Hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States, with approximately three million persons living with current infection. Needle puncture exposure to contaminated blood is the most efficient mode of transmission and injection drug use (IDU) is the primary risk factor for infection.
Data from 2006 to 2012 reveal a nationwide increase in reported cases of acute HCV infection, which is an important cause of morbidity and mortality in the United States. Adolescents and young adults (30 years old or younger) from nonurban areas account for the majority of cases, with approximately 73% citing injection drug use as the principal risk factor. The largest increases in HCV infections occurred east of the Mississippi River, particularly in states in central Appalachia.
To better understand the increase in acute cases of HCV infection and its correlation to IDU, the CDC examined surveillance data for acute case reports in conjunction with analyzing drug treatment admissions data from the Treatment Episode Data Set-Admissions (TEDS-A) among persons 30 years old or younger in four states (Kentucky, Tennessee, Virginia, and West Virginia) for the period 2006 to 2012. During this period, significant increases in cases of acute HCV infection were found among persons in both urban and nonurban areas, with a substantially higher incidence observed each year among persons residing in nonurban areas.
During the same period, the proportion of treatment admissions for opioid dependency increased 21.1% in the four states, with a significant increase in the proportion of persons admitted who identified injecting as their main route of drug administration (an increase of 12.6%). Taken together, these increases indicate a geographic intersection among opioid abuse, drug injecting, and HCV infection in central Appalachia and underscore the need for integrated health services in substance abuse treatment settings to prevent HCV infection and ensure that those who are infected receive medical care.
Confirmed cases of acute HCV infection and associated demographic and risk characteristics were obtained from the National Notifiable Disease Surveillance System (NNDSS) for Kentucky, Tennessee, Virginia, and West Virginia for the period 2006 to 2012 for persons aged 30 years old or younger. A case report was classified as "urban" if the person lived in a metropolitan county with a population of 50,000 or higher and as "nonurban" if the person lived in a nonmetropolitan county with a population under 50,000.
During 2006 to 2012, a total of 1,377 cases of acute HCV infection were reported to the CDC from Kentucky, Tennessee, Virginia, and West Virginia. Of the 1,374 cases with a recorded age and classified as either urban or nonurban, 616 (44.8%) were among persons aged 30 years old or younger. The median age of persons with acute infection was 25 years in both nonurban (range = 6–30 years) and urban (range = 6–30 years) counties. Of the number of cases in persons aged 30 years old or younger in nonurban counties, 247 (78.4%) were in non-Hispanic whites, and 156 (49.5%) in males; in urban counties, 249 (82.7%) cases were in non-Hispanic whites, and 155 (51.5%) were in males. Among the 265 (43.0%) cases in both urban and nonurban counties with identified risks for HCV infection, 196 (73.1%) were among persons who reported IDU, with similar percentages by urbanicity. During 2006 to 2012, a significant increase occurred in the incidence of acute HCV infection among young persons in both nonurban (p=0.007) and urban counties (p<0.001) in the four states. However, in each year, incidence was more than twice the rate among persons who resided in nonurban compared with urban areas.
Among all treatment admissions for persons between the ages of 12 and 29 years in the four states, the change in the proportion of any-opioid admissions increased by 21.1% from 2006 to 2012. In addition, increases of 16.8% and 7.4% were observed in the proportion of prescription opioid admissions and heroin admissions, respectively. Further, from 2006 to 2012, the proportion of admissions related to any-opioid injection increased by 12.6%, and the proportion of admissions of a patient reporting nonopioid injection increased by 2.1%. Both trends (any-opioid and nonopioid injections) were significant (p<0.05) over the seven-year period.
Surveillance data from four states (Kentucky, Tennessee, Virginia, and West Virginia) showed a substantial increase (364%) in the number of cases of acute HCV infection from 2006 to 2012 among persons 30 years old or younger. Those affected were primarily non-Hispanic-white residents from both urban and nonurban areas, with more than double the rate of cases from nonurban areas. Urban and nonurban cases had the same distribution by sex. Among cases with identified risk information, IDU was most commonly reported (73%). Similar increases among persons with analogous demographic characteristics have been reported over the period (2006–2012) in Massachusetts, Wisconsin, and upstate New York.
During this same period, these four states experienced an increase in the number of adolescents and young adults (aged 12–29 years) admitted to substance abuse treatment for opioid dependency (based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), with prescription opioid abuse accounting for about one third of all treatment admissions (compared with 8.3% of admissions for heroin). However, during 2011to 2012, the proportion of heroin admissions increased (from 8.6% to 12.0%) at the same time as the proportion of prescription opioid admissions decreased. This regional increase in heroin use is consistent with national survey reports estimating an increase in first-time heroin use from 90,000 persons in 2006 to 156,000 persons in 2012, with three out of four persons who used heroin and prescription opioids in the past year reporting prescription opioid misuse before initiating heroin, and a doubling of the number of persons reporting heroin dependency from 214,000 in 2002 to 467,000 in 2012.
The concomitant increase in the proportion of treatment admissions for prescription opioid abuse, heroin abuse, and the number of admitted patients who report injecting suggests that the increase in acute HCV infections in central Appalachia is highly correlated with the region's epidemic of prescription opioid abuse and facilitated by an upsurge in the number of persons who inject drugs in these four states. Increases in the incidence of HCV infection have the potential to thwart the nation's effort to control morbidity and mortality associated with HCV infection, in addition to undermining the U.S. Department of Health and Human Services' Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis, which has set reducing HCV infections caused by drug use behaviors as a priority area.
Although the prevalence of HIV infection among young persons who inject drugs in central Appalachia is currently low, the regional increase in cases of acute HCV infection described in this report raises concerns about the potential for an increase in HIV infections because IDU is a risk factor for both HCV and HIV infection. Thus, integrated health care services are needed to treat substance abuse and prevent and treat blood-borne infections deriving from illicit drug use behaviors. Because persons who inject drugs underutilize health services, additional efforts are urgently needed to enlist them into substance abuse treatment, ensure they are tested for HCV, and link those with HCV infection into care to receive appropriate treatment. These efforts will require further collaboration among federal partners and state and local health departments, particularly in those regions most heavily impacted, to better address the set of linked health problems--opioid abuse and HCV infection.
See the CDC Report
See also Medical Law Perspectives, September 2014 Report: Hepatitis: Provider Malpractice and Patient Injury
See the Medical Law Perspectives February 16, 2015, Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids
See the Medical Law Perspectives October 24, 2014, Blog: Expensive HCV Drug Price Going Up in U.S; Gilead Offers Cheaper Versions in Developing Nations
See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double