.png)
By: Marcus J. Hopkins
May 2nd, 2023
May is #Hepatitis Awareness Month, and the Appalachian Learning Initiative is highlighting the impact of #ViralHepatitis (VH) in #Appalachia.
In this article:
About Viral Hepatitis
Viral Hepatitis (VH) is a series of diseases that directly impact the liver, a vital organ that processes nutrients, filters the blood, and fights infections. The most common forms of VH in the United States are Hepatitis A (HAV), Hepatitis B (HBV), and Hepatitis C (HCV), although cases of Hepatitis D (HDV) and Hepatitis E (HEV) are occasionally identified.
While HAV and HBV are preventable by vaccination, HCV does not yet have a vaccine to prevent or reduce the risk of transmission. Though vaccines for HAV and HBV exist, vaccination uptake rates are low. According to the U.S. Department of Health & Human Services (HHS), just 10% of adults aged 19+ have been vaccinated against HAV, and just 25% against HBV (HHS, 2020). HBV, while preventable via vaccine, does not yet have a cure, though there are consistent drug trials in an attempt to find one.
Though HCV does not have a vaccine, it can be effectively cured through the use of direct-acting antiviral (DAA) drugs, the first of which—Sovaldi and Olysio—debuted in 2013. There are currently seven identified genotypes of HCV, of which genotypes 1-4 can be successfully treated with DAA therapies. Genotypes 5-7 have not been studied in large part because they are endemic to specific regions of the world and are very rare.
Since the release and further development of DAA regimens, concerns have been raised about the affordability and accessibility of these medications (Watson, 2022). Even with the release of authorized generic versions of Gilead Sciences' pangenotypic drugs, Harvoni and Epclusa, the cost of treatment ranges between $10,000 - $97,000 for a full course (Keikha, 2020).
IMPORTANT NOTE ABOUT SURVEILLANCE:
The onset of the COVID-19 pandemic in 2020 heavily impacted testing, disease investigation, and surveillance of Viral Hepatitis in the United States, in general, and in Appalachia. State officials across the U.S. have reported that the number of tests administered decreased significantly, and data for the year 2020 should be viewed through that lens.
Hepatitis A in Appalachia
HAV is the most easily spread form of VH and can be contracted through close, personal contact with persons infected with the virus and through eating contaminated food or drinks.
Multi-State Outbreak of 2018
In 2018, West Virginia became part of a multi-state outbreak of HAV that primarily impacted persons experiencing homelessness as well asand persons who inject drugs (PWID). Between January 2018 and August 2018, the Kanawha County Health Department identified 664 diagnoses associated with the outbreak (Wilson, et al., 2018).
During this outbreak, disease investigators from the CDC found that 10% of patients diagnosed with HAV showed evidence of a past or current HBV infection, and 47% showed evidence of a past or current HCV infection.
This outbreak kickstarted new policies in West Virginia starting in 2019 that began requiring that every person admitted into urgent care or emergency room facilities be automatically tested for HCV and HIV using an opt-out delivery model that requires informed refusal from patients.
The Viral Hepatitis in West Virginia 2020 Surveillance Summary released in May 2022 reported that rates of HAV have decreased from an historic high of 128.9 in 2018 to 4.9 in 2020 (West Virginia Department of Health and Human Resources, 2022). According to the state's surveillance summary, 43% of cases with risk factor reporting included Injection Drug Use (IDU) as a primary risk factor, and 30% included Non-Injection Drug Use (NIDU).
Current HAV Statistics
According to the CDC's 2020 Viral Hepatitis Surveillance Report, from 2019 to 2020 there was a 47% decrease in the number of new HAV diagnoses, but the number of cases still remains seven times higher than in 2015.
South Carolina and Alabama had the highest rates of new Acute HAV diagnoses in the U.S.:
Table 1 - Rate of Hepatitis A Diagnoses per 100,000 Residents by State, 2020
State | Rate per 100k Residents |
|---|---|
South Carolina | 22.9 |
Alabama | 19.6 |
Mississippi | 12.0 |
Maryland | 6.0 |
Georgia | 5.5 |
West Virginia | 5.4 |
North Carolina | 4.8 |
Tennessee | 3.8 |
Virginia | 2.5 |
Ohio | 2.4 |
Kentucky | 1.3 |
New York | 1.3 |
Pennsylvania | 1.0 |
Source: CDC, 2022
Hepatitis B in Appalachia
Appalachian states have consistently had some of the highest rates of HBV in the United States. Since at least 2015, Appalachian states have held a majority of the ten highest rates of new diagnoses in the U.S., with West Virginia, Kentucky, and Tennessee frequently leading the nation.
West Virginia's HBV Crisis
Since 2015, the number of new HBV infections has been steadily decreasing across the United States, including in Appalachia, where infection rates in West Virginia have decreased from an astounding 14.9 (per 100k) in 2016 to 3.2 in 2020—the lowest rate of new diagnoses since at least 2011 (WV DHHR, 2022).
According to the state's surveillance summary, 48% of cases with risk factor reporting included Injection Drug Use (IDU) as a primary risk factor, and 55% included Non-Injection Drug Use (NIDU).
Current HBV Statistics
According to the CDC's 2020 Viral Hepatitis Surveillance Report, the number of new HBV diagnoses abruptly decreased by 32% from 2019 to 2020, likely as a result of fewer people having access to or seeking healthcare services and being tested for HBV due to the COVID-19 pandemic.
West Virginia continues to lead the nation in new HBV diagnoses, with Kentucky, Tennessee, North Carolina, South Carolina, Alabama, Mississippi, Ohio, and Georgia having rates that place them within the ten highest rates in the United States.
Table 2 - Rate of Hepatitis B Diagnoses per 100,000 Residents by State, 2020
State | Rate per 100k Residents |
|---|---|
West Virginia | 3.2 |
Kentucky | 2.5 |
Tennessee | 2.3 |
North Carolina | 1.3 |
South Carolina | 1.3 |
Mississippi | 1.2 |
Alabama | 1.2 |
Ohio | 1.1 |
Georgia | 1.0 |
Maryland | 0.6 |
Virginia | 0.5 |
Pennsylvania | 0.4 |
New York | 0.2 |
Source: CDC, 2022
Hepatitis C in Appalachia
Since at least 2015, Appalachian states have consistently ranked in the ten highest rates of HCV in the United States, with West Virginia ranking within the five highest rates throughout that period. Because Hepatitis C is inefficiently transmitted via sexual contact, the majority of new HCV diagnoses in the United States are related to injection drug use, with 66% of cases with risk information reported listing IDU as the primary risk fact (CDC, 2022)
The high rates of HCV and the risk of HIV co-infection led many Appalachian states to either legalize or provisionally expand access to Syringe Services Programs (SSP) as a harm reduction measure to prevent the spread of the diseases amongst persons who inject drugs. This increase in the number of SSPs in Appalachia was directly tied to an HIV/HCV outbreak in Scott County, Indiana, from 2014-2015, which saw 215 new HIV diagnoses directly tied to a community of PWID in the Indiana/Ohio/Kentucky region (Gonsalves & Crawford, 2018).
Unfortunately, legislators in many of those states, including Indiana, have begun rescinding the authorization of SSPs and other harm reduction measures. This has been done at both the local and state levels, with ordinances and legislation being passed to either outlaw SSPs or regulate them out of existence. These increased restrictions on SSPs have forced them to operate outside of best practices which have the downstream consequence of increasing the likelihood of IDU-related Viral Hepatitis and HIV outbreaks in PWID communities and their social and sexual networks.
Current HCV Statistics
According to the CDC's 2020 Viral Hepatitis Surveillance Report, the number of new HCV diagnoses has more than doubled since 2013 and increased by 15% from 2019 to 2020. As a result of fewer people having access to or seeking healthcare services and being tested for HCV due to the COVID-19 pandemic, this increase may be an unestimate.
For the first time since at least 2015, West Virginia did not have the highest or 2nd-highest rate of new HCV diagnoses, with state health officials reporting that an abrupt cessation of HCV testing efforts as a result of the COVID-19 pandemic resulted in significantly fewer cases of HCV being identified, particularly in PWID.
West Virginia currently has the 4th-highest rate of new HCV diagnoses, with Kentucky, Tennessee, New York, and Ohio each having rates that place them within the ten highest rates in the United States.
Table 3 - Rate of Hepatitis C Diagnoses per 100,000 Residents by State, 2020
State | Rate per 100k Residents |
|---|---|
West Virginia | 5.3 |
Tennessee | 3.0 |
Kentucky | 2.9 |
North Carolina | 2.4 |
Ohio | 2.4 |
Alabama | 1.8 |
New York | 1.6 |
Pennsylvania | 1.6 |
Mississippi | 1.3 |
Virginia | 0.8 |
Georgia | 0.6 |
Maryland | 0.5 |
South Carolina | 0.2 |
Source: CDC, 2022
References
Centers for Disease Control and Prevention. (2022, August 18). Viral Hepatitis Surveillance Report – United States, 2020. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV, Viral Hepatitis, STD, and TB Prevention: Division of Viral Hepatitis. https://www.cdc.gov/hepatitis/statistics/2020surveillance/index.htm
Gonsalves, G. S., & Crawford, F. W. (2018). Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study. The Lancet. HIV, 5(10), e569–e577. https://doi.org/10.1016/S2352-3018(18)30176-0
Keikha, M., Eslami, M., Yousefi, B., Ali-Hassanzadeh, M., Kamali, A., Yousefi, M., & Karbalaei, M. (2020). HCV genotypes and their determinative role in hepatitis C treatment. Virusdisease, 31(3), 235–240. https://doi.org/10.1007/s13337-020-00592-0
Legan, M. (2021, June 03). Indiana Needle Exchange That Helped Contain A Historic HIV Outbreak To Be Shut Down. Washington, DC: National Public Radio: Shots: Up First. https://www.npr.org/sections/health-shots/2021/06/01/1001278712/indiana-needle-exchange-that-helped-contain-an-hiv-outbreak-may-be-forced-to-clo
United States Department of Health and Human Services. (2020). Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination (2021–2025). Washington, DC. https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf
Watson, S. (2022, March 29). Navigating Hepatitis C Treatment Costs: 5 Things to Know. New York, NY: Healthline Media LLC: Healthline: Health: Hepatitis C. https://www.healthline.com/health/hepatitis-c/treatment-costs
West Virginia Department of Health and Human Resources. (2022, May). Viral Hepatitis in West Virginia, 2020 Surveillance Summary. Charleston, WV: West Virginia Department of Health and Human Resources: Office of Epidemiology and Prevention Services: Division of STD, HIV, Hepatitis, and Tuberculosis. https://oeps.wv.gov/hepatitis/documents/data/Summary_2020_Acute_HBV-HCV.pdf
Wilson, E., Hofmeister, M.G., McBee, S., et al. (2019, April 12) Notes from the Field: Hepatitis A Outbreak Associated with Drug Use and Homelessness — West Virginia, 2018. MMWR Morb Mortal Wkly Rep 68(14), 330–331. http://dx.doi.org/10.15585/mmwr.mm6814a4
Comments