In this review, I will discuss the outbreaks of
acute infections of hepatitis C across the United States in urban and
Before I start discussing this
very important issue, I would like to set the stage by going over the
case definition of hepatitis C (HCV) acute infection as defined by the
Centers for Disease Control and Prevention (CDC):
infection with infection with acute illness of discreet onsite. An
acute illness is considered as the presence of any sign or symptom of
acute viral hepatitis plus either jaundice or elevated alanine
aminotransferase >400 IU/L. In 2012, the surveillance case
definition was expanded to include cases with negative HCV antibody
followed by positive antibody within six months.”
To me there are problems with the CDC case
definition. Regarding the first part of the definition—an estimated
two-thirds of people acutely infected have few or no symptoms. This
means that they are missing the majority of people who are acutely
infected with HCV. The new case definition regarding prior antibody
testing is better, but it does not accurately capture people who are
new to injecting drugs or people who have never been tested for
hepatitis C. However, it is understandable how difficult it is to set
the criteria to define an acute infection. Note: In “Snapshots” this month there is a recap of a study that may provide a test to identify acute cases of HCV.
In the July 2015 HCV Advocate Mid-Monthly Edition
, I wrote about an article published in the Annals of Internal Medicine
titled “Underascertainment of Acute Hepatitis C Virus Infections in
the U.S. Surveillance System: A Case Series and Chart Review,” by S
Onofrey, MPH et. al. The authors concluded that only 1%
of acute infections has been reported to the CDC based on their case definition. Keep the 1%
in mind when reading the information below.
In July 2011 I wrote about the Massachusetts
outbreak of acute HCV among young people who inject drugs. In the CDC
report Massachusetts initiated a comprehensive surveillance system and
identified 1,925 new cases of HCV infections among people aged 15-24
years during 2007 to 2009. Of these cases, 1026 were confirmed new
hepatitis C infections and the remaining cases were classified as
probable. It was also interesting that the new hepatitis C infections
were not just confined to the major metropolitan and suburban areas of
Boston, but high rates were also found in smaller cities and rural
areas. It was also reported that the incidence of new HCV infections
were similar in women and men and were seen mostly among non-Hispanic
whites. In the analysis, 72% of the people reported current or past
injection drug use. Among the people who self-disclosed that they
injected drugs—85% used heroin, 29% cocaine, 1% methamphetamine and 4%
had used other drugs. Some of the characteristics seen in the
Massachusetts outbreaks —rural, young, mostly White using heroin—were
the beginning of a trend seen throughout the country.
Massachusetts has an extensive
network of needle exchanges. One can only imagine what the number of
acute infections would be without a needle exchange network.
In “Notes from the Field: Hepatitis C Virus
Infections Among Young Adults—Rural Wisconsin, 2010,” a report from the
CDC issued on May 18, 2012 /61(19);358-358 a number of outbreaks in
rural counties of Wisconsin were discussed. It was reported that in 6
contiguous rural counties of Wisconsin that in persons under 30 yo that
the number of HCV infections had increased from an average of 8 cases
per year during 2004 – 2008 to an average of 24 cases per year during
2009 – 2010.
The CDC investigated 25 cases
during 2010 of the adults under 30 years old who resided in the 6
counties. Of these patients 7 had jaundice (a rare symptom of acute
HCV). All 21 had positive antibody tests. Twenty-one had positive
EIA with signal-to-cutoff ratio or had a test to confirm the presence
of HCV RNA (viral load test). Additionally, seventeen patients were
interviewed. Of the patients who were interviewed (17 pts) 94% had
either injected drugs, snorted drugs or both.
The age group that had the
highest prevalence was those 20-29 yo, which is a national trend of
people who inject drugs in rural areas. No information about the sex of
the patients was given in the report.
In Ohio, the number of
confirmed cases of acute cases HCV was 112 in 2013 and 105 in 2014.
The demographics are similar to the demographics in other outbreaks
across the U.S. —mostly white, equally divided among gender and many of
the acute cases occurred in rural settings.
The May 1st issue of the Morbidity and Mortality Weekly Report (MMWR),
contained “Community Outbreak of HIV Infection Linked to Injection
Drug Use of Oxymorphone—Indiana, 2015, by C Conrad,” which describes a
recent outbreak of HIV and HCV in a rural community of Indiana. On
January 23, 2015 the Indiana State Department of Health began an
investigation on an outbreak of HIV after 11 cases were reported and
confirmed. Although little attention was given to HCV there was a
confirmed HIV/HCV coinfection rate of 84.4%! All of the people who
injected drugs reported crushing, dissolving and injecting oxymorphone
tablets as well using other drugs including methamphetamine and
heroin. The total number of people who tested positive for HIV was
135. The community in rural southeastern Indiana had a population of
4,200. The age range was 18 to 57 yo (median 35 yo), 54.8% were
The response to the outbreak is best summed up by a statement in the MMWR:
“A public health emergency was declared on March 26 by executive
order. The response has included a public education campaign,
establishment of an incident command center and a community outreach
center, short-term authorization of syringe exchange, and
support of comprehensive medical care including HIV and hepatitis C
virus care and treatment as well as substance abuse counseling and
treatment.” Hopefully, the ‘short-term’ will be changed to
On July 6, 2015 the Portland Press Herald reported
on a surge of hepatitis C cases: during 2013 to 2014 the incidence of
acute HCV increased from 9 to 31 cases and there were 14 cases in the
first 6 months of 2015. The users who were interviewed stated that
they had started with opiates like Oxycontin and switched to heroin.
This is a recurring theme. Maine has 5 needle exchange programs.
Kentucky, Tennessee, Virginia and West Virginia (2006-2012)
The CDC released an MMWR report on May 8,
2015 titled “Increases in Hepatitis C Virus Infection Related to
Injection Drug Use Among Persons Aged ≤ 30 Years –Kentucky, Tennessee,
Virginia, and West Virginia, 2006—2012,” by J E Zibbell and Colleagues
detailing the outbreaks in the Appalachia region of the U.S.
A total of
1,377 cases of acute HCV were reported to the CDC during the period
2006-2012 from Kentucky, Tennessee, Virginia and West Virginia. There
were 1,374 cases reported where the age was available—616 (44.8%) were ≤
30 yo (median age 25 yo—range in urban and non-urban 6-30 yo).
The number of persons who were
non-Hispanic whites in non urban settings was 247 (78.4%); males, 156
(49.5%); in urban counties, 249 (82.7%) cases were non-Hispanic whites,
and 155 (51.5%) were males. See Figure 1 below.
trend of acute HCV outbreaks that started in Massachusetts is
continuing across the United States. This includes more adolescents and
young adults injecting, infecting as many women as men and in rural
more than urban settings. What is even more disturbing is the
reaction of the local and state governments—needle exchange being
started post-outbreak rather than establishing needle exchange as
prevention. Almost every outbreak has resulted in the establishment of
a needle exchange program after an outbreak. If needle exchange
programs had been in place before an outbreak many of the HIV and HCV
infections could have been prevented.
Figure 1. Incidence
of acute hepatitis C among persons ≤ 30, by urbanicity and year
–Kentucky, Virginia, Tennessee, and West Virginia, 2006 –2012.
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