Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 71 Records) |
Query Trace: Moorman AC[original query] |
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Regional differences in hepatitis C-related hospitalization rates, United States, 2012-2019
Hofmeister MG , Zhong Y , Moorman AC , Teshale EH , Samuel CR , Spradling PR . Public Health Rep 2024 333549241260252 OBJECTIVES: In the United States, hepatitis C is the most commonly reported bloodborne infection. It is a leading cause of liver cancer and death from liver disease and imposes a substantial burden of hospitalization. We sought to describe regional differences in hepatitis C virus (HCV)-related hospitalizations during 2012 through 2019 to guide planning for hepatitis C elimination. METHODS: We analyzed discharge data from the National Inpatient Sample for 2012 through 2019. We considered hospitalizations to be HCV-related if (1) hepatitis C was the primary diagnosis or (2) hepatitis C was any secondary diagnosis and the primary diagnosis was a liver disease-related condition. We analyzed demographic and clinical characteristics of HCV-related hospitalizations and modeled the annual percentage change in HCV-related hospitalization rates, nationally and according to the 9 US Census Bureau geographic divisions. RESULTS: During 2012-2019, an estimated 553 900 HCV-related hospitalizations occurred in the United States. The highest hospitalization rate (34.7 per 100 000 population) was in the West South Central region, while the lowest (17.6 per 100 000 population) was in the West North Central region. During 2012-2019, annual hospitalization rates decreased in each region, with decreases ranging from 15.3% in the East South Central region to 48.8% in the Pacific region. By type of health insurance, Medicaid had the highest hospitalization rate nationally and in all but 1 geographic region. CONCLUSIONS: HCV-related hospitalization rates decreased nationally and in each geographic region during 2012-2019; however, decreases were not uniform. Expanded access to direct-acting antiviral treatment in early-stage hepatitis C would reduce future hospitalizations related to advanced liver disease and interrupt HCV transmission. |
Temporal trends in hepatitis C-related hospitalizations, United States, 2000-2019
Hofmeister MG , Zhong Y , Moorman AC , Samuel CR , Teshale EH , Spradling PR . Clin Infect Dis 2023 77 (12) 1668-1675 BACKGROUND: Hospitalization burden related to hepatitis C virus (HCV) infection is substantial. We sought to describe temporal trends in hospitalization rates before and after release of direct-acting antiviral (DAA) agents. METHODS: We analyzed 2000-2019 data from adults aged ≥18 years in the National Inpatient Sample. Hospitalizations were HCV-related if 1) hepatitis C was the primary diagnosis, or 2) hepatitis C was any secondary diagnosis with a liver-related primary diagnosis. We analyzed characteristics of HCV-related hospitalizations nationally, and examined trends in age-adjusted hospitalization rates. RESULTS: During 2000-2019, there were an estimated 1,286,397 HCV-related hospitalizations in the United States. The annual age-adjusted hospitalization rate was lowest in 2019 (18.7/100,000 population) and highest in 2012 (29.6/100,000 population). Most hospitalizations occurred among persons aged 45-64 (71.8%), males (67.1%), white non-Hispanic persons (60.5%), and Medicaid/Medicare recipients (64.0%). The national age-adjusted hospitalization rate increased during 2000-2003 (annual percent change [APC] 9.4%, P<.001) and 2003-2013 (APC 1.8%, P<.001) before decreasing during 2013-2019 (APC -7.6%, P<.001). Comparing 2000 to 2019, the largest increases in hospitalization rates occurred among persons aged 55-64 years (132.9%), Medicaid recipients (41.6%), and black non-Hispanic persons (22.3%). CONCLUSIONS: Although multiple factors likely contributed, overall HCV-related hospitalization rates declined steadily after 2013, coinciding with the release of DAAs. However, the declines were not observed equally among age, race/ethnicity, or insurance categories. Expanded access to DAA treatment is needed, particularly among Medicaid and Medicare recipients, to reduce disparities and morbidity, and eliminate hepatitis C as a public health threat. |
Donor-derived transmission of hepatitis A virus following kidney transplantation: Clinical course of two cases from one donor
Jones JM , Agarwal A , Moorman AC , Hofmeister MG , Hulse JC , Meneveau MO , Mixon-Hayden T , Ramachandran S , Jones CM , Kellner S , Ferrell D , Sifri CD . Transplant Direct 2023 9 (8) e1506 ![]() ![]() Donor-derived transmission of infections is a rare complication of kidney transplant. Hepatitis A virus (HAV) is a common cause of acute viral hepatitis worldwide, but donor-derived transmission to organ recipients has been reported in the literature only twice previously. The timeline for HAV incubation and clearance in transplant recipients is not well understood. METHODS: In 2018, 2 kidneys and a liver were procured from a deceased donor resident of Kentucky, one of many states that was experiencing an HAV outbreak associated with person-to-person transmission through close contact, primarily among people who reported drug use. Both kidney recipients, residents of Virginia, subsequently developed acute HAV infections. We report the results of an investigation to determine the source of transmission and describe the clinical course of HAV infection in the infected kidney recipients. RESULTS: The liver recipient had evidence of immunity to HAV and did not become infected. The donor and both kidney recipients were found to have a genetically identical strain of HAV using a next-generation sequencing-based cyber molecular assay (Global Hepatitis Outbreak Surveillance Technology), confirming donor-derived HAV infections in kidney recipients. At least 1 kidney recipient experienced delayed development of detectable hepatitis A anti-IgM antibodies. By 383 and 198 d posttransplant, HAV RNA was no longer detectable in stool specimens from the left and right kidney recipients, respectively. CONCLUSIONS: Adherence to current guidance for hepatitis A vaccination may prevent future morbidity due to HAV among organ recipients. http://links.lww.com/TXD/A548. |
Hepatitis C virus-HIV coinfection in the United States among people who inject drugs: Data needed for ending dual epidemics
Moorman AC , Bixler D , Teshale EH , Hofmeister M , Roberts H , Chapin-Bardales J , Gupta N . Public Health Rep 2023 333549231181348 The overlapping epidemics of hepatitis C virus (HCV) and HIV infection stem from underlying behaviors and health disparities among disproportionately affected populations, especially people who inject drugs (PWID). Characterizing the prevalence of HCV-HIV coinfection offers improved data to address these underlying determinants of health. We performed a literature search for articles that describe US populations, were published during 2005-2021, and summarized evidence of the prevalence of HCV infection in recent HIV clusters and outbreaks among PWID. In population- and community-based studies, HCV antibody prevalence among PWID with HIV ranged from 10.7% to 71.4%, depending on the setting and study design. HCV-HIV coinfection ranged from 70% to 94% among 5 larger HIV clusters or outbreaks among PWID during 2014-2021; where characterized, HCV diagnosis preceded HIV detection by a median of 4 to 5 years. Robust modernized surveillance is needed to support and measure the progress of city, state, and national activities for ending the HIV epidemic and eliminating hepatitis C. Developing and leveraging surveillance systems can identify missed opportunities for prevention, evaluate care, and build capacity for outbreak investigation. In addition, improved data on injection drug use are crucial to inform efforts for improved HCV and HIV testing, prevention, and treatment in settings that serve PWID. By providing data in a wholistic, integrated manner, public health surveillance programs can support efforts to overcome inefficiencies of disease-specific silos, accelerate delivery of preventive and clinical services, and address the excess disease burden and health disparities associated with HCV-HIV coinfection. |
Prevention and care opportunities for people who inject drugs in an HIV outbreak - Kanawha County, West Virginia, 2019-2021
Bonacci RA , Moorman AC , Bixler D , Penley M , Wilson S , Hudson A , McClung RP . J Gen Intern Med 2022 38 (3) 828-831 In 2019, the West Virginia (WV) Bureau for Public Health identified 15 HIV diagnoses among people who inject drugs (PWID) in Kanawha County, an area disproportionately affected by the opioid crisis; previously, annual diagnoses were less than 5. We investigated health care use and service delivery among PWID during the outbreak to identify opportunities to improve HIV- and opioid-related interventions. |
Hepatitis C virus infection preceding an outbreak of HIV among persons who inject drugs- Kanawha County, West Virginia, 2019-2021
Hudson AG , Bonacci RA , Moorman AC , Penley M , Wilson SM , Hoffman JL , Thomasson ER , Paul McClung R , Bixler D . Clin Infect Dis 2022 76 (3) e752-e754 Of 65 cases during an HIV outbreak among persons who inject drugs (PWID) in Kanawha County, West Virginia during 2019-2021, 61 (94%) had hepatitis C diagnosed at a median of 46 months prior to HIV diagnosis. Hepatitis C diagnosis among PWID should trigger improved access to prevention and treatment services. |
Trends in cirrhosis and mortality by age, sex, race, and antiviral treatment status among US chronic hepatitis B patients (2006-2016)
Lu M , Li J , Zhou Y , Rupp LB , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Daida YG , Schmidt MA , Trudeau S , Gordon SC . J Clin Gastroenterol 2022 56 (3) 273-279 BACKGROUND: Changing US demographics and evolving chronic hepatitis B (CHB) treatments may affect longitudinal trends in CHB-related complications. We studied trends in the prevalence of cirrhosis (past or present) and incidence of all-cause mortality, stratified by patient age, sex, race, and antiviral treatment status, in a sample from US health care systems. METHODS: Joinpoint and Poisson regression (univariate and multivariable) were used to estimate the annual percent change in each outcome from 2006 to 2016. RESULTS: Among 5528 CHB patients, cirrhosis prevalence (including decompensated cirrhosis) rose from 6.7% in 2006 to 13.7% in 2016; overall mortality was unchanged. Overall rates of cirrhosis and mortality were higher among treated patients, but adjusted annual percent changes (aAPC) were significantly lower among treated than untreated patients (cirrhosis: aAPC +2.4% vs. +6.2%, mortality: aAPC -3.9% vs. +4.0%). Likewise, among treated patients, the aAPC for mortality declined -3.9% per year whereas among untreated patients, mortality increased +4.0% per year. CONCLUSIONS: From 2006 to 2016, the prevalence of cirrhosis among CHB patients doubled. Notably, all-cause mortality increased among untreated patients but decreased among treated patients. These results suggest that antiviral treatment attenuates the progression of cirrhosis and the risk of death among patients with CHB. |
Lower rates of emergency visits and hospitalizations among chronic hepatitis C patients with sustained virological response to interferon-free direct-acting antiviral therapy (2014-2018)
Gordon SC , Teshale EH , Spradling PR , Moorman AC , Boscarino JA , Schmidt MA , Daida YG , Rupp LB , Trudeau S , Zhang J , Lu M . Clin Infect Dis 2022 75 (8) 1453-1456 We compared rates of emergency department (ED) visits and hospitalizations between HCV patients who achieved sustained virological response (SVR) after direct-acting antiviral (DAA) therapy (cases) to matched controls. Among 3049 pairs, cases demonstrated lower rates of liver-related ED visits (P=.01) than controls; all-cause and liver-related hospitalization rates and hospitalized days were also lower in cases (P<.0001). |
Incidence of malignancies among patients with chronic hepatitis B in US health care organizations, 2006-2018
Spradling PR , Xing J , Zhong Y , Rupp LB , Moorman AC , Lu M , Teshale EH , Schmidt MA , Daida YG , Boscarino JA , Gordon SC . J Infect Dis 2022 226 (5) 896-900 Hepatitis B virus (HBV) infection causes hepatocellular carcinoma but its association with other cancers is not well established. We compared age-adjusted incidence of primary cancers among 5,773 HBV-infected persons with US cancer registries during 2006-2018. Compared with the US population, substantially higher incidence among HBV-infected persons was observed for hepatocellular carcinoma (Standardized rate ratio [SRR] 30.79), gastric (SRR 7.95), neuroendocrine (SRR 5.88), cholangiocarcinoma (SRR 4.62), and ovarian (SRR 3.72) cancers, and non-Hodgkin lymphoma (SRR 2.52). Clinicians should be aware of a heightened potential for certain non-hepatic malignancies among hepatitis B patients, as earlier diagnosis favors improved survival. |
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013-2018
Kilmer GA , Ly KN , Moorman AC . Popul Health Manag 2021 24 (6) 651-653 The recently released US Viral Hepatitis National Strategic Plan: A Roadmap to Elimination designed to achieve disease elimination goals for 2021–20251 promotes screening to identify and treatment for the more than 3 million Americans with hepatitis B or C. Chronic hepatitis B and C together comprise a significant proportion of all hepatitis diagnoses in the United States given the current estimates of nearly 900,000 infected with chronic hepatitis B and 2.4 million infected with chronic hepatitis C, with new hepatitis C infections related to the opioid epidemic on the rise. Guidance from the US Centers for Disease Control and Prevention (CDC) updated in 2020 now recommends a universal 1-time hepatitis C virus (HCV) test for all adults as well as testing during each pregnancy.2 |
The persistence of underreporting of hepatitis C as an underlying or contributing cause of death, 2011-2017
Spradling PR , Zhong Y , Moorman AC , Rupp LB , Lu M , Teshale EH , Schmidt MA , Daida YG , Boscarino JA , Gordon SC . Clin Infect Dis 2021 73 (5) 891-894 Using electronic health records, we found that hepatitis C reporting on death certificates of 2,901 HCV-infected decedents from four U.S. healthcare organizations during 2011-2017 was documented in only 50% of decedents with hepatocellular carcinoma and less than half with decompensated cirrhosis. National figures likely underestimate the U.S. HCV mortality burden. |
Psychosocial obstacles to hepatitis C treatment initiation among patients in care: A hitch in the cascade of cure
Spradling PR , Zhong Y , Moorman AC , Rupp LB , Lu M , Gordon SC , Teshale EH , Schmidt MA , Daida YG , Boscarino JA . Hepatol Commun 2020 5 (3) 400-411 There are limited data examining the relationship between psychosocial factors and receipt of direct-acting antiviral (DAA) treatment among patients with hepatitis C in large health care organizations in the United States. We therefore sought to determine whether such factors were associated with DAA initiation. We analyzed data from an extensive psychological, behavioral, and social survey (that incorporated several health-related quality of life assessments) coupled with clinical data from electronic health records of patients with hepatitis C enrolled at four health care organizations during 2017-2018. Of 2,681 patients invited, 1,051 (39.2%) responded to the survey; of 894 respondents eligible for analysis, 690 (77.2%) initiated DAAs. Mean follow-up among respondents was 9.2 years. Compared with DAA recipients, nonrecipients had significantly poorer standardized scores for depression, anxiety, and life-related stressors as well as poorer scores related to physical and mental function. Lower odds of DAA initiation in multivariable analysis (adjusted by age, race, sex, study site, payment provider, cirrhosis status, comorbidity status, and duration of follow-up) included Black race (adjusted odds ratio [aOR], 0.59 vs. White race), perceived difficulty getting medical care in the preceding year (aOR, 0.48 vs. no difficulty), recent injection drug use (aOR, 0.11 vs. none), alcohol use disorder (aOR, 0.58 vs. no alcohol use disorder), severe depression (aOR, 0.42 vs. no depression), recent homelessness (aOR, 0.36 vs. no homelessness), and recent incarceration (aOR, 0.34 vs. no incarceration). Conclusion(s): In addition to racial differences, compared with respondents who initiated DAAs, those who did not were more likely to have several psychological, behavioral, and social impairments. Psychosocial barriers to DAA initiation among patients in care should also be addressed to reduce hepatitis C-related morbidity and mortality. |
Adolescent with COVID-19 as the Source of an Outbreak at a 3-Week Family Gathering - Four States, June-July 2020.
Schwartz NG , Moorman AC , Makaretz A , Chang KT , Chu VT , Szablewski CM , Yousaf AR , Brown MM , Clyne A , DellaGrotta A , Drobeniuc J , Korpics J , Muir A , Drenzek C , Bandy U , Kirking HL , Tate JE , Hall AJ , Lanzieri TM , Stewart RJ . MMWR Morb Mortal Wkly Rep 2020 69 (40) 1457-1459 There is increasing evidence that children and adolescents can efficiently transmit SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1-3). During July-August 2020, four state health departments and CDC investigated a COVID-19 outbreak that occurred during a 3-week family gathering of five households in which an adolescent aged 13 years was the index and suspected primary patient; 11 subsequent cases occurred. |
Testing and clinical management of health care personnel potentially exposed to hepatitis C virus - CDC Guidance, United States, 2020
Moorman AC , de Perio MA , Goldschmidt R , Chu C , Kuhar D , Henderson DK , Naggie S , Kamili S , Spradling PR , Gordon SC , Russi MB , Teshale EH . MMWR Recomm Rep 2020 69 (6) 1-8 Exposure to hepatitis viruses is a recognized occupational risk for health care personnel (HCP). This report establishes new CDC guidance that includes recommendations for a testing algorithm and clinical management for HCP with potential occupational exposure to hepatitis C virus (HCV). Baseline testing of the source patient and HCP should be performed as soon as possible (preferably within 48 hours) after the exposure. A source patient refers to any person receiving health care services whose blood or other potentially infectious material is the source of the HCP's exposure. Two options are recommended for testing the source patient. The first option is to test the source patient with a nucleic acid test (NAT) for HCV RNA. This option is preferred, particularly if the source patient is known or suspected to have recent behaviors that increase risk for HCV acquisition (e.g., injection drug use within the previous 4 months) or if risk cannot be reliably assessed. The second option is to test the source patient for antibodies to hepatitis C virus (anti-HCV), then if positive, test for HCV RNA. For HCP, baseline testing for anti-HCV with reflex to a NAT for HCV RNA if positive should be conducted as soon as possible (preferably within 48 hours) after the exposure and may be simultaneous with source-patient testing. If follow-up testing is recommended based on the source patient's status (e.g., HCV RNA positive or anti-HCV positive with unavailable HCV RNA or if the HCV infection status is unknown), HCP should be tested with a NAT for HCV RNA at 3-6 weeks postexposure. If HCV RNA is negative at 3-6 weeks postexposure, a final test for anti-HCV at 4-6 months postexposure is recommended. A source patient or HCP found to be positive for HCV RNA should be referred to care. Postexposure prophylaxis of hepatitis C is not recommended for HCP who have occupational exposure to blood and other body fluids. This guidance was developed based on expert opinion (CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recommend Rep 2001;50[No. RR-11]; Supplementary Figure, https://stacks.cdc.gov/view/cdc/90288) and reflects updated guidance from professional organizations that recommend treatment for acute HCV infection. Health care providers can use this guidance to update their procedures for postexposure testing and clinical management of HCP potentially exposed to hepatitis C virus. |
Mortality among patients with chronic hepatitis B infection: The Chronic Hepatitis Cohort Study (CHeCS)
Bixler D , Zhong Y , Ly KN , Moorman AC , Spradling PR , Teshale EH , Rupp LB , Gordon SC , Boscarino JA , Schmidt MA , Daida YG , Holmberg SD . Clin Infect Dis 2019 68 (6) 956-963 BACKGROUND: According to death certificates, approximately 1800 persons die from hepatitis B annually in the United States; however, this figure may underestimate true mortality from chronic hepatitis B (CHB). METHODS: We analyzed data from CHB patients seen in the Chronic Hepatitis Cohort Study (CHeCS) between 1 January 2006 and 31 December 2013. We compared overall and cause-specific death rates and mean ages at death between CHeCS CHB decedents and U.S. decedents from the Multiple Cause of Death (MCOD) file. RESULTS: Of 4389 CHB patients followed for a mean of 5.38 years, 492 (11%) CHB patients died after a mean follow-up of 3.00 years. Compared to survivors, decedents were older, more likely to be White (40.6%), African-American (27.1%), or male (74.2%); and more likely to have had cirrhosis (59.8%), diabetes (27.2%), alcohol abuse (17.7%), hepatocellular carcinoma (17.5%), or a liver transplant (5.7%); whereas survivors were more likely to be Asian (48.8%; all P < .001). CHB patients died at an average age of 59.8 years-14 years younger than the general U.S. population-and at higher rates for all causes (relative risk [RR] = 1.85, 95% confidence interval [CI], 1.851-1.857) and liver-related causes (RR = 15.91, 95% CI, 15.81-16.01). Only 19% of CHB decedents and 40% of those dying of liver disease had hepatitis B reported on their death certificates. CONCLUSIONS: Compared to the general population, CHB patients die at younger ages and higher rates from all causes and liver-related causes. Death certificates underrepresent the true mortality from CHB. |
Low uptake of direct-acting antiviral therapy among hepatitis C patients with advanced liver disease and access to care, 2014-2017
Spradling PR , Xing J , Rupp LB , Moorman AC , Gordon SC , Lu M , Teshale EH , Boscarino JA , Schmidt MA , Daida YG , Holmberg SD . J Clin Gastroenterol 2020 55 (1) 77-83 GOALS: To determine the proportion and characteristics of adults with hepatitis C at health care organizations in 4 US states who initiated direct-acting antivirals (DAAs). BACKGROUND: There are almost no data to assess the penetrance of treatment of the hepatitis C population in general US health care settings. STUDY: We conducted a prospective observational study using electronic clinical, pharmacy, and mortality data to determine the fraction of patients who initiated DAAs between January 2014 and December 2017, by start date and regimen. We used stepwise multivariate logistic regression analysis to identify sociodemographic and clinical characteristics associated with receipt of DAAs. RESULTS: Of 8823 patients, 2887 (32.7%) received DAAs. Quarterly (Q) uptake ranged from 1.1% in Q3 2014 to a high of 5.6% in Q2 2015. Characteristics associated with receipt of DAAs included age 51 to 70 years, higher income, pre-2014 treatment failure, and higher noninvasive fibrosis score (FIB4); however, over one half of patients with FIB4 scores >3.25, consistent with severe liver disease, were not treated. A lower likelihood of initiation was associated with Medicaid coverage. Of 5936 patients who did not initiate treatment, 911 (15.3%) had died and 2774 (46.7%) had not had a clinical encounter in >/=12 months by the end of the study. Fewer than 1% of DAA prescriptions originated from nonspecialty providers. CONCLUSIONS: During 4 calendar years of follow-up, one third of patients initiated DAAs. Large fractions of untreated patients had advanced liver disease, died, or were lost to follow-up. Even among patients in integrated health care systems, receipt of DAAs was limited. |
Mental and physical health status among chronic hepatitis B patients
Daida YG , Boscarino JA , Moorman AC , Lu M , Rupp LB , Gordon SC , Teshale EH , Schmidt MA , Spradling PR . Qual Life Res 2020 29 (6) 1567-1577 PURPOSE: Little is known about health-related quality of life (HRQoL) in patients with chronic hepatitis B virus (CHB) infection in the United States. Our goal is to understand factors associated with HRQoL in this population. METHODS: We conducted a survey to assess HRQoL and behavioral risks among patients with CHB infection from four large U.S. health care systems. Primary outcomes were generated from the SF-8 scale to assess HRQoL, as measured by the mental component scores (MCS) and physical component scores (PCS). The survey also measured socio-demographic information, hepatitis-related behavioral risk factors, treatment exposure/history, stress, and social support. We supplemented survey data with electronic health records data on patient income, insurance, disease severity, and comorbidities. Multivariate analysis was used to estimate and compare adjusted least square means of MCS and PCS, and examine which risk factors were associated with lower MCS and PCS. RESULTS: Nine hundred sixty-nine patients (44.6%) responded to the survey. Current life stressors and unemployment were associated with both lower MCS and PCS results in multivariate analyses. Lower MCS was also associated with White race and low social support, while lower PCS was also associated with Medicaid insurance. CONCLUSIONS: Stressful life events and unemployment were related to mental and physical health status of CHB patients. Those who have social support have better mental health; White and Medicaid patients are more likely to have poorer mental and physical health, respectively. Management of CHB patients should include stress management, social support, and financial or employment assistance. |
Hepatitis B virus mutant infections in hemodialysis patients: A case series
Apata IW , Nguyen DB , Khudyakov Y , Mixson-Hayden T , Rosenberg J , Zahn M , Greenko J , Clement E , Portney AE , Kulkarni PA , Comer M , Adams E , Kamili S , Patel PR , Moorman AC . Kidney Med 2019 1 (6) 347-353 Rationale & Objective: Hepatitis B virus (HBV) transmission in hemodialysis units has become a rare event since implementation of hemodialysis-specific infection control guidelines: performing hemodialysis for hepatitis B surface antigen (HBsAg)-positive patients in an HBV isolation room, vaccinating HBV-susceptible (HBV surface antibody and HBsAg negative) patients, and monthly HBsAg testing in HBV-susceptible patients. Mutations in HBsAg can result in false-negative HBsAg results, leading to failure to identify HBsAg seroconversion from negative to positive. We describe 4 unique cases of HBsAg seroconversion caused by mutant HBV infection or reactivation in hemodialysis patients. Study Design: Following identification of a possible HBsAg seroconversion and mutant HBV infection, public health investigations were launched to conduct further HBV testing of case patients and potentially exposed patients. A case patient was defined as a hemodialysis patient with suspected mutant HBV infection because of false-negative HBsAg testing results. Confirmed case patients had HBV DNA sequences demonstrating S-gene mutations. Setting & Participants: Case patients and patients potentially exposed to the case patient in the respective hemodialysis units in multiple US states. Results: 4 cases of mutant HBV infection in hemodialysis patients were identified; 3 cases were confirmed using molecular sequencing. Failure of some HBsAg testing platforms to detect HBV mutations led to delays in applying HBV isolation procedures. Testing of potentially exposed patients did not identify secondary transmissions. Limitations: Lack of access to information on past HBsAg testing platforms and results led to challenges in ascertaining when HBsAg seroconversion occurred and identifying and testing all potentially exposed patients. Conclusions: Mutant HBV infections should be suspected in patients who test HBsAg negative and concurrently test positive for HBV DNA at high levels. Dialysis providers should consider using HBsAg assays that can also detect mutant HBV strains for routine HBV testing. |
Late diagnosis of hepatitis C virus infection, 2014-2016: continuing missed intervention opportunities
Moorman AC , Xing J , Rupp LB , Gordon SC , Lu M , Spradling PR , Boscarino JA , Schmidt MA , Daida YG , Teshale EH . Am J Manag Care 2019 25 (8) 369-374 OBJECTIVES: Chronic hepatitis C virus (HCV) infection is typically asymptomatic until severe liver disease occurs and even then can remain undiagnosed for some time; thus, screening and treatment of asymptomatic persons are needed to prevent poor outcomes. In a previous analysis of data from between 2006 and 2011, we found that 17% of newly diagnosed HCV infections in 4 large health systems were among persons with cirrhosis and/or end-stage liver disease, termed "late diagnosis." We sought to determine the proportion with late diagnosis during 2014-2016, after release of CDC baby boomer (1945-1965 birth cohort) testing guidelines in 2012. STUDY DESIGN: The cohort was based on analysis of electronic health records and administrative data of about 2.7 million patients visiting the same healthcare systems during 2014-2016. METHODS: Among persons with newly diagnosed chronic HCV infection during 2014-2016, we analyzed data collected up to January 1, 2017. RESULTS: Among 2695 patients with newly diagnosed HCV infection, 576 (21.4%) had late diagnosis. Most were born between 1945 and 1965 (n = 1613 [59.9%]), and among these, 27.6% had late diagnosis. Patients with versus without late diagnosis had equally lengthy prediagnosis observation in the health systems (mean and median, 9.1 and 9.1 vs 8.3 and 7.8 years, respectively) but were more likely to have a postdiagnosis hospitalization (32.5% vs 12.5%; P <.001) with greater number of hospital days (358.8 vs 78.5 per 100 person-years; P <.001). CONCLUSIONS: More than one-fifth of patients with newly diagnosed HCV infection during 2014-2016-and more than a quarter of those born between 1945 and 1965-had late diagnosis despite many years of in-system care, an increase of 5 percentage points since 2006-2011, after the interim initiation of age-based screening recommendations. Our data highlight missed opportunities for diagnosis and therapeutic intervention before the onset of severe liver disease, which is associated with high cost and diminished outcomes. |
Trends in diagnosed chronic hepatitis B in a US health system population, 2006-2015
Lu M , Zhou Y , Holmberg SD , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Daida YG , Schmidt MA , Li J , Rupp LB , Trudeau S , Gordon SC . Open Forum Infect Dis 2019 6 (7) ofz286 Background: Trends in the epidemiology of chronic hepatitis B (CHB) among routine clinical care patients in the United States are not well documented. We used data from the Chronic Hepatitis Cohort Study to investigate changes in prevalence and newly recorded cases of CHB from 2006 to 2015. Methods: Annual percentage changes (APCs) were estimated using join point Poisson regression. Analyses were adjusted by study site; when an interaction with the trend was observed, APCs were estimated by subgroups. Differences in rates based on race, age, and sex were calculated with rate ratios. Results: We identified 5492 patients with CHB within select health systems with total populations that ranged from 1.9 to 2.4 million persons. From 2006 to 2014, the prevalence of diagnosed CHB increased from 181.3 to 253.0 per 100 000 persons in the health system population; from 2014 to 2015, it declined to 237.0 per 100 000 persons. APC was +3.7%/y through 131 December 2014 (P < .001) and -15.0%/y (P < .001) thereafter. The rate of newly reported cases of CHB did not change significantly across the study period (APC, -1.1%/y; P = .07). The rates of newly reported cases were 20.5 times higher among patients in the Asian American/American Indian/Pacific Islander (ASINPI) category, compared with white patients, and 2.8 times higher among African American patients. The ratio of male to female patients was roughly 3:2. Conclusions: The prevalence of diagnosed CHB in this US patient population increased from 2006 to 2014, after which it decreased significantly. Rates declined most rapidly among patients </=40 or 61-70 years old, as well as among ASINPI patients. The rate of newly reported cases remained steady over the study period. |
Adjuvant ribavirin and longer direct-acting antiviral treatment duration improve sustained virological response among hepatitis C patients at risk of treatment failure
Lu M , Wu KH , Li J , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Daida YG , Schmidt MA , Rupp LB , Zhang T , Trudeau S , Gordon SC . J Viral Hepat 2019 26 (10) 1210-1217 The role of ribavirin (RBV) in the era of direct-acting antivirals (DAA) is not clear, and DAA studies have been largely genotype- and regimen-specific. Using data from the Chronic Hepatitis Cohort Study, we evaluated the role of RBV and increased DAA treatment duration among patients with chronic hepatitis C (HCV) in routine clinical care. Multivariable analysis of data from 4133 patients receiving any of the following: sofosbuvir (SOF); daclatasvir +SOF; grazoprevir +elbasvir; paritaprevir/ ritonavir +ombitasvir; simeprevir +SOF; and SOF +ledipasvir; SOF +velpatasvir +/-voxilaprevir; and glecaprevir+pibrentasvir-all with/ without RBV. Inverse probability treatment weighting was used to adjust for treatment-selection bias. Sustained virological response (SVR) was defined by undetectable HCV RNA 12 weeks after end of therapy. The overall SVR rate was 95%. Mean treatment duration was 12+/-4.5 weeks. The final model included treatment duration and diabetes, as well as the interaction of RBV with previous treatment status (treatment naive, interferon treatment failure [TF], or previous DAA TF), cirrhosis status, and HCV genotype (GT). Each one month increment of treatment duration increased odds of SVR by 99% (aOR=1.99). Diabetes, previous DAA TF, and decompensated cirrhosis significantly reduced odds of SVR. RBV significantly increased the likelihood of SVR among patients with decompensated cirrhosis (aOR=5.05), previous DAA treatment failure (aOR=5.43), and GT3 (aOR=13.28). Among RBV-free regimens, patients with GT3 were less likely to achieve SVR than those with GT1 or 2 (aOR 0.07). Diabetes, decompensated cirrhosis, and prior DAA TF independently reduced the likelihood of SVR. Longer treatment duration increased likelihood of SVR. RBV increased likelihood of SVR among patients with GT3, previous DAA TF, or decompensated cirrhosis. This article is protected by copyright. All rights reserved. |
Underreporting of Hepatitis B and C virus infections - Pennsylvania, 2001-2015
Roberts H , Boktor SW , Waller K , Daar ZS , Boscarino JA , Dubin PH , Suryaprasad A , Moorman AC . PLoS One 2019 14 (6) e0217455 CONTEXT: In Pennsylvania, reporting of viral hepatitis B (HBV) and viral hepatitis C (HCV) infections to CDC has been mandated since 2002. Underreporting of HBV and HCV infections has long been identified as a problem. Few reports have described the accuracy of state surveillance case registries for recording clinically-confirmed cases of HBV and HCV infections, or the characteristics of populations associated with lower rates of reporting. OBJECTIVE: The primary objective of the current study is to estimate the proportion of HBV and HCV infections that went unreported to the Pennsylvania Department of Health (PDoH), among patients in the Geisinger Health System of Pennsylvania. As a secondary objective, we study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest: sex, age group, race/ethnicity, rural status, and year of initial diagnosis. DESIGN: Per medical record review, the study population was limited to Geisinger Health System patients, residing in Pennsylvania, who were diagnosed with a chronic HBV and/or HCV infection, between 2001 and 2015. Geisinger Health System patient medical records were matched to surveillance records of confirmed cases reported to the Pennsylvania Department of Health (PDoH). To quantify the extent that underreporting occurred among the Geisinger Health System study participants, we calculated the proportion of study participants that were not reported to PDoH as confirmed cases of HBV or HCV infections. An analysis of adjusted prevalence ratio estimates was conducted to study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest. RESULTS: Geisinger Health System patients living with HBV were reported to PDoH 88.4% (152 of 172) of the time; patients living with HCV were reported to PDoH 94.6% (2,257 of 2,386) of the time; and patients who were co-infected with both viruses were reported to PDoH 72.0% (18 of 25) of the time. Patients living with HCV had an increased likelihood of being reported if they were: less than or equal to age 30 vs ages 65+ {PR = 1.2, [95%CI, (1.1, 1.3)]}, and if they received their initial diagnosis of HCV during the 2010-2015 time period vs the 1990-1999 time period {PR = 1.08, [95%CI, (1.05, 1.12)]}. CONCLUSION: The findings in this study are promising, and suggests that PDoH has largely been successful with tracking and monitoring viral hepatitis B and C infections, among persons that were tested for HBV and/or HCV. Additional efforts should be placed on decreasing underreporting rates of HCV infections among seniors (ages 65 and over), and persons who are co-infected with HBV and HCV. |
The HCV care continuum: linkage to HCV care and treatment among patients at an urban health network, Philadelphia, PA
Coyle C , Moorman AC , Bartholomew T , Klein G , Kwakwa H , Mehta SH , Holtzman D . Hepatology 2019 70 (2) 476-486 BACKGROUND/AIMS: Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five Federally Qualified Health Centers (FQHCs) in Philadelphia, PA where a testing and linkage to care program had been established. METHODS: Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012-2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. RESULTS: Of 885 chronically infected patients, 92.2% received their RNA positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (aOR=2.76; 95% CI=1.82, 4.17) and undergo liver disease staging (aOR=1.92, 95% CI=1.02, 2.86) than patients at the other FQHCs combined. CONCLUSIONS: In this U.S. urban setting, over two-thirds of HCV-infected patients were linked to care. Although treatment uptake was low overall, it was highest at the test and treat site. Scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum. This article is protected by copyright. All rights reserved. |
Sustained virological response to hepatitis C treatment decreases the incidence of complications associated with type 2 diabetes
Li J , Gordon SC , Rupp LB , Zhang T , Trudeau S , Holmberg SD , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Schmidt MA , Daida YG , Lu M . Aliment Pharmacol Ther 2019 49 (5) 599-608 BACKGROUND: The role of hepatitis C (HCV) eradication on the long-term complications of type 2 diabetes mellitus remains incompletely studied. AIM: We investigated whether antiviral treatment impacted risk of acute coronary syndrome, end-stage renal disease, ischaemic stroke, and retinopathy among diabetic patients from the four US health systems comprising the Chronic Hepatitis Cohort Study (CHeCS). METHODS: We included CHeCS HCV patients with diagnosis codes for type 2 diabetes who were on antidiabetic medications. Patients were followed until an outcome of interest, death, or last health system encounter. The effect of treatment on outcomes was estimated using the competing risk analysis (Fine-Gray subdistribution hazard ratio [sHR]), with death as a competing event. RESULTS: Among 1395 HCV-infected patients with type 2 diabetes, 723 (52%) were treated with either interferon-based or direct-acting antivirals (DAAs); 539 (75% of treated) achieved sustained virological response (SVR). After propensity score adjustment to address treatment selection bias, patients with SVR demonstrated significantly decreased risk of acute coronary syndrome (sHR = 0.36; P < 0.001), end-stage renal disease (sHR = 0.46; P < 0.001), stroke (sHR = 0.34; P < 0.001), and retinopathy (sHR = 0.24; P < 0.001) compared to untreated patients. Results were consistent in subgroup analyses of DAA-treated patients and interferon-treated patients, an analysis of cirrhotic patients, as well as in sensitivity analyses considering cause-specific hazards, exclusion of patients with on-treatment retinopathy, and treatment status as a time-varying covariate. CONCLUSION: Successful HCV treatment among patients with type 2 diabetes significantly reduces incidence of acute coronary syndrome, end-stage renal disease, ischaemic stroke, and retinopathy, regardless of cirrhosis. Our findings support the importance of HCV antiviral therapy among patients with type 2 diabetes to reduce the risk of these extrahepatic outcomes. |
Sustained virological response does not improve long-term glycemic control in patients with type 2 diabetes and chronic hepatitis C
Li J , Gordon SC , Rupp LB , Zhang T , Trudeau S , Holmberg SD , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Schmidt MA , Daida YG , Lu M . Liver Int 2018 39 (6) 1027-1032 BACKGROUND: Sustained virological response (SVR) to treatment for chronic hepatitis C (HCV) may improve short-term glucose control among patients with type 2 diabetes (T2D), but the long-term impact remains largely unknown. We used data from the Chronic Hepatitis Cohort Study to investigate the impact of SVR on long-term trends in HbA1c in patients with T2D. METHODS: "Index date" was defined as the date of treatment initiation (treated patients) or HCV diagnosis (untreated patients). To address treatment selection bias, we used a propensity score approach. We used a piecewise, linear-spline, mixed-effects model to evaluate changes in HbA1c over a five-year period. RESULTS: Our sample included 384 HCV patients with T2D (192 untreated, 192 treated, with SVR or treatment failure [TF]). After adjusting for BMI, HbA1c was stable among untreated and TF patients. In SVR patients, Hb1Ac trajectories evolved in three phases: 1) index through 6 months post-index, average HbA1c decreased significantly from 7.7-5.4% per 90 days (p<0.001); 2) 6-30 months post-index, HbA1c rebounded at a rate of 1.5% every 90 days (p=0.003); and 3) from 30 months onward, HbA1c stabilized at an average level of 7.9 (p-value =0.34). Results from an analysis restricted to patients receiving direct-acting antivirals were consistent with the main findings. CONCLUSION: Successful HCV treatment among patients with T2D significantly reduces HbA1 shortly after treatment, but these decreases are not sustained long-term. Less than three years after SVR, HbA1c rebounds to levels similar to untreated/TF patients, and higher than recommended for type 2 diabetic maintenance. This article is protected by copyright. All rights reserved. |
Quantifying the risk of undetected HIV, hepatitis B virus, or hepatitis C virus infection in Public Health Service increased risk donors.
Jones JM , Gurbaxani BM , Asher A , Sansom S , Annambhotla P , Moorman AC , Brooks JT , Basavaraju SV . Am J Transplant 2019 19 (9) 2583-2593 ![]() ![]() To reduce the risk of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) transmission through organ transplantation, donors are universally screened for these infections by nucleic acid tests (NAT). Deceased organ donors are classified as "increased risk" if they engaged in specific behaviors during the 12 months before death. We developed a model to estimate the risk of undetected infection for HIV, HBV, and HCV among NAT-negative donors specific to the type and timing of donors' potential risk behavior to guide revisions to the 12-month timeline. Model parameters were estimated, including risk of disease acquisition for increased-risk groups, number of virions that multiply to establish infection, virus doubling time, and limit of detection by NAT. Monte Carlo simulation was performed. The risk of undetected infection was <1/1,000,000 for HIV after 14 days, for HBV after 35 days, and for HCV after 7 days from the time of most recent potential exposure to the day of a negative NAT. The period during which reported donor risk behaviors result in an "increased risk" designation can be safely shortened. This article is protected by copyright. All rights reserved. |
Long-term liver disease, treatment, and mortality outcomes among 17,000 persons diagnosed with chronic hepatitis C virus infection: Current Chronic Hepatitis Cohort Study status and review of findings
Moorman AC , Rupp LB , Gordon SC , Zhong Y , Xing J , Lu M , Boscarino JA , Schmidt MA , Daida YG , Teshale EH , Spradling PR , Holmberg SD . Infect Dis Clin North Am 2018 32 (2) 253-268 Chronic Hepatitis Cohort Study (CHeCS) publications using data from "real-world" patients with hepatitis C virus (HCV) have described demographic disparities in access to care; rates of advanced liver disease, morbidity, and mortality (2.5%-3.5% per year during 2006-10, although only 19% of all CHeCS decedents, and just 30% of those with deaths attributed to liver disease, had HCV listed on death certificate); substantial comorbidities, such as diabetes, advanced liver fibrosis (29% prevalence), renal disease, and depression, and partial reversal of all these with successful antiviral therapy; patient risk behaviors; and use of noninvasive markers to assess liver disease. |
Need for increasing hepatitis A virus vaccination among patients infected with hepatitis B virus and hepatitis C virus
Moorman AC , Xing J , Nelson NP . Gastroenterology 2018 154 (8) 2015-2017 Severe morbidity can result from viral hepatitis co-infection, particularly in persons with existing chronic liver disease. Vaccination is the most effective way of preventing infection with the hepatitis A virus (HAV) and hepatitis B virus (HBV). Persons with chronic liver disease are currently recommended by the Advisory Committee on Immunization Practices to receive the hepatitis A (HepA) and hepatitis B (HepB) vaccines if they have not previously been vaccinated. Recently, the Advisory Committee on Immunization Practices approved language clarifying that all patients with hepatitis C virus (HCV) infection are recommended for HepB vaccination1 and that persons with HBV and HCV infections should also be specifically considered for vaccination against HAV.2,3 |
The predictive value of International Classification of Disease codes for chronic hepatitis C virus infection surveillance: The utility and limitations of electronic health records
Abara WE , Moorman AC , Zhong Y , Collier MG , Rupp LB , Gordon SC , Boscarino JA , Schmidt MA , Trinacty CM , Holmberg SD . Popul Health Manag 2018 21 (2) 110-115 Surveillance of chronic hepatitis C virus (HCV) cases faces limitations that result in delays and underreporting. With increasing use of electronic health records (EHRs), the authors evaluated the predictive value of using International Classification of Diseases, Ninth Revision (ICD-9) codes to identify chronic HCV cases from EHR data. Longitudinal EHR data from 4 health care systems during 2006-2012 were evaluated. Using chart abstraction and review to confirm chronic HCV cases ("gold standard" definition), the authors calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 2 case definitions: (1) >/=2 ICD-9 codes separated by >/= 6 months and (2) >/=1 positive HCV RNA (ribonucleic acid) test. Among 2,718,995 patients, 20,779 (0.8%) with ICD-9 codes indicating a likely diagnosis of chronic HCV infection were identified; 13,595 (65.4%) of these were randomly selected for review. Case definition 1 (>/= 2 ICD-9 codes separated by >/= 6 months) had 70.3% sensitivity, 91.9% PPV, 99.9% specificity, and 99.9% NPV while case definition 2 (>/= 1 positive HCV RNA test) had 74.1% sensitivity, 97.4% PPV, 99.9% specificity, and 99.9% NPV. The predictive values of these alternate EHR-derived ICD-9 code-based case definitions suggest that these measures may be useful in capturing the burden of diagnosed chronic HCV infections. Their use can augment current chronic HCV case surveillance efforts; however, their accuracy may vary by length of observation and completeness of EHR data. |
Impact of sustained virological response on risk of type 2 diabetes among hepatitis C patients in the US
Li J , Zhang T , Gordon SC , Rupp LB , Trudeau S , Holmberg SD , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Schmidt MA , Daida YG , Lu M . J Viral Hepat 2018 25 (8) 952-958 Data regarding the impact of hepatitis C (HCV) therapy on incidence of type 2 diabetes mellitus are limited. We used data from the longitudinal Chronic Hepatitis Cohort Study-drawn from four large US health systems-to investigate how response to HCV treatment impacts risk of subsequent type 2 diabetes mellitus. Among HCV patients without a history of type 2 diabetes mellitus or hepatitis B, we investigated incidence of type 2 diabetes mellitus from 12 weeks post-HCV treatment through December 2015. Cox proportional hazards models were used to test the effect of treatment status (sustained virological response [SVR] or treatment failure) and baseline risk factors on development of type 2 diabetes mellitus, considering any possible risk factor-by-SVR interactions and death as a competing risk. Among 5,127 patients with an average follow-up of 3.7 years, type 2 diabetes mellitus incidence was significantly lower among patients who achieved SVR (231/3748; 6.2%) than among patients with treatment failure (299/1379; 21.7%; adjusted hazard ratio [aHR]= 0.79; 95%CI 0.65-0.96). Risk of type 2 diabetes mellitus was higher among African American and Asian American patients than white patients (aHR=1.82 and 1.75, respectively; p<0.05), and among Hispanic patients than non-Hispanics (aHR=1.86). Patients with BMI >/=30 and 25-30 (aHR=3.62 and 1.72, respectively; p<0.05) demonstrated higher risk than those with BMI <25; patients with cirrhosis at baseline had higher risk than those without cirrhosis (aHR=1.47). Among a large US cohort of patients treated for HCV, patients who achieved SVR demonstrated a substantially lower risk for development of type 2 diabetes mellitus than patients with treatment failure. This article is protected by copyright. All rights reserved. |
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