The first study of hepatitis C infection among different Hispanic groups in the U.S. has found that infection with the virus varies widely, with Puerto Rican Hispanics much more likely than other groups to be infected. The study, led by researchers at Albert Einstein College of Medicine of Yeshiva University, highlights which Hispanic populations would benefit most from increased hepatitis C testing and treatment. It was published today in the online edition of the Journal of Infectious Diseases.
Hepatitis C is a viral disease that primarily affects the liver and is caused by the hepatitis C virus. The virus is usually spread through contact with the blood of an infected person, often from sharing needles to inject drugs. Many people were also infected through blood transfusions before testing of donated blood began in 1992. About 150 million people worldwide are now infected with hepatitis C, including three to four million in the U.S., according to the Centers for Disease Control and Prevention (CDC). The majority of infected people don’t know they’re infected, since it may take decades for the virus to cause liver damage severe enough to cause symptoms.
“Until now, national health surveys that assessed hepatitis C’s prevalence among U.S. Hispanics have looked only at Mexican-Americans,” said Mark Kuniholm, Ph.D., lead author of the study and assistant professor of epidemiology & population health at Einstein. “As a result, no one knew whether the rates were higher or lower in other Hispanic populations. It turns out that there’s a dramatic variation in prevalence, with infection rates ranging from less than 1 percent in Hispanic men of South American or Cuban background to 11.6 percent in men of Puerto Rican background - a more than 10-fold difference. This suggests that it’s not appropriate to lump all U.S. Hispanics into a single, broad at-risk group.”
The prevalence of hepatitis C infection found for men in other Hispanic groups are: Mexican (1.9 percent), Dominican (1.5 percent), Central American (1 percent), South American (.4 percent), and Cuban (0.8 percent).
Hispanic women generally had a lower prevalence of hepatitis C infection than men, with Puerto Rican background women having the highest prevalence (3.9 percent) among Hispanic women. The overall prevalence of hepatitis C among men and women in the U.S. is 1.3 percent, according to the National Health and Nutrition Examination Survey (NHANES). The researchers said it was not clear why the prevalence of hepatitis C was highest among Hispanic men and women of Puerto Rican background compared with Hispanics of other backgrounds.
The Einstein study used data collected on 11,964 individuals as part of the Hispanic Community Health Study/Study of Latinos, a National Institutes of Health-funded study of Hispanic adults from four communities (Bronx, Miami, Chicago and San Diego). It was led by Robert Kaplan, Ph.D., the Dorothy and William Manealoff Foundation and Molly Rosen Chair in Social Medicine and professor of epidemiology & population health, and by Gloria Ho, Ph.D., professor of epidemiology & population health, both at Einstein.
“Clearly, our findings strongly support the need for community-based campaigns to increase testing and treatment in the Hispanic population,” said Dr. Kuniholm. “But in our view, outreach efforts should be redoubled in those communities with large numbers of people of Hispanic background and a high prevalence of the disease.. For example, if you’re in Miami with its mostly Cuban Hispanic population, the cost effectiveness of extra screening may be less than in the Bronx or Chicago, which both have large Puerto Rican communities. Extra efforts to increase screening may be warranted in those communities.”
Most HCV-infected Americans were born between 1945 and 1964, and most have engaged in high-risk drug and sexual behaviors at some point in their lives. Many with such histories may not recognize that transient behavior decades earlier has put them at risk for a potentially lifelong infection. Of those who ever injected drugs, for example, more than 8 out of 10 had not done so in the past year and may not have injected drugs for many years.
High-risk behavior does not account for all HCV infections in the United States. Among HCV-positive survey participants 60 years of age or older, more than half reported receiving blood transfusions before 1992. Among younger participants, blood transfusion probably accounted for a relatively smaller proportion of HCV infections. This trend reflects public health interventions during the 1980s and 1990s that led to a progressive reduction in the risk for post-transfusion HCV infection. Other well-known risk factors, such as long-term hemodialysis and health care work involving frequent exposure to blood, could not be evaluated in NHANES because of their low frequency or lack of availability in the NHANES data set. These risk factors generally account for fewer than 10% of infections.
The lower prevalence of anti-HCV among adolescents and young adults (<30 years of age) compared with that among older adults is encouraging. The similarity of the prevalences among young non-Hispanic black and white adults, as well as the lower prevalence of injection drug use among young non-Hispanic black persons, is consistent with that of another national survey; this finding suggests that younger non-Hispanic black persons may not be subject to the disproportionately high burden of disease that was seen in the previous generation. However, the small number of younger anti-HCV–positive participants limits definitive conclusions.
The prevalence of chronic infection did not vary significantly by race. In the previous NHANES, non-Hispanic black persons were more likely to have chronic infection than non-Hispanic white persons. This difference could represent a loss of HCV markers as the cohort aged; a real change in prevalence of chronic infection; or a chance observation, particularly because of the smaller numbers of HCV-positive participants in the current survey.
In 2012, the Centers for Disease Control and Prevention recommended that all Baby Boomers (people born from 1945 through 1965) be tested for hepatitis C. Those at increased risk for hepatitis C infection should also be tested, including people who ever injected illegal drugs (even if they did so only once or many years ago), have abnormal liver tests, received donated blood or organs before 1992, have been exposed to blood at work through needle sticks or injury with a sharp object, or were ever on hemodialysis.
The study’s findings take on added importance with the development of a new class of hepatitis C drugs, recently approved by the FDA that can potentially cure more than 80 percent of people infected with hepatitis C. “In the past, treating hepatitis C was often very difficult and was associated with severe side effects,” said Dr. Kuniholm. “The newer treatments cause far fewer side effects and are more effective and more convenient to take.”
Because of a high prevalence of hepatitis C virus (HCV) infection (10–20%) among veterans seeking care in Department of Veterans Affairs (VA) hospitals, current US military forces were evaluated for HCV infection. Banked serum samples were randomly selected from military personnel serving in 1997 and were tested for antibody to HCV (anti-HCV). Overall prevalence of anti-HCV among 10,000 active-duty personnel was 0.48% (5/1,000 troops); prevalence increased with age from 0.1% among military recruits and active-duty personnel aged <30 years to 3.0% among troops aged ≥ 40 years. Prevalence among 2,000 Reservists and active-duty troops was similar. Based on sequential serum samples from 7,368 active-duty personnel (34,020 person-years of observation), annual incidence of infection was 2/10,000. Of 81 HCV RNA-positive troops for whom genotype was determined, genotypes 1a (63%) and 1b (22%) predominated, as in the civilian population. These data indicate that HCV infection risk among current military forces is lower than in VA studies and the general civilian population aged <40 years. The low level of HCV infection may be attributed to infrequent injection drug use in the military due to mandatory testing for illicit drugs prior to induction and throughout military service.
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The paper is titled “Prevalence of
Hepatitis C Virus Infection in US Hispanic/Latino Adults: Results from the NHANES 2007-2010 and HCHS/SOL Studies.” In addition to Drs. Kuniholm, Kaplan and Ho, other Einstein contributors are Molly Jung, M.P.H., Ryung Kim, Ph.D., and Howard Strickler, M.D., M.P.H. Additional contributors are James E. Everhart, M.D., M.P.H., at National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD; Scott Cotler, M.D., at Loyola University Medical Center, Maywood, IL; Gerardo Heiss, M.D., Ph.D., and Marston Youngblood, M.A., M.P.H. at University of North Carolina, Chapel Hill, NC; Geraldine McQuillan, Ph.D., at U.S. Centers for Disease Control and Prevention, Hyattsville, MD; and Bharat Thyagarajan, M.D., at University of Minnesota, Minneapolis, MN.
The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.
The prevalence of anti-HCV in the United States was 1.6% (95% CI, 1.3% to 1.9%), equating to an estimated 4.1 million (CI, 3.4 million to 4.9 million) anti-HCV-positive persons nationwide; 1.3% or 3.2 million (CI, 2.7 million to 3.9 million) persons had chronic HCV infection. Peak prevalence of anti-HCV (4.3%) was observed among persons 40 to 49 years of age. A total of 48.4% of anti-HCV-positive persons between 20 and 59 years of age reported a history of injection drug use, the strongest risk factor for HCV infection. Of all persons reporting such a history, 83.3% had not used injection drugs for at least 1 year before the survey.
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Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ.
The Hispanic Community Health Study/Study of Latinos is supported by contracts from the National Heart, Lung, and Blood Institute to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). The following Institutes/Centers/Offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Institute on Minority Health and Health Disparities, National Institute on Deafness and Other Communication Disorders, National Institute of Dental and Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Neurological Disorders and Stroke, NIH Institution-Office of Dietary Supplements. Dr. Kuniholm is supported in part by the National Center for Advancing Translational Sciences, through CTSA grants UL1RR025750 and KL2RR025749.
The authors report no conflicts of interest.
About Albert Einstein College of Medicine of Yeshiva University
Albert Einstein College of Medicine of Yeshiva University is one of the nation’s premier centers for research, medical education and clinical investigation. During the 2013-2014 academic year, Einstein is home to 734 M.D. students, 236 Ph.D. students, 106 students in the combined M.D./Ph.D. program, and 353 postdoctoral research fellows. The College of Medicine has more than 2,000 full-time faculty members located on the main campus and at its clinical affiliates. In 2013, Einstein received more than $155 million in awards from the NIH. This includes the funding of major research centers at Einstein in diabetes, cancer, liver disease, and AIDS. Other areas where the College of Medicine is concentrating its efforts include developmental brain research, neuroscience, cardiac disease, and initiatives to reduce and eliminate ethnic and racial health disparities. Its partnership with Montefiore Medical Center, the University Hospital and academic medical center for Einstein, advances clinical and translational research to accelerate the pace at which new discoveries become the treatments and therapies that benefit patients. Through its extensive affiliation network involving Montefiore, Jacobi Medical Center - Einstein’s founding hospital, and five other hospital systems in the Bronx, Manhattan, Long Island and Brooklyn, Einstein runs one of the largest residency and fellowship training programs in the medical and dental professions in the United States.
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