Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014.

OBJECTIVES: To compare US trends in rates of injection drug use (IDU), specifically opioid injection, with national trends in the incidence of acute HCV infection to assess whether these events correlated over time. METHODS: We calculated the annual incidence rate and demographic and risk characteristics of reported cases of acute HCV infection using surveillance data from 2004 to 2014 and the annual percentage of admissions to substance use disorder treatment facilities reporting IDU for the same time period by type of drug injected and demographic characteristics. We then tested for trends. RESULTS: The annual incidence rate of acute HCV infection increased more than 2-fold (from 0.3 to 0.7 cases/100 000) from 2004 to 2014, with significant increases among select demographic subgroups. Admissions for substance use disorder attributed to injection of heroin and prescription opioid analgesics increased significantly, with an almost 4-fold increase in prescription opioid analgesic injection. Significant increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups. CONCLUSIONS: These findings strongly suggest that the national increase in acute HCV infection is related to the country's opioid epidemic and associated increases in IDU.

Impact of Stroke Risk Factors on Ethnic Stroke Disparities Among Midlife Mexican Americans and Non-Hispanic Whites.

BACKGROUND AND PURPOSE: We examined the contribution of stroke risk factors to midlife (age 45-59 years) Mexican American and non-Hispanic White ischemic stroke (IS) rate disparities from 2000 to 2010. METHODS: Incident IS cases (n=707) and risk factors were identified from the Brain Attack Surveillance in Corpus Christi Project, Nueces County, TX (2000-2010). US Census data (2000-2010) were used to estimate the population at-risk for IS, and the Behavioral Risk Factor Surveillance System (2000-2010) was used to estimate risk factor prevalence in the stroke-free population. Poisson regression models combined IS counts (numerator) and population at-risk counts (denominator) classified by ethnicity and risk factor status to estimate unadjusted and risk factor-adjusted associations between ethnicity and IS rates. Separate models were run for each risk factor and extended to include an interaction term between ethnicity and risk factor. RESULTS: The crude rate ratio (RR) for ethnicity (Mexican American versus non-Hispanic White) was 2.01 (95% confidence interval [CI], 1.71-2.36) and was attenuated in models that adjusted for diabetes mellitus (RR: 1.50; 95% CI, 1.26-1.78) and hypertension (RR: 1.84; 95% CI, 1.50-2.26). In addition, diabetes mellitus had a stronger association with IS rates among Mexican Americans (RR: 6.42; 95% CI, 5.31-7.76) compared with non-Hispanic Whites (RR: 4.07; 95% CI, 3.68-4.51). CONCLUSIONS: The higher prevalence of diabetes mellitus and hypertension and stronger association of diabetes mellitus with IS among midlife Mexican Americans likely contribute to persistent midlife ethnic stroke disparities.

Results of Hepatitis C Birth-Cohort Testing and Linkage to Care in Selected U.S. Sites, 2012-2014.

OBJECTIVE: Following its recommendation for one-time hepatitis C virus (HCV) testing of people born between 1945 and 1965, CDC implemented the Hepatitis Testing and Linkage to Care (HepTLC) initiative to conduct birth-cohort hepatitis testing in U.S. health-care settings. We describe demographic characteristics, HCV infection prevalence, and HCV-related risk factors among people born between 1945 and 1965 who were tested as part of the program, which ran from 2012 to 2014. METHODS: As part of the HepTLC initiative, 14 grantees supporting 104 health-care sites in 21 U.S. municipalities tested participants born between 1945 and 1965 for HCV antibody (anti-HCV). Demographic characteristics and HCV risk factors were reported for people tested for anti-HCV and who were anti-HCV or HCV RNA positive. We evaluated outcomes along the HCV testing-to-care continuum using the following indicators: anti-HCV positive, HCV RNA test offered, HCV RNA positive, referred to care, and attended first medical appointment. RESULTS: Among 24,966 people tested for HCV infection, 2,900 (11.6%) were anti-HCV positive. Anti-HCV positivity was highest among those who self-identified as non-Hispanic black (n=1,701 of 12,202, 13.9%), men (n=2,073 of 12,130, 17.1%), and people born between 1951 and 1955 (n=795 of 5,768, 13.8%). Of the 2,900 people testing anti-HCV positive, 2,108 (72.7%) received an HCV RNA test, 1,497 (51.6%) were HCV RNA positive, 1,201 (41.4%) were referred to care, and 938 (32.3%) attended their first appointment. CONCLUSION: Testing for HCV infection among those born between 1945 and 1965 without soliciting HCV risk factors was successful. Providers implementing birth-cohort testing should develop and evaluate strategies to improve outcomes along the testing-to-care continuum.

Improving Screening Methods for Hepatitis C Among People Who Inject Drugs: Findings from the HepTLC Initiative, 2012-2014.

OBJECTIVE: People who inject drugs (PWID) are at increased risk for hepatitis C virus (HCV) infection. We examined HCV testing outcomes among PWID through CDC's Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites during 2012-2014. Ten grantees in nine geographically diverse cities conducted HCV testing among PWID. METHODS: Among those testing positive for HCV antibody (anti-HCV), we calculated the proportion who were offered a confirmatory HCV ribonucleic acid (RNA) test, positively diagnosed, and referred to a specialist for care. We stratified anti-HCV-positive people who completed each step by same-day testing (i.e., an HCV RNA test administered on the same date as an anti-HCV test) vs. person not receiving same-day testing to evaluate whether the need for follow-up testing affected diagnosis of chronic infection and linkage to care. RESULTS: A total of 15,274 people received an anti-HCV test at 84 testing sites targeting PWID. Of those, 11,159 (73%) reported having injected drugs in their lifetime, 7,789 (51%) reported injecting drugs in the past 12 months, and 3,495 (23%) tested anti-HCV positive. A total of 1,630 people received testing for HCV RNA, of whom 1,244 (76%) were HCV RNA positive. When not receiving both tests on the same day, 601 of 2,465 (24%) anti-HCV-positive people received an HCV RNA test. CONCLUSION: Strategies to diagnose PWID for HCV infection are needed to reduce associated morbidity and mortality. Agencies can substantially increase the number of PWID who are diagnosed and informed of their HCV infection by administering both anti-HCV and HCV RNA tests during a single testing event.

Hepatitis E virus infections in children age 0-15, Uganda outbreak, 2007.

BACKGROUND: The epidemiology of hepatitis E virus (HEV) infections among children is not well understood, with some studies reporting that hepatitis E infections do not affect children. OBJECTIVES: We analyzed seroepidemiologic data collected during a hepatitis E outbreak in Uganda to determine prevalence of past and recent HEV infections among children aged 0-15 years. STUDY DESIGN: Individuals were randomly selected from a household census to participate in a seroprevalence survey. We analyzed data on IgM and IgG antibody to HEV among children aged 0-15 years. We categorized the study population by age group [aged 0-5, 6-10, and 11-15 years], and further stratified the youngest children [aged 0-1, 2-3, and 4-5 years]. Presence of IgG anti-HEV alone indicated past HEV infection, whereas recent infection was defined as presence of IgM anti-HEV with or without IgG anti-HEV. RESULTS: Among children aged 0-15 years (N=244), prevalence of past HEV infection was 25.4% (62/244) and was highest among children aged 0-5 years [31.0% (27/87)]. Evidence of recent HEV infection was detected in 37.3% (91/244) of children aged 0-15 years. Among younger children, recent HEV infection increased with age from 4.3% (1/23) in children aged 0-1 year to 36.7% (11/30) in children aged 4-5 years. CONCLUSION: These data show that children are not spared from HEV infections. Illness during childhood in developing countries is common and HEV infections may be misdiagnosed as another acute illness, or under diagnosed. The lack of clinical care, HEV diagnostics, and surveillance in developing countries limit our full understanding of hepatitis E epidemiology.

Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years - Kentucky, Tennessee, Virginia, and West Virginia, 2006-2012.

Hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States, with approximately three million persons living with current infection. Percutaneous exposure to contaminated blood is the most efficient mode of transmission, and in the United States, injection drug use (IDU) is the primary risk factor for infection. State surveillance reports from the period 2006-2012 reveal a nationwide increase in reported cases of acute HCV infection, with the largest increases occurring east of the Mississippi River, particularly among states in central Appalachia. Demographic and behavioral data accompanying these reports show young persons (aged ≤30 years) from nonurban areas contributed to the majority of cases, with about 73% citing IDU as a principal risk factor. To better understand the increase in acute cases of HCV infection and its correlation to IDU, CDC examined surveillance data for acute case reports in conjunction with analyzing drug treatment admissions data from the Treatment Episode Data Set-Admissions (TEDS-A) among persons aged ≤30 years in four states (Kentucky, Tennessee, Virginia, and West Virginia) for the period 2006-2012. During this period, significant increases in cases of acute HCV infection were found among persons in both urban and nonurban areas, with a substantially higher incidence observed each year among persons residing in nonurban areas. During the same period, the proportion of treatment admissions for opioid dependency increased 21.1% in the four states, with a significant increase in the proportion of persons admitted who identified injecting as their main route of drug administration (an increase of 12.6%). Taken together, these increases indicate a geographic intersection among opioid abuse, drug injecting, and HCV infection in central Appalachia and underscore the need for integrated health services in substance abuse treatment settings to prevent HCV infection and ensure that those who are infected receive medical care.

Residential ethnic segregation and stroke risk in Mexican Americans: the Brain Attack Surveillance in Corpus Christi project.

OBJECTIVE: Residential ethnic segregation may operate through multiple mechanisms to increase stroke risk. The current study evaluated if residential ethnic segregation was associated with stroke risk in a bi-ethnic population. DESIGN: Incident strokes were identified in Nueces County, Texas from 2000 to 2010. Residential ethnic segregation (range: 0-1) was derived for each census tract in the county (n=64) using 2000 US Census data, and categorized into: predominantly non-Hispanic White (NHW, <.3); ethnically mixed (.3-.7); predominantly Mexican American (MA, >.7). Multilevel Poisson regression models were fitted separately for NHWs and MAs to assess the association between residential ethnic segregation (predominantly NHW referent) and relative risk for stroke, adjusted for age category, sex and census tract-level median per capita income. Effect modification by age was also examined. RESULTS: In adjusted models, residential ethnic segregation was not associated with stroke risk in either ethnic group. Effect modification by age was significant in both groups. Young MAs and NHWs living in predominantly MA census tracts were at greater relative risk for stroke than those living in predominantly NHW census tracts, but this association was only significant for MAs (MAs: RR = 2.38 [95% CI: 1.31-4.31]; NHWs: RR = 1.53 [95% CI: .92-2.52]). CONCLUSION: Our findings demonstrate that residential ethnic segregation may influence downstream stroke risk in young MAs. Pathways between residential ethnic segregation and stroke in young MAs should be explored.