Brief Report
Follow-Up Testing for Hepatitis C Virus Infection: An Analysis of Massachusetts Surveillance Data, 2007–2010
Kerri Barton, MPHa Dan Church, MPHa Shauna Onofrey, MPHa Noelle Cocoros, DSca Alfred DeMaria, Jr., MDa
ABSTRACT The Massachusetts Department of Public Health (MDPH) identified cases of hepatitis C virus (HCV) infection reported from 2007 through 2010 to assess evidence of appropriate follow-up testing for the diagnosis of active HCV infection. Surveillance data were used to assess the number of people with reported HCV who had an antibody test and nucleic acid test (NAT) for HCV, to determine the time between tests, and to identify demographic characteristics. Out of the 34,005 cases of HCV reported with laboratory results during the study period, 45% (n15,279) had only an antibody test reported and 55% (n18,726) had a NAT reported, with differences by age, gender, and region of residence. Nearly half of those with reported cases of HCV infection in Massachusetts did not have a NAT reported to MDPH, indicating that these individuals may not have received appropriate diagnostic testing. Analysis of demographics suggests differences by age, gender, and region.
a
Massachusetts Department of Public Health, Bureau of Infectious Disease, William A. Hinton State Laboratory Institute, Jamaica Plain, MA.
Address correspondence to: Kerri Barton, MPH, Massachusetts Department of Public Health, Bureau of Infectious Disease, William A. Hinton State Laboratory Institute, 305 South St., Jamaica Plain, MA 02130; tel. 617-983-6800; fax 617-983-4305; e-mail . ©2014 Association of Schools and Programs of Public Health
Public Health Reports / September–October 2014 / Volume 129
䉫
403
404 䉫 Brief Report
Hepatitis C virus (HCV) infection is a major public health concern in the United States, with as many as 5.2 million people affected.1 It is a major cause of morbidity and mortality and a leading cause of hepatocellular carcinoma. HCV-related mortality has now surpassed that of human immunodeficiency virus-related mortality in the U.S.2 While available treatment may reduce mortality,3 HCV-infected individuals first need to be tested appropriately and have active infection confirmed.4 In 2009, the American Association for the Study of Liver Disease recommended that a positive screening test for antibodies against HCV should prompt a nucleic acid test (NAT) to confirm active infection and determine if treatment is warranted.5 The standard screening test for HCV infection is an enzyme-linked immunoassay (EIA), which detects anti-HCV antibodies in the blood; the most accurate test for identification of current HCV infection is the NAT, which detects HCV ribonucleic acid (RNA) in the blood. Recognition that risk-based screening for HCV infection had not been identifying a sufficient portion of those at risk led the Centers for Disease Control and Prevention (CDC) to recommend routine, one-time-only screening of everyone in the U.S. born between 1945 and 1965,6 the major cohort of people diagnosed as having chronic HCV infection. We conducted an analysis of surveillance data to determine how many of those with HCV infection reported to the Massachusetts Department of Public Health (MDPH) from 2007 through 2010 could be documented to have received appropriate follow-up testing. We examined the time to NAT follow-up testing and the demographic characteristics of those who did and did not receive such follow-up testing. METHODS In Massachusetts, all laboratory results indicative of HCV infection are reportable to MDPH. Reports are received via electronic laboratory reporting, faxed reports, and one-page optical character recognition forms called TeleForms® (HP Autonomy, Sunnyvale, California), all of which are entered into the Massachusetts Virtual Epidemiologic Network (MAVEN), MDPH’s secure, Web-based, electronic surveillance system. For this analysis, data on individuals with evidence of past or current HCV infection were extracted from MAVEN and analyzed using SAS® version 9.3.7 Laboratory tests coded by Logical Observation Identifiers Names and Codes (LOINC®, the Regenstrief Institute, Inc., Indianapolis, Indiana) and Systematized Nomenclature of Medicine (The International Health Terminology Standards Development Organisation,
Copenhagen, Denmark) were categorized based on test type and MDPH’s disease classification protocol, which accords with CDC case classifications.8 EIA, recombinant immunoblot assay (RIBA), and signal-tocutoff ratios were included in the antibody test category, while RNA (quantitative and qualitative) and genotype tests were considered NATs. Negative test results are not routinely reported to MDPH, although they may be received with viral hepatitis test panels, where at least one other test on the panel is positive. People with current or past HCV infection who have an event date (i.e., date of onset of symptoms, specimen collection date, test result date, or report date—whichever was earliest) from January 1, 2007, to December 31, 2010, were included and followed through December 31, 2012. We calculated the time between the first antibody test and the first NAT, if reported, using specimen collection dates. People in this category who had missing laboratory results or specimen dates were excluded from our analysis (n148, 1%). We compared people with HCV infection who had a reported NAT with those without a reported NAT by age group (35 years or 35 years of age), gender, and region of the state (West, Central, Northeast, Boston Metrowest, Boston Inner Suburbs, Boston, or Southeast). As a supplemental analysis, we used a logistic regression model to examine the odds of having a reported NAT in relation to region, controlling for gender and age group. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using SAS. RESULTS From 2007 through 2010, MDPH received 72,478 laboratory reports indicating past or current HCV infection on 34,005 individuals. Of the 34,005 individuals, 45% (n15,279) had only a screening or supplementary antibody test(s) reported but no NAT (this proportion was constant during each year of the study period), and 55% (n18,726) had a NAT, with or without an antibody test reported (Figure). The Table shows the characteristics of study subjects with antibody-only results and those with NAT results. A lower percentage of people aged 35 years had a NAT reported than those aged 35 years (49% vs. 59%). Females and males in both age groups had similar results, with 57% of females and 59% of males having a NAT reported (Table). An analysis of factors associated with having a NAT revealed that among both age groups, after adjusting for gender, several regions of residence had significantly decreased odds of NATs compared with results for the region with the highest
Public Health Reports / September–October 2014 / Volume 129
Testing for Hepatitis C in Massachusetts
䉫
405
Figure. Laboratory results for reported cases of HCV infection in Massachusetts, 2007–2010 HCV events: 34,005
Only an antibody test: 15,279 (45%)
Any NAT: 18,726 (55%) 1 NAT: 9,901 (29%) 1 NAT: 8,825 (26%) Genotype: 6,695 (20%)
Both an antibody test and an NAT: 15,053a
NAT before antibody test: 1,640b
NAT at the same time as antibody test: 2,845b
NAT before antibody test: 10,568b
NAT within one week: 1,541 (15%) NAT 1–4 weeks later: 2,433 (23%) NAT 1–6 months later: 2,466 (23%) NAT 6–12 months later: 1,041 (10%) NAT 1–2 years later: 1,371 (13%) NAT 2 years later: 1,716 (16%)
a
Genotype testing was included in the NAT category.
b
For all cases, the earliest specimen date available for each test category was used.
HCV hepatitis C virus NAT nucleic acid test
proportion of NATs reported (Boston Metrowest), particularly in the Southeast region of the state (35 years of age: OR0.55, 95% CI 0.45, 0.67; 35 years of age: OR0.71, 95% CI 0.61, 0.82). Females aged 35 years also had decreased odds of having a NAT (OR0.87, 95% CI 0.82, 0.93) compared with their male counterparts (data not shown). DISCUSSION With 8,000–10,000 cases of HCV infection reported to MDPH annually, hepatitis C is one of the most common reportable diseases in Massachusetts. We found that for nearly half of all cases, MDPH had never received results of the recommended follow-up NAT, which determines active infection. We therefore cannot
determine whether these cases were of past (resolved) HCV infection or current active infection, and these results suggest that many of the infected individuals did not receive appropriate follow-up testing. These results are very similar to those in a recent CDC report, which was based on data from eight jurisdictions.9 CDC reported that 49% (n107,209) of all people with newly reported HCV cases had only an antibody test reported, 59% of whom were born between 1945 and 1965.8 We also found differences by age group in whether or not MDPH had received a NAT report. Most people reported to MDPH to have HCV infection are males aged 35 years, with residence relatively evenly distributed across the state. These reports are generally of cases of chronic HCV infection, likely with exposure in the 1970s and 1980s, when incidence rates
Public Health Reports / September–October 2014 / Volume 129
406 䉫 Brief Report
Table. Demographic characteristics of people with only a reported HCV antibody test and those with any reported NAT in Massachusetts, 2007–2010 Demographic characteristics
Antibody only N (percent of total)
Any NAT N (percent of total)
Total reported cases
Age group (in years) 35 35
6,114 (51.3) 9,165 (41.5)
5,793 (48.7) 12,933 (58.5)
11,907 22,098
Gendera Female Male
5,179 (43.3) 7,985 (40.8)
6,784 (56.7) 11,567 (59.2)
11,963 19,552
Regionb West Central Northeast Boston Metrowest Boston Inner Suburbs Boston Southeast
1,867 1,682 1,873 542 1,400 1,328 2,758
Total
(42.9) (44.9) (37.6) (35.8) (38.9) (36.7) (46.3)
15,279 (44.9)
2,488 2,062 3,106 972 2,201 2,287 3,195
(57.1) (55.1) (62.4) (64.2) (61.1) (63.3) (53.7)
4,355 3,744 4,979 1,514 3,601 3,615 5,953
18,726 (55.1)
34,005
a
n2,490 missing gender
b
n6,244 missing region
HCV hepatitis C virus NAT nucleic acid test
of HCV infection were high.6,9 Recently, an epidemic of HCV infection has been identified among young injection drug users aged 15–25 years.10 In our analysis, people with HCV infection who were 35 years of age had a lower percentage of reports of NATs than those aged 35 years. Females had a slightly lower percentage of reported NATs than males, particularly among those aged 35 years. There were differences by region of the state in reports of NATs, even after controlling for age and gender. We hypothesize that the younger members of the group may not be seeking the follow-up care that their older counterparts are receiving. This lack of follow-up may be due to provider factors (e.g., access to care, awareness, or failure to obtain a risk history prompting confirmation of test), less overall health-care utilization, continued drug use, or not having received the initial positive antibody test result. In addition, among individuals with a documented NAT after antibody testing, 16% did not receive such testing until at least two years later, implying delay in diagnosis, care, and potential treatment. Limitations This study was subject to several limitations. Because this analysis was based on surveillance data, it is reliant only on information in reports to MDPH. As in other jurisdictions, we do not typically receive reports of negative NATs,9 but we expect that most individuals
with a positive anti-HCV antibody test would have evidence of active infection by NAT. In a study of 47,041 EIA-repeat-reactive blood donations, 79% of those that were RIBA positive were also NAT reactive.11 We were also unable to analyze MDPH surveillance data by clinical care provider type or location, so we could not determine how provider type or setting may impact testing. Additionally, the analysis of factors associated with having a NAT was limited due to a large proportion of infected people with missing race/ethnicity information; thus, potential racial/ethnic disparities could not be examined. CONCLUSION Our results mirror those in a recent CDC report, which found that almost half of all newly reported people with HCV infection in eight U.S. sites during 2005–2011 were HCV antibody positive only.9 As new medications become available, HCV infection is becoming increasingly treatable and even curable.3,12 Successful treatment has been shown to be cost effective, decreasing morbidity and mortality associated with HCV infection.3,13 However, if patients do not receive complete evaluation for active infection, they cannot engage in appropriate care and receive the benefit of treatment. Enhanced diagnostic services and education for health-care providers and people at risk of
Public Health Reports / September–October 2014 / Volume 129
Testing for Hepatitis C in Massachusetts
infection would serve to improve screening, diagnosis, and access to care.
6.
The study was considered exempt from institutional review board approval because it was part of routine surveillance.
8.
REFERENCES
9.
1. 2.
3. 4.
5.
Chak E, Talal AH, Sherman KE, Schiff ER, Saab S. Hepatitis C virus infection in USA: an estimate of true prevalence. Liver Int 2011;31:1090-101. Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007 [published erratum appears in Ann Intern Med 2012;156:840]. Ann Intern Med 2012;156:271-8. Wilby KJ, Partovi N, Ford JA, Greanya E, Yoshida EM. Review of boceprevir and telaprevir for the treatment of chronic hepatitis C. Can J Gastroenterol 2012;26:205-10. Lee MH, Yang HI, Lu SN, Jen CL, You SL, Wang LY, et al. Chronic hepatitis C virus infection increases mortality from hepatic and extrahepatic diseases: a community-based long-term prospective study. J Infect Dis 2012;206:469-77. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009;49:1335-74.
7.
10. 11.
12. 13.
䉫
407
Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep 2013;62(18):362-5. SAS Institute, Inc. SAS®: Version 9.3 for Windows. Cary (NC): SAS Institute, Inc.; 2010. Centers for Disease Control and Prevention (US). National Notifiable Diseases Surveillance System: hepatitis C, past or present, 2012 case definition [cited 2014 Jan 5]. Available from: URL: http:// wwwn.cdc.gov/NNDSS/script/casedef.aspx?CondYrID728&Date Pub1/1/2012%2012:00:00%20AM Vital signs: evaluation of hepatitis C virus infection testing and reporting—eight U.S. sites, 2005–2011. MMWR Morb Mortal Wkly Rep 2013;62(18):357-61. Hepatitis C virus infection among adolescents and young adults— Massachusetts, 2002–2009. MMWR Morb Mortal Wkly Rep 2011;60(17):537-41. Kleinman SH, Stramer SL, Brodsky JP, Caglioti S, Busch MP. Integration of nucleic acid amplification test results into hepatitis C virus supplemental serologic testing algorithms: implications for donor counseling and revision of existing algorithms. Transfusion 2006;46:695-702. Aman W, Mousa S, Shiha G, Mousa SA. Current status and future directions in the management of chronic hepatitis C. Virol J 2012;9:57. Liu S, Cipriano LE, Holodniy M, Owens DK, Goldhaber-Fiebert JD. New protease inhibitors for the treatment of chronic hepatitis C: a cost-effectiveness analysis. Ann Intern Med 2012;156:279-90.
Public Health Reports / September–October 2014 / Volume 129
Follow-Up Testing for Hepatitis C Virus Infection: An Analysis of Massachusetts Surveillance Data, 2007–2010
Kerri Barton, MPHa Dan Church, MPHa Shauna Onofrey, MPHa Noelle Cocoros, DSca Alfred DeMaria, Jr., MDa
ABSTRACT The Massachusetts Department of Public Health (MDPH) identified cases of hepatitis C virus (HCV) infection reported from 2007 through 2010 to assess evidence of appropriate follow-up testing for the diagnosis of active HCV infection. Surveillance data were used to assess the number of people with reported HCV who had an antibody test and nucleic acid test (NAT) for HCV, to determine the time between tests, and to identify demographic characteristics. Out of the 34,005 cases of HCV reported with laboratory results during the study period, 45% (n15,279) had only an antibody test reported and 55% (n18,726) had a NAT reported, with differences by age, gender, and region of residence. Nearly half of those with reported cases of HCV infection in Massachusetts did not have a NAT reported to MDPH, indicating that these individuals may not have received appropriate diagnostic testing. Analysis of demographics suggests differences by age, gender, and region.
a
Massachusetts Department of Public Health, Bureau of Infectious Disease, William A. Hinton State Laboratory Institute, Jamaica Plain, MA.
Address correspondence to: Kerri Barton, MPH, Massachusetts Department of Public Health, Bureau of Infectious Disease, William A. Hinton State Laboratory Institute, 305 South St., Jamaica Plain, MA 02130; tel. 617-983-6800; fax 617-983-4305; e-mail . ©2014 Association of Schools and Programs of Public Health
Public Health Reports / September–October 2014 / Volume 129
䉫
403
404 䉫 Brief Report
Hepatitis C virus (HCV) infection is a major public health concern in the United States, with as many as 5.2 million people affected.1 It is a major cause of morbidity and mortality and a leading cause of hepatocellular carcinoma. HCV-related mortality has now surpassed that of human immunodeficiency virus-related mortality in the U.S.2 While available treatment may reduce mortality,3 HCV-infected individuals first need to be tested appropriately and have active infection confirmed.4 In 2009, the American Association for the Study of Liver Disease recommended that a positive screening test for antibodies against HCV should prompt a nucleic acid test (NAT) to confirm active infection and determine if treatment is warranted.5 The standard screening test for HCV infection is an enzyme-linked immunoassay (EIA), which detects anti-HCV antibodies in the blood; the most accurate test for identification of current HCV infection is the NAT, which detects HCV ribonucleic acid (RNA) in the blood. Recognition that risk-based screening for HCV infection had not been identifying a sufficient portion of those at risk led the Centers for Disease Control and Prevention (CDC) to recommend routine, one-time-only screening of everyone in the U.S. born between 1945 and 1965,6 the major cohort of people diagnosed as having chronic HCV infection. We conducted an analysis of surveillance data to determine how many of those with HCV infection reported to the Massachusetts Department of Public Health (MDPH) from 2007 through 2010 could be documented to have received appropriate follow-up testing. We examined the time to NAT follow-up testing and the demographic characteristics of those who did and did not receive such follow-up testing. METHODS In Massachusetts, all laboratory results indicative of HCV infection are reportable to MDPH. Reports are received via electronic laboratory reporting, faxed reports, and one-page optical character recognition forms called TeleForms® (HP Autonomy, Sunnyvale, California), all of which are entered into the Massachusetts Virtual Epidemiologic Network (MAVEN), MDPH’s secure, Web-based, electronic surveillance system. For this analysis, data on individuals with evidence of past or current HCV infection were extracted from MAVEN and analyzed using SAS® version 9.3.7 Laboratory tests coded by Logical Observation Identifiers Names and Codes (LOINC®, the Regenstrief Institute, Inc., Indianapolis, Indiana) and Systematized Nomenclature of Medicine (The International Health Terminology Standards Development Organisation,
Copenhagen, Denmark) were categorized based on test type and MDPH’s disease classification protocol, which accords with CDC case classifications.8 EIA, recombinant immunoblot assay (RIBA), and signal-tocutoff ratios were included in the antibody test category, while RNA (quantitative and qualitative) and genotype tests were considered NATs. Negative test results are not routinely reported to MDPH, although they may be received with viral hepatitis test panels, where at least one other test on the panel is positive. People with current or past HCV infection who have an event date (i.e., date of onset of symptoms, specimen collection date, test result date, or report date—whichever was earliest) from January 1, 2007, to December 31, 2010, were included and followed through December 31, 2012. We calculated the time between the first antibody test and the first NAT, if reported, using specimen collection dates. People in this category who had missing laboratory results or specimen dates were excluded from our analysis (n148, 1%). We compared people with HCV infection who had a reported NAT with those without a reported NAT by age group (35 years or 35 years of age), gender, and region of the state (West, Central, Northeast, Boston Metrowest, Boston Inner Suburbs, Boston, or Southeast). As a supplemental analysis, we used a logistic regression model to examine the odds of having a reported NAT in relation to region, controlling for gender and age group. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using SAS. RESULTS From 2007 through 2010, MDPH received 72,478 laboratory reports indicating past or current HCV infection on 34,005 individuals. Of the 34,005 individuals, 45% (n15,279) had only a screening or supplementary antibody test(s) reported but no NAT (this proportion was constant during each year of the study period), and 55% (n18,726) had a NAT, with or without an antibody test reported (Figure). The Table shows the characteristics of study subjects with antibody-only results and those with NAT results. A lower percentage of people aged 35 years had a NAT reported than those aged 35 years (49% vs. 59%). Females and males in both age groups had similar results, with 57% of females and 59% of males having a NAT reported (Table). An analysis of factors associated with having a NAT revealed that among both age groups, after adjusting for gender, several regions of residence had significantly decreased odds of NATs compared with results for the region with the highest
Public Health Reports / September–October 2014 / Volume 129
Testing for Hepatitis C in Massachusetts
䉫
405
Figure. Laboratory results for reported cases of HCV infection in Massachusetts, 2007–2010 HCV events: 34,005
Only an antibody test: 15,279 (45%)
Any NAT: 18,726 (55%) 1 NAT: 9,901 (29%) 1 NAT: 8,825 (26%) Genotype: 6,695 (20%)
Both an antibody test and an NAT: 15,053a
NAT before antibody test: 1,640b
NAT at the same time as antibody test: 2,845b
NAT before antibody test: 10,568b
NAT within one week: 1,541 (15%) NAT 1–4 weeks later: 2,433 (23%) NAT 1–6 months later: 2,466 (23%) NAT 6–12 months later: 1,041 (10%) NAT 1–2 years later: 1,371 (13%) NAT 2 years later: 1,716 (16%)
a
Genotype testing was included in the NAT category.
b
For all cases, the earliest specimen date available for each test category was used.
HCV hepatitis C virus NAT nucleic acid test
proportion of NATs reported (Boston Metrowest), particularly in the Southeast region of the state (35 years of age: OR0.55, 95% CI 0.45, 0.67; 35 years of age: OR0.71, 95% CI 0.61, 0.82). Females aged 35 years also had decreased odds of having a NAT (OR0.87, 95% CI 0.82, 0.93) compared with their male counterparts (data not shown). DISCUSSION With 8,000–10,000 cases of HCV infection reported to MDPH annually, hepatitis C is one of the most common reportable diseases in Massachusetts. We found that for nearly half of all cases, MDPH had never received results of the recommended follow-up NAT, which determines active infection. We therefore cannot
determine whether these cases were of past (resolved) HCV infection or current active infection, and these results suggest that many of the infected individuals did not receive appropriate follow-up testing. These results are very similar to those in a recent CDC report, which was based on data from eight jurisdictions.9 CDC reported that 49% (n107,209) of all people with newly reported HCV cases had only an antibody test reported, 59% of whom were born between 1945 and 1965.8 We also found differences by age group in whether or not MDPH had received a NAT report. Most people reported to MDPH to have HCV infection are males aged 35 years, with residence relatively evenly distributed across the state. These reports are generally of cases of chronic HCV infection, likely with exposure in the 1970s and 1980s, when incidence rates
Public Health Reports / September–October 2014 / Volume 129
406 䉫 Brief Report
Table. Demographic characteristics of people with only a reported HCV antibody test and those with any reported NAT in Massachusetts, 2007–2010 Demographic characteristics
Antibody only N (percent of total)
Any NAT N (percent of total)
Total reported cases
Age group (in years) 35 35
6,114 (51.3) 9,165 (41.5)
5,793 (48.7) 12,933 (58.5)
11,907 22,098
Gendera Female Male
5,179 (43.3) 7,985 (40.8)
6,784 (56.7) 11,567 (59.2)
11,963 19,552
Regionb West Central Northeast Boston Metrowest Boston Inner Suburbs Boston Southeast
1,867 1,682 1,873 542 1,400 1,328 2,758
Total
(42.9) (44.9) (37.6) (35.8) (38.9) (36.7) (46.3)
15,279 (44.9)
2,488 2,062 3,106 972 2,201 2,287 3,195
(57.1) (55.1) (62.4) (64.2) (61.1) (63.3) (53.7)
4,355 3,744 4,979 1,514 3,601 3,615 5,953
18,726 (55.1)
34,005
a
n2,490 missing gender
b
n6,244 missing region
HCV hepatitis C virus NAT nucleic acid test
of HCV infection were high.6,9 Recently, an epidemic of HCV infection has been identified among young injection drug users aged 15–25 years.10 In our analysis, people with HCV infection who were 35 years of age had a lower percentage of reports of NATs than those aged 35 years. Females had a slightly lower percentage of reported NATs than males, particularly among those aged 35 years. There were differences by region of the state in reports of NATs, even after controlling for age and gender. We hypothesize that the younger members of the group may not be seeking the follow-up care that their older counterparts are receiving. This lack of follow-up may be due to provider factors (e.g., access to care, awareness, or failure to obtain a risk history prompting confirmation of test), less overall health-care utilization, continued drug use, or not having received the initial positive antibody test result. In addition, among individuals with a documented NAT after antibody testing, 16% did not receive such testing until at least two years later, implying delay in diagnosis, care, and potential treatment. Limitations This study was subject to several limitations. Because this analysis was based on surveillance data, it is reliant only on information in reports to MDPH. As in other jurisdictions, we do not typically receive reports of negative NATs,9 but we expect that most individuals
with a positive anti-HCV antibody test would have evidence of active infection by NAT. In a study of 47,041 EIA-repeat-reactive blood donations, 79% of those that were RIBA positive were also NAT reactive.11 We were also unable to analyze MDPH surveillance data by clinical care provider type or location, so we could not determine how provider type or setting may impact testing. Additionally, the analysis of factors associated with having a NAT was limited due to a large proportion of infected people with missing race/ethnicity information; thus, potential racial/ethnic disparities could not be examined. CONCLUSION Our results mirror those in a recent CDC report, which found that almost half of all newly reported people with HCV infection in eight U.S. sites during 2005–2011 were HCV antibody positive only.9 As new medications become available, HCV infection is becoming increasingly treatable and even curable.3,12 Successful treatment has been shown to be cost effective, decreasing morbidity and mortality associated with HCV infection.3,13 However, if patients do not receive complete evaluation for active infection, they cannot engage in appropriate care and receive the benefit of treatment. Enhanced diagnostic services and education for health-care providers and people at risk of
Public Health Reports / September–October 2014 / Volume 129
Testing for Hepatitis C in Massachusetts
infection would serve to improve screening, diagnosis, and access to care.
6.
The study was considered exempt from institutional review board approval because it was part of routine surveillance.
8.
REFERENCES
9.
1. 2.
3. 4.
5.
Chak E, Talal AH, Sherman KE, Schiff ER, Saab S. Hepatitis C virus infection in USA: an estimate of true prevalence. Liver Int 2011;31:1090-101. Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007 [published erratum appears in Ann Intern Med 2012;156:840]. Ann Intern Med 2012;156:271-8. Wilby KJ, Partovi N, Ford JA, Greanya E, Yoshida EM. Review of boceprevir and telaprevir for the treatment of chronic hepatitis C. Can J Gastroenterol 2012;26:205-10. Lee MH, Yang HI, Lu SN, Jen CL, You SL, Wang LY, et al. Chronic hepatitis C virus infection increases mortality from hepatic and extrahepatic diseases: a community-based long-term prospective study. J Infect Dis 2012;206:469-77. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009;49:1335-74.
7.
10. 11.
12. 13.
䉫
407
Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep 2013;62(18):362-5. SAS Institute, Inc. SAS®: Version 9.3 for Windows. Cary (NC): SAS Institute, Inc.; 2010. Centers for Disease Control and Prevention (US). National Notifiable Diseases Surveillance System: hepatitis C, past or present, 2012 case definition [cited 2014 Jan 5]. Available from: URL: http:// wwwn.cdc.gov/NNDSS/script/casedef.aspx?CondYrID728&Date Pub1/1/2012%2012:00:00%20AM Vital signs: evaluation of hepatitis C virus infection testing and reporting—eight U.S. sites, 2005–2011. MMWR Morb Mortal Wkly Rep 2013;62(18):357-61. Hepatitis C virus infection among adolescents and young adults— Massachusetts, 2002–2009. MMWR Morb Mortal Wkly Rep 2011;60(17):537-41. Kleinman SH, Stramer SL, Brodsky JP, Caglioti S, Busch MP. Integration of nucleic acid amplification test results into hepatitis C virus supplemental serologic testing algorithms: implications for donor counseling and revision of existing algorithms. Transfusion 2006;46:695-702. Aman W, Mousa S, Shiha G, Mousa SA. Current status and future directions in the management of chronic hepatitis C. Virol J 2012;9:57. Liu S, Cipriano LE, Holodniy M, Owens DK, Goldhaber-Fiebert JD. New protease inhibitors for the treatment of chronic hepatitis C: a cost-effectiveness analysis. Ann Intern Med 2012;156:279-90.
Public Health Reports / September–October 2014 / Volume 129
