Research Article: Underreporting of Hepatitis B and C virus infections — Pennsylvania, 2001–2015

Date Published: June 6, 2019

Publisher: Public Library of Science

Author(s): Henry Roberts, Sameh W. Boktor, Kirsten Waller, Zahra S. Daar, Joseph A. Boscarino, Perry H. Dubin, Anil Suryaprasad, Anne C. Moorman, Livia Melo Villar.

http://doi.org/10.1371/journal.pone.0217455

Abstract

In Pennsylvania, reporting of viral hepatitis B (HBV) and viral hepatitis C (HCV) infections to CDC has been mandated since 2002. Underreporting of HBV and HCV infections has long been identified as a problem. Few reports have described the accuracy of state surveillance case registries for recording clinically-confirmed cases of HBV and HCV infections, or the characteristics of populations associated with lower rates of reporting.

The primary objective of the current study is to estimate the proportion of HBV and HCV infections that went unreported to the Pennsylvania Department of Health (PDoH), among patients in the Geisinger Health System of Pennsylvania. As a secondary objective, we study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest: sex, age group, race/ethnicity, rural status, and year of initial diagnosis.

Per medical record review, the study population was limited to Geisinger Health System patients, residing in Pennsylvania, who were diagnosed with a chronic HBV and/or HCV infection, between 2001 and 2015. Geisinger Health System patient medical records were matched to surveillance records of confirmed cases reported to the Pennsylvania Department of Health (PDoH). To quantify the extent that underreporting occurred among the Geisinger Health System study participants, we calculated the proportion of study participants that were not reported to PDoH as confirmed cases of HBV or HCV infections. An analysis of adjusted prevalence ratio estimates was conducted to study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest.

Geisinger Health System patients living with HBV were reported to PDoH 88.4% (152 of 172) of the time; patients living with HCV were reported to PDoH 94.6% (2,257 of 2,386) of the time; and patients who were co-infected with both viruses were reported to PDoH 72.0% (18 of 25) of the time. Patients living with HCV had an increased likelihood of being reported if they were: less than or equal to age 30 vs ages 65+ {PR = 1.2, [95%CI, (1.1, 1.3)]}, and if they received their initial diagnosis of HCV during the 2010–2015 time period vs the 1990–1999 time period {PR = 1.08, [95%CI, (1.05, 1.12)]}.

The findings in this study are promising, and suggests that PDoH has largely been successful with tracking and monitoring viral hepatitis B and C infections, among persons that were tested for HBV and/or HCV. Additional efforts should be placed on decreasing underreporting rates of HCV infections among seniors (ages 65 and over), and persons who are co-infected with HBV and HCV.

Partial Text

The estimated 3.5 million hepatitis C (HCV) infections and 1.0–2.0 million hepatitis B (HBV) infections represent the largest infectious disease epidemic in the United States, but have remained largely a “silent epidemic”[1] despite their high burden of disease [2, 3, 4]. Viral hepatitis B and C infections are often characterized as silent epidemics, to some extent, because the majority of the persons infected with HBV or HCV are not aware that they are infected until they are screened for the virus, or until their liver disease progresses to cirrhosis, or hepatocellular carcinoma (HCC), several years later. Together, HBV and HCV infections are the leading causes of death from cirrhosis and HCC [1]. The high burden of HBV infections in the United States, is largely due to the migration of foreign-born persons from HBV endemic countries. Persons living with HBV in the United States are largely foreign born and may account for as many as 50% – 70% of HBV infections in the United States [3, 5]. In spite of routine childhood vaccination and targeted vaccination of at-risk populations, the prevalence of HBV infections in the United States has not seen a significant decrease in the 21st century [3]. The high burden of HCV infections in the United States, in part, is due to the increasing rates of injection drug use among young adults who reside in suburban and rural communities. Recent advances in the treatment of HBV and HCV infections has fostered hope that these infections can eventually be eliminated from the US population.

Among the 2,533 Geisinger Health System study participants, 6.8% (n = 172) were living with HBV and 94.2% (n = 2,386) were living with HCV (Tables 1 and 2). Co-infections (patients infected with HBV and HCV) were present in 1.0% (n = 25) of these patients. Men accounted for 60.5% (104 of 172) of the HBV infections (Table 1) and 54.0% (1,289 of 2,386) of the HCV infections (Table 2). A disproportionate number of those infected with HBV were Asian/Pacific Islanders [17.4% or (30 of 172)], and a disproportionate number of those infected with HCV were non-Hispanic whites [89.9% or (2,144 of 2,386)]. It should be noted that Asian/Pacific Islanders and non-Hispanic whites represent 3.5% and 82.4% of Pennsylvania’s population, respectively [22].

In the United States, all persons who test positive for HBV or HCV infections, should be reported to their state health departments to facilitate more precise measurements of the true burden of HBV and/or HCV infections. In Pennsylvania, all persons who test positive for HBV or HCV infections, must be reported to PDoH, cited in 28 Pa. Code § 27.21a. Prior to this study, very little was known about the extent that underreporting of HBV or HCV infections occurred in Pennsylvania. In this study, the assessment of underreporting was limited to Geisinger Health System patients whom were residents of Pennsylvania, enrolled as CHeCS participants, and diagnosed with a chronic HBV or HCV infection between 2001 and 2015. All of these patients should have been accounted for in the Pennsylvania viral hepatitis state registry (PA-NEDSS).

 

Source:

http://doi.org/10.1371/journal.pone.0217455