Data supporting updating estimates of the prevalence of chronic hepatitis B and C in the United States

T he current estimates of chronic hepatitis B (CHB) and chronic hepatitis C (CHC) prevalence that are widely used by the press and cited in many publications and presentations are 805,0001,405,000 persons with CHB (prevalence 0.8%-1.2%) and 2.7 million (confidence interval 2.2 million-3.2 million) with CHC (prevalence 0.3%-0.5%). Although these figures accurately represent findings from national prevalence studies, we believe that because of underrepresented or excluded populations they should be revised upward to increase public awareness about viral hepatitis and to support increasing funding for both the National Institutes of Health’s viral hepatitis research and the Centers for Disease Control and Prevention’s (CDC’s) Division of Viral Hepatitis, which has by far the smallest budget in the National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention. The CHC estimate is based entirely and the CHB estimate in large part (with some adjustments) on data from the National Health and Nutrition Examination Survey (NHANES), which the CDC is careful to point out excludes some populations with increased infection risk, including the incarcerated, the homeless, and institutionalized persons, and does not adequately represent multiple racial/ethnic groups with higher infection rates, including Native Americans, Alaskan Natives, and Asians and Pacific Islanders. Using the same approach the CDC uses to estimate CHB prevalence in the foreign-born, a meta-analysis of hepatitis B surface antigen seroprevalence rates in 102 countries multiplied country-specific CHB prevalence rates by the number of foreign-born in the United States by country of birth. This study estimated 1.32 million foreign-born persons with CHB and, adding the current prevalence estimates for the general population and institutionalized persons, a total CHB population of up to 2.2 million. A similar estimate of 2.09 million was calculated by Hepatitis B Foundation researchers, using NHANES and 2005 census data, with an estimated additional 100,000 CHB persons among undocumented Asians and Pacific Islanders. The current CHB estimate for institutionalized persons, which includes residents both of correctional settings (2.0% estimated prevalence) and of other group living quarters, and the homeless (0.5%) may be too low. US incarcerated population prevalence estimates range from 0.9% in Tennessee to 8.7% in Maryland. The current 2.0% estimate considered only five peer-reviewed studies reporting 0.9%-3.1% prevalence rates. Because 20% of state and 13% of federal inmates are injection drug users, CHB prevalence is likely much higher. Similarly, prevalence in the homeless may be much higher than 0.5%. An estimated 24.2% of those in homeless shelters are current or former injection drug users. One study found that 32.5% of homeless persons with mental illness and substance use disorders were positive for antibody to hepatitis B core antigen and 29.8% were anti– hepatitis C virus–positive (HCV). Taking all of this into consideration, we believe that the 2012 estimate of 2.2 million US CHB persons may be the most accurate. In the NHANES-based study that provides the CHC prevalence estimate that is currently most often used by the press and cited in many journal publications and conference presentations, the CDC researchers state, “A major limitation of NHANES is that it does not include Abbreviation: CDC, Centers for Disease Control and Prevention; CHB, chronic hepatitis B; CHC, chronic hepatitis C; HBV, hepatitis B virus; HCV, hepatitis C virus; NHANES, National Health and Nutrition Examination Survey. Received January 23, 2015; accepted July 30, 2015. Address reprint requests to: Robert Gish, M.D., 6022 La Jolla Mesa Drive, San Diego, CA 92037. E-mail: rgish@robertgish.com; tel: 11-858-229-9865; fax: 11-858-886-7093. Copyright VC 2015 The Authors. HEPATOLOGY published by Wiley Periodicals, Inc., on behalf of American Association for the Study of Liver Diseases. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made. View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.28026 Potential conflict of interest: Dr. T. Block is employed by and owns stock in Contravir. He consults, advises, and holds intellectual property rights with OnCore-Tekmira. Dr. J. Block consults for Arrowhead. Dr. Brosgart consults, owns stock in, and is on the board of directors for Tobira. She consults, owns stock in, and is on the scientific advisory board for Contravir. She consults for Dynavax. Dr. Cohen advises Gilead. Dr. Sandt advises and received grants from Gilead, Bristol-Myers Squibb, Merck, Genentech, AbbVie, AbbVie Foundation, and Janssen. Dr. Gish consults, advises, and is on the speakers’ bureau for Gilead, AbbVie, and Merck. Dr. Kowdley consults, advises, and received grants from Gilead. He consults for AbbVie and advises Achillion, BristolMyers Squibb, and Merck.