survey, 1988--94</TITLE><SECONDARY_TITLE>Adv Data</SECONDARY_TITLE><PAGES>1-9</PAGES><DATE>2005 Mar 9</DATE></MDL></Cite></EndNote>(3).


Because of the implementation of routine vaccinations of infants in 1992 and adolescents in 1995, the prevalence of HBV is expected to decline.


Race: The prevalence of the disease is higher among African Americans (13.7%) than persons of Hispanic origin (5.3%) or white persons (3.0%)(3).


Sex: Between cohorts ranging in age from 20-59 years, there were more cases of HBV in men (6.5%) than in women (4.7%)(3). 


Age: The longer that a person has the infection, the more likely it is to develop chronic inflammation. For instance, infants have a 90% chance, children have a 25-50% chance, adults have an approximately 5% chance, and persons who are elderly have an approximately 20-30% chance of developing chronic disease(7).


Other people who are at increased risk of being infected with the hepatitis B virus include the following (8):

·        Men or women who have multiple sex partners, especially if they don't use a condom

·        Men who have sex with men

·        Men or women who have sex with a person infected with HBV

·        People who are diagnosed with other sexually transmitted diseases

·        Injection drug users who share needles

·        People who receive transfusions of blood or blood products

·        Hemodialysis patients undergoing dialysis for kidney disease

·        Institutionalized mentally handicapped people and their attendants and family members

·        Health care workers who are stuck with needles or other sharp instruments contaminated with infected blood

·        Infants born to infected mothers


In some cases, the source of transmission is never known.


Economic Burden of Hepatitis B

The hepatitis B virus accounts for 5 -10% of chronic end-stage liver failure and 10-15% of the development of HCC.  It is due to these complications that utilizes most of the health care expenditures.  Margolis et al. estimated that, in 1981, expenditures due to acute and chronic HBV-related liver disease was at least $197 million in direct costs and $126 million for work-loss attributed to the illness (9).



The good news is that infection with HBV is almost always preventable.   According to the CDC, vaccination is recommended for the following groups (8):

·        All infants regardless of the potential of exposure to HBV

·        All adolescents at high risk of infection (i.e. injection drug users or multiple sex partners)

·        People with occupational risk (i.e. medical employees who come in contact with blood or blood products)

·        Patients and staff of institutions of the developmentally disabled

·        Hemodialysis patients

·        Chronic recipients of blood transfusions or certain other blood products

·        Household contact and sexual partners of HBV carriers

·        Adoptee from countries where HBV infections are endemic

·        International travelers especially to countries where HBV is prevalent

·        Men who have sex with men

·        Sexually active men and women identified as already contracting a sexually transmitted disease

·        Inmates of long-term correctional facilities


In an article published in JAMA, Hamilton (1983) found that a program to immunize high-risk medical personnel at the Duke University Medical Center to be cost-beneficial(10).  According to the study, the program would cost $206,304 in the first year and by seven years, the cumulative cost of the program would equal those without the program(10).  Hamilton also reports that at 10 years, there would be a cost saving ($746,742 with the programs versus $9191,950 without the program)(10).



Global eradication of HBV is achievable (11).   The hepatitis vaccine is effective and safe to use.  According to McIntyre (2001) and Alter (2003), to accomplish such a goal, universal hepatitis B immunization needs to be integrated into existing childhood vaccination schedules.  The dilemma is in establishing such a policy worldwide.  In 2000, only 116 of 215 countries had such a policy (12).  This number represents only 31% of the global birth cohorts (12).   Complications arising from chronic HBV-related liver disease are another burden on the health care system.    At-risk adults also need to be immunized to truly realize the benefits of the vaccine (12).


Hepatitis C Overview 

Hepatitis C is an increasing public health concern in the United States and throughout the world.  The World Health Organization estimates 170 million individuals worldwide are infected with hepatitis C virus (HCV) (13).   Approximately 15-20% of people infected develop the acute form of the illness.  The remaining cases develop chronic hepatitis leading to such complications as cirrhosis, end-stage liver disease, and HCC.  Chronic liver disease because of hepatitis C causes 10,000 deaths each year in the United States.   

Sources of Infections

HCV is not related to the other viruses that cause hepatitis. However, like the other hepatic viruses, it is contagious and spread via the exchange of blood or blood products.   Since sharing of contaminated needles among IV drug users also involves exchange in blood products, the mode of transmission is the most common for the HCV.


Prior to 1992, blood transfusions during surgeries with infected blood, hemodialysis patients, and organ transplants from affected persons were common modes of transmission for the HCV.  In 1992, a test became available for checking blood for HCV. Blood and blood products are now tested to ensure that they are not contaminated.   Other less common transmissions of HCV include the following: 



The source of transmission is unknown in about 10% of people with acute hepatitis C and in about 30% of people with chronic hepatitis C.


Characteristics of At-risk Populations

                Populations at high risk for contracting the HCV are similar to those of hepatitis B.  HCV tends to be more prevalent in males than females.  Other risk factors include persons living below the poverty level, age of first intercourse less than 18 years of age, having more than 50 sexual partners over a lifetime, lifetime use of cocaine, and more than 100 lifetime use of marijuana a(3).


Race: The prevalence of the disease is higher among African Americans (4.1%) than persons of Hispanic origin (3.4%) or white persons (2.0%)(3).


Sex: Between cohorts ranging in age from 20-59 years, there were more cases of HCV in men (3.4%) than in women (1.5%)(3).  Again, when this data is stratified by race, more African American (5.8%) and Hispanic (4.1%) men are HCV-infected than their female counterparts (2.8% and 2.6%, respectively)(3).  


Age: The age groups for hepatitis C infections are difficult to ascertain.  Historically, 20-39 years have been known to have high incidence rate of HCV infections.  Chronic hepatitis C has a long latency period, 10-20 years, so persons may be unknowing carriers.  Groups under 15 years of age have very low incidence rate of infection (5).


Economic Burden of Hepatitis C (14)

                The economic burden of hepatitis C is directly related to the complications such as cirrhosis and HCC.  Hospitalization is a large proportion of the expenditures for HCV-related care.  In 1995, approximately 27,000 hospitalizations in the US were attributed to liver disease due to HCV.  This, in turn, corresponds to a crude incidence of one hospitalization per 1,000 persons infected.  The estimated annual total expenditure for hospitalization due to HCV-related liver disease was between $129 and $514 million (14).  This estimated cost does not factor in the cost of liver transplantation due to severe cirrhosis or HCC.


                For physician services, there were an estimated 317,000 physician office visits incurring $23.9 million in expenditure during 1998.  In addition, there were a total cost of $10.5 million emergency department costs and $530 million for pharmaceutical therapies in 1999.  According to Alter’s report, in the late 1990’s, the total economic impact of HCV-related liver disease was estimated at $1 to $1.3 billion per year(14).



                One method to prevent the incidence of HCV is to modify the risky behaviors among those most at risk.  The high prevalence of hepatitis C infection among injection drug users (IDU) indicates a need for such behavior modifying programs.  The cost and illegality of purchasing syringes has made IDU more likely to share needles.  To counter against this practice, many states have implemented syringe exchange programs (SEP).  Data on the effectiveness of such programs is still inconclusive.  In a study by Hahn et al., the investigators found that although sterile syringes are accessible to IDU, sharing of needles still persists.  This finding does not suggest that SEP’s are not working.  It does, however, suggest that additional measures are needed in an attempt to curb the spread of HCV.  Several studies have found that SEP’s are the optimal settings for further intervention measures(15, 16).  In fact, Pollack (2001) suggests that “more comprehensive harm reduction models, coupled with referral of active IDUs to treatment, must complement syringe exchange to successfully contain highly infectious blood-borne diseases”(17).


                Another program evaluated by researchers is the medically supervised safer injecting facilities or SIF’s.  Wood et al. in British Columbia, Canada found that IDU were willing to attend SIF’s (18).  Although this program is not currently available in the US, Wood et al. suggest that the data “indicate a high potential for immediate community and public health benefits if SIF’s were presently available.


                In an article by Boutwell et al. (2005), the authors estimate that 15%-40% of persons incarcerated in US prisons are infected with HCV (19).  The authors suggest that “testing, education, and when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States.”


                In a Medline search, I did not find much literature on programs educating the general public about the hepatitis epidemic in the US.  However, there are many websites that contain educational materials on hepatitis both government-sponsored as well as industry-sponsored.  Following is only a sample of the websites:



                Hepatitis C varies greatly in its long-term effects.  Some people may be infected for 10-20 years before symptoms appear.  Others may never develop the severe complications that go along with the disease.  However, if the cirrhosis or other complications do develop, then special care is needed to safe-guard the liver.  Persons infected with HCV should avoid alcohol or other toxins that may further exacerbate the damage to the liver.   Cirrhosis from chronic hepatitis C can lead to liver failure. If damage is severe, liver transplantation is the only treatment. 

                The good news is, according to the CDC, rates of hepatitis C have been declining in all age groups.  In fact, the greatest decline appears among 25-39 year olds, a group which historically had the highest incidence rates.


Support Groups and Counseling

American Liver Foundation

75 Maiden Lane, Suite 603

New York, NY 10038

(800) 465-4837


Hepatitis B Foundation

700 East Butler Avenue

Doylestown, PA 18901-2697

(215) 489-4900


Hepatitis Foundation International

30 Sunrise Terrace

Cedar Grove, NJ 07009-1423

(800) 891-0707


U.S. Centers for Disease Control and Prevention (CDC) Hepatitis Branch--National Information Hotline

(888) 443-7232



1.         CDC. Protection Against Viral Hepatitis Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(RR-2):1-26.


2.         CDC. Prevention of Hepatitis A Through Active or Passive Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(RR-12):1-37.


3.         Kruszon-Moran D, McQuillan G. Seroprevalence of six infectious diseases among adults in the United States by race/ethnicity: data from the third national health and nutrition examination survey, 1988--94. Adv Data 2005:1-9.


4.         Samandari T, Bell B, Armstrong G. Quantifying the impact of hepatitis A immunization in the United States, 1995-2001. Vaccine 2004;22(31-32):4342-50.


5.         CDC. Hepatitis Surveillance: CDC; 2004 September. Report No.: 59.


6.         Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat 2004;11(2):97-107.


7.         WHO. Hepatitis B: World Health Organization October 2000. Report No.: 204.


8.         CDC. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(RR-13):1-9.


9.         Margolis H, Schatz G, Kane M. Development of recommendations for control of hepatitis B virus infections: the role of cost analysis. Vaccine 1990;8(Suppl S81-5):S93 - S94.


10.       Hamilton J. Hepatitis B virus vaccine: an analysis of its potential use in medical workers. JAMA 1983;250(16):2145-50.


11.       McIntyre C. Hepatitis B vaccine: risks and benefits of universal neonatal vaccination. J Pediatr Child Health 2001;37(3):215-7.


12.       Alter M. Epidemiology and prevention of hepatitis B. Semin Liver Dis 2003;23(1):39-46.


13.       CDC. NIH Consensus Statement on Management of Hepatitis C: National Institutes of Health; 2002 2002 Jun 10-12. Report No.: 19(3).


14.       Alter M. Viral hepatitis: hepatitis C. In: Kim W, Brown Jr. R, Terrault N, El-Serag H, editors. Epidemiology and the impact of liver disease in the United States; 2001; Atlanta, GA; 2001.


15.       Stancliff S, Agins B, Rich J, Burris S. Syringe access for the prevention of blood borne infections among injection drug users. BMC Public Health 2003;3(1):37.


16.       Tortu S, McMahon J, Hamid R, Neaigus A. Women's drug injection practices in East Harlem: an event analysis in a high-risk community. AIDS Behav 2003;7(3):317-28.


17.       Pollack H. Cost-effectiveness of harm reduction in preventing hepatitis C among injection drug users. Med Decis Making 2001;21(5):357-67.


18.       Wood E, Kerr T, Spittal P, Li K, Small W, Tyndall M, et al. The potential public health and community impact of safer injecting facilities: evidence from a cohort of injection drug users. J Acquir Immune Defic Syndr 2003;32(1):2-8.


19.       Boutwell A, Allen S, Rich J. Opportunities to address the hepatitis C epidemic in the correctional setting. Clin Infect Dis 2005;40(Suppl 5):S367-72.