Rising HCV-related mortality in US greater than all other infectious diseases

Issue: November 2015

SAN DIEGO — Hepatitis C virus is now the most frequently recorded underlying or contributing infection on death certificates in the United States, superseding all 60 other infectious conditions reported to CDC combined and unabated by improving antiviral therapy, according to data presented at IDWeek 2015.

“We wanted to see if improving antiviral therapy has had a perceptible effect on rising mortality in these patients,” Scott D. Holmberg, MD, MPH, FIDSA, division of viral hepatitis at the CDC, said during his presentation.

Scott D. Holmberg

Holmberg and colleagues examined ICD-10 codes from the national Multiple Cause of Death records database between 2003 and 2013 and death records of patients enrolled in the Chronic Hepatitis Cohort Study.

“We looked at HCV and all 60 other infectious diseases required to be reported to CDC and examined the multiple cause of death records for all 61 conditions,” Holmberg said. “To home in on a well-characterized large cohort of HCV patients, we also examined death rates and causes of death in them.”

According to Holmberg, analysis of the death record showed HCV to be the highest recorded condition for mortality after 2011.

“Again comparison of HCV recording, our death certificates show that HCV-related deaths, both absolute … or in terms of relative race, exceeded such recording of all 60 other infectious conditions after 2011,” Holmberg said.

According to Holmberg’s presentation, the top six infectious disease conditions cited as an underlying condition to mortality and reported to the CDC in 2013 were: HCV (n = 19,358), HIV (n = 8,831), Staphylococcus aureus, including MRSA (n = 5,136), HBV (n = 1,871), tuberculosis (n = 992) and pneumococcal disease (n = 885).

“HCV accounts for more than double the deaths and mortality rate of HIV,” Holmberg said.

These overall numbers did not include 4,444 adult influenza deaths, but did include 165 childhood influenza deaths in 2013, according to the presentation.

After evaluating data of patients from the Chronic Hepatitis Cohort Study, Holmberg and colleagues found that HCV mortality rates more than doubled from 2.4 deaths per 100 person-years in 2007 to 5.4 deaths per 100 person-years in 2013.

“We got a clear understanding of the true impact of HCV mortality,” Holmberg said. “Over an 8-year period, we had complete data on over 12,000 HCV patients seen in four large integrated health care systems in the United States, and this gave us well over 50,000 person-years of observation.”

According to the presentation, there were 1,600 deaths among patients in the Chronic Hepatitis Cohort Study between 2006 and 2010. Only 19% of these HCV patients who died had HCV mentioned on their death certificate. However, more than 75% of them had “evidence of serious liver disease” at time of death, according to Holmberg.

Holmberg said that even with oral curative therapies now available for treatment, barriers stand in the way of treating patients with HCV and achieving lower mortality rates.

“Over the longer term, in reaction to high cost of therapies, which have come down substantially [over time], we are now at an era when public insurance, especially state Medicaid offices, and private insurance restrict who will qualify to receive HCV therapy,” Holmberg said. “In addition to not using drugs and alcohol, qualifying patients need moderate or worse hepatic fibrosis or cirrhosis.”

Frequent barriers for treatment include: some states requiring biopsies for fibrosis scoring, finding a Fibroscan (Echosens, France) machine to document liver fibrosis or cirrhosis, or finding a specialist, as required by many state Medicaid offices, especially in rural areas can be very difficult, according to Holmberg.

“We think cost is not the only barrier,” Holmberg said. “There are definitely many other structural problems we think to prevent HCV morbidity and mortality. Many doctors still consider HCV to be a benign infection that poses a problem for only a minority of those infected. These hepatitis C patients too often have many acute life stressors and medical problems that need their attention before HCV can be addressed.”

Holmberg concluded: “Deaths in chronic HCV-infected persons, even when grossly under-enumerated on death certificates, far outstrip deaths from 60 other infectious conditions reportable to CDC. Control of the chronic and the acute outbreaks will require a multipronged approach, with interventions along a testing-to-cure continuum of care.” – by Melinda Stevens

Reference:

Holmberg SD, et al. Abstract 1972. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.

Disclosure: Holmberg reports no relevant financial disclosures.