest HCV infection rate to annual live births from 2011 to 2014 resulted in an estimated average of 29 000 women (CI, 27 400 to 30 900 women) with HCV infection, who gave birth to 1700 infants (CI, 1200 to 2200 infants) with the infection each year. Limitations: Only a fraction of HCV infections is detected and reported to the NNDSS. Quest data are potentially biased, because women who are asymptomatic, do not access health care, or have unreported risks may be less likely to be tested for HCV infection. Conclusion: These data suggest a recent increase in HCV infection among reproductive-aged women and may inform deliberations regarding a role for routine HCV screening during pregnancy. Primary Funding Source: Centers for Disease Control and Prevention.

INTRODUCTION: Excessive alcohol use exacerbates morbidity and mortality among hepatitis C virus (HCV)-infected people. The purpose of this study was to describe self-reported patterns of alcohol use and examine the association with HCV infection and other sociodemographic and health-related factors. METHODS: Data from 20,042 participants in the 2003-2010 National Health and Nutrition Examination Survey were analyzed in 2014. Estimates were derived for self-reported demographic characteristics, HCV-RNA (indicative of current HCV infection) status, and alcohol use at four levels: lifetime abstainers, former drinkers, non-excessive current drinkers, and excessive current drinkers. RESULTS: Former drinkers and excessive current drinkers had a higher prevalence of HCV infection (2.2% and 1.5%, respectively) than never or non-excessive current drinkers (0.4% and 0.9%, respectively). HCV-infected adults were estimated to ever drink five or more drinks/day almost every day at some time during their lifetime about 3.3 times more often (43.8% vs 13.7%, p<0.001) than those who were never infected with HCV. Controlling for age, sex, race/ethnicity, education, and having a usual source of health care, HCV infection was significantly associated with excessive current drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6) and former drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6). CONCLUSIONS: Chronic HCV infection is associated with both former and excessive current drinking. Public health HCV strategies should implement interventions with emphasis on alcohol abuse, which negatively impacts disease progression for HCV-infected individuals.

In the United States, hepatitis C virus (HCV)-associated mortality is significant. From 2003-2013, this study found that the number of deaths associated with HCV significantly increased while other national notifiable infectious conditions decreased significantly. The increasing HCV-associated mortality trend underscores the urgency in finding, evaluating, and treating patients.

BACKGROUND: The number of persons with chronic hepatitis B virus (HBV) infection in the United States is affected by diminishing numbers of young persons who are susceptible because of universal infant vaccination since 1991, offset by numbers of HBV-infected persons migrating to the United States from endemic countries. METHODS: The prevalence of HBV infection was determined by serologic testing and analysis among non-institutionalized persons aged 6 years and older for: antibody to hepatitis B core antigen (anti-HBc), indicative of prior HBV infection; hepatitis B surface antigen (HBsAg), indicative of chronic (current) infection; and antibody to hepatitis B surface antigen(anti-HBs), indicative of immunity from vaccination. These prevalence estimates were analyzed in three periods of the National Health and Nutrition Examination Survey (NHANES): 1988-1994 (21,260 persons); 1999-2008 (29,828); and 2007-2012 (22,358). In 2011-2012, for the first time, non-Hispanic Asians were oversampled sampled in NHANES. RESULTS: For the most recent period (2007-2012), 3.9% had anti-HBc, indicating about 10.8 (95% CI 9.4-12.2) million non-institutionalized US residents having ever been infected with HBV. The overall prevalence of chronic HBV infection has remained constant since 1999: 0.3% (95% confidence intervals, 0.2% - 0.4%), and since 1999, prevalence of chronic HBV infection among non-Hispanic blacks has been 2-3 fold greater than the general population. An estimated 3.1% (1.8% - 5.2%) of non-Hispanic Asians were chronically infected with HBV during 2011-2012; which reflects a 10-fold greater prevalence than the general population. Adjusted prevalence of vaccine induced immunity increased 16% since 1999, and the number of persons (mainly young) with serologic evidence of vaccine-protection from HBV infection rose from 57.8 (95% CI 55.4-60.1) million to 68.5 (95% CI 65.4-71.2) million. CONCLUSION: Despite increasing immune protection in young persons vaccinated in infancy, an analysis of chronic hepatitis B prevalence in racial and ethnic populations indicates that during 2011-2012 there were 847,000 HBV infections (which included approximately 400,000 non-Hispanic Asians) in the non-institutionalized US population.

OBJECTIVES: To estimate the predictive value of self-reported hepatitis A vaccine (HepA) receipt for the presence of hepatitis A virus (HAV) antibody (anti-HAV) from either past infection or vaccination, as an indicator of HAV protection. METHODS: Using 2007-2012 National Health and Nutrition Examination Survey data, we assigned participants to 4 groups based on self-reported HepA receipt and anti-HAV results. We compared characteristics across groups and calculated three measures of agreement between self-report and serologic status (anti-HAV): percentage concordance, and positive (PPV) and negative (NPV) predictive values. Using logistic regression we investigated factors associated with agreement between self-reported vaccination status and serological results. RESULTS: Demographic and other characteristics varied significantly across the 4 groups. Overall agreement between self-reported HepA receipt and serological results was 63.6% (95% confidence interval [CI] 61.9-65.2); PPV and NPV of self-reported vaccination status for serological result were 47.0% (95% CI 44.2-49.8) and 69.4% (95% CI 67.0-71.8), respectively. Mexican American and foreign-born adults had the highest PPVs (71.5% [95% CI 65.9-76.5], and 75.8% [95% CI 71.4-79.7]) and the lowest NPVs (21.8% [95% CI 18.5-25.4], and 20.0% [95% CI 17.2-23.1]), respectively. Young (ages 20-29 years), US-born, and non-Hispanic White adults had the lowest PPVs (37.9% [95% CI 34.5-41.5], 39.1% [95% CI, 36.0-42.3], and 39.8% [36.1-43.7]), and the highest NPVs (76.9% [95% CI 72.2-81.0, 78.5% [95% CI 76.5-80.4)], and 80.6% [95% CI 78.2-82.8), respectively. Multivariate logistic analyses found age, race/ethnicity, education, place of birth and income to be significantly associated with agreement between self-reported vaccination status and serological results. CONCLUSIONS: When assessing hepatitis A protection, self-report of not having received HepA was most likely to identify persons at risk for hepatitis A infection (no anti-HAV) among young, US-born and non-Hispanic White adults, and self-report of HepA receipt was least likely to be reliable among adults with the same characteristics.

BACKGROUND: Knowledge of the number of persons with chronic hepatitis C virus (HCV) infection in the United States is critical for public health and policy planning. OBJECTIVE: To estimate the prevalence of chronic HCV infection between 2003 and 2010 and to identify factors associated with this condition. DESIGN: Nationally representative household survey. SETTING: U.S. noninstitutionalized civilian population. PARTICIPANTS: 30 074 NHANES (National Health and Nutrition Examination Survey) participants between 2003 and 2010. MEASUREMENTS: Interviews to ascertain demographic characteristics and possible risks and exposures for HCV infection. Serum samples from participants aged 6 years or older were tested for antibody to HCV; if results were positive or indeterminate, the samples were tested for HCV RNA, which indicates current chronic infection. RESULTS: Based on 273 participants who tested positive for HCV RNA, the estimated prevalence of HCV infection was 1.0% (95% CI, 0.8% to 1.2%), corresponding to 2.7 million chronically infected persons (CI, 2.2 to 3.2 million persons) in the U. S. noninstitutionalized civilian population. Infected persons were more likely to be aged 40 to 59 years, male, and non-Hispanic black and to have less education and lower family income. Factors significantly associated with chronic HCV infection were illicit drug use (including injection drugs) and receipt of a blood transfusion before 1992; 49% of persons with HCV infection did not report either risk factor. LIMITATION: Incarcerated and homeless persons were not surveyed. CONCLUSION: This analysis estimated that approximately 2.7 million U. S. residents in the population sampled by NHANES have chronic HCV infection, about 500 000 fewer than estimated in a similar analysis between 1999 and 2002. These data underscore the urgency of identifying the millions of persons who remain infected and linking them to appropriate care and treatment.

OBJECTIVES: Because only a fraction of patients with acute viral hepatitis A, B, and C are reported through national surveillance to the Centers for Disease Control and Prevention, we estimated the true numbers. METHODS: We applied a simple probabilistic model to estimate the fraction of patients with acute hepatitis A, hepatitis B, and hepatitis C who would have been symptomatic, would have sought health care tests, and would have been reported to health officials in 2011. RESULTS: For hepatitis A, the frequencies of symptoms (85%), care seeking (88%), and reporting (69%) yielded an estimate of 2730 infections (2.0 infections per reported case). For hepatitis B, the frequencies of symptoms (39%), care seeking (88%), and reporting (45%) indicated 18 730 infections (6.5 infections per reported case). For hepatitis C, the frequency of symptoms among injection drug users (13%) and those infected otherwise (48%), proportion seeking care (88%), and percentage reported (53%) indicated 17 100 infections (12.3 infections per reported case). CONCLUSIONS: These adjustment factors will allow state and local health authorities to estimate acute hepatitis infections locally and plan prevention activities accordingly.

Many persons infected with hepatitis C virus (HCV) are unknown to the healthcare system because they may be asymptomatic for years, have not been tested for HCV infection, and only seek medical care when they develop liver-related complications. We analyzed data from persons who tested positive for past or current HCV infection during participation in the National Health and Nutrition Examination Survey (NHANES) from 2001 through 2008. A follow-up survey was conducted 6 months after examination to determine (1) how many participants testing positive for HCV infection were aware of their HCV status before being notified by NHANES, (2) what actions participants took after becoming aware of their first positive test, and (3) participants' knowledge about hepatitis C. Of 30,140 participants tested, 393 (1.3%) had evidence of past or current HCV infection and 170 (43%) could be contacted during the follow-up survey and interviewed. Only 49.7% were aware of their positive HCV infection status before being notified by NHANES, and only 3.7% of these respondents reported that they had first been tested for HCV because they or their doctor thought they were at risk for infection. Overall, 85.4% had heard of hepatitis C; correct responses to questions about hepatitis C were higher among persons 40-59 years of age, white non-Hispanics, and respondents who saw a physician after their first positive HCV test. Eighty percent of respondents indicated they had seen a doctor about their first positive HCV test result. CONCLUSION: These data indicate that fewer than half of those infected with HCV may be aware of their infection. The findings suggest that more intensive efforts are needed to identify and test persons at risk for HCV infection. (HEPATOLOGY 2012;55:1652-1661).

BACKGROUND: The increasing health burden and mortality from hepatitis B virus (HBV) and hepatitis C virus (HCV) in the United States are underappreciated. OBJECTIVE: To examine mortality from HBV; HCV; and, for comparison, HIV. DESIGN: Analysis of U.S. multiple-cause mortality data from 1999 to 2007 from the National Center for Health Statistics. SETTING: All U.S. states and the District of Columbia. PARTICIPANTS: Approximately 22 million decedents. MEASUREMENTS: Age-adjusted mortality rates from HBV, HCV, and HIV. Logistic regression analyses of 2007 data generated 4 independent models per outcome (HCV- or HBV-related deaths) that each included 1 of 4 comorbid conditions and all sociodemographic characteristics. RESULTS: Between 1999 and 2007, recorded deaths from HBV increased significantly to 15,106, whereas deaths from HIV declined to 12,734 by 2007. Factors associated with HCV-related deaths included chronic liver disease, HBV co-infection, alcohol-related conditions, minority status, and HIV co-infection. Factors that increased odds of HBV-related death included chronic liver disease, HCV co-infection, Asian or Pacific Islander descent, HIV co-infection, and alcohol-related conditions. Most deaths from HBV and HCV occurred in middle-aged persons. LIMITATION: A person other than the primary physician of the decedent frequently completed the death certificate, and HCV and HBV often were not detected and thus not reported as causes of death. CONCLUSION: By 2007, HCV had superseded HIV as a cause of death in the United States, and deaths from HCV and HBV disproportionately occurred in middle-aged persons. To achieve decreases in mortality similar to those seen with HIV requires new policy initiatives to detect patients with chronic hepatitis and link them to care and treatment. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.