September 03, 2014EDITORS' NEW YORK (Reuters Health) - The incidence of acute hepatitis C infection is rising rapidly among Americans aged 30 years and younger, especially those living in non-urban areas, according to U.S. data.
"Because our study revealed a strong relationship between new infections and injection drug use among youth, we would encourage providers to be on high alert for these risk behaviors in young patients," said senior author Dr. Scott D. Holmberg from the Centers for Disease Control and Prevention in Atlanta, Georgia.
"Assessing their risk can be an important opportunity -- not only for testing but also to provide appropriate therapy or referral to drug-cessation treatment," he told Reuters Health by email.
The number of acute cases of hepatitis C virus (HCV) infection had declined rapidly between 1992 and 2003. But since 2006, there has been a resurgence, especially among younger persons who inject drugs.
Between 2006 and 2012, the agency received reports of 7,169 cases of acute hepatitis C. Nearly half of all cases in 2012 involved people aged 30 years and younger, versus only 36% of cases in 2006, the researchers report in Clinical Infectious Diseases, online August 11.
Thirty of 34 states and territories reporting to CDC reported higher incidence of acute HCV in 2012 compared to 2006 among young persons. Fifteen percent of these states had increases between 100% and 199%, and 50% had increases of at least 200%.
In this age group, the incidence of reported acute HCV infection increased 13% per year in non-urban counties and 5% per year in urban counties. The greatest year-to-year increase occurred from 2010 to 2011, when the increase was 38% in non-urban and 85% in urban counties.
Supplemental case follow-up of 1,202 cases in six jurisdictions revealed that 77% of those newly infected had used injected drugs (57% of these shared needles or syringes and 82% shared other drug preparation equipment).
Among those interviewed, 84% reported having ever used drugs, including marijuana (91%), alcohol (83%), prescription opioids (76%), powder cocaine (71%) and heroin (61%). For the 54% who used both heroin and prescription opioids, heroin use followed the use of prescription opioids by an average 2.4 years.
The researchers note that these reports "grossly underestimate HCV incidence in young persons for many reasons, but mainly because most acute infections are asymptomatic and cannot be detected."
"A comprehensive approach is needed to address the increases in HCV infection among young persons," they conclude. "The early abuse of prescription opioids presents an opportunity to mitigate high-risk behaviors. Possible interventions include provider education to reduce opioid misuse, treatment of drug abuse and addiction, national prescription opioid monitoring, and aggressive early education to mitigate evolution to injection drug use."
"Currently, CDC is supporting demonstration projects in two rural and Appalachian settings to conduct outreach to young people who inject drugs," Dr. Holmberg said. "Our goal is to better understand how to identify these at-risk youth, as well as how to test and appropriately treat them."
"While we've recently seen great advances in hepatitis C treatment, including the availability of new treatments, these new therapies only work if people receive them," Dr. Holmberg said. "The potential of these and other advances depends on our ability to get more people screened and into care."
"Testing, specifically, is the first critical step to stemming the toll of death and disease from hepatitis C in this nation," he added. "CDC recommends testing for those known to be at high risk, which includes anyone with a history of injection drug use (other key hepatitis C testing recommendations can be found at http://1.usa.gov/1B8Zj9d). "
Dr. Brian R. Edlin and Emily Winkelstein from the National Development and Research Institutes in New York, who were not involved in the study, recently published an article on the question of whether hepatitis C can be eradicated in the U.S.
"We're at a watershed in this disease now, with the opportunity to end the hepatitis C epidemic within our grasp, but there's a lot that needs to be done to take advantage of the opportunity," Dr. Edlin told Reuters Health by email. "A potentially fatal, lifelong blood-borne viral disease has gone from incurable to curable, which is a historic event in the history of medicine. But the way things are going, it will just move into the forgotten sectors of society, stay there, and continue to spread, until we make a concerted effort to eradicate it."
"Primary care doctors have a terrific opportunity," Dr. Edlin said. "They see patients before they wind up in the emergency room, or jail, or the morgue. Even better, they can organize outreach to young people at risk. Work with the health department, the police, churches and social services to reach out to young people at risk. As doctors, they have a special credibility that others don't. Express concern. Teach. Counsel. Test. And treat."
Winkelstein added, "While I am not a physician, I have heard countless stories from young people who use drugs who have been treated poorly once drug use is discovered or disclosed. More often than not, young people report that physicians shift their dialogue entirely from whatever brought the young person to the physician to a lecture about cessation of all drug use. As a result, young people either stop seeking medical care or don't disclose important health information to in order to avoid backlash."
"Physicians need to find a way to challenge drug-related stigma rather than reinforce it," Winkelstein said. "They must find ways to treat young people with compassion and empathy regardless of their choices around drug use, and seize the opportunity to build trust, provide meaningful education about ways to reduce their risk of getting or transmitting HCV and treat people who are already infected regardless of ongoing use. Physicians can use treatment as a way to continue engagement with young people and prevent reinfection."
Dr. Benjamin P. Linas from Boston University School of Public Health argued that it will be difficult for doctors to have a big impact because young drug users rarely go to the doctor.
"To really stop this spread of infection, we need to focus on substance abuse treatment," he told Reuters Health by email.
"There is a great deal of discussion about the new HCV meds and how we may be able to use them to eradicate HCV," said Dr. Linas, who was not involved in the study. "Maybe we can -- but treatment as prevention cannot work if kids are relapsing to injection drug use and becoming reinfected."
He added, "As a public health/medical community, we need to expand our thinking about HCV beyond the 'boomers.' It was important and appropriate to begin with the recommendation to screen the birth cohort, but it's time to move to the next phase and realize that if we want to really stop new infections, we need to do the very hard work of identifying and engaging HCV-infected active drug users in care, help them stop their drug use, and treat their HCV."
Clin Infect Dis 2014.