Risk factors for hepatitis C virus infection among patients receiving health care in a Department of Veterans Affairs hospital

Causes of death among U.S. Veterans with a prior nonfatal opioid overdose

BACKGROUND

For over a decade, there has been a surge in opioid-related morbidity and mortality among Veterans. To better understand the impact of the growing epidemic, it is important to identify the cause-specific mortality rates among Veterans with a prior nonfatal opioid overdose.

METHODS

We followed 8370 Veterans who received medical care for a nonfatal opioid overdose between 2011 through 2015.Mortality records were linked to clinical records from the Veterans Health Administration (VHA). We compared the mortality rates among those with a nonfatal opioid overdose to a 5 % stratified random sample of patients accessing services during the same time period. SMRs were calculated using age-adjusted cause-specific mortality rates for the l U.S. population obtained from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER).

RESULTS

The crude mortality for Veterans with a history of a nonfatal overdose was 370.6 per 10,000 person years. Those with a prior nonfatal overdose had a higher risk of substance-related mortality (aHR [adjusted Hazard Ratio] 5.0), including a higher risk of death from drugs (aHR 6.9) and alcohol (aHR 2.7). Similarly, cause-specific mortalities assessed between Veterans and the U.S. population, SMRs were also highest for deaths associated with substances (114.0).

CONCLUSION

Veterans with a prior nonfatal overdose experienced substantially higher mortality rates compared to other Veterans or the general U.S.

POPULATION

Causes of death related to substance use and mental health were significantly higher than other causes of death, highlighting the importance of integrated treatment and substance use services.

Provider Perceptions of Hepatitis C Treatment Adherence and Initiation

BACKGROUND

Significant disparities in hepatitis C (HCV) treatment existed in the interferon treatment era, such that patients with mental health and substance use disorders were less likely to be treated. We aimed to evaluate whether these perceptions continue to influence HCV treatment decisions.

METHODS

We e-mailed HCV providers a survey to assess their perceptions of barriers to HCV treatment adherence and initiation. We assessed the frequency of perceived barriers and willingness to initiate HCV treatment in patients with these barriers. We identified a group of providers more willing to treat patients with perceived barriers to adherence and determined the associated provider characteristics using Spearman's rho and Wilcoxon rank-sum tests.

RESULTS

A total of 103 providers (29%) responded to the survey. The most commonly endorsed perceived barriers to adherence were homelessness (65%), ongoing drug (58%), and ongoing alcohol use (33%). However, 90%, 68%, and 90% of providers were still willing to treat patients with these comorbidities, respectively. Ongoing drug use was the most common reason providers were never or rarely willing to initiate HCV treatment. Providers who were less willing to initiate treatment more frequently endorsed patient-related determinants of adherence, while providers who were more willing to initiate treatment more frequently endorsed provider-based barriers to adherence (e.g., communication).

CONCLUSIONS

Most responding providers were willing to initiate HCV treatment in all patients, despite the presence of perceived barriers to adherence or previous contraindications to interferon-based treatments. Ongoing substance use remains the most prominent influencer in the decision not to treat.

A scoping review of military veterans involved in the criminal justice system and their health and healthcare

BACKGROUND

In the criminal justice system, special populations, such as older adults or patients with infectious diseases, have been identified as particularly vulnerable to poor health outcomes. Military veterans involved in the criminal justice system are also a vulnerable population warranting attention because of their unique healthcare needs. This review aims to provide an overview of existing literature on justice-involved veterans' health and healthcare to identify research gaps and inform policy and practice.

METHODS

A systematic search was conducted to identify research articles related to justice-involved veterans' health and healthcare that were published prior to December 2017. Study characteristics including healthcare category, study design, sample size, and funding source were extracted and summarized with the aim of providing an overview of extant literature.

RESULTS

The search strategy initially identified 1830 unique abstracts with 1387 abstracts then excluded. Full-text review of 443 articles was conducted with 252 excluded. There were 191 articles included, most related to veterans' mental health (130/191, 68%) or homelessness (24/191, 13%). Most studies used an observational design (173/191, 91%).

CONCLUSIONS

Knowledge gaps identified from the review provide guidance on future areas of research. Studies on different sociodemographic groups, medical conditions, and the management of multiple conditions and psychosocial challenges are needed. Developing and testing interventions, especially randomized trials, to address justice-involved veterans care needs will help to improve their health and healthcare. Finally, an integrated conceptual framework that draws from diverse disciplines, such as criminology, health services, psychology, and implementation science is needed to inform research, policy and practice focused on justice-involved veterans.

Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015

The Veterans Health Administration (VHA) is the largest provider of hepatitis C virus (HCV) care nationally and provides health care to >200 000 homeless veterans each year. We used the VHA's Corporate Data Warehouse and HCV Clinical Case Registry to evaluate engagement in the HCV care cascade among homeless and nonhomeless veterans in VHA care in 2015. We estimated that, among 242 740 homeless veterans in care and 5 424 712 nonhomeless veterans in care, 144 964 (13.4%) and 188 156 (3.5%), respectively, had chronic HCV infection. Compared with nonhomeless veterans, homeless veterans were more likely to be diagnosed with chronic HCV infection and linked to HCV care but less likely to have received antiviral therapy despite comparable sustained virologic response rates. Homelessness should not necessarily preclude HCV treatment eligibility with available all-oral antiviral regimens.

Hepatitis C virus infection in USA: an estimate of true prevalence

The recent National Health and Nutrition Examination Survey (NHANES) sampled only the civilian, non-institutionalized population of USA and may have underestimated the prevalence of hepatitis C virus (HCV) in this country. We searched the database MEDLINE, the Bureau of Justice Statistics, Center for Medicare and Medicaid and individual states Department of Corrections for all epidemiological studies regarding the prevalence of HCV in populations not sampled by the NHANES survey namely the incarcerated, homeless, nursing home residents, hospitalized and those on active military duty. Because of their relatively low frequency in the NHANES sample, we also expanded our search to include healthcare workers and long-term dialysis patients. Although included in the NHANES sample, we also performed searches on drug users (injection and non-injection) and veterans to confirm the findings of the NHANES study. Based on the prevalence of studies identified meeting our inclusion criteria, our most conservative estimates state that there at least 142,761 homeless persons, 372,754 incarcerated persons and 6805 persons on active military duty unaccounted for in the NHANES survey. While the NHANES estimates of drug users (both injection and non-injection) appear to be reasonable, the survey seems to have underestimated the number of HCV-positive veterans. Our most conservative estimates suggest that there are at least 5.2 million persons living with HCV in USA today, approximately 1.9 million of whom were unaccounted for in the NHANES survey.

Development of the hepatitis C self-management program

OBJECTIVE

Chronic hepatitis C infection (HCV) is a major health problem that disproportionately affects people with limited resources. Many people with HCV are ineligible or refuse antiviral treatment, but less curative treatment options exist. These options include adhering to follow-up health visits, lifestyle changes, and avoiding hepatotoxins like alcohol. Herein, we describe a recently developed self-management program designed to assist HCV-infected patients with adherence and improve their health-related quality of life (HRQOL).

METHODS

The development of the Hepatitis C Self-Management Program (HCV-SMP) was informed by scientific literature, qualitative interviews with HCV-infected patients, self-management training, and feedback from HCV clinical experts.

RESULTS

The Hepatitis C Self-Management Program (HCV-SMP) is a multi-faceted program that employs cognitive-behavioral principles and is designed to provide HCV-infected people with knowledge and skills for improving their HRQOL. The program consists of six 2-h workshop sessions which are held weekly. The sessions consist of a variety of group activities, including disease-specific information dissemination, action planning, and problem-solving.

CONCLUSION

The intervention teaches skills for adhering to challenging treatment recommendations using a validated theoretical model. A randomized trial will test the efficacy of this novel HCV self-management program for improving HRQOL in a difficult to reach population.

The epidemiology of hepatitis C infection in the United States

BACKGROUND

The prevalence of hepatitis C virus (HCV) infection in the United States has remained constant from 1988 through 2002, although the peak age of infection has increased. While the number of new HCV cases is declining, the rates of HCV-associated morbidity and mortality are increasing. We reviewed the risk factors for HCV infection, the laboratory methods used to diagnose it, the dynamics of disease progression, and the natural history of HCV infection.

METHODS

Medline searches were performed using the key word HCV, together with incidence, risk factors, demographics, diagnostic methods, disease progression, natural history, normal alanine aminotransferase (ALT), fibrosis, and hepatocellular carcinoma (HCC).

RESULTS

Three characteristics-abnormal serum ALT, history of injection drug use, and blood transfusion before 1992-identified 85% of HCV-positive individuals 20-59 years old. About 75%-85% of acutely infected individuals progress to chronic infection, with up to 20% developing liver cirrhosis over 20-25 years, putting them at increased risk for end-stage liver disease and/or HCC. HCV-associated cirrhosis is the leading cause of liver transplantation in the United States. Rates of infection are higher in non-Hispanic blacks than in non-Hispanic whites and Mexican Americans and higher in men than in women. In the United States, over 70% of HCV-infected individuals are infected with genotype 1.

CONCLUSIONS

HCV infection is more prevalent than human immunodeficiency virus or hepatitis B virus infection and is particularly common among certain demographic groups. Individual rates of fibrosis progression vary, but identification of host and viral characteristics associated with disease progression may reveal the mechanisms of HCV-associated hepatic fibrosis/cirrhosis.

Hepatitis C in African Americans

Hepatitis C is one of the most common etiologies for chronic liver disease, cirrhosis, and hepatocellular carcinoma. The majority of liver transplants performed today are due to end stage liver disease induced by chronic hepatitis C. The prevalence of the disease is not the same across various races and a great epidemiologic disparity exists. Hepatitis C virus is more prevalent in the African American population with a higher rate of detectable viremia, predominance of genotype 1, and a higher viral load. Paradoxically the natural history of the disease and the progression to cirrhosis is less accelerated, although the development of hepatocellular carcinoma is more evident. African Americans in particular are resistant to antiviral regimens and the response to treatment with interferon monotherapy, a combination of interferon and ribavirin or pegylated interferon and ribavirin is significantly less. There are on going studies that determine the mechanisms in the lack of response in African Americans. An underrepresentation of African Americans in various study trials that are consequently on a list for a liver transplant have been noted and is postulated that the survival after liver transplantation is not equivalent to the one reported for other races, for unclear reasons.

Risk factors for hepatitis C fibrosis: a prospective study of United States veterans compared with nonveterans

Chronic hepatitis C virus (HCV) infection causes cirrhosis in many infected patients; however, a better understanding of the risk factors for fibrosis progression in high HCV prevalence groups such as US veterans is needed. We wished to compare the demographic, clinical characteristics, and independent variables that influence fibrosis in US veterans vs nonveterans with chronic HCV. HCV-seropositive US veterans (n = 459) and nonveterans (n = 395) prospectively completed a detailed medical, social and occupational questionnaire. Clinical factors for progressive liver disease were compared between veterans and nonveterans and fibrosis stage assessed on liver biopsies (168 veterans and 208 nonveterans). Using polychotomous logistic regression, fibrosis was analysed as both a progressive and categorical outcome to determine independent risk factors for both patient groups. Although veterans were significantly older and had higher lifetime alcohol consumption than nonveterans, their median fibrosis scores did not differ from nonveterans. By univariate analysis, alanine aminotransferase, necroinflammatory activity (NIA), and cryoglobulin positivity were associated with fibrosis in veterans and nonveterans (P < 0.05, all comparisons), whereas steatosis was associated with fibrosis only in nonveterans (P < 0.0001). By multivariate analysis, NIA was an independent risk factor for fibrosis in both groups (P < 0.01). However, fibrosis in nonveterans was also independently associated with steatosis, significant alcohol consumption and age (P < 0.04, all comparisons). Independent risk factors for fibrosis vary among high HCV prevalence groups such as veterans when compared with nonveterans. Understanding specific patient cohort effects is important for determining independent risk factors for disease progression in chronic HCV infection.

Relationship of cosmetic procedures and drug use to hepatitis C and hepatitis B virus infections in a low-risk population

We conducted an anonymous cross-sectional seroprevalence study of a population with a low frequency of injection drug use to determine whether persons with a history of cosmetic procedures, such as tattooing and body piercing, or intranasal drug use were at increased risk for hepatitis C virus (HCV) or hepatitis B virus (HBV) infection. Students 18 years and older from eight college campuses in Houston, Texas, were invited to participate in the study. Of the 7,960 who completed a self-administered questionnaire and provided a blood sample, 5,282 U.S.- or Canadian-born participants were analyzed. Their median age was 21, 62% were female, 42% were white, 26% black, 22% Hispanic, and 10% Asian or other. Two percent reported injection drug use, 13.7% intranasal drug use, 21.2% body piercings, and 25.2% tattoos. The overall prevalence of HCV infection was 0.9% and of HBV infection was 5.2%. Higher HCV prevalence was independently associated with increasing age (odds ratio [OR] per year = 1.11; 95% confidence interval [CI] = 1.08-1.14), history of injection drug use (OR = 18.24; 95% CI = 7.74-42.92), blood transfusion before 1991 (OR = 3.21; 95% CI = 1.02-10.12), and incarceration (OR = 3.48; 95% CI = 1.45-8.37). Among 5,066 students who denied injecting drugs, HCV prevalence was 0.8% in those who reported intranasal drug use and 0.6% each in those who reported tattoos and those who reported body piercing. Increased HBV prevalence was associated with high-risk sexual behaviors and black or Asian race. In conclusion, there was no increased risk for HCV or HBV infection in low-risk adults based solely on history of cosmetic procedures or snorting drugs. However, proper infection control practices for cosmetic procedures should be followed, illegal drug use discouraged, and hepatitis B vaccination provided to adolescents and sexually active adults.

Analysis of a hepatitis C screening programme for US veterans

This study analyses a screening programme for hepatitis C virus (HCV) infection among US veterans in a suburban Veterans Affairs Medical Center, in New York. This is the first study examining all 11 potential risk factors listed in the 2001 National U.S. Veterans Health Administration Screening Guidelines. A retrospective study was conducted of 5400 veterans 'at risk' of HCV, identified through a questionnaire in this institution's primary-care outpatient departments between 1 October 2001 and 31 December 2003. Multivariate logistic regression models were built to identify independent predictors of infection. Of 2282 veterans tested for HCV, 4.6% were confirmed by HCV PCR to be HCV infected. In the multivariate model developed, injection drug use, blood transfusion before 1992, service during the Vietnam era, tattoo, and a history of abnormal liver function tests were independent predictors of HCV infection. Our data support considering a more targeted screening approach that includes five of the 11 risk factors.

Outcome analysis of patients with squamous cell carcinoma of the head and neck and hepatitis C virus

OBJECTIVE/HYPOTHESIS

Infection with the hepatitis C virus (HCV) is a global problem with over 170 million people infected. Recently, we have noticed that a large number of patients diagnosed with squamous cell carcinoma of the head and neck (SCCHN) have also been diagnosed with HCV. A review of the literature reveals little information concerning this patient population. The objective of this study was to compare the outcome of SCCHN patients who have been exposed to HCV with naïve SCCHN patients.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review from June 1991 through December 2002 was performed to identify patients diagnosed with SCCHN who were screened for HCV. Patients were stratified into two groups (HCV positive and HCV negative). Data were recorded on patients for status of disease at last clinic visit, pretreatment serum albumin and hematocrit levels, and RNA quantities of HCV. Statistical analysis was performed using paired t test to compare serum albumin and hematocrit levels. Kaplan-Meier survival curves were used to compare outcomes. The log-rank test was used to determine significance. Cox regression was used to examine the association of prognostic predictor variables with overall survival and disease-free survival.

RESULTS

There was no difference noted in 5 year survival between hepatitis C positive and hepatitis C negative groups in overall outcomes (66.7% vs. 67.9%, P = 1.000) or 5 year disease-free survival (90.5% vs. 80.8%, P = .514). The two groups, HCV positive versus HCV negative, also had similar serum albumin levels (3.62 g/dL vs. 3.72 g/dL, P = .37) as well as serum hematocrit levels (42.9% vs. 41.0%, P = .12). Serum levels of hepatitis C RNA were obtained in seven patients, with only one being undetectable. The only prognostic predictor variable that was significantly associated with overall survival was age. None of the predictor variables were significantly associated with disease-free survival.

CONCLUSION

Co-infection with HCV, although prevalent in the Veterans Administration Hospital population, did not affect patient outcome as defined by disease-free survival. Patients who were seropositive for HCV had comparable serum albumin levels as well as serum hematocrit when compared with HCV negative patients.

Prospective multicenter study of eligibility for antiviral therapy among 4,084 U.S. veterans with chronic hepatitis C virus infection

BACKGROUND

Many veterans may not be candidates for hepatitis C virus (HCV) treatment due to contraindications to therapy. The aims of this study were to determine the proportion of HCV-infected veterans who were eligible for interferon alfa and ribavirin therapy and to evaluate barriers to HCV treatment.

METHODS

We prospectively enrolled 4,084 veterans who were referred for HCV treatment over a 1-yr period at 24 Veterans Affairs (VA) Medical Centers. Treatment candidacy was assessed using standardized criteria and the opinion of the treating clinician.

RESULTS

Overall, 32.2% (95% CI, 30.8-33.7%) were candidates for HCV treatment according to standardized criteria, whereas 40.7% (95% CI, 39.2-42.3%) were candidates in the opinion of the treating clinician. Multivariable analysis identified ongoing substance abuse (OR = 17.68; 95% CI, 12.24-25.53), comorbid medical disease (OR = 9.62; 95% CI, 6.85-13.50), psychiatric disease (OR = 9.45; 95% CI, 6.70-13.32), and advanced liver disease (OR = 8.43; 95% CI, 4.42-16.06) as the strongest predictors of not being a treatment candidate. Among patients who were considered treatment candidates, 76.2% (95% CI, 74.0-78.3%) agreed to be treated and multivariable analysis showed that persons >/=50 yr of age (OR = 1.37; 95% CI, 1.07-1.76) and those with >50 lifetime sexual partners (OR = 1.44; 95% CI, 1.08-1.93) were more likely to decline treatment.

CONCLUSIONS

The majority of veteran patients are not suitable candidates for HCV treatment because of substance abuse, psychiatric disease, and comorbid medical disease, and many who are candidates decline therapy. Multidisciplinary collaboration is needed to overcome barriers to HCV therapy in this population.

Chronic hepatitis C in African Americans

The prevalence of hepatitis C virus infection is higher in the African American population in comparison with Caucasians and Hispanics. The majority of African Americans are infected with genotype 1 and have a high viral load, but the rate of progression to cirrhosis is lower. After the development of cirrhosis, the chance of developing hepatocellular carcinoma is higher. African Americans have been under-represented in clinical trials, and the initial preliminary observations pointing toward a lower sustained virologic response with interferon monotherapy has been confirmed in larger studies. A lower response to antiviral therapy has been demonstrated in African Americans receiving combination interferon plus ribavirin and combination peginterferon plus ribavirin. The reasons for these differences in natural history and outcomes of therapy are not understood but are the subject of ongoing study.

Hepatitis C virus infection among prisoners in the California state correctional system

BACKGROUND

Incarcerated populations are at high risk for hepatitis C virus (HCV) infection, yet prisoners are not routinely screened or treated for HCV infection. Understanding the risk factors of HCV infection among prisoners could help improve HCV interventions.

METHODS

Prevalence and risk of HCV infection among 469 prisoners entering California State correctional facilities were assessed using HCV antibody screening, HCV RNA measurement, and structured interviews. Multivariate logistic regression analysis was used to identify independent correlates of HCV infection.

RESULTS

The prevalence of HCV infection was 34.3% overall (95% confidence interval [CI], 30%-38%) and was 65.7% among those with a history of injection drug use (IDU), compared with 10.2% among those with no history of IDU (odds ratio [OR], 17.24; 95% CI, 10.52-28.25). Significant differences in HCV antibody positivity were found in association with age at first detention but not with the nature of the crime. Independent correlates of HCV infection included age, history of IDU, cumulative time of incarceration, biological sex (OR for females subjects compared with males subjects, 0.35; 95% CI, 0.13-0.96), and a history of having sex with a male IDU (OR, 4.42; 95% CI, 1.46-13.37). We identified significant differences in risk factors between male and female subjects--notably, that the risk of HCV infection was significantly elevated among female non-IDUs who reported having sexual partners with a history of IDU. Among non-IDUs, correlates of HCV infection included history of receipt of blood products and cumulative years of incarceration.

CONCLUSIONS

HCV infection is pervasive among the California prison population, including prisoners who are non-IDUs and women with high-risk sexual behavior. These results should promote consideration of routine HCV antibody screening and behavioral interventions among incarcerated men and women.

Risk factors for HCV infection among blood donors confirmed to be positive for the presence of HCV RNA and not reactive for the presence of anti-HCV

BACKGROUND

In 1999, NAT of blood donations was implemented to detect "window-period" infections. Blood donors who have confirmed NAT results positive for the presence of HCV in the absence of anti-HCV are likely to have been recently infected. Of over 26.8 million donations tested between March 3, 1999, and March 31, 2003, 810 were HCV-reactive by NAT. A subset of these donors was assessed for recent exposure risk.

STUDY DESIGN AND METHODS

All anti-HCV- blood donors with reactive, unconfirmed HCV NAT results were invited to participate in a study that included an extensive demographic and risk questionnaire. Confirmed HCV+ cases were compared to HCV- (falsely positive) controls for histories of potential risk factors during the 6 months before donation.

RESULTS

Recent injection drug use (IDU) was independently associated with HCV infection (29.2% vs. 0% of cases vs. controls, p < 0.001). In addition, likely sources were identified for three other cases (4.6%), including occupational exposure, sexual contact with an HCV-infected partner (who was an IDU), and perinatal exposure, none of which was known to the donors at the time of donation. Incarceration was independently associated with HCV infection among the group not reporting IDU and after removal of the three donors with likely sources of risk (14.6% vs. 1.3% of cases vs. controls, p < 0.001).

CONCLUSIONS

A likely risk, primarily IDU, was found for 43 percent of HCV+ donors whose infections were identified solely by NAT. Because the maximum efficiency of the donor history questions may have been reached, NAT will continue to be an important measure to interdict recently infected blood donors.