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Association of Hepatitis C Virus With Alcohol Use
Among U.S. Adults: NHANES 2003-2010, CDC
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"HCV-infected adults were estimated to ever drink five or more drinks/day almost every day at some time during their lifetime about 3.3 times more often (43.8% vs 13.7%, p<0.001) than those who were never infected with HCV".....Public health HCV strategies should implement interventions with emphasis on alcohol abuse, which negatively impacts disease progression for HCV-infected individuals.....physicians are less inclined to offer treatments to patients if they have a history of alcohol use, despite being abstinent even a year before therapy.....People infected with HCV are often not aware of their infection status, and thus not aware of the medical risks associated with the consumption of alcohol or guidelines to educate them on reducing alcohol intake
Former drinkers and excessive current drinkers had the highest prevalence of HCV infection....Public health HCV strategies should implement interventions with emphasis on alcohol abuse, which negatively impacts disease progression for HCV-infected individuals......Clinical management guidelines for HCV-infected individuals include addressing alcohol use before initiating treatment for HCV. ........ However, physicians are less inclined to offer treatments to patients if they have a history of alcohol use, despite being abstinent even a year before therapy
Former drinkers and excessive current drinkers had a higher prevalence of HCV infection (2.2% and 1.5%, respectively) than never or non-excessive current drinkers (0.4% and 0.9%, respectively). HCV-infected adults were estimated to ever drink five or more drinks/day almost every day at some time during their lifetime about 3.3 times more often (43.8% vs 13.7%, p<0.001) than those who were never infected with HCV. Controlling for age, sex, race/ethnicity, education, and having a usual source of health care, HCV infection was significantly associated with excessive current drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6) and former drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6).
In summary, former and excessive current drinkers had the highest prevalence of chronic HCV infection. Higher prevalence of HCV infection among excessive current drinkers indicates a need for more-comprehensive approaches to primary, secondary, and tertiary care. People infected with HCV are often not aware of their infection status, and thus not aware of the medical risks associated with the consumption of alcohol or guidelines to educate them on reducing alcohol intake. The implementation of behavioral screenings to identify at-risk drinking among both HCV-infected and uninfected individuals could prevent alcohol abuse and serve as a platform to educate patients on the associated risks. Targeted strategies should emphasize testing to increase HCV awareness among undiagnosed people and decrease disease progression among the infected. Findings suggest that many excessive current drinkers did not have a usual source of medical care and or health insurance. Public health actions against alcohol abuse, therefore, should also be available outside of clinical settings and targeted to both those with and without HCV infection.
Former and excessive current drinkers had a higher estimated prevalence of HCV infection. Specifically, adults with chronic infection were estimated to be former drinkers about 1.7 times more often (31.0%, 95% CI=25.1, 37.6) than those never infected with HCV (17.0%, 95% CI=15.7, 18.3, p<0.001). Among current drinkers, HCV-infected adults were estimated to be excessive current drinkers about 1.3 times more often (54.9%, 95% CI=43.2, 66.0) compared with those not infected (41.4%, 95% CI=40.0, 42.8, p<0.05). In addition, those with chronic infection were estimated to have consumed five or more drinks/day every day or almost every day at some time(s) during their life (43.8%, 95% CI=36.3, 51.6) about 3.3 times more often than those not infected (13.7%, 95% CI=13.0, 14.5, p<0.001). Based on these differences, two separate outcomes were investigated: excessive versus non-excessive current drinking and former versus current drinking......In simple logistic models, excessive current drinking was significantly more likely among those who were HCV-infected, younger, male, with no usual source of medical care or no health insurance, with no education above high school, and with income below twice the poverty level. .....In the final multivariate model, HCV infection was still significantly associated with excessive current drinking; only health insurance and poverty did not retain significant associations."
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Article in Press
Association of Hepatitis C Virus With Alcohol Use Among U.S. Adults: NHANES 2003-2010
American Jnl of Preventive Medicine May 10 2016
Amber L. Taylor, MPH,1 Maxine M. Denniston, MSPH,1 R. Monina Klevens, DDS, MPH,1
Lela R. McKnight-Eily, PhD,2 Ruth B. Jiles, PhD, MS, MPH1
From the 1Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; and 2Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Introduction
Excessive alcohol use exacerbates morbidity and mortality among hepatitis C virus (HCV)-infected people. The purpose of this study was to describe self-reported patterns of alcohol use and examine the association with HCV infection and other sociodemographic and health-related factors.
Methods
Data from 20,042 participants in the 2003-2010 National Health and Nutrition Examination Survey were analyzed in 2014. Estimates were derived for self-reported demographic characteristics, HCV-RNA (indicative of current HCV infection) status, and alcohol use at four levels: lifetime abstainers, former drinkers, non-excessive current drinkers, and excessive current drinkers.
Results
Former drinkers and excessive current drinkers had a higher prevalence of HCV infection (2.2% and 1.5%, respectively) than never or non-excessive current drinkers (0.4% and 0.9%, respectively). HCV-infected adults were estimated to ever drink five or more drinks/day almost every day at some time during their lifetime about 3.3 times more often (43.8% vs 13.7%, p<0.001) than those who were never infected with HCV. Controlling for age, sex, race/ethnicity, education, and having a usual source of health care, HCV infection was significantly associated with excessive current drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6) and former drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6).
Conclusions
Chronic HCV infection is associated with both former and excessive current drinking. Public health HCV strategies should implement interventions with emphasis on alcohol abuse, which negatively impacts disease progression for HCV-infected individuals.
Measures
Main outcome was pattern of alcohol use. Analyses were restricted to participants aged ≥20 years because public use files do not include alcohol data on those aged <20 years. Responses to questions on amount and frequency of alcohol consumption were used to create four mutually exclusive levels of alcohol use, adapted from the classification by Tsai et al.17 Lifetime abstainers reported <12 drinks ever. Former drinkers reported ≥12 drinks in their lifetime but none in the past year. Non-excessive current drinkers, on average, reported ≤14 drinks/week for men or, on average, seven or fewer drinks/week for women, and never five or more drinks/day in a single day during the past year for either.
Excessive current drinkers, on average, reported >14 drinks/week for men or, on average, more than seven drinks/week for women, or five or more drinks/day in a single day at least once during the past year for either. HCV-RNA status was determined from laboratory testing of participant blood specimens. Specimens were tested by CDC's Division of Viral Hepatitis Laboratory, first for HCV antibody (anti-HCV) using a qualitative screening test. Repeatedly reactive specimens were then tested using a confirmatory recombinant immunoblot assay. Samples with positive or indeterminate assay results were tested for HCV-RNA. Details on laboratory testing are available from CDC.18 Participants were classified as chronically HCV infected if their recombinant immunoblot assay test for anti-HCV was positive or indeterminate and their test for HCV-RNA was positive and as never HCV infected if they were anti-HCV-negative. Those who were anti-HCV-positive or indeterminate but RNA-negative (resolved infections) were not included in the analysis because of the small size of this group (n=90).
Several HCV- and alcohol-relevant factors were evaluated, including access to care (have a usual source of medical care) and having health insurance. Other independent categorical variables included in analyses were age, sex, race/ethnicity, poverty status, and education level. The poverty index ratio was categorized for analysis into below poverty (<1.0), near poverty (1.0-1.9), or above poverty (≥2.0).19
Discussion
Patterns of alcohol use were estimated in a representative sample of the general U.S. population aged ≥20 years. The study examined whether selected sociodemographic and health-related factors, including HCV infection, were associated with alcohol drinking patterns. Former drinkers and excessive current drinkers had the highest prevalence of HCV infection. Controlling for other factors, HCV infection remained significantly associated with both excessive current drinking and former drinking. Former drinkers were significantly more likely to be non-Hispanic black, with chronic HCV infection, high school education or less, and income less than twice the poverty level. Additionally, former drinkers were significantly less likely among those of younger age, male sex, and with no usual source of medical care. Excessive current drinkers were significantly more likely among those of younger age, male sex, high school education or less, and with no usual source of medical care and significantly less likely among non-Hispanic blacks.
Former drinkers were older with a usual source of medical care or health insurance and perhaps more likely to have had their infection progress to a point where they sought medical care, received an HCV diagnosis, and were advised to stop drinking. Excessive current drinkers being younger and with perhaps less disease progression and being less likely to have a usual source of medical care or health insurance may have been also less likely to have been diagnosed and advised to stop drinking. Morbidity and mortality among people with chronic HCV infection is exacerbated by excessive alcohol use, which accelerates fibrosis.12, 20 Those with HCV who are hospitalized for alcohol-related complications have a 24% longer length of stay and are twice as likely to die during the hospitalization.21 Clinical management guidelines for HCV-infected individuals include addressing alcohol use before initiating treatment for HCV.22 This is important, given that the latest generation of HCV treatments has expanded viral genetic targets of therapy. When used in combination as all-oral therapies or together with pegylated interferon and ribavirin, an estimated 90% of treated patients achieved cure after 12-24 weeks of therapy.23 However, physicians are less inclined to offer treatments to patients if they have a history of alcohol use, despite being abstinent even a year before therapy.24 There are challenges to HCV infection treatment, particularly the lack of infrastructure in prevention strategies and the lack of awareness of effective therapies.25 Although abstinence from alcohol is preferred, it may not be realistic or necessary for physicans to expect of HCV-infected people.26 One option is to use the 2010 U.S. Dietary Guidelines for Americans, which recommend that women consume one or fewer drink/day and men consume two or fewer drinks/day.27
A follow-up survey of people with positive anti-HCV test results during NHANES 2001-2008 found that 50.3% were unaware of their HCV status before being notified of their positive test by NHANES and that lack of health insurance was associated with being unaware of their infection.28 Of those who had visited a healthcare professional regarding their first positive anti-HCV test and had been told they needed regular medical follow-up, nearly 88% reported they had been advised to avoid or limit alcoholic beverages. However, their self-reported drinking, on average, one or more drink/day during the past 12 months, did not differ from those who said they had not been told to avoid or limit alcohol (49.1% vs 50.0%).28 This highlights the need for health professionals to offer comprehensive and effective interventions targeting alcohol use/abuse for HCV-infected individuals.
Integrated hepatology care systems that offer access to mental health clinicians and patient-aligned care teams would be an ideal setting for such interventions.29
Excessive alcohol use is a preventable medical and social problem that may be reduced through behavior modification. To reduce alcohol misuse, the U.S. Preventive Services Task Force recommended alcohol screenings and brief behavioral counseling interventions in primary care settings for adults.30 The Task Force found that behavioral counseling could reduce total number of drinks/week, episodes of binge or heavy episodic drinking, and increase adherence to drinking guidelines at 6-12 months of follow-up. There is evidence that brief counseling with follow-up and external support can be effective in controlling alcohol use among people with HCV infection.29 Motivational Enhancement Therapy has been found to increase abstinence among chronic HCV patients who currently drink and suffer from alcohol use disorders.29
Excessive current drinkers were younger and less likely to have insurance or a usual source of care, suggesting a need for targeted alcohol prevention beyond healthcare settings. The Community Preventive Services Task Force Guide reviewed evidence-based strategies to prevent excessive alcohol consumption, and recommended strategies that include but are not limited to increasing alcohol taxes, regulation of alcohol outlet density, and maintaining limits on days of sale.30
Limitations
There were limitations to this study. NHANES data are generalizable to the non-institutionalized civilian population of the U.S. and exclude the homeless and those living in correctional institutions (among whom injection drug use and HCV infection are higher than in the general population) and other group settings (e.g., student dormitories, military recruits). It was estimated that these marginalized groups account for almost 1 million HCV-infected people.31 Furthermore, an estimated 50%-90% of people who inject drugs have anti-HCV, depending on the duration of their use.32, 33 Injection drug users are stigmatized and often decline to answer questions related to health behaviors or undergo phlebotomy procedures.31 If this group were also to be identified in household surveys, there could be an increase of more than 1 million Americans identified with HCV infection.31 Possible impact of these exclusions on the association between alcohol use and HCV infection could not be assessed. Importantly, temporal sequence cannot be determined between HCV infection and drinking patterns using cross-sectional data. In addition, alcohol use was self-reported and therefore subject to response and recall bias. Finally, data are not available on average lifetime alcohol consumption or duration of drinking, so these factors could not be evaluated.
Conclusions
In summary, former and excessive current drinkers had the highest prevalence of chronic HCV infection. Higher prevalence of HCV infection among excessive current drinkers indicates a need for more-comprehensive approaches to primary, secondary, and tertiary care. People infected with HCV are often not aware of their infection status, and thus not aware of the medical risks associated with the consumption of alcohol or guidelines to educate them on reducing alcohol intake. The implementation of behavioral screenings to identify at-risk drinking among both HCV-infected and uninfected individuals could prevent alcohol abuse and serve as a platform to educate patients on the associated risks. Targeted strategies should emphasize testing to increase HCV awareness among undiagnosed people and decrease disease progression among the infected. Findings suggest that many excessive current drinkers did not have a usual source of medical care and or health insurance. Public health actions against alcohol abuse, therefore, should also be available outside of clinical settings and targeted to both those with and without HCV infection.
Introduction
Excessive alcohol consumption causes an estimated 88,000 deaths/year and $223.5 billion in economic costs in the U.S.1 It has caused 2.5 million years of potential life lost each year in the U.S. from 2006 to 2010. Among those who died, excessive alcohol use shortened lives by an average of 30 years.2 There are an estimated 2.7 million people chronically infected with hepatitis C virus (HCV) and HCV infection is associated with 17,000 deaths in the U.S. each year.3, 4 However, owing to under-reporting of HCV deaths, it has been suggested that at least 80,000 HCV-infected people may have died in 2010.5 Complications associated with chronic HCV infection include cirrhosis and hepatocellular carcinoma, which are projected to increase substantially within the next decade and are leading causes for liver transplantation.6, 7, 8, 9, 10 Alcohol use has been identified as a primary predictor in the progression of those complications.11 Excessive alcohol use among individuals chronically infected with HCV was associated with an increased risk of all-cause and liver-related mortality compared with infected people without excessive alcohol use.12 In 2010, alcohol-related liver disease ranked third as a cause of death among people with hepatitis C.4
Highlighting the comorbidity of HCV infection and alcohol abuse, the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force recommendations for HCV testing of people born during 1945-1965 explicitly included screening for alcohol use among HCV antibody-positive individuals.13 Although alcohol use is a known factor in the progression of liver disease, there are few studies that have assessed the association between chronic HCV infection and patterns of alcohol use among U.S. adults using nationally representative data. Other studies have identified a significantly higher prevalence of HCV in liver cancer patients with alcoholic cirrhosis.14 A study examining patient reports of drinking among people with chronic HCV found that almost two thirds reported drinking more than once a week at diagnosis.15 The purpose of this study was to describe self-reported patterns of alcohol use and examine the association with HCV infection and other sociodemographic and health-related factors.
Results
Of the 30,114 people aged ≥20 years sampled for NHANES 2003-2010, there were 22,173 (73.6%) interviewed and 21,281 (96.0% of those interviewed) examined. Serum samples were available for anti-HCV testing for 20,042 (94.2%) of the examined participants. Of the 456 who were anti-HCV-positive (n=381) or indeterminate (n=75), 395 (86.6%) had additional serum available for HCV-RNA testing; 271 were RNA-positive (estimated RNA prevalence, 1.3%; 95% CI=1.1, 1.5). Of the 271 currently HCV-infected participants, 244 provided sufficient information on alcohol consumption for inclusion in the analysis.
Estimated population characteristics by self-reported alcohol use are shown in Table 1. Most U.S. adults were current drinkers, most frequently non-excessive (41.7%) drinkers. An estimated 17.2% were former drinkers and 11.3% were lifetime abstainers. Statistically significant differences were found for all characteristics investigated across the four categories of alcohol use. Excessive current drinkers were younger, whereas former drinkers or lifetime abstainers were older. Lifetime abstainers, former drinkers, and non-excessive current drinkers were more frequently female than male and excessive current drinkers were more frequently male than female. Differences were observed across patterns of alcohol consumption within all race/ethnicity groups. Excessive current drinkers had the lowest frequency of having a usual source of medical care or having health insurance. Current drinkers most frequently had income at or above poverty level and more than a high school education.
Former and excessive current drinkers had a higher estimated prevalence of HCV infection. Specifically, adults with chronic infection were estimated to be former drinkers about 1.7 times more often (31.0%, 95% CI=25.1, 37.6) than those never infected with HCV (17.0%, 95% CI=15.7, 18.3, p<0.001). Among current drinkers, HCV-infected adults were estimated to be excessive current drinkers about 1.3 times more often (54.9%, 95% CI=43.2, 66.0) compared with those not infected (41.4%, 95% CI=40.0, 42.8, p<0.05). In addition, those with chronic infection were estimated to have consumed five or more drinks/day every day or almost every day at some time(s) during their life (43.8%, 95% CI=36.3, 51.6) about 3.3 times more often than those not infected (13.7%, 95% CI=13.0, 14.5, p<0.001). Based on these differences, two separate outcomes were investigated: excessive versus non-excessive current drinking and former versus current drinking.
In simple logistic models, excessive current drinking was significantly more likely among those who were HCV-infected, younger, male, with no usual source of medical care or no health insurance, with no education above high school, and with income below twice the poverty level. Furthermore, excessive current drinking was significantly less likely among non-Hispanic blacks (Table 2). In the final multivariate model, HCV infection was still significantly associated with excessive current drinking; only health insurance and poverty did not retain significant associations (Table 2). When testing for collinearity, only removing the variable for HCV resulted in all condition indices being <30.0. Spearman correlations between the six independent variables in the final model ranged from 0.01064 to 0.21731; only three were >0.1 (0.14309, 0.14940, and 0.21731) and all correlations with the HCV status variable were <0.1.
Estimated characteristics of former and current (both non-excessive and excessive) drinkers are shown in Table 3. Former drinking was significantly more likely among those who were HCV-infected, older, female, of non-Hispanic black race/ethnicity, and with high school education or less. Additionally, former drinking was significantly more likely among those having a usual source of medical care or health insurance and an income less than twice the poverty level. In simple logistic models, being a former rather than a current drinker was significantly more likely among those who were HCV-infected, of non-Hispanic black race/ethnicity, and with high school education or less or income less than twice poverty level, and significantly less likely among those who were younger, male, and who had no health insurance or usual source of medical care (Table 4). In the final multivariate model, only health insurance coverage did not remain statistically associated with being a former drinker (Table 4). When testing for collinearity, only removing the variable for HCV status resulted in all condition indices being <30.0. Spearman correlations between the seven independent variables in the final model ranged from 0.00289 to 0.37306; six were >0.1 (0.10747, 0.11034, 0.13663, 0.15224, 0.23306, and 0.373106) and all correlations with the HCV status variable were <0.1.
Because Spearman correlations did not indicate high levels of correlation between independent variables in either of the final multivariate models, models presented in Table 2, Table 4 were believed to be statistically valid and not subject to problems with collinearity.
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