Hepatitis C cases rising in young adults

Last Updated: 2020-04-15

By Will Boggs MD

NEW YORK (Reuters Health) - New acute and chronic hepatitis C cases increased significantly between 2009 and 2018, especially in people ages 20 to 39, according to a new Centers for Disease Control and Prevention (CDC) report.

"While we've known for several years that new infections have been increasing in younger adults, seeing data showing that younger adults made up the majority of chronic diagnoses in 2018 is sobering," Dr. Carolyn Wester, director of the CDC's Division of Viral Hepatitis, Atlanta, Georgia, told Reuters Health by email.

"It is also sobering to recognize that despite recommendations for risk-based testing since 1998 and universal one-time screening for all baby boomers (people born from 1945-1965) since 2012, four out of 10 individuals living with hepatitis C remain unaware that they are infected with this potentially deadly infection," she said.

At least 50% of acute hepatitis C infections will progress to chronic hepatitis C, which is typically asymptomatic until there is severe liver damage.

Dr. Wester and colleagues used data from the National Notifiable Diseases Surveillance System from 2009 to 2018 to highlight the epidemic of hepatitis C among all adults in support of the new CDC recommendation for universal testing for hepatitis C among adults once in their lifetime and pregnant women during each pregnancy.

The number of reported acute hepatitis C cases per 100,000 population increased threefold during this period, from 0.3 in 2009 to 1.2 in 2018, according to the Morbidity and Mortality Weekly Report (MMWR).

Between 2009 and 2018, the annual case counts per 100,000 increased approximately 300% among those aged 20-29 years, and approximately 400% among those aged 30-39 years.

People aged 20-29 years had the highest rate of reported acute hepatitis C cases in 2018 (3.1 per 100,000), followed by people aged 30-39 years (2.6), 40-49 years (1.3), 50-59 years (0.9), and 60 years and older (0.4). People under 20 had the lowest rate (0.1).

During 2018, 137,713 new chronic hepatitis C cases were reported. The largest proportion of newly reported chronic cases were among people ages 20-39 and 50-69.

Among participants aged 20 and older in the National Health and Nutrition Examination Survey (NHANES) 2015-2018 who were hepatitis C virus RNA-positive, only 60.6% said they'd been told they have hepatitis C.

"To stop hepatitis C, we must radically transform the way we screen for this disease," Dr. Wester said. "We must expand testing to all adults, increase the proportion of hepatitis C diagnoses among people with the disease, and help people to access treatment - which can cure hepatitis C and ultimately prevent further transmission."

"Services for people at increased risk for hepatitis C (such as people who inject drugs) can play a critical role in diagnosing, treating, and reducing transmission of this disease," she said. "This includes syringe service programs, substance use disorder programs, and medication-assisted treatment programs; as well as healthcare settings such as emergency departments, health clinics, even primary care settings."

Dr. Philippa Easterbrook from the World Health Organization's Global HIV, Hepatitis, and STI Program in Geneva, Switzerland, told Reuters Health by email, "We are now seeing a different epidemic profile of hepatitis C infection in the United States. From the historical one of the highest prevalence and burden of infection among the baby boomers to now a bimodal distribution with a peak in older age groups (the baby boomers aged 52 to 68 years) but now a second peak in younger age groups aged 20-40 years, reflecting more recent infection from injecting drug use."

"The progressive expansion in CDC testing recommendations from risk-based screening in late 1990s to a focus on baby-boomers in 2012 had limited success in identifying a high proportion of those infected," she said. "It is recognized that a risk-based screening approach fails to identify many of those who have been infected who may never identify themselves as at risk. The new 2020 expansion to include testing of all adults aged 18 years and older at least one in their lifetime is clear and intended to simplify and substantially expand access to testing. It also includes any person who requests hepatitis C testing, regardless of disclosure or risk, because many may be reluctant to disclose stigmatizing risks."

"The challenge is in the implementation of this 'test all' recommendation, and how to make testing very accessible and low cost, and with easy and rapid linkage for care and treatment in those positive," Dr. Easterbrook said. "This needs a clear operational approach of where testing will be done and by whom, and the need for monitoring and evaluation of the uptake of testing in different age groups by region."

"This challenge is not unique to the States," she said. "Many countries with a problem with hepatitis C infection are struggling with an effective case finding strategy, and after already prioritizing testing in high-risk populations, where to find the remaining infected persons."

SOURCE: https://bit.ly/2XJPsL7 MMWR, online April 10, 2020.