Regional Differences in Mortality Rates and Characteristics of Decedents With Hepatitis B Listed as a Cause of Death, United States, 2000-2019

Key Points Question Were there regional differences in mortality rates and characteristics among decedents with hepatitis B listed as a cause of death in the US during 2000 to 2019? Findings In this nationwide cross-sectional study including 35 280 decedents from 2000 to 2019, the highest hepatitis B–listed death rates were observed in coastal and Appalachian states; in addition, younger median age at death occurred predominantly in Appalachian states. Most decedents, regardless of birthplace, had liver-related conditions listed as underlying cause of death, and decedents born in the US, who constituted approximately two-thirds of all deaths, more frequently had nonliver conditions listed as underlying cause of death compared with non-US–born decedents. Meaning These findings suggest that in addition to addressing liver-related complications, US-born persons with chronic infection may also require diagnosis and management of multiple comorbidities.


Main Finding Interpretation/Comment
• Hepatitis B-listed death rates were significantly higher in 12 coastal and Appalachian states.
• Baseline estimates of state and regional level hepatitis B deaths can be used to identify high mortality burden areas and inform state public health and elimination efforts.
• Significant increases in hepatitis B-listed death rate were observed exclusively in WV and KY.
• These states have also experienced high death rate from all causes and pronounced declines in life expectancy (e.g., opioid deaths).• Support universal hepatitis B vaccination and harm reduction efforts.
• US-born decedents constituted 63% of all hepatitis B-listed deaths.• Contrary to published NHANES prevalence data indicating more non-US-born persons living with chronic hepatitis B, USborn decedents constituted most hepatitis B-listed deaths.
• Significantly younger median age at death occurred in KY, WV, TN, OH, and MS where most decedents were US-born.• Significantly older median age at death occurred among California decedents, who were predominantly non-US-born.• Hepatitis B-listed decedents had a significantly younger median age at death when compared to non-hepatitis B-listed decedents.
• In the context of chronic hepatitis B, despite US-born persons having presumably a shorter duration of infection, they had a significantly younger median age at death.

Main Finding Interpretation/Comment
• Liver-related conditions were the most frequently listed UCOD among both US-born and non-US-born hepatitis B-listed decedents.
• Liver cancer was the predominant UCOD among non-US-born decedents.(Nearly ½ had any cancer listed as UCOD.) • Compared to non-US-born decedents, US-born decedents more had non-hepatic conditions listed as UCOD.
• US-born persons with hepatitis B may more frequently require diagnosis and management of viral coinfections, respiratory and cardiovascular conditions, non-viral liver disease, and addiction-related sequelae.
• These findings support universal adult hepatitis B screening and vaccination.
• All persons with chronic hepatitis B need diagnosis and ongoing clinical management.

Work in Progress
▪ Are there differences in social vulnerability indicators among hepatitis B decedents according to US-vs non-US birth, to state/county location?
▪ Is there a relationship between social vulnerability and mortality rates?
▪ Is there a relationship between social vulnerability and early hepatitis Brelated mortality?
▪ Can identification of geolocation-specific social vulnerabilities among HBV decedents inform, focus, and improve public health interventions for persons living with CHB?
Follow-up Questions

CDC ATSDR Social Vulnerability Index
▪ Social determinants of health (e.g., socioeconomic and health insurance status, minority status and language, access to housing and transportation) can affect access to health care and treatment, as well as patient-level outcomes for a variety of conditions.▪ Social Vulnerability Index (SVI) was created by the CDC/ATSDR 1 as a standardized metric that incorporates census tract-and county-level social determinants to identify and compare communities deemed vulnerable.▪ We plan to merge SVI data with US MCOD data by county of residence.

2 -▪o▪
Hepatitis B-listed death state-level analyses -Hepatitis B-listed death counts and age-adjusted rates 1, Median age at hepatitis B-listed death -Distribution of US birthplace status -Distribution of HCV, HIV, and HDV coinfection status ▪ Hepatitis B-listed death US-birthplace analyses (US-born vs non-US-born) -Distribution of • Sociodemographic characteristics (sex, age, year of birth, and race/ethnicity) • UCOD categories 3 (for decedents who had hepatitis B listed as a CCOD) Age-adjusted hepatitis B-listed death rates in 50 states and DC, Death rates in 12 states significantly surpassed the national death rate (0.47) Primarily coastal and Appalachian states o DC (high, 1.78), HI, OK, CA, TN, WV, MS, OR, WA, LA, KY, and NY (Adjusted P<.05) ▪ Death rates were lowest in o MT (0.14) followed by ID and IL (0.21 for both) ▪ US median age (IQR) at hepatitis B-listed death: 60.0 (53.0-69.0)years.▪ Significantly younger median age at death in KY, WV, TN, OH, and MS (red) Significantly older median age at hepatitis Blisted death (yellow) o CA (63.0 years)

o▪
CT (-45.8%),PA, NC, MD, VA, LA, TX, MI, IL, GA, WA, FL, CA, and NY (-18.7%)▪State-level death rates significantly increased in o WV (+83.8%) and KY (+69.4%)Lack of population denominators to calculate age-adjusted deaths rates in US-born and non-US-born persons ▪ Variability in provider reporting of conditions leading to death ▪ Underestimation of the true hepatitis B mortality burden due to under-diagnosis of hepatitis B 1 ▪ American Indian and Alaska Native persons are often misclassified as other race groups on their death certificate, resulting in underreporting of conditions 2

1 .-
https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html▪ Web-based data platform used by many CDC programs for data integration, management, and analyses of public health surveillance data ▪ DVH plans to use DCIPHER for viral hepatitis case-based surveillance and mortality data Jurisdictional health departments can access the platform to view their data and produce reports ▪ Integration of NNDSS and mortality data with SVI and other place-based SDOH datasets so jurisdictions can view their surveillance and mortality data in context of SDOH data sources ▪ Starting pilot with six health departments this month ▪ Anticipate to onboard other jurisdictions beginning later this year DCIPHER Data Integration Project -CDC Online query tool -Aggregated data at the US, region, state, and county -Examples: o Hawai'i Hepatitis B Mortality Report (2000-2020) o CDC DVH Annual Viral Hepatitis Surveillance Reports CDC WONDER Mortality For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

-Hispanic, Black 25% 9% Had HCV, HIV, or HDV co-infection 39% 9%
*Chi-Square test of independence to assess differences in characteristics between US-born and non-US-born decedents.Statistically significant, P<.001 for all comparisons.

Distribution of US birthplace status among hepatitis B-listed deaths, United States, 2010-2019
*P<.05 vs overall national distribution.US birthplace data for Alabama, Delaware, Montana, New Hampshire, North Dakota, South Dakota, Vermont, West Virginia, and Wyoming were not displayed because at least 1 cell (either US-born or non-US-born) had fewer than 10 deaths.%

At national % (USB 63%, NUSB 37%) 3
UT, OR, NV Significantly* higher % of USB than national distribution 22 MS (95.2%),KY, TN, LA, IN, AR, SC, OH, OK, MI, GA, MO, NC, DC, ME, KS, NM, IA, PA, AZ, TX, and FL (70.6%)Higher % of USB than national distribution but not significantly Distribution of underlying causes of death by birthplace of hepatitis Blisted decedents, United States, 2010-2019 ▪ There was no difference in the frequency with which "hepatitis B" was listed as the UCOD among US-and non-US-born hepatitis B-listed decedents (Both ~30%, P=.24) ▪ For decedents with hepatitis B listed as a CCOD, o Liver cancer was more frequently listed as UCOD among non-US decedents compared with USborn decedents (53.7% vs 20.6%, P<.001) o Several conditions more frequently* listed as UCOD among US-born (Table) *Chi-Square test of independence to assess differences in characteristics between US-born and non-US-born decedents.P<.001 for all comparisons.

Median age at hepatitis B-listed death by causes of death, US-vs. non-US place of birth, United States, 2010-2019
▪ Compared to non-US-born hepatitis B-listed decedents, US-born decedents had a significantly* younger median age at death for the following UCOD conditions:*Kruskal-Wallis test to assess differences in median age at death between US-born and non-US-born decedents, P<.01 for all comparisons.

age at death and underlying COD among decedents with and without hepatitis B, 2010-2019 ▪
Overall and for most UCOD categories, both US-born and non-US born hepatitis B-listed decedents had a significantly younger median age at death when compared to decedents who did not have hepatitis B listed at death.▪ Most frequently listed UCOD categories among both US-born and non-US-born hepatitis B decedents were -Hepatitis B (USB: 30.2%,NUSB: 29.4%) -Liver cancer (USB: 14.4%, NUSB: 37.9%) -Non-liver cancers (USB: 11.4%, NUSB: 11.7%) ▪ Most frequently UCOD categories among decedents who did NOT have hepatitis B listed -Circulatory conditions (30.9%) and non-liver cancers (21.7%)HepatitisB-