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Epidemiologic Update: Hepatitis C. Miriam J. Alter, Ph.D. Division of Viral Hepatitis Centers for Disease Control and Prevention. Hepatitis C Virus Infection. Clinical entity (non-A, non-B hepatitis) in transfused patients reported late 1960s RNA Flavivirus (Hepacivirus)

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Epidemiologic update hepatitis c l.jpg

Epidemiologic Update: Hepatitis C

Miriam J. Alter, Ph.D.

Division of Viral Hepatitis

Centers for Disease Control and Prevention

Hepatitis c virus infection l.jpg
Hepatitis C Virus Infection

  • Clinical entity (non-A, non-B hepatitis) in transfused patients reported late 1960s

  • RNA Flavivirus (Hepacivirus)

    • Discovered using recombinant DNA technology 1989

  • Bloodborne (primarily) and sexually-transmitted

  • Vaccine difficult to develop

    • Mutations occur during viral replication

    • Substantial heterogeneity (quasispecies) selects for neutralization escape variants

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HCV Accomplishments During Past 15 Years

  • Determined burden of infection and morbidity in the general population

  • Eliminated transfusion-associated infections

  • Characterized the epidemiology

  • Documented >80% decline in incidence

  • Implemented community-based prevention

    • Slowed rates of infection in new IDUs

  • Vaccine developed that may prevent chronic infection (subtype specific)

  • Tissue culture systems effective for growing infectious virus

    • May speed development of new antivirals

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Hepatitis C Virus Infection, United States

New infections per year 1985-89 242,000

2003 30,000

Persons ever infected (1.6%) 4.1 million (3.4-4.9)*

Persons with chronic infection 3.1 million (2.5-3.7)*

HCV-positives tested 40%

Persons with HIV co-infection 225,000

* 95% confidence interval (data from NHANES 1999-2002

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Estimated Incidence of Acute HCV, U.S.


Decline in injection

drug users


Decline in

transfusion recipients

Source: Armstrong GL. Hepatology 2000;31:777-82;

Alter MJ. Hepatology 1997;26:62S-65S; CDC, unpublished data

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Prevalence of HCV Infection in the General Population by Age, U.S., 1988-2002

Source: NHANES: Alter MJ, NEJM 1999;341:556-562;

Armstrong GL, Ann Intern Med 2006, in press

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Distribution of HCV Genotypes in the US General Population, NHANES, 1988-1994

Nainan et al. Gastroenterology 2006, in press

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Risk Factors Associated With NHANES, 1988-1994Acquiring HCV Infection

  • Transfusion, transplant from infectious donor

  • Injecting drug use

  • Occupational blood exposure (needle sticks)

  • Birth to an infected mother

  • Infected sex partner

  • Multiple heterosexual partners

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Outbreaks of HCV Infections NHANES, 1988-1994Clustered in Time and Place

  • Health-care related transmission

    • In- and outpatient care, long-term dialysis

    • Most due to unsafe injection practices

      • Finger stick devices, multi-dose medication vials, reuse of syringes/needles for anesthesia, pain management, saline flushes

  • Sexual transmission among HIV-pos. MSM

    • Reported from France and UK

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Relative Efficiency of HBV, HCV, HIV Transmission by Type of Exposure

Type of exposure Efficiency of transmission

to infected sourceHBVHCVHIV

Transfusion ++++ ++++ ++++

Injecting drug use ++++ ++++ ++++

Unsafe injections +++ +++ +

Needlestick +++ + <+

Sexual +++ + +++

Perinatal ++++ ++ +++

Non-intact skin ++ +/- +/-

Intact skin - - -

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Relative Infectivity of HBV, HCV, HIV Exposure


Copies/mL 108-9 105 103

Environmental stability ++++ ++ -

Infectious after drying

at room temperature >7 days >16 h 0

Sources: Bond Lancet 1981; Krawczynski Hepatology 2003

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Effect of Environmental Stability on Transmission of HCV and HBV

  • More rapid acquisition among IDUs

    • Associated with sharing drug preparation equipment (i.e., cookers and cotton)

    • Clean needles and syringes insufficient to interrupt transmission

  • Facilitates iatrogenic transmission

    • Patient-to-patient from contaminated multi-dose vials, reused needles and syringes

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Prevalence of Chronic HBV and HCV in HIV Positives by HIV Risk Group

HIV risk group

Denis F, Pathol Biol1997; Thio CL, Lancet 2002; Sherman K, CID 2002, Kellerman S JID 2003; Konopnicki D, AIDS 2005

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Exposures Not Associated With Acquiring HCV Risk GroupCase Control Studies of Acute Hepatitis C, U.S., 1979-85

Cases Controls

Exposure (prior 6 months)n=148n=200

Medical care procedures 30.4% 29.5%

Dental work 24.3% 23.5%

Health care work (no blood contact) 4.1% 5.0%

Ear piercing 2.7% 3.0%

Tattooing 0.7% 0.5%

Acupuncture 0 1.0%

Sources: JID 1982;145:886-93; JAMA 1989;262:1201-5.

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Presence of a Risk Factor Risk GroupDoes Not Necessarily Equate With“Increased Risk”

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Hemophilia Risk Group

Injecting drug users


STD clients

Gen population adults

Surgeons, Nurses, PSWs

Pregnant women

Military personnel

Average Percent Anti-HCV Positive

HCV Prevalence by Selected GroupsUnited States

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Prevalence of Risk Group

Group in







STD clients


First responders

( 9%)

Surgeons, nurses

Snorted cocaine




Body pierced


Average Percent Anti-HCV Positive

HCV Prevalence in Selected Groups of Adults United States

Hcv prevalence in selected groups of adults by history of injection drug use united states l.jpg

Males Risk Group




STD clients

First responders

Surgeons, nurses

Snorted cocaine


Body pierced

Average Percent Anti-HCV Positive

HCV Prevalence in Selected Groups of Adults by History of Injection Drug Use, United States

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Screening for IDU Efficiently Identifies Most Risk GroupHCV-Positives

Setting and CriteriaScreenedHCV Pos

STD clients 3356 165 (5%)

IDU, transfusion <1992 12% 70%

Incoming prison inmates 1148 152 (13%)

IDU 11% 61%

IDU, hx liver disease 13% 70%

General population 20-59 years old

IDU, transfusion <1992 7% 53%

IDU, transfusion <1992, abnl ALT 18% 85%

Source: Gunn RA, Sex Transm Dis 2003; D Burnett, Wisconsin;

Armstrong GL, Annals 2006.

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Progress in HCV Prevention and Control Risk GroupAmong Injecting Drug Users

  • Cumulative infection rates have slowed

    • 30% prevalence after 2-3 years

  • Harm reduction messages more HCV-specific

    • All drug paraphernalia, not just needles/syringes

  • Incidence still remains high

    • 15% annual rate

    • Accounts for 60-70% of all new infections