Ruth Jiles

The Increasing Burden of Mortality From Viral Hepatitis in the United States Between 1999 and 2007

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 CONCLUSION By 2007, HCV had superseded HIV as a cause of death in the United States, and deaths from HCV and HBV disproportionately occurred in middle-aged persons.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

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

Surveillance for certain health behaviors and conditions among states and selected local areas — Behavioral Risk Factor Surveillance System, United States, 2015

Problem Chronic conditions and disorders (e.g., diabetes, cardiovascular diseases, arthritis, and depression) are leading causes of morbidity and mortality in the United States. Healthy behaviors (e.g., physical activity, avoiding cigarette use, and refraining from binge drinking) and preventive practices (e.g., visiting a doctor for a routine check-up, tracking blood pressure, and monitoring blood cholesterol) might help prevent or successfully manage these chronic conditions. Monitoring chronic diseases, health-risk behaviors, and access to and use of health care are fundamental to the development of effective public health programs and policies at the state and local levels. Reporting Period January–December 2015. Description of the System The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit–dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to and use of health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico (Puerto Rico), and Guam and for 130 metropolitan and micropolitan statistical areas (MMSAs) (N = 441,456 respondents) for 2015. Results The age-adjusted prevalence estimates of health-risk behaviors, self-reported chronic health conditions, access to and use of health care, and use of preventive health services varied substantially by state, territory, and MMSA in 2015. Results are summarized for selected BRFSS measures. Each set of proportions refers to the median (range) of age-adjusted prevalence estimates for health-risk behaviors, self-reported chronic diseases or conditions, or use of preventive health care services by geographic jurisdiction, as reported by survey respondents. Adults with good or better health: 84.6% (65.9%–88.8%) for states and territories and 85.2% (66.9%–91.3%) for MMSAs. Adults with ≥14 days of poor physical health in the past 30 days: 10.9% (8.2%–17.2%) for states and territories and 10.9% (6.6%–19.1%) for MMSAs. Adults with ≥14 days of poor mental health in the past 30 days: 11.3% (7.3%–15.8%) for states and territories and 11.4% (5.6%–20.5%) for MMSAs. Adults aged 18–64 years with health care coverage: 86.8% (72.0%–93.8%) for states and territories and 86.8% (63.2%–95.7%) for MMSAs. Adults who received a routine physical checkup during the preceding 12 months: 69.0% (58.1%–79.8%) for states and territories and 69.4% (57.1%–81.1%) for MMSAs. Adults who ever had their blood cholesterol checked: 79.1% (73.3%–86.7%) for states and territories and 79.5% (65.1%–87.3%) for MMSAs. Current cigarette smoking among adults: 17.7% (9.0%–27.2%) for states and territories and 17.3% (4.5%–29.5%) for MMSAs. Binge drinking among adults during the preceding 30 days: 17.2% (11.2%–26.0%) for states and territories and 17.4% (5.5%–24.5%) for MMSAs. Adults who reported no leisure-time physical activity during the preceding month: 25.5% (17.6%–47.1%) for states and territories and 24.5% (16.1%–47.3%) for MMSAs. Adults who reported consuming fruit less than once per day during the preceding month: 40.5% (33.3%–55.5%) for states and territories and 40.3% (30.1%–57.3%) for MMSAs. Adults who reported consuming vegetables less than once per day during the preceding month: 22.4% (16.6%–31.3%) for states and territories and 22.3% (13.6%–32.0%) for MMSAs. Adults who have obesity: 29.5% (19.9%–36.0%) for states and territories and 28.5% (17.8%–41.6%) for MMSAs. Adults aged ≥45 years with diagnosed diabetes: 15.9% (11.2%–26.8%) for states and territories and 15.7% (10.5%–27.6%) for MMSAs. Adults aged ≥18 years with a form of arthritis: 22.7% (17.2%–33.6%) for states and territories and 23.2% (12.3%–33.9%) for MMSAs. Adults having had a depressive disorder: 19.0% (9.6%–27.0%) for states and territories and 19.2% (9.9%–27.2%) for MMSAs. Adults with high blood pressure: 29.1% (24.2%–39.9%) for states and territories and 29.0% (19.7%–41.0%) for MMSAs. Adults with high blood cholesterol: 31.8% (27.1%–37.3%) for states and territories and 31.4% (23.2%–42.0%) for MMSAs. Adults aged ≥45 years who have had coronary heart disease: 10.3% (7.2%–16.8%) for states and territories and 10.1% (4.7%–17.8%) for MMSAs. Adults aged ≥45 years who have had a stroke: 4.9% (2.5%–7.5%) for states and territories and 4.7% (2.1%–8.4%) for MMSAs. Interpretation The prevalence of health care access and use, health-risk behaviors, and chronic health conditions varied by state, territory, and MMSA. The data in this report underline the importance of continuing to monitor chronic diseases, health-risk behaviors, and access to and use of health care in order to assist in the planning and evaluation of public health programs and policies at the state, territory, and MMSA level. Public Health Action State and local health departments and agencies and others interested in health and health care can continue to use BRFSS data to identify groups with or at high risk for chronic conditions, unhealthy behaviors, and limited health care access and use. BRFSS data also can be used to help design, implement, monitor, and evaluate health-related programs and policies.

Evolving Epidemiology of Hepatitis C Virus in the United States

The impact of hepatitis C virus (HCV) infection on health and medical care in the United States is a major problem for infectious disease physicians. Although the incidence of HCV infection has declined markedly in the past 2 decades, chronic infection in 3 million or more residents now accounts for more disease and death in the United States than does human immunodeficiency virus (HIV)/AIDS. Current trends in the epidemiology of HCV infection include an apparent increase in young, often suburban heroin injection drug users who initiate use with oral prescription opioid drugs; infections in nonhospital healthcare (clinic) settings; and sexual transmission among HIV-infected persons. Infectious disease physicians will increasingly have the responsibility of diagnosing and treating HCV patients. An understanding of how these patients were infected is important for determining whom to screen and treat.

Patterns of alcohol consumption and the metabolic syndrome.

CONTEXT AND OBJECTIVE Protective and detrimental associations have been reported between alcohol consumption and the metabolic syndrome. This may be due to variations in drinking patterns and different alcohol effects on the metabolic syndrome components. This study is designed to examine the relationship between alcohol consumption patterns and the metabolic syndrome. DESIGN, SETTING, PARTICIPANTS, AND MEASURES The 1999-2002 National Health and Nutrition Examination Survey is a population-based survey of noninstitutionalized U.S. adults. Current drinkers aged 20-84 yr without cardiovascular disease who had complete data on the metabolic syndrome and drinking patterns were included in the analysis (n = 1529). The metabolic abnormalities comprising the metabolic syndrome included having three of the following: impaired fasting glucose/diabetes mellitus, high triglycerides, abdominal obesity, high blood pressure, and low high-density-lipoprotein cholesterol. Measures of alcohol consumption included usual quantity consumed, drinking frequency, and frequency of binge drinking. RESULTS In multinomial logistic regression models controlling for demographics, family history of cardiovascular disease and diabetes, and lifestyle factors, increased risk of the metabolic syndrome was associated with daily consumption that exceeded U.S. dietary guideline recommendations (more than one drink per drinking day for women and more than two drinks per drinking day for men (odds ratio 1.60, 95% confidence interval 1.22-2.11) and binge drinking once per week or more [odds ratio (95% confidence interval) 1.51 (1.01-2.29]. By individual metabolic abnormality, drinking in excess of the dietary guidelines was associated with an increased risk of impaired fasting glucose/diabetes mellitus, hypertriglyceridemia, abdominal obesity, and high blood pressure. CONCLUSION Public health messages should emphasize the potential cardiometabolic risk associated with drinking in excess of national guidelines and binge drinking.

Patterns of Alcohol Consumption and Alcohol-Impaired Driving in the United States

BACKGROUND Alcohol-related motor vehicle crashes kill approximately 17,000 Americans annually and were associated with more than

Rising Mortality Associated With Hepatitis C Virus in the United States, 2003–2013

51 billion in total costs in 2000. Relatively little is known about the drinking patterns of alcohol-impaired (AI) drivers in the United States. METHODS 2006 Behavioral Risk Factor Surveillance System (BRFSS) was analyzed for alcohol consumption and self-reported AI driving among U.S. adults aged > or =18 years for all states. Alcohol consumption was divided into 4 categories: binge/heavy, binge/nonheavy, nonbinge/heavy, and nonbinge/nonheavy. Binge drinking was defined as > or =5 drinks for men or > or =4 drinks for women on one or more occasions in the past month, and heavy drinking was defined as average daily consumption of >2 drinks/day (men) or >1 drink/day (women). The prevalence of AI driving was examined by drinking pattern and by demographic characteristics. Logistic regression analysis was used to assess the association between drinking patterns and AI driving. RESULTS Five percent of drinkers were engaged in AI driving during the past 30 days. Overall, 84% of AI drivers were binge drinkers and 88% of AI driving episodes involved binge drinkers. By drinking category, binge/nonheavy drinkers accounted for the largest percentage of AI drivers (49.4%), while binge/heavy drinkers accounted for the most episodes of AI driving (51.3%). The adjusted odds of AI driving were 20.1 (95% CI: 16.7, 24.3) for binge/heavy, 8.2 (6.9, 9.7) for binge/nonheavy, and 3.9 (2.4, 6.3) for nonbinge/heavy drinkers, respectively. CONCLUSIONS There is a strong association between binge drinking and AI driving. Most AI drivers and almost half of all AI driving episodes involve persons who are not heavy drinkers (based on average daily consumption). Implementing effective interventions to prevent binge drinking could substantially reduce AI driving.

Depression and anxiety associated with cardiovascular disease among persons aged 45 years and older in 38 states of the United States, 2006.

In the United States, hepatitis C virus (HCV)-associated mortality is increasing. From 2003-2013, the number of deaths associated with HCV has now surpassed 60 other nationally notifiable infectious conditions combined. The increasing HCV-associated mortality trend underscores the urgency in finding, evaluating, and treating HCV-infected persons.

Prevalence of chronic hepatitis B virus (HBV) infection in U.S. households: National Health and Nutrition Examination Survey (NHANES), 1988‐2012

OBJECTIVE To highlight the close association of cardiovascular disease (CVD) with depression and anxiety in US non-institutionalized adults and examine the sociodemographic correlates of depression and anxiety among CVD survivors. METHOD The data were obtained from 38 states which administered an Anxiety and Depression Module as part of the 2006 Behavioral Risk Factor Surveillance System. CVD was assessed with three questions on coronary heart disease and stroke. Adjusted prevalence ratios (APRs) were obtained after adjustment for demographic characteristics using SUDAAN 9.0. RESULTS The prevalence of a CVD history was 15.3% among studied population (sample size n=129,499). Persons with a CVD history were more likely than those without to experience current depression (15.8% versus 7.1%, APR [95% CI]=1.69 [1.54-1.85]), to have a lifetime diagnosis of depressive disorders (22.3% versus 15.1%, APR [95% CI]=1.56 [1.45-1.67]) or anxiety disorders (16.6% versus 10.0%, APR [95% CI]=1.46 [1.37-1.54]). CVD survivors with low education attainment or minority background were less likely to receive a diagnosis of depression though their experience of depression was comparable with or higher than their counterparts. CONCLUSION CVD is associated significantly with depression and anxiety. Disparities exist among CVD survivors on the diagnosis of depression and anxiety.

Undervaccinated African-American preschoolers: A case of missed opportunities

The number of persons with chronic hepatitis B virus (HBV) infection in the United States is affected by diminishing numbers of young persons who are susceptible because of universal infant vaccination since 1991, offset by numbers of HBV‐infected persons migrating to the United States from endemic countries. The prevalence of HBV infection was determined by serological testing and analysis among noninstitutionalized persons age 6 years and older for: antibody to hepatitis B core antigen (anti‐HBc), indicative of previous HBV infection; hepatitis B surface antigen (HBsAg), indicative of chronic (current) infection; and antibody to hepatitis B surface antigen (anti‐HBs), indicative of immunity from vaccination. These prevalence estimates were analyzed in three periods of the National Health and Nutrition Examination Survey (NHANES): 1988‐1994 (21,260 persons); 1999‐2008 (29,828); and 2007‐2012 (22,358). In 2011‐2012, for the first time, non‐Hispanic Asians were oversampled in NHANES. For the most recent period (2007‐2012), 3.9% had anti‐HBc, indicating approximately 10.8 (95% confidence interval [CI]: 9.4‐12.2) million noninstitutionalized U.S. residents having ever been infected with HBV. The overall prevalence of chronic HBV infection has remained constant since 1999: 0.3% (95% CI: 0.2‐0.4), and since 1999, prevalence of chronic HBV infection among non‐Hispanic blacks has been 2‐ to 3‐fold greater than the general population. An estimated 3.1% (1.8%‐5.2%) of non‐Hispanic Asians were chronically infected with HBV during 2011‐2012, which reflects a 10‐fold greater prevalence than the general population. Adjusted prevalence of vaccine‐induced immunity increased 16% since 1999, and the number of persons (mainly young) with serological evidence of vaccine protection from HBV infection rose from 57.8 (95% CI: 55.4‐60.1) million to 68.5 (95% CI: 65.4‐71.2) million. Conclusion: Despite increasing immune protection in young persons vaccinated in infancy, an analysis of chronic hepatitis B prevalence in racial and ethnic populations indicates that during 2011‐2012, there were 847,000 HBV infections (which included ∼400,000 non‐Hispanic Asians) in the noninstitutionalized U.S. population. (Hepatology 2016;63:388–397)