In the United States (US), the prevalence of hepatitis C virus (HCV) is higher in the western and Appalachian states, according to a survey published in JAMA Network Open.

HCV is the most frequently reported bloodborne infection in the US and is transmitted through exposure to infected bodily fluids. This infection is a leading cause of liver-related morbidity, transplantation, and mortality. Between 15% and 42% of infections resolve themselves when left untreated, but liver disease, including cirrhosis and hepatocellular carcinoma, develops in approximately half of those who are chronically infected. Elimination of HCV is a possible goal with the increasing availability of direct-acting antiviral medications. To create effective elimination strategies, accurate estimations of the current HCV burden in each US jurisdiction are needed.

However, national case surveillance does not provide a complete picture of the HCV burden because only a small portion of cases are recorded. The current approach for approximating HCV prevalence uses an analysis of the US National Health and Nutrition Examination Survey (NHANES), which conducts HCV testing among noninstitutionalized persons aged >6 years. Using this, an updated national HCV prevalence for 2013 to 2016 has been estimated, yielding a result of approximately 2.4 million persons who are positive for HCV RNA. Therefore, this survey estimated the prevalence of current HCV infection in adults in each US state and the District of Columbia during the years 2013 to 2016.

Using a multistep statistical approach and direct estimates for each state using NHANES national prevalence in sex, race/ethnicity, birth cohort, and poverty strata, the distribution of each state’s cause‑specific death rates relative to the US average as signals for local patterns of HCV infection were examined. Additional analyses estimated state-level HCV infections in populations that were not included in the NHANES sampling frame.

Results demonstrated a higher prevalence of HCV infection in the western and Appalachian states compared with other areas. Represented from the NHANES sampling frame, the estimated national prevalence of HCV from 2013 to 2016 was 0.84% (95% CI, 0.75%-0.96%) in American adults who were noninstitutionalized and was adjusted to 0.93% when populations not included in NHANES were accounted for. A total of 9 states contained more than half (51.9%) of all persons living with HCV infection: California, Texas, Florida, New York, Pennsylvania, Ohio, Michigan, Tennessee, and North Carolina — 5 of these states are in the Appalachian region. Jurisdiction-level median HCV RNA prevalence was 0.88%. Of 13 western states, 10 were above this median; 3 of these 10 states with the highest HCV prevalence were in Appalachia. Results demonstrated a trend for substantial HCV prevalence in regions with long-standing HCV epidemics and with newly emergent cases driven by the opioid crisis. States experiencing higher rates of narcotic overdose mortality saw relative increases in estimated HCV prevalence, whereas those with lower rates saw HCV prevalence decline.

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Overall, the study authors concluded that, “Progress toward hepatitis C elimination is theoretically possible with the right investments in prevention, diagnosis, and cure. The urgency for action and the resources necessary will vary by jurisdiction.”


Rosenberg ES, Rosenthal EM, Hall EW, et al. Prevalence of hepatitis C virus infection in the US states and the District of Columbia, 2013 to 2016. JAMA Netw Open. 2018;1(8):e186371.