Pardha Devaki

The changing epidemiology of hepatitis C virus infection in the United States: National health and nutrition examination survey 2001 through 2010

BACKGROUND & AIMS In light of the dramatically changing hepatitis C therapeutic landscape, knowledge of the current burden of HCV infection in the general population of the United States is critical. METHODS The National Health and Nutrition Examination survey collects nationally representative data on HCV infection in the civilian population of the United States. Data from 2001 to 2010 were combined for this study. HCV testing was completed in 38,025 participants. RESULTS The prevalence of anti-HCV in the United Sates decreased from 1.9% (95% CI 1.5%-2.5%) in 2001-2002 to 1.3% (95% CI 0.9%-1.8%) in 2005-2006, and remained stable up to 2010. About 67% of all infected persons were positive for HCV RNA, indicating 2.3 million people with chronic HCV infection, of whom 68% have genotype 1. Seventy percent of infected persons were born between 1945 and 1965, with prevalence of 3.5% (95% CI 2.2%-4.8%). The stable rate since 2006 is mostly related to prevalent cases and foreign born persons migrating into US. Other important risk factors include less education and low economic status. Race, HIV status, number of sexual partners, and blood transfusions are no longer associated with HCV infection. CONCLUSIONS As of 2010, approximately 2.3 million persons were chronically infected with Hepatitis C in the US. Most of those infected are prevalent, rather than incident cases. The prevalence of HCV was on the decline, but has stabilized since 2006. Future studies should explore reasons for no decline in HCV prevalence since 2006.

Prevalence, Trends, and Risk Factors for Fecal Incontinence in United States Adults, 2005-2010

BACKGROUND & AIMS We investigated the prevalence of and trends and risk factors for fecal incontinence (FI) in the United States among non-institutionalized adults from 2005 to 2010. METHODS We analyzed data from 14,759 participants in the U.S. National Health and Nutrition Examination Survey (49% women, 20 years or older) from 2005 to 2010 (the FI Severity Index was added in 2005-2006). FI was defined as accidental leakage of solid or liquid stool or mucus at least once in preceding month. Sampling weights were used to obtain estimates for the national population. Logistic regression was used to identify risk factors for FI. RESULTS The prevalence of FI among non-institutionalized U.S. adults was 8.39% (95% confidence interval, 7.76-9.05). It was stable throughout the study period: 8.26% in 2005-2006, 8.48% in 2007-2008, and 8.41% in 2009-2010. FI resulted in release of liquid stool in most cases (6.16%). Prevalence increased with age from 2.91% among 20- to 29-year-old participants to 16.16% (14.15%-18.39%) among participants 70 years and older. Independent risk factors for FI included older age, diabetes mellitus, urinary incontinence, frequent and loose stools, and multiple chronic illnesses. FI was more common among women only when they had urinary incontinence. CONCLUSIONS FI is a common problem among non-institutionalized U.S. adults. Its prevalence remained stable from 2005-2010. Diabetes mellitus and chronic diarrhea are modifiable risk factors. Future studies on risk factors for FI should assess for presence of urinary incontinence.

Current epidemiology of hepatitis E virus infection in the United States: Low seroprevalence in the National Health and Nutrition Evaluation Survey

Analysis of the National Health and Nutrition Evaluation Survey (NHANES) 1988‐1994 dataset found a relatively high seroprevalence (21%) of hepatitis E virus (HEV) infection in the U.S. general population. Using data obtained within the NHANES 2009‐2010 survey, where a high performance assay for HEV was used, we estimated the weighted seroprevalence of HEV infection among U.S. individuals 6 years and older. We also evaluated factors associated with HEV seropositivity. A total of 8,814 individuals were included in the analysis. The median age of study participants was 37 years (interquartile range [IQR] 17‐58 years), with 51.2% being female. The weighted national seroprevalence of HEV was 6% (95% confidence interval [CI] 5.1%‐6.9%). About 0.5% of those with HEV had evidence of recent exposure (immunoglobulin M‐positive). In the univariate analyses, factors associated with HEV seropositivity were increasing age (P‐trend < 0.001), birth outside of the U.S., Hispanic race, and “meat” consumption (>10 times/month). No significant association was observed with low socioeconomic status, water source, or level of education. In the multivariate analysis, only older age remained predictive of HEV seropositivity. Conclusion: The weighted national seroprevalence of HEV in the U.S. is much less than previously reported. Using data obtained with a high performance assay, the seroprevalence of HEV was estimated at 6.0% in the U.S. Based on these results, the seroprevalence of HEV is only one‐third as high as previously reported. (Hepatology 2014;60:815–822)

Prevalence of non-alcoholic fatty liver disease and risk factors for advanced fibrosis and mortality in the United States

In the United States, non-alcoholic fatty liver disease (NAFLD) is the most common liver disease and associated with higher mortality according to data from earlier National Health and Nutrition Examination Survey (NHANES) 1988–1994. Our goal was to determine the NAFLD prevalence in the recent 1999–2012 NHANES, risk factors for advanced fibrosis (stage 3–4) and mortality. NAFLD was defined as having a United States Fatty Liver Index (USFLI) > 30 in the absence of heavy alcohol use and other known liver diseases. The probability of low/high risk of having advanced fibrosis was determined by the NAFLD Fibrosis Score (NFS). In total, 6000 persons were included; of which, 30.0% had NAFLD and 10.3% of these had advanced fibrosis. Five and eight-year overall mortality in NAFLD subjects with advanced fibrosis was significantly higher than subjects without NAFLD ((18% and 35% vs. 2.6% and 5.5%, respectively) but not NAFLD subjects without advanced fibrosis (1.1% and 2.8%, respectively). NAFLD with advanced fibrosis (but not those without) is an independent predictor for mortality on multivariate analysis (HR = 3.13, 95% CI 1.93–5.08, p<0.001). In conclusion, in this most recent NHANES, NAFLD prevalence remains at 30% with 10.3% of these having advanced fibrosis. NAFLD per se was not a risk factor for increased mortality, but NAFLD with advanced fibrosis was. Mexican American ethnicity was a significant risk factor for NAFLD but not for advanced fibrosis or increased mortality.

Ethnic disparities and liver transplantation rates in hepatocellular carcinoma patients in the recent era: Results from the surveillance, epidemiology, and end results registry

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. After the implementation of the Model for End‐Stage Liver Disease system, rates of liver transplantation (LT) for HCC patients increased. However, it is not clear whether this trend has continued into recent times. Using the Surveillance, Epidemiology, and End Results registry (1998‐2010), we retrospectively analyzed trends for LT among HCC patients in 3 time periods: 1998‐2003, 2004‐2008, and 2009‐2010. A total of 60,772 HCC patients were identified. In the more recent time periods, the proportion of localized‐stage HCC increased (45.0% in 1998‐2003, 50.4% in 2004‐2008, and 51.7% in 2009‐2010; P < 0.001). Although the proportion of HCC patients within the Milan criteria also increased with time (22.8% in 1998‐2003, 31.8% in 2004‐2008, and 37.1% in 2009‐2010; P < 0.001), the proportion of those patients undergoing LT increased from 1998‐2003 to 2004‐2008 but decreased from 2004‐2008 to 2009‐2010. However, the actual frequencies of LT were similar in 2004‐2008 (208.2 per year) and 2009‐2010 (201.5 per year). A multivariate logistic regression, including sex, age, ethnicity, Milan criteria, tumor stage, tumor size and number, and time periods, demonstrated a lower likelihood of LT in 2009‐2010 versus 1998‐2003 [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.57‐0.71]. Blacks (OR = 0.48, 95% CI = 0.41‐0.56), Asians (OR = 0.65, 95% CI = 0.57‐0.73), and Hispanics (OR = 0.76, 95% CI = 0.68‐0.85) were all less likely to undergo LT in comparison with non‐Hispanic whites. Despite the increasing proportion of patients with HCC diagnosed at an earlier stage, LT rates declined in the most recent era. In addition, ethnic minorities were significantly less likely to undergo LT. The growing imbalance between the number of transplant‐eligible HCC patients and the shortage of donor livers emphasizes the need to improve donor availability and curative alternatives to LT. Liver Transpl 20:528–535, 2014.

Su1397 Very Low and Similar Proportions of Patients With Celiac Disease Among Patients With Normal and Elevated ALT Levels, Especially Among Non-Whites: Results of a U.S. Nationwide Sample of 16,795 Persons

Background: Studies investigating the prevalence of celiac disease (CD) in persons with elevated aminotransferases have yielded conflicting results. It raises the question, whether clinicians should consider including celiac serology in initial evaluation of patients with abnormal liver tests. Elevated ALT in asymptomatic patients is commonly encountered in practice and a common reason for referral to gastroenterologists or hepatologists. The aim of our study is to determine the prevalence of CD in a large nationwide sample representative of the general population in the U.S. Methods: This study included 16,975 persons aged 6 years or older from the National Health and Nutrition Examination Survey (NHANES), which collects nationally representative data in the U.S. civilian population. Data from 20092012 were combined for this study. Upper limit of normal for ALT was ≥29 in men and ≥ 22 for women (Ruhl et al, Hepatol 2012). CD was defined as having positive tissue transglutaminase plus endomysial IgA Abs or a reported clinical diagnosis (reported diagnosis of CD by a doctor or a health-care professional and being on gluten-free diet). Primary study outcome was proportions of patients with CD in individuals with normal ALT and elevated ALT. Sample weights were used to determine weighted prevalence of CD. Results: The median age of the entire cohort was 36 years (range 6-80, IQR 16-57). Close to half (49.6%) were male with similar distribution between those with normal and elevated ALT. Overall, 38% were Non-Hispanic White, 22.9% were Non-Hispanic Blacks, 27.7% were Hispanic, and 11.4% had other races. Elevated ALT was seen in 29.1% of the cohort. Among the 3,725 individuals with elevated ALT, 41.5% were Non-Hispanic Whites, 16.9% were Non-Hispanic Blacks, 31.5% were Hispanic, and 10.1% were other races. CD was found in 56 individuals out of 16,975 (0.61%, 95%CI 0.43%-0.79%): 20 with elevated ALT (0.80%, 95% CI 0.42%-1.2%) and 29 with normal ALT (0.61%, 95% CI 0.30%-0.91%) (Table 1). CD prevalence was highest in non-Hispanic White with both normal and elevated ALT at 0.87% (95% CI, 0.40%-1.3%) and 1.12% (95% CI, 0.58%-1.65%), respectively. Overall, CD prevalence was much lower in other races: 0.09% (95% CI 0%-0.2%) for NonHispanic Blacks, 0.12% (95% CI 0%-0.24%) in Hispanic, and 0.05% (95% CI, 0%-0.1%) in other races, and these were also similar among individuals with normal and elevated ALT (Table 1). Conclusion: Interestingly, the prevalence of CD in individuals with elevated ALT is similar to that seen in individuals with normal liver enzymes in U.S. and was approximately 1% or less in both populations. CD prevalence is particularly low in non-White individuals. Based on our results, we do not advocate routine testing with celiac serology to determine if CD is the cause of abnormal liver enzymes, especially in asymptomatic non-White patients.

Sa2028 Epidemiology of Fecal Incontinence in US Adults From 2005 to 2010: Prevalence, Trends and Risk Factors

the anal verge (P,0.01), whilst gender and anastomotic height were not associated with constipation. Neither age nor radiotherapy were associated with constipation or FI. Conclusions: Bowel dysfunction, consisting of FI and constipation (characterised by evacuatory dysfunction), appears to be prevalent after anterior resection surgery and persists up to a decade after surgery. Low anastomotic height, reflecting loss of more rectum, is associated with FI, but not constipation.