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    2 Comments for this article
    Nationwide chronic hepatitis C surveillance is necessary for accurate state‐level prevalence estimates
    Ann Winters, MD | New York City Department of Health And Mental Hygiene
    NHANES is one method for establishing state prevalence estimates but for states and large cities with robust surveillance, surveillance-based prevalence estimates are likely to be more accurate. Hepatitis C is curable in 8-12 weeks in almost all people, and hepatitis C elimination is now possible at the city, state and local level with appropriate allocation of resources. Support for robust viral hepatitis surveillance in all jurisdictions is essential to any hepatitis C elimination plan. In New York City, we drafted a commentary in collaboration with colleagues from four other jurisdictions (Philadelphia, Massachusetts, Illinois, and Michigan) highlighting methodological concerns with an NHANES approach to hepatitis C prevalence estimates and advocating for comprehensive surveillance:

    “[…]Estimating the number of all current diagnosed and undiagnosed infections among living persons at the state level will allow states to accurately plan and monitor elimination efforts. However, generating these estimates is difficult and multiple approaches can be considered. A recent study by Rosenberg et al. presented state-level estimates of hepatitis C prevalence in 2016 using indirect standardization of NHANES survey data and weighting based on hepatitis C-related mortality data. However, we believe the accuracy of these prevalence estimates was likely affected by strong methodologic assumptions, and therefore, the need for actionable prevalence estimates still exists. […] published prevalence estimates, like those presented by Rosenberg et al., are likely to be used for resource allocation and targets for elimination efforts. Substantially underestimating chronic hepatitis C prevalence can damage advocacy efforts and the ability to appropriately allocate limited resources to maximize public health benefits. Where available, reliable surveillance data should be leveraged to generate or at least validate prevalence estimates. However, robust surveillance systems are not currently available in all states and jurisdictions. If hepatitis C elimination is going to be prioritized, then accurate prevalence estimates are vital, and greater resources are needed for consistent and comprehensive acute and chronic hepatitis C surveillance nationwide.”
    CONFLICT OF INTEREST: The Viral Hepatitis Program at the New York City Department of Health has in the past worked on projects with fiscal agents such as Public Health Solutions of the Fund for Public Health New York who receive funding from Gilead
    Winters' comment on strong methodological assumptions
    Anne Spaulding, MD, MPH | Rollins School of Public Health, Emory University
    To expand on comment on this article, made below by Winters in August 2019, and her commentary in JVH, about strong methodological assumptions in this article:

    One assumption is that hepatitis C viremia is uniform state-by-state in justice-involved populations. For a consideration of how observed variability in state prison HCV viremia could affect estimates of overall statewide prevalence of HCV, see: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749445

    I for one would appreciate discussion/comments on whether examining measured prevalence in non-NHANES populations is relevant.
    CONFLICT OF INTEREST: Research grant through institution, participation on advisory board: Gilead Sciences; honoraria for speaking on HCV in corrections, funded by third parties, who received grants from Abbvie, Merck, Gilead
    Original Investigation
    Public Health
    December 21, 2018

    Prevalence of Hepatitis C Virus Infection in US States and the District of Columbia, 2013 to 2016

    Author Affiliations
    • 1Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer
    • 2Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
    • 3Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 4Office of the Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    JAMA Netw Open. 2018;1(8):e186371. doi:10.1001/jamanetworkopen.2018.6371
    Key Points español 中文 (chinese)

    Question  During 2013 to 2016, what proportion of adults were living with hepatitis C virus (HCV) infection in each US state?

    Findings  In this survey study, US national HCV prevalence during 2013 to 2016 was 0.93% and varied by jurisdiction between 0.45% and 2.34%. Three of the 10 states with the highest prevalence and 5 of the 9 states with the highest number of HCV infections were in the Appalachian region.

    Meaning  Regions with long-standing HCV epidemics, and those with newly emergent ones partly driven by the opioid crisis, face substantial HCV prevalence.


    Importance  Infection with hepatitis C virus (HCV) is a major cause of morbidity and mortality in the United States, and incidence has increased rapidly in recent years, likely owing to increased injection drug use. Current estimates of prevalence at the state level are needed to guide prevention and care efforts but are not available through existing disease surveillance systems.

    Objective  To estimate the prevalence of current HCV infection among adults in each US state and the District of Columbia during the years 2013 to 2016.

    Design, Setting, and Participants  This survey study used a statistical model to allocate nationally representative HCV prevalence from the National Health and Nutrition Examination Survey (NHANES) according to the spatial demographics and distributions of HCV mortality and narcotic overdose mortality in all National Vital Statistics System death records from 1999 to 2016. Additional literature review and analyses estimated state-level HCV infections among populations not included in the National Health and Nutrition Examination Survey sampling frame.

    Exposures  State, accounting for birth cohort, biological sex, race/ethnicity, federal poverty level, and year.

    Main Outcomes and Measures  State-level prevalence estimates of current HCV RNA.

    Results  In this study, the estimated national prevalence of HCV from 2013 to 2016 was 0.84% (95% CI, 0.75%-0.96%) among adults in the noninstitutionalized US population represented in the NHANES sampling frame, corresponding to 2 035 100 (95% CI, 1 803 600-2 318 000) persons with current infection; accounting for populations not included in NHANES, there were 231 600 additional persons with HCV, adjusting prevalence to 0.93%. Nine states contained 51.9% of all persons living with HCV infection (California [318 900], Texas [202 500], Florida [151 000], New York [116 000], Pennsylvania [93 900], Ohio [89 600], Michigan [69 100], Tennessee [69 100], and North Carolina [66 400]); 5 of these states were in Appalachia. Jurisdiction-level median (range) HCV RNA prevalence was 0.88% (0.45%-2.34%). Of 13 states in the western United States, 10 were above this median. Three of 10 states with the highest HCV prevalence were in Appalachia.

    Conclusions and Relevance  Using extensive national survey and vital statistics data from an 18-year period, this study found higher prevalence of HCV in the West and Appalachian states for 2013 to 2016 compared with other areas. These estimates can guide state prevention and treatment efforts.