Maxine M. Denniston

Chronic Hepatitis C Virus Infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010

Context Chronic hepatitis C virus (HCV) infection is an important public health issue. Using data from a U.S. household survey conducted between 2003 and 2010, the authors compared the estimated prevalence of chronic HCV infection and risk factors for infection with those from earlier periods. Contribution The estimated prevalence of chronic HCV infection in the United States has decreased. Risk factors are essentially unchanged from previous periods and were reported by only about one half of infected persons. Caution Homeless and incarcerated persons were not surveyed. Implication The burden of chronic HCV infection in the United States is substantial. National data on prevalence are useful for the design of programs for HCV screening, linkage to care, and treatment. The Editors Hepatitis C virus (HCV) infection is a treatable but underrecognized and underdiagnosed disease. An estimated 130 to 170 million persons, 2% to 3% of the worlds population, are living with HCV infection, and almost 500000 persons die of HCV-related conditions each year (primarily decompensated cirrhosis and liver cancer) (1). In the United States, previous estimates have consistently indicated that approximately 3 million or more persons have chronic HCV infection. An analysis of 21241 serum specimens from participants in NHANES (National Health and Nutrition Examination Survey), which provides nationally representative statistics on the health of the U.S. noninstitutionalized civilian population, indicated that 2.7 million persons (95% CI, 2.4 to 3.0 million persons) had chronic HCV infection between 1988 and 1994 (2). A similar analysis of 15079 NHANES specimens between 1999 and 2002 estimated that 3.2 million persons (95% CI, 2.7 to 3.9 million persons) had chronic HCV infection (3). These estimates do not include cases of chronic HCV not captured by NHANES, notably among homeless persons and persons who were incarcerated during the survey (4). The Institute of Medicine recently concluded that it is essential to know the dimensions and direction of this epidemic, which has major implications for health burden and costs for the United States (5). Current treatment can cure HCV in a substantial proportion of persons who complete therapy, thereby decreasing the risk for hepatocellular carcinoma and all-cause mortality. However, many persons infected with HCV remain untested and unaware of their infection, are unknown to the health care system, and are not captured in case-based surveillance because they are typically asymptomatic (6). Deaths among persons with HCV infection have superseded deaths in those with HIV infection (7). Surveillance for antibody to HCV (anti-HCV) and HCV RNA has been part of NHANES since the 1980s, although RNA testing for NHANES III was done retrospectively. Surveillance through such a large national survey presents the best measurement of the prevalence of anti-HCV and chronic HCV infection in the general U.S. population. Accordingly, using methods similar to analyses from 20 and 10 years ago (2, 3), we analyzed data from participants in NHANES between 2003 and 2010 to estimate the prevalence of HCV infection and to determine risk factors and exposures associated with chronic infection. Methods Survey Design The National Health and Nutrition Examination Survey, conducted by the Centers for Disease Control and Preventions National Center for Health Statistics, collects nationally representative data on the health and nutritional status of the U.S. noninstitutionalized civilian population. This survey uses a complex, stratified, multistage probability sampling design and collects information from approximately 5000 persons annually using standardized interviews, physical examinations, and tests of biological samples. Participants were interviewed in their homes using the interviewer-administered Computer-Assisted Personal Interviewing system to ascertain demographic characteristics and in the Mobile Examination Center to ascertain possible risks and exposures for HCV infection. Persons aged 16 years or older and emancipated minors were interviewed directly; an adult proxy provided information for participants younger than 16 years and for persons unable to answer the questions themselves. All participants provided written informed consent. More detailed information on survey design for NHANES, including approval from the National Center for Health Statistics Institutional Review Board (Hyattsville, Maryland), is available from the survey documentation at www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Laboratory Testing Qualitative determination of anti-HCV in blood serum or plasma was measured using direct solid-phase enzyme immunoassay with an anti-HCV screening chemiluminescence immunoassay (VITROS Anti-HCV Immunodiagnostic System, Ortho Clinical Diagnostics, Rochester, New York). Screening reactive specimens were then tested using a confirmatory recombinant immunoblot assay (RIBA) (RIBA HCV 3.0 Strip Immunoblot Assay, Chiron, Emeryville, California), an in vitro qualitative immunoassay for the detection of anti-HCV in human serum or plasma. Samples with positive results on RIBA testing were reported as confirmed positive for anti-HCV, those with results that were negative were reported as negative for anti-HCV, and those with indeterminate results were reported as indeterminate. In clinical practice, it is most important to identify persons who are currently infected; however, for surveillance purposes, we are interested in having a reliable measure of both those who are currently infected and those who were ever infected. Although the sensitivity and specificity of anti-HCV tests have improved over time for at-risk populations, estimating the true prevalence in a low-risk, low-prevalence population, such as that sampled in NHANES, requires a confirmatory test, such as RIBA, to eliminate false-positive results from our estimates of persons ever infected. Serum samples that were confirmed positive or indeterminate for anti-HCV were further tested for HCV RNA using an in vitro nucleic acid amplification test for the quantitation of HCV RNA in human serum or plasma. We used the COBAS AMPLICOR HCV Test, version 2.0 (Roche Diagnostics, Indianapolis, Indiana), on the COBAS AMPLICOR Analyzer (Roche Diagnostics) for samples from 2005 to 2010 and the COBAS AmpliPrep/TaqMan HCV Test, version 2 (Roche Diagnostics), on the COBAS TaqMan 48 Analyzer (Roche Diagnostics) for samples from 2003 to 2004. We considered persons to have chronic HCV infection if results of their test for anti-HCV were confirmed positive or indeterminate and results of their test for HCV RNA were positive. Our comparison group comprised persons who tested negative for anti-HCV; these participants were considered to be never infected with HCV. Those who tested positive for anti-HCV but negative for HCV RNA (resolved infections; n= 90) and those who had no serum available for RNA testing (n= 51) were not included in our analyses, except for estimation of overall anti-HCV prevalence, because we wanted to focus on chronic HCV infection. Statistical Analysis SAS-Callable SUDAAN, Release 10.0 (Research Triangle Institute, Research Triangle Park, North Carolina) (8), a statistical package designed to analyze complex survey data, was used for analysis. Estimates were weighted to represent the total U.S. noninstitutionalized civilian population and to account for oversampling and nonresponse to the household interview and physical examination. Two-year sample weights (WTMEC2yr) were further adjusted to account for the fact that not all examination participants were tested for anti-HCV, not all participants who tested positive or indeterminate for anti-HCV had samples available for HCV RNA testing, and multiple years of data were used. A P value less than 0.05 was considered statistically significant. We analyzed demographic characteristics (age at interview, sex, race/ethnicity, birthplace, education, and income), potential risk factors or exposures (receipt of blood or a blood product before 1992, any past injection drug use, and number of lifetime sexual partners), and a proxy for sexual risk (antibodies to herpes simplex virus type 2) (9, 10). Although sex is not a usual method of transmission of HCV infection (11), number of sexual partners and presence of herpes simplex virus type 2 antibodies are included because these are indices of increased likelihood of being infected with HCV and have been used in previous analyses. We restricted most analyses to persons aged 20 years or older because only 2 persons aged 6 to 19 years had evidence of chronic HCV infection (that is, tested positive for HCV RNA) and because data on drug use and sexual behaviors among those younger than 20 years are not available from NHANES public-use data files. Ages included in our reporting of risks and exposures reflect age eligibility for a particular question or laboratory test rather than a focus on particular age groups. We used bivariate analyses to estimate demographic characteristics of persons with chronic HCV infection and those who were never infected and to estimate the prevalence of potential risk factors or exposures among population subgroups. Chi-square tests were used for statistical comparisons between subgroups. Simple (unadjusted) and multivariate logistic regression analyses were used to identify factors associated with chronic HCV infection. We performed separate logistic analyses for persons aged 20 to 59 years and those aged 60 years or older because NHANES does not query those older than 59 years about sexual behaviors or drug use. We retained 3 potential confoundersage at interview, sex, and race/ethnicityin all multivariate models. Variables that were associated with HCV infection in previous NHANES analyses (2, 3) were included in multivariate models to identify factors independently associated with chronic HCV infection. Variables not inclu

Hepatitis C in the United States

Recent analyses suggest that of the estimated 3.2 million people infected with hepatitis C virus, only about half have been tested and know their status, about a third have been referred for HCV care, and only 5 to 6% have been successfully treated.

Long-term Breast Cancer Survivors’ Use of Complementary Therapies: Perceived Impact on Recovery and Prevention of Recurrence:

Objective:Many cancer survivors use some form of complementary therapy (CT); this is particularly true for women with breast cancer. The majority of reports on CT use in women with breast cancer have focused on CT use during cancer treatment or within a year or two of treatment completion. The purpose of this study was to evaluate longertermbreast cancer survivors’ (average, 8.7 years) frequency of CT use and their beliefs about the role of CT in cancer recovery and the prevention of cancer recurrence, as well as the relationship of CT use with current life satisfaction. Methods: A mail survey was completed by 608 breast cancer survivors a minimum of 2 years after their most recent cancer diagnosis. Participants were contacted through the American Cancer Society Reach to Recovery program in Florida. The self-report questionnaire inquired about the use of various CTs, beliefs about CT, current life satisfaction, demographic characteristics, and cancer treatment history.Results: Most of the respondents were older than 50, were Caucasian, were married, had attended or completed college, and were at least 5 years after breast cancer treatment. The most commonly used CTs included exercise, vitamins, prayer/spiritual practice, support groups, humor, self-help books, and relaxation. These survivors used CT therapies because they wanted to play a more active role in their cancer recovery, to manage stress, and to maintain hope. A majority of them reported that they used CT to reduce the risk of cancer recurrence. Use of CT was not correlated with life satisfaction.Conclusions: Most of the breast cancer survivors in this study had used some form of CT since the time of their most recent cancer diagnosis and believed that such therapies could be of significant benefit, despite a lack of correlation between CT use and current life satisfaction. Many believed that use of CT may prevent cancer recurrence. It is important, therefore, to investigate the efficacy of variousCTs among longer-termcancer survivors, especially with regard to their potential in preventing cancer recurrence.

Comparison of paper-and-pencil versus Web administration of the Youth Risk Behavior Survey (YRBS): risk behavior prevalence estimates.

The authors examined whether paper-and-pencil and Web surveys administered in the school setting yield equivalent risk behavior prevalence estimates. Data were from a methods study conducted by the Centers for Disease Control and Prevention (CDC) in spring 2008. Intact classes of 9th- or 10th-grade students were assigned randomly to complete a survey via paper-and-pencil or Web. Data from 5,227 students were analyzed using logistic regression to identify associations of mode with reporting of 74 risk behaviors. Mode was associated with reporting of only 7 of the 74 risk behaviors. Results indicate prevalence estimates from paper-and-pencil and Web school-based surveys are generally equivalent.

Long-term Health and Economic Impact of Preventing and Reducing Overweight and Obesity in Adolescence

PURPOSE Using data from the 2000 National Medical Expenditure Panel Survey and estimates from published studies, this study projected the long-term health and economic impacts of preventing and reducing overweight and obesity in todays adolescents. METHODS We developed a body mass index progression model to project the impact of a 1% point reduction in both overweight and obese adolescents aged 16-17 years at present on the number of nonoverweight, overweight, and obese adults at age 40 years. We then estimated its impact on the lifetime medical costs and quality-adjusted life years (QALYs) after age 40. Medical costs (in 2007 dollars) and QALYs were discounted to age 17 years. RESULTS A 1% point reduction in both overweight and obese adolescents ages 16-17 years at present could reduce the number of obese adults by 52,821 in the future. As a result, lifetime medical care costs after age 40 years would decrease by

Decline in Hepatitis E Virus Antibody Prevalence in the United States From 1988–1994 to 2009–2010

586 million and lifetime QALYs would increase by 47,138. In the worst case scenario, the 1% point reduction would lower medical costs by

Quality of Care for HIV Infection Provided by Ryan White Program-Supported versus Non-Ryan White Program-Supported Facilities

463 million and increase QALYs by 34,394; in the best case scenario, it would reduce medical costs by

Progress Toward Eliminating Hepatitis A Disease in the United States

691 million and increase QALYs by 57,149. CONCLUSIONS Obesity prevention in adolescents goes beyond its immediate benefits; it can also reduce medical costs and increase QALYs substantially in later life. Therefore, it is important to include long-term health and economic benefits when quantifying the impact of obesity prevention in adolescents.

Association of Hepatitis C Virus With Alcohol Use Among U.S. Adults: NHANES 2003–2010

BACKGROUND Previous population-based estimates in the United States have shown a relatively high prevalence of hepatitis E virus (HEV) antibody. We sought to determine whether changes in the prevalence of HEV antibody have occurred over time. METHODS We analyzed data from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) and NHANES III (1988-1994). Using the same serologic assay, we compared the estimated anti-HEV immunoglobulin G (IgG) prevalence and risk factors for antibody positivity for the 2 periods. RESULTS The prevalence of HEV antibody among those aged ≥6 years declined from 10.2% (95% confidence interval [CI], 9.1%-11.4%) during 1988-1994 to 6.0% (5.2%-6.8%) during 2009-2010, and the prevalence for those of US birth ranged from 9.6% (8.4%-10.9%) to 5.2% (4.4%-6.2%). Among US-born persons, the estimated HEV antibody prevalence declined significantly for all subgroups of age, sex, region of residence, and number of persons per room in the household; significant declines also were observed for persons at or above poverty level and for persons of non-Hispanic white, non-Hispanic black, and Mexican American race/ethnicity. No clear associations with food consumption were found. CONCLUSIONS The anti-HEV prevalence is declining in the United States. Although the decline suggests a decrease in exposure to HEV over time, the risks associated with exposure remain unknown.

Decreasing immunity to hepatitis A virus infection among US adults: Findings from the National Health and Nutrition Examination Survey (NHANES), 1999-2012.

Background The Ryan White HIV/AIDS Care Act (now the Treatment Modernization Act; Ryan White Program, or RWP) is a source of federal public funding for HIV care in the United States. The Health Services and Resources Administration requires that facilities or providers who receive RWP funds ensure that HIV health services are accessible and delivered according to established HIV-related treatment guidelines. We used data from population-based samples of persons in care for HIV infection in three states to compare the quality of HIV care in facilities supported by the RWP, with facilities not supported by the RWP. Methodology/Principal Findings Within each area (King County in Washington State; southern Louisiana; and Michigan), a probability sample of patients receiving care for HIV infection in 1998 was drawn. Based on medical records abstraction, information was collected on prescription of antiretroviral therapy according to treatment recommendations, prescription of prophylactic therapy, and provision of recommended vaccinations and screening tests. We calculated population-level estimates of the extent to which HIV care was provided according to then-current treatment guidelines in RWP-supported and non-RWP-supported facilities. For all treatment outcomes analyzed, the compliance with care guidelines was at least as good for patients who received care at RWP-supported (vs non-RWP supported) facilities. For some outcomes in some states, delivery of recommended care was significantly more common for patients receiving care in RWP-supported facilities: for example, in Louisiana, patients receiving care in RWP-supported facilities were more likely to receive indicated prophylaxis for Pneumocystis jirovecii pneumonia and Mycobacterium avium complex, and in all three states, women receiving care in RWP-supported facilities were more likely to have received an annual Pap smear. Conclusions/Significance The quality of HIV care provided in 1998 to patients in RWP-supported facilities was of equivalent or better quality than in non-RWP supported facilities; however, there were significant opportunities for improvement in all facility types. Data from population-based clinical outcomes surveillance data can be used as part of a broader strategy to evaluate the quality of publicly-supported HIV care.