Also known as HCV for short, the hepatitis C virus is considered one of the most prevalent sexually transmitted diseases in the USA. It is also associated with an elevated acute risk of liver cancer in an estimated 20-25% of infants exposed during neonatal weeks 3-19. With an estimated 35-45% in adults, HCV is much more common than HIV, but for various reasons, HCV often is not included as an STD in the CDC’s Medline database, despite presenting with similar symptoms. To map patient characteristics via patient visits, we conducted a review of hospital discharge diagnostic services records from January 1, 2011, to April 1, 2013 to identify patients with HCV identified by other “diagnoses” within general and surgery, as well as with specialty centers. The resulting map reveals the HCV demographic and clinical profiles of patients admitted to 22 Florida general hospitals, each with a 100,000 patient population from January 1, 2011 to March 31, 2013. HCV patients are identified by having core viralology positive, HCV antibody positive, and HCV RNA negative. HCV RNA’s are measured in plasma samples collected at discharge, typically before the patient has tested positive for HCV antibodies, or hepatitis C viremia is realized. HCV is statistically associated with spine and extremity complications; however, concentrating on the treatable conditions masks intimate risk out-groups, such as alcohol, HIV, and cigarette smoking. We present our maps in this blog two-fold: (1) top-level geographical clustering of patients, and (2) analysis of HCV demographics.
HCV is most common in HIV-positive and homosexual men in the USA. Among MSM, the age and race of morbidity are dramatically different. Blacks and Hispanic men are more likely to experience a full-blown hepatic failure. Among HEPI, the proportion of African Americans is 2 to 3 times their proportion in the general population.10 However, among Blacks and Hispanics, the proportion of HCV-positive patients is higher than for HEPI-positive patients. These contrasts are potentially important in terms of identifying pathways to care and understanding why certain groups of patients are more substantially affected. However, it is not known if HCV is differentially affected among the general population or among HEPI patients, with implications for the asking of questions or in the interpretation of laboratory results. Out-group surplus seems a plausible explanation since the HCV prevalence ratio is 2.5 in our population, while for HEPI’s HCV prevalence ratio is more than 3.
Even though HCV is found more commonly in HCV negative than HCV positive patients, disparities, especially among Blacks and Hispanics, are not fully understood. The same is true for HCV RNA. HCV RNA two months after hospital admission is negatively associated with cancers other than liver and other non-hepatic drug-related cancers, and positively associated with liver cancer. Although HCV underlying environmental fire or motor vehicle accidents may be protective, these accidents are more likely to be fatal in Blacks. Blacks are also 2 to 3 times more likely than Whites to be diagnosed with liver cancer, which is a particularly relevant study in epidemiology. Across CDC HCV surveillance, HCV-related cancer was reported in one third of 185 cholesterol, liver, bone, thrombosis, HIV, and myocardial disease cases. These results also imply that different unrecognized risk factors (racially, socioeconomic Status, and similar levels of early cancer-related mortality) may have an impact on mortality risks.
Agresti’s and Lee’s piece suggests that, with a high proportion of HEPI patients, Southern blacks and JBP patients may be a “high-risk” stratification. However, our analysis does not support that assumption. HEPI patients are similar in their hepatitis C phenotype to the general population, with % HCV negative representing a distortion of the baseline across individuals by diabetes (below) and by drug treatment (above). The HCV prevalence ratio for HEPI patients is only 0.2, compared with 0.6 for HCV-positive patients. Other recent analysis shows HEPI disproportionately dehydrogenates donated cells and contains disproportionately young and frail patients (age, 55 to 64 years) with a higher prevalence of obesity and diabetes.
Admittedly, eligible patients who consume alcohol on a regular basis have more cause for concern and need to enter into routine global and outreach exclusionary practices before seeking treatment, such as substance-free clinic, abstinence-only meetings, or rapid-acting prophylaxis use. However, as Belle et al. reports, among patients below the age of 12 years, alcohol is common initial drug of abuse as early as the age of 12. When infected with Hepatitis C, reliance on alcohol only makes treatment harder.