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CDC: [HBV Epidemic/IDUs] Increases in Acute Hepatitis B Virus Infections - Kentucky, Tennessee, and West Virginia, 2006-2013
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"A hepatitis B epidemic is emerging in Kentucky, Tennessee, and West Virginia. The increase in incident HBV-infections might contribute to future increases in liver-related morbidity and mortality. Evidence-based prevention strategies, including increasing hepatitis B vaccination coverage, testing and linkage to care activities, and education campaigns targeting persons who inject drugs are urgently needed."
"acute HBV infection increased 114% in these three states......Population-based surveillance data from Kentucky, Tennessee, and West Virginia indicate a 114% increase in acute HBV infection during 2006-2013; this increase occurred after 2009, among whites, aged 30-39 years who reported injection drug use. In an analysis of 6 years of enhanced surveillance data for hepatitis B, Tennessee reported similar findings, including a large increase among white adults, with both injection and noninjection drug use as a commonly reported risk factor during 2006-2011 (7).....The concurrent increase in reports of acute HBV and HCV infections, as well as an increase in injection drug use reported among this population is concerning.....A concomitant increase in the number of substance abuse treatment admissions for opioid dependency in Appalachian states during 2006-2013 was also observed: admissions for prescription opioid and heroin abuse increased among young adults by 17.1% and 7.4%, respectively (6). In 2015, a rural county in Indiana was the site of a large outbreak of HIV infection and HCV infection among young (median age = 32 years) injection drug users (8).....hepatitis B vaccination coverage is low among adults in the general population (4), and it is likely to be lower among injection drug users"
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CDC: Increases in Acute Hepatitis B Virus Infections - Kentucky, Tennessee, and West Virginia, 2006-2013
MMWR Weekly Jan 29 2016
http://www.cdc.gov/mmwr/volumes/65/wr/mm6503a2.htm?s_cid=mm6503a2_e
As many as 2.2 million persons in the United States are chronically infected with hepatitis B virus (HBV) (1), and approximately 15%-25% of persons with chronic HBV infection will die prematurely from cirrhosis or liver cancer (2). Since 2006, the overall U.S. incidence of acute HBV infection has remained stable; the rate in 2013 was 1.0 case per 100,000 persons (3). Hepatitis B vaccination is highly effective in preventing HBV infection and is recommended for all infants (beginning at birth), all adolescents, and adults at risk for HBV infection (e.g., persons who inject drugs, men who have sexual contact with men, persons infected with human immunodeficiency virus [HIV], and others). Hepatitis B vaccination coverage is low among adults: 2013 National Health Interview Survey data indicated that coverage with ≥3 doses of hepatitis B vaccine was 32.6% for adults aged 19-49 years (4). Injection drug use is a risk factor for both hepatitis C virus (HCV) and HBV. Among young adults in some rural U.S. communities, an increased incidence of HCV infection has been associated with a concurrent increase of injection drug use (5); and recent data indicate an increase of acute HCV infection in the Appalachian region associated with injection drug use (6). Using data from the National Notifiable Diseases Surveillance System (NNDSS) during 2006-2013, CDC assessed the incidence of acute HBV infection in three of the four Appalachian states (Kentucky, Tennessee, and West Virginia) included in the HCV infection study (6). Similar to the increase of HCV infections recently reported, an increase in incident cases of acute HBV infection in these three states has occurred among non-Hispanic whites (whites) aged 30-39 years who reported injection drug use as a common risk factor. Since 2009, cases of acute HBV infection have been reported from more non-urban than urban regions. Evidence-based services to prevent HBV infection are needed.
Data from confirmed cases of acute HBV infection reported to CDC from Kentucky, Tennessee, and West Virginia during 2006-2013, including demographic and risk characteristics, were obtained from NNDSS. These states used the CDC/Council of State and Territorial Epidemiologists case definition to identify cases of acute HBV infection.† Cases of acute HBV infection were categorized as "urban" if the infected person lived in a metropolitan county with a population ≥50,000 and as "non-urban" if the infected person lived in a nonmetropolitan county with a population <50,000.§ Data were analyzed by year of report and urban/non-urban county resident status to assess annual incidence (per 100,000 persons), demographic characteristics, and injection drug use in persons with reported acute HBV infections during 2006-2013. To calculate annual incidence, the number of cases reported through NNDSS was used as the numerator and midyear (July) population estimates from the U.S. Census Bureau were used as the denominator. Statistical significance of a monotonic trend in annual incidence of acute HBV infection by urban/non-urban status was tested with the Spearman rank correlation test. A 20% increase in incident HBV infections was observed from 2009 to 2010; therefore, the data are presented for two reporting time periods: 2006-2009 and 2010-2013. Chi-square tests were used to determine whether cases reported during the two time periods differed significantly by demographic characteristics and reported injection drug use. Statistical significance was defined as p<0.05.
During 2006-2013, a total of 3,305 cases of acute HBV infection were reported to CDC from Kentucky, Tennessee, and West Virginia. During 2009-2013, incidence of acute HBV infection increased 114% in these three states, but remained stable in the United States overall (Figure 1). Comparing the number of cases of acute HBV infection reported during 2006-2009 and 2010-2013, the proportion of cases among whites and persons aged 30-39 years increased during 2010-2013 (Table). Among cases in which at least one risk factor was reported, the proportion of persons reporting injection drug use as a risk factor was significantly greater in 2010-2013, compared with 2006-2009 (75% versus 53%; p<0.001).
Among 3,185 of 3,305 (96%) total cases where urban and non-urban classification for HBV-infected persons could be determined, 1,344 (42%) were classified as residing in non-urban counties. During 2006-2013, the incidence of acute HBV infections from both urban and non-urban counties increased, but the increase was statistically significant only among cases occurring in non-urban counties (Figure 2) (p-value for trend <0.001).
Discussion
Population-based surveillance data from Kentucky, Tennessee, and West Virginia indicate a 114% increase in acute HBV infection during 2006-2013; this increase occurred after 2009, among whites, aged 30-39 years who reported injection drug use. In an analysis of 6 years of enhanced surveillance data for hepatitis B, Tennessee reported similar findings, including a large increase among white adults, with both injection and noninjection drug use as a commonly reported risk factor during 2006-2011 (7).
Forty-two percent of cases of acute HBV infection in this report occurred among persons residing in non-urban counties, which is where the largest increases in incidence of acute HBV infection occurred. A similar increase of acute HCV infections occurred among young adults residing in non-urban areas in Kentucky, Tennessee, Virginia, and West Virginia (6). The concurrent increase in reports of acute HBV and HCV infections, as well as an increase in injection drug use reported among this population is concerning. Together, the increase in cases of acute HBV infection among persons who reported injection drug use and the typically low hepatitis B vaccination coverage among young adults are likely contributing to the increase in acute HBV infection incidence in Kentucky, Tennessee, and West Virginia. A concomitant increase in the number of substance abuse treatment admissions for opioid dependency in Appalachian states during 2006-2013 was also observed: admissions for prescription opioid and heroin abuse increased among young adults by 17.1% and 7.4%, respectively (6). In 2015, a rural county in Indiana was the site of a large outbreak of HIV infection and HCV infection among young (median age = 32 years) injection drug users (8).
Hepatitis B vaccination is recommended as primary prevention for adults who are at increased risk for HBV infection, including injection drug users who were not previously infected (9). Data from the National Health Interview Survey indicate that hepatitis B vaccination coverage is low among adults in the general population (4), and it is likely to be lower among injection drug users. Routine hepatitis B vaccination has been recommended for infants since 1991 and for children aged ≤18 years since 1999; thus, adults aged ≥33 years in 2013 would be too old to have benefited from routine hepatitis B vaccination recommendations, and would be susceptible to HBV infection.
In response to this increase in acute HBV infections, state health officials are employing various prevention strategies. Since 2012, Tennessee has partnered with county jails to increase hepatitis B vaccination coverage among incarcerated persons. West Virginia has collaborated with addiction centers and harm reduction services to provide viral hepatitis prevention trainings. West Virginia is establishing an adult hepatitis B vaccination pilot project in the 17 counties with the highest incidence of acute HBV infection. To enhance viral hepatitis surveillance in Kentucky, reporting of HBV infection among pregnant women and children aged <5 years, in addition to all acute HBV infection cases, is mandatory. Kentucky has also increased hepatitis B awareness campaigns through annual statewide hepatitis conferences, health care provider education, and legislative amendments allowing syringe exchange programs.
The National Viral Hepatitis Action Plan recommends full vaccination of adolescents, as well as ensuring that injection drug users have access to viral hepatitis prevention, care, and treatment services (10). This can be accomplished by mobilizing community resources to identify persons at risk, increase hepatitis B vaccination coverage among all adolescents and adult injection drug users, screen and test for HBV, HCV, and HIV infections, and link persons with viral hepatitis to care. A goal for hepatitis B elimination is vaccination of all vulnerable youth and adults; thus, the delivery of hepatitis prevention and care should be expanded to include correctional facilities and abuse treatment centers.
The findings in this report are subject to at least five limitations. First, NNDSS is a passive surveillance system, and therefore, unreported cases might have been missed. Second, the current case definition for acute HBV infection captures only symptomatic persons and excludes persons with asymptomatic HBV infection, and therefore might result in underreporting of total acute HBV cases. Third, acute HBV infection case reports typically originate from past or present medical care; thus, certain populations at high risk (e.g., persons who are incarcerated, homeless, and uninsured) with limited access to care could potentially be underrepresented. Fourth, increased reporting and changes in testing practices might have contributed to the increase in HBV incidence observed in the three Appalachian states in this report. However, an upward trend in incidence was not seen in other areas of the country, and began before the release of the CDC HCV testing recommendations that might have affected HBV testing and reporting. Finally, risk factor data, including injection drug use, were not available for all reported cases.
A hepatitis B epidemic is emerging in Kentucky, Tennessee, and West Virginia. The increase in incident HBV-infections might contribute to future increases in liver-related morbidity and mortality. Evidence-based prevention strategies, including increasing hepatitis B vaccination coverage, testing and linkage to care activities, and education campaigns targeting persons who inject drugs are urgently needed.
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Drug abuse fuels steep rise in hepatitis B in Appalachia, study shows
LOUISVILLE - Three Appalachian states have seen a huge surge in the potentially-serious liver infection hepatitis B, driven by the relentless scourge of injection drug abuse in the region, a new study says.
The research, released by the U.S. Centers for Disease Control and Prevention on Thursday, found that acute hepatitis B rose 114% in Kentucky, Tennessee and West Virginia from 2009-2013, even as incidence remained stable nationally. Injection drugs were factor in three-quarters of cases in those states from 2010 onward.
"I wish I could say this is a surprise, but it's not," says Van Ingram, executive director of the Kentucky Office of Drug Control Policy. "All of the blood-borne pathogens are a concern because of how they spread...Nine in 10 people who abuse prescription pills or heroin are injecting them intravenously, and many are using dirty needles."
Hepatitis B spreads when someone comes in contact with blood, semen or other bodily fluids from an infected person. For some patients, it's a short-term illness, but others develop long-term, chronic infections. About 2.2 million Americans live with chronic hepatitis B, which can lead to cirrhosis or liver cancer.
Unlike hepatitis C, which is caused by a similar virus and can be spread in similar ways, hepatitis B can be prevented with a vaccine, which is recommended for infants at birth, people with multiple sex partners and injection drug users, among others. But federal surveys show that hepatitis B vaccination coverage is low among adults nationally.
Researchers say they fear the rising hepatitis B cases in Appalachia could foreshadow a larger, national problem. Drug overdose is the leading cause of accidental death in the United States, federal statistics show, with more than 47,000 drug overdose deaths in 2014, about 19,000 linked to prescription pain pills and 10,600 tied to heroin.
Researchers also point to a large outbreak of HIV, the virus that causes AIDS, in the rural southeastern Indiana county of Scott last year. With 185 cases, it was Indiana's worst-ever HIV outbreak, fueled mostly by addicts shooting up the powerful painkiller Opana. Health officials say it's essential to work on preventing blood-borne diseases among addicts in hard-hit states and across the nation.
"The increase in (hepatitis B infections in Appalachia) has the potential to impede the nation's hepatitis B elimination strategy," researchers wrote in Thursday's study, adding that better vaccination coverage, testing for the disease, and educational campaigns targeting addicts "are urgently needed."
States in the study have been trying to prevent further spread of the disease. Tennessee has partnered with county jails since 2012 to increase hepatitis B vaccination among inmates. West Virginia has collaborated with addiction centers on hepatitis prevention training and is establishing a pilot hepatitis B vaccination project in the 17 counties with the highest incidence. And Kentucky has boosted awareness campaigns and education for health care providers.
In addition, Kentucky's legislature last year passed a law giving local communities the authority to institute needle exchange programs, which Ingram called an important weapon in the fight against hepatitis B and C and HIV. Louisville and Lexington have already started exchanges, and Ingram says they've been approved in three counties in other parts of the state.
Health officials also expect to see more programs nationally, since Congress effectively lifted the nation's long-standing ban on federal funding for needle exchange programs. Though the funds still can't be used for syringes themselves, they can go toward the costlier expenses associated with these programs, such as staff, vans, and substance abuse counseling.
"These programs do more than just give out needles," Ingram says.
Needle exchanges are also operating in West Virginia, which State Health Officer Rahul Gupta says are part of a larger strategy to tackle addiction and disease prevention in his state. That strategy includes, among other things, boosting surveillance, providing hepatitis B vaccine to household contacts of people infected with the virus, and targeting high risk residents in places they are likely to visit, such as substance abuse treatment centers.
"This is something we have been focusing on at all levels..." Gupta says. "We certainly are very hopeful that the comprehensiveness of our approach will now help us get a handle on this."
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