| |
Awareness of chronic viral hepatitis in the United States: An update from the National Health and Nutrition Examination Survey
|
| |
| |
Dowload the PDF here
10 January 2019
Lack of diagnosis of viral hepatitis is the primary barrier to antiviral treatment in the United States.4 Our findings suggest that current awareness of both HBV and HCV infection in the United States remains suboptimal. Using data from the most recent wave of NHANES, we found that 33.9% of persons with HBV infection were aware of their infection status. Although a higher proportion of HCV-infected persons (55.6%) were aware of their HCV status, this estimate was not much higher than the 49% awareness rate in 2007-2008 (only ∼13% relative increase).4
In conclusion, our findings suggest that the overall awareness of chronic viral hepatitis was 33.9% in chronic HBV infection, 55.6% in chronic HCV infection and 11.7% in past HBV infection. Awareness levels of chronic viral hepatitis remained suboptimal across demographic subgroups. The awareness rate in baby boomers still leaves significant room for improvement. With these persistent gaps in diagnosis, it would be difficult, if not impossible, to achieve the WHO's goal of eliminating viral hepatitis by 2030. Active public health policy to identify persons at risk and provide appropriate management is warranted.
HCV Elimination: Universal Routine Screening Should be Mandated - (06/01/21)
Disparities persist:
Our findings suggest that awareness of both HBV and HCV infection tended to be higher in persons with high education and household income, and those who were born in the United States. Low awareness among persons born in a foreign country was prominent in HCV infection. This finding is consistent with the previous studies that showed immigrants were diagnosed with their liver disease after almost 10 years following arrival and at more advanced stage.24-28 This may be due to lack of healthcare access and health information, poor knowledge of the disease and asymptomatic disease progression. There was also racial disparity in the awareness; Blacks were less likely to be aware of HBV infection whereas Hispanics and Asians were less likely to be aware of HCV status.
Based on our findings, there are ∼0.3 million persons with chronic hepatitis B infection and ∼0.4 million persons with chronic HCV infection who are not receiving HCC screening due to lack of knowledge of their infection and the importance of surveillance in the United States.31
Current American Association for the Study of Liver Diseases (AASLD) guidelines recommend that those at risk of HCC, including any persons with cirrhosis, Asian men with hepatitis B aged ≥50, Asian women with hepatitis B aged ≥40, African/North American Blacks with hepatitis B aged ≥20, should be routinely screened by ultrasonography every 6-12 months for progression to cirrhosis and development of HCC.29, 30
Summary
The World Health Organization has set the goal of reducing the hepatitis-related mortality rate by 65% between 2015 and 2030. Diagnosis and awareness of infection is the first essential step towards achieving this goal. Our study examined the current awareness rate of chronic viral hepatitis in the United States and the potentially associated factors. In the National Health Nutrition and Examination Survey 2013-2016, there were 11 488 persons who participated in serology testing for chronic viral hepatitis. We defined chronic hepatitis B virus (HBV) infection by HbsAg, HBV past exposure by anti-HBc and hepatitis C virus (HCV) infection by HCV RNA. At risk for significant fibrosis was determined by AST to Platelet Ratio Index >0.7.
Awareness of chronic HBV infection, past HBV exposure and HCV infection were present in 33.9%, 11.7% and 55.6% of participants, respectively. Among HCV-infected baby boomers, the awareness was in 61.5%.
The awareness of HBV infection was significantly higher in individuals with high education level.
Age group (40-60 years), women, non-Black race/ethnicity and those with high household income who were born in the United States with insurance plans tend to be aware of their infection. For HCV, awareness was the lowest in Hispanics and Asians, foreign-born who lived below the federal poverty level and low education level.
Awareness among chronic viral hepatitis patients at risk for significant fibrosis was 62.0% in HBV and 38.2% in HCV infection. In conclusion, current awareness of chronic viral hepatitis in the United States remains suboptimal. Active public health policy to identify persons at risk and provide appropriate management is warranted.
INTRODUCTION
Chronic viral hepatitis, hepatitis B virus (HBV) or hepatitis C virus (HCV) results in more than 1 million deaths annually worldwide and 20 000 deaths in the United States. Collectively, chronic viral hepatitis accounts for more deaths than that from HIV/AIDS, tuberculosis or malaria.1-3 In 2014, the World Health Organization (WHO) set a goal to reduce the incidence of chronic viral hepatitis by 90% and reduce the mortality rate by 65% between 2015 and 2030.2
Diagnosis and awareness of infection is the first essential step towards achieving this goal. Using National Health and Nutrition Examination Survey (NHANES) data from 2002 to 2007, Volk et al4 found that ∼49% of individuals with HCV infection were unaware of their infection. We also reported 26.2% awareness of HBV chronic infection using NHANES 2013-2014 data.5 Recently, several national initiatives have focused on enhancing screening and diagnosis of chronic viral hepatitis in the United States.6, 7 For example, the Centers for Disease Control and Prevention (CDC) set forth the birth cohort screening recommendation in 2012 for HCV infection.8However, the effect of these efforts on the current diagnosis and awareness rate of chronic viral hepatitis in the United States is not fully understood. Lack of these data is one of the key roadblocks in implementing appropriate health policy towards achieving the WHO's goal.9
Our study aimed to estimate the current awareness of chronic viral hepatitis and possible factors associated with the awareness, using the nationally representative NHANES data for the most current cycles from 2013 to 2016.
RESULTS
3.1 Awareness of hepatitis B virus infection
There were 68 persons with chronic HBV (0.3% [95% confidence interval (CI): 0.2-0.4]) in NHANES 2013-2016 data, corresponding to 0.59 million adults in the United States. The awareness of HBV infection was 33.9% [95% CI: 16.7-51.1], showing that approximately 0.39 million adults with chronic HBV were unaware of their disease (Table 1). HBV awareness was significantly lower in individuals with less than high school education (odds ratio=3.24 [95% CI: 1.10-9.54]).
Higher awareness was also observed in persons between 40 and 60 years old, females, non-black race/ethnicity, those with high household income, those who were born in the United States and persons with an insurance plan, although these differences did not reach statistical significance. Similarly, there were 866 persons with HBV past exposure (4.9% [95% CI: 4.2-5.6]), corresponding to 9.6 million adults in the United States. The awareness of HBV past exposure was 11.7% [95% CI: 7.9-15.6] (Table 2). Non-Hispanic White group had significantly higher awareness of past exposure compared to non-White race/ethnicity group. Higher awareness was observed in age group between 40 and 60 years old, males, persons with higher education and those born in the United States than their comparison groups, although these differences did not reach statistical significance. There was no difference in the awareness by household income category and insurance type.
3.2 Awareness of hepatitis C virus infection
There were 117 persons with HCV infection (0.9% [95% CI: 0.8-1.1]), corresponding to approximately 1.8 million adult patients in the entire United States. The awareness of HCV infection was 55.6% [95% CI: 42.6-68.6]; thus, approximately 0.8 million adults with chronic HCV in the United States were estimated to be unaware of their disease status (Table 3). Among HCV-infected baby boomers (born between 1945 and 1965), awareness was present in 61.5% [95% CI: 46.2-76.7]. Awareness of HCV infection was lowest in Hispanics and Asians/Other race, those with low education level, who live below the federal poverty level and those who were foreign-born, although none of these differences reached statistical significance. There was no difference in the awareness proportions by gender and insurance type.
3.3 Proportions with awareness in persons with chronic hepatitis B virus or hepatitis C virus at risk for significant fibrosis
In total, 24.8% (13/67) of patients with HBV had elevated liver enzymes and were at risk for significant fibrosis; of these 62.0% were aware of their infection (Tables 1 and 3). Of the 35.6% (45/117) of persons with chronic HCV infection at risk for advanced fibrosis, only 38.2% were aware of their infection. Using a higher cut-off for APRI (>1.0, 76% sensitivity and 74% specificity for predicting cirrhosis), three participants with HBV infection and 30 participants with HCV infection were at risk for advanced fibrosis or cirrhosis. The awareness of their infection status was higher in these subgroups than the rest, but remained suboptimal at 78.9% [95% CI: 38.6-119.2] for HBV and 57.7% [95% CI: 32.7-82.8] for HCV.
| |
| |
| |
|
|
|
