Background
Purpose
Methods
Results
Conclusions
Introduction
Batki S, Sorensen J. Care of injection drug users with HIV. In: Cohen PT, Sande MA, Volberding P, eds. The AIDS knowledge base: a textbook on HIV disease from the University of California, San Francisco and San Francisco General Hospital. 3rd ed. Philadelphia PA. Lippincott, Williams, & Wilkins, 1999.
Rein DB, Wagner D, Brown K, et al. Hepatitis C antibody testing and follow-up in primary care settings: a retrospective study of four large, primary care service centers infection among persons born during 1945–1965 in the U.S. National Summit on HIV and Viral Hepatitis Diagnosis, Prevention and Access to Care; 2012 Nov 26–28; Washington DC.
Rein DB, Wagner D, Brown K, et al. Hepatitis C antibody testing and follow-up in primary care settings: a retrospective study of four large, primary care service centers infection among persons born during 1945–1965 in the U.S. National Summit on HIV and Viral Hepatitis Diagnosis, Prevention and Access to Care; 2012 Nov 26–28; Washington DC.
Methods
Study Population
CDC. National Center for Health Statistics. NHANES Questionnaires, Datasets, and Related Documentation. cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.
Outcome Variable
Anti-HCV Testing Variables
Other Variables
Statistical Analysis
CDC. National Center for Health Statistics. NHANES Questionnaires, Datasets, and Related Documentation. cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.
Results
Participant Characteristics

Characteristic | All participants | Anti-HCV-positive | ||
---|---|---|---|---|
Unweighted, n | Weighted, % (95% CI) | Unweighted, n | Weighted, % (95% CI) | |
Overall | 19,055 | 429 | ||
Age (years; M [SE]) | 19,055 | 42.7 (0.2) | 429 | 45.7 (0.5) |
Born from 1945 to 1965 | ||||
No | 11,332 | 53.2 (52.1, 54.2) | 121 | 23.4 (18.8, 28.9) |
Yes | 7,723 | 46.8 (45.8, 47.9) | 308 | 76.6 (71.1, 81.2) |
Serum alanine aminotransferase level (U/L) | ||||
<40 | 16,635 | 88.2 (87.6, 88.8) | 204 | 50.0 (43.8, 56.2) |
≥40 | 2,264 | 11.8 (11.2, 12.4) | 217 | 50.0 (43.8, 56.2) |
Gender | ||||
Female | 9,981 | 51.0 (50.4, 51.6) | 153 | 37.2 (31.0, 43.7) |
Male | 9,074 | 49.0 (48.4, 49.6) | 276 | 62.8 (56.3, 69.0) |
Race/ethnicity | ||||
Non-Hispanic white | 8,726 | 70.0 (67.2, 72.7) | 178 | 66.5 (60.9, 71.7) |
Non-Hispanic black | 3,961 | 10.9 (9.4, 12.6) | 147 | 20.0 (16.2, 24.5) |
Mexican American | 4,391 | 8.3 (7.1, 9.7) | 73 | 6.5 (4.4, 9.5) |
Other | 1,977 | 10.8 (9.2, 12.6) | 31 | 7.0 (4.3, 11.1) |
Family income to poverty threshold | ||||
>2 times | 9,920 | 67.6 (65.7, 69.4) | 138 | 41.6 (36.1, 47.4) |
1–2 times | 4,334 | 19.1 (17.9, 20.4) | 128 | 28.8 (23.6, 34.6) |
Below | 3,403 | 13.3 (12.3, 14.3) | 137 | 29.6 (24.4, 35.3) |
Health insurance coverage | ||||
Yes | 14,179 | 79.8 (78.5, 81.0) | 285 | 65.3 (59.5, 70.8) |
No | 4,746 | 20.2 (19.0, 21.5) | 136 | 34.7 (29.2, 40.5) |
Served in the U.S. armed forces | ||||
No | 16,977 | 88.3 (87.6, 89.1) | 350 | 83.2 (77.6, 87.6) |
Yes | 2,074 | 11.7 (10.9, 12.4) | 78 | 16.8 (12.4, 22.4) |
Average number of alcoholic drinks per day, last year | ||||
0–1 | 6,168 | 32.2 (31.0, 33.4) | 57 | 12.7 (9.0, 17.6) |
≥2 | 8,305 | 46.7 (45.3, 48.1) | 223 | 57.6 (51.4, 63.5) |
Unknown | 4,582 | 21.1 (20.0, 22.3 ) | 149 | 29.7 (25.0, 34.8) |
Lifetime drug use (20–59 years, n=15,138) | ||||
Never | 10,963 | 71.8 (70.3, 73.2) | 84 | 23.2 (18.0, 29.4) |
Non-IDU | 2,469 | 17.8 (16.7, 19.0) | 93 | 22.9 (18.8, 27.5) |
IDU | 297 | 2.1 (1.8, 2.5) | 149 | 43.4 (37.6, 49.5) |
Unknown | 1,409 | 8.3 (7.6, 9.1) | 43 | 10.4 (7.5, 14.4) |
Blood transfusion prior to 1992 | ||||
No | 17,576 | 93.7 (93.2, 94.1) | 354 | 84.8 (79.9, 88.7) |
Yes | 1,222 | 6.3 (5.9, 6.8) | 63 | 15.2 (11.3, 20.1) |
Prevalence of Anti-HCV
CDC. National Center for Health Statistics. NHANES Response Rates and Population Totals. cdc.gov/nchs/nhanes/response_rates_cps.htm.
Characteristic | Participants, n | Weighted anti-HCV prevalence, % (95% CI) | p-value |
---|---|---|---|
Overall | 19,055 | 2.0 (1.8, 2.3) | |
Born from 1945 to 1965 | |||
No | 11,332 | 0.9 (0.7, 1.1) | ref |
Yes | 7,723 | 3.2 (2.8, 3.8) | <0.001 |
Serum alanine aminotransferase level (U/L) | |||
<40 | 16,635 | 1.1 (0.9, 1.3) | ref |
≥40 | 2,264 | 8.4 (7.0, 9.9) | <0.001 |
Gender | |||
Female | 9,981 | 1.4 (1.2, 1.8) | ref |
Male | 9,074 | 2.5 (2.2, 3.0) | <0.001 |
Race/ethnicity | |||
Non-Hispanic white | 8,726 | 1.9 (1.6, 2.2) | ref |
Non-Hispanic black | 3,961 | 3.6 (3.1, 4.3) | <0.001 |
Mexican American | 4,391 | 1.6 (1.1, 2.2) | 0.26 |
Other | 1,977 | 1.3 (0.8, 2.1) | 0.10 |
Family income to poverty threshold | |||
>2 times | 9,920 | 1.2 (1.0, 1.5) | ref |
1–2 times | 4,334 | 3.0 (2.4, 3.7) | <0.001 |
Below | 3,403 | 4.4 (3.7, 5.3) | <0.001 |
Health insurance coverage | |||
Yes | 14,179 | 1.6 (1.4, 1.9) | ref |
No | 4,746 | 3.4 (2.7, 4.1) | <0.001 |
Served in the U.S. armed forces | |||
No | 16,977 | 1.9 (1.6, 2.2) | ref |
Yes | 2,074 | 2.9 (2.1, 3.9) | <0.05 |
Average number of alcoholic drinks per day, last year | |||
0–1 | 6,168 | 0.8 (0.5, 1.1) | ref |
≥2 | 8,305 | 2.5 (2.1, 2.9) | <0.001 |
Unknown | 4,582 | 2.8 (2.3, 3.4)) | <0.001 |
Lifetime drug use (20–59 years, n=15,138) | |||
Never | 10,963 | 0.7 (0.5, 0.9) | ref |
Non-IDU | 2,469 | 2.8 (2.2, 3.5) | <0.001 |
IDU | 297 | 44.5 (37.9, 51.3) | <0.001 |
Unknown | 1,409 | 2.7 (1.9, 3.8) | <0.001 |
Blood transfusion prior to 1992 | |||
No | 17,576 | 1.8 (1.5, 2.1) | ref |
Yes | 1,222 | 4.7 (3.4, 6.4) | <0.001 |
Comparison of Birth Cohort and ALT Testing Strategies
CDC. National Center for Health Statistics. NHANES Response Rates and Population Totals. cdc.gov/nchs/nhanes/response_rates_cps.htm.
Testing strategy | ||
---|---|---|
Elevated ALT | 1945–1965 birth cohort | |
Anti-HCV+ adults aged 20–70 years, n | 3.6 | 3.6 |
Adults tested, n | 21.5 | 85.5 |
Anti-HCV-positive persons identified by strategy, n | 1.8 | 2.8 |
Current HCV infections identified by strategy, n | 1.4–1.5 | 2.1–2.4 |
Sensitivity, % | 50 | 76.6 |
Discussion
Rein DB, Wagner D, Brown K, et al. Hepatitis C antibody testing and follow-up in primary care settings: a retrospective study of four large, primary care service centers infection among persons born during 1945–1965 in the U.S. National Summit on HIV and Viral Hepatitis Diagnosis, Prevention and Access to Care; 2012 Nov 26–28; Washington DC.
U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. uspreventiveservicestaskforce.org/uspstf12/hepc/hepcfinalrs.htm.
American College of Physicians. Screening for hepatitis C. smartmedicine.acponline.org/content.aspx?gbosId=496.
American Medical Association. AMA adopts new policies during first day of voting at interim meeting. ama-assn.org/ama/pub/news/news/2012-11-13-ama-adopts-new-policies.page.
Acknowledgments
References
- The prevalence of hepatitis C virus infection in the U.S., 1999 through 2002.Ann Intern Med. 2006; 144: 705-714
- The natural history of hepatitis C virus (HCV) infection.Int J Med Sci. 2006; 3: 47-52
- The past incidence of hepatitis C virus infection: implications for the future burden of chronic liver disease in the U.S.Hepatology. 2000; 31: 777-782
- HCV routes of transmission: what goes around comes around.Semin Liver Dis. 2011; 31: 340-346
- Forecasting the morbidity and mortality associated with prevalent cases of pre-cirrhotic chronic hepatitis C in the U.S.Dig Liver Dis. 2011; 43: 66-72
- The increasing burden of mortality from viral hepatitis in the U.S. between 1999 and 2007.Ann Intern Med. 2012; 156: 271-278
- Once-daily simeprevir (TMC435) with peginterferon/ribavirin for treatment-naive hepatitis C genotype 1-infected patients in Japan: the DRAGON study.J Gastroenterol. 2014; 49: 138-147
- Sofosbuvir for previously untreated chronic hepatitis C infection.N Engl J Med. 2013; 368: 1878-1887
- Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence.Clin Infect Dis. 2012; 55: 1047-1055
- Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.J Viral Hepat. 2011; 18: 474-481
- HCV screening practices and prevalence in an MCO, 2000–2007.Am J Manag Care. 2011; 17: 548-555
- Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: NHANES 2001–2008.Hepatology. 2012; 55: 1652-1661
- Self-reported hepatitis C virus antibody status and risk behavior in young injectors.Public Health Rep. 2006; 121: 710-719
Galbraith JW, Franco R, Rodgers J, et al. Screening in emergency department identifies a large cohort of unrecognized chronic hepatitis C virus. Paper presented at the 64th Annual Meeting of the American Association for the Study of Liver Diseases; 2013 Nov 1–5; Washington DC.
- Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.Am J Public Health. 2012; 102: e115-e121
- Comparison of current U.S. risk strategy to screen for hepatitis C virus with a hypothetical targeted birth cohort strategy.Am J Public Health. 2012; 102: e101-e106
- Management of hepatitis C patients by primary care physicians in the USA: results of a national survey.J Viral Hepat. 2001; 8: 377-383
- Patient acceptance of universal screening for hepatitis C virus infection.BMC Infect Dis. 2011; 11: 160
- Screening for hepatitis B, C and non-alcoholic fatty liver disease: a survey of community-based physicians.Aliment Pharmacol Ther. 2009; 29: 1019-1024
- Identification and management of hepatitis C patients in primary care clinics.Am J Gastroenterol. 2003; 98: 639-644
- Hepatitis C identification and management by family physicians.Fam Med. 2005; 37: 644-649
- Risk behavior disclosure during HIV test counseling.AIDS Patient Care STDS. 2010; 24: 551-561
- Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users.Clin Infect Dis. 2005; 40: S276-S285
- Barriers to and facilitators of hepatitis C testing, management, and treatment among current and former injecting drug users: a qualitative exploration.AIDS Patient Care STDS. 2010; 24: 753-762
Batki S, Sorensen J. Care of injection drug users with HIV. In: Cohen PT, Sande MA, Volberding P, eds. The AIDS knowledge base: a textbook on HIV disease from the University of California, San Francisco and San Francisco General Hospital. 3rd ed. Philadelphia PA. Lippincott, Williams, & Wilkins, 1999.
- Understanding non-disclosure of deferrable risk: a study of blood donors with a history of intravenous drug use.Transfus Med. 2010; 20: 15-21
- Clinical practice. Chronic hepatitis C infection.N Engl J Med. 2011; 364: 2429-2438
- Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk.Dig Liver Dis. 2012; 44: 497-503
- Physician nonadherence with a hepatitis C screening program.Qual Manag Health Care. 2014; 23: 1-9
- Public Policy Committee of the American Association for the Study of Liver Disease. Serum activity of alanine aminotransferase (ALT) as an indicator of health and disease.Hepatology. 2008; 47: 1363-1370
- Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease.MMWR Recomm Rep. 1998; 47: 1-39
- Hepatitis C knowledge among primary care residents: is our teaching adequate for the times?.Am J Gastroenterol. 2004; 99: 1720-1725
- Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care.Br J Gen Pract. 2012; 62: e212-e216
- Routes of infection, viremia, and liver disease in blood donors found to have hepatitis C virus infection.N Engl J Med. 1996; 334: 1691-1696
Rein DB, Wagner D, Brown K, et al. Hepatitis C antibody testing and follow-up in primary care settings: a retrospective study of four large, primary care service centers infection among persons born during 1945–1965 in the U.S. National Summit on HIV and Viral Hepatitis Diagnosis, Prevention and Access to Care; 2012 Nov 26–28; Washington DC.
- Evaluation of abnormal liver-enzyme results in asymptomatic patients.N Engl J Med. 2000; 342: 1266-1271
- How are abnormal results for liver function tests dealt with in primary care? Audit of yield and impact.BMJ. 2001; 322: 276-278
- Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort. BMC.Fam Pract. 2011; 12: 9
- Variability in the upper limit of normal for serum alanine aminotransferase levels: a statewide study.Hepatology. 2009; 50: 1957-1962
- Nonalcoholic Steatohepatitis Clinical Research Network. Influence of local reference populations on upper limits of normal for serum alanine aminotransferase levels.Arch Intern Med. 2008; 168: 663-666
- Upper limits of normal for alanine aminotransferase activity in the U.S. population.Hepatology. 2012; 55: 447-454
- Persistent hepatitis C viraemia without liver disease.Lancet. 1993; 341: 464-465
- Diagnosis and monitoring of hepatic injury. I. Performance characteristics of laboratory tests.Clin Chem. 2000; 46: 2027-2049
- Estimation of the healthy upper limits for serum alanine aminotransferase in Asian populations with normal liver histology.Hepatology. 2010; 51: 1577-1583
- Updated definitions of healthy ranges for serum alanine aminotransferase levels.Ann Intern Med. 2002; 137: 1-10
- Upper limits of normal for serum alanine aminotransferase levels in Chinese Han population.PLoS One. 2012; 7: e43736
- Chronic hepatitis C with normal aminotransferase levels.Gastroenterology. 2004; 126: 1409-1415
- Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR Recomm Rep. 2012; 61: 1-32
- The prevalence of hepatitis C virus infection in the U.S., 1988 through 1994.N Engl J Med. 1999; 341: 556-562
CDC. National Center for Health Statistics. NHANES Questionnaires, Datasets, and Related Documentation. cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.
- Previous exposure to HCV among persons born during 1945–1965: prevalence and predictors, U.S., 1999–2008.Am J Public Health. 2014; 104: 474-481
- Diurnal variation in serum alanine aminotransferase activity in the U.S. population.J Clin Gastroenterol. 2013; 47: 165-173
- National Center for Health Statistics. NHANES laboratory protocol: biochemistry profile.USDHHS, Hyattsville MD1999–2000
- National Center for Health Statistics. NHANES 2001–2002 laboratory protocol: alanine amino transferase (ALT) in refrigerated serum.USDHHS, Hyattsville MD2001–2002
- National Center for Heaalth Statistics. NHANES public release data file: laboratory 40—standard biochemistry profile, follicle stimulating hormone, and luteinizing hormone.USDHHS, Hyattsville MD2001–2002
- National Center for Health Statistics. NHANES laboratory protocol: alanine amino transferase (ALT) in refrigerated serum.USDHHS, Hyattsville MD2003–2004
- National Center for Health Statistics. NHANES laboratory protocol: alanine amino transferase (ALT) in refrigerated serum.USDHHS, Hyattsville MD2005–2006
- National Center for Health Statistics. NHANES laboratory protocol: alanine amino transferase (ALT) in refrigerated serum.USDHHS, Hyattsville MD2007–2008
- National Center for Health Statistics. NHANES analytic and reporting guidelines.USDHHS, Hyattsville MD2005
CDC. National Center for Health Statistics. NHANES Response Rates and Population Totals. cdc.gov/nchs/nhanes/response_rates_cps.htm.
- Hepatitis C virus infection in the U.S..J Hepatol. 1999; 31: S88-S91
- HCV carriers with persistently normal aminotransferase levels: normal does not always mean healthy.J Hepatol. 2003; 38: 529-532
- Viral and metabolic factors influencing alanine aminotransferase activity in patients with chronic hepatitis C.J Hepatol. 2006; 44: 679-685
- Prevalence of liver disease in a population of asymptomatic persons with hepatitis C virus infection.Ann Intern Med. 2002; 137: 961-964
- Natural history of initially mild chronic hepatitis C.Dig Liver Dis. 2004; 36: 646-654
- Clinical approach to the patient with chronic hepatitis C infection and normal aminotransferases.Ann Hepatol. 2010; 9S: S72-S79
- The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.Ann Intern Med. 2012; 156: 263-270
- The impact of timing and prioritisation on the cost-effectiveness of birth-cohort testing and treatment for hepatitis C virus in the U.S.J Hepatol. 2013; 58: 54-64
- Economic model of a birth cohort screening program for hepatitis C virus.Hepatology. 2012; 55: 1344-1355
- Persistent alanine aminotransferase elevation among the general Iranian population: prevalence and causes.World J Gastroenterol. 2008; 14: 2867-2871
- The upper limit of normal of serum alanine and aspartate aminotransferase levels in Korea.J Gastroenterol Hepatol. 2013; 28: 522-529
U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. uspreventiveservicestaskforce.org/uspstf12/hepc/hepcfinalrs.htm.
- Recommendations for testing, managing,and treating hepatitis C.American Association for the Study of Liver Diseases, Alexandria VA2014
American College of Physicians. Screening for hepatitis C. smartmedicine.acponline.org/content.aspx?gbosId=496.
American Medical Association. AMA adopts new policies during first day of voting at interim meeting. ama-assn.org/ama/pub/news/news/2012-11-13-ama-adopts-new-policies.page.