The Prevalence of Hepatitis C Virus Infection in the United States, 1999 through

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ANNALS OF INTERNAL MEDICINE

The Prevalence of Hepatitis C Virus Infection in the United States, 1999

through 2002

L. Armstrong, MD; Annemarie Wasley, ScD; Edgar P. Simard, MPH;

Geraldine M. McQuillan, PhD; Wendi L. Kuhnert, PhD; and Miriam J. Alter, PhD

16 May 2006 | Volume 144 Issue 10 | Pages 705-714

Background: Defining the primary characteristics of persons infected with

hepatitis C virus (HCV) enables physicians to more easily identify persons

who are most likely to benefit from testing for the disease.

Objective: To describe the HCV-infected population in the United States.

Design: Nationally representative household survey.

Setting: U.S. civilian, noninstitutionalized population.

Participants: 15 079 participants in the National Health and Nutrition

Examination Survey between 1999 and 2002.

Measurements: All participants provided medical histories, and those who

were 20 to 59 years of age provided histories of drug use and sexual

practices. Participants were tested for antibodies to HCV (anti-HCV) and HCV

RNA, and their serum alanine aminotransferase (ALT) levels were measured.

Results: The prevalence of anti-HCV in the United States was 1.6% (95% CI,

1.3% to 1.9%), equating to an estimated 4.1 million (CI, 3.4 million to 4.9

million) anti-HCV–positive persons nationwide; 1.3% or 3.2 million (CI, 2.7

million to 3.9 million) persons had chronic HCV infection. Peak prevalence

of anti-HCV (4.3%) was observed among persons 40 to 49 years of age. A total

of 48.4% of anti-HCV–positive persons between 20 and 59 years of age

reported a history of injection drug use, the strongest risk factor for HCV

infection. Of all persons reporting such a history, 83.3% had not used

injection drugs for at least 1 year before the survey. Other significant

risk factors included 20 or more lifetime sex partners and blood transfusion

before 1992. Abnormal serum ALT levels were found in 58.7% of HCV

RNA–positive persons. Three characteristics (abnormal serum ALT level, any

history of injection drug use, and history of blood transfusion before 1992)

identified 85.1% of HCV RNA–positive participants between 20 and 59 years of

age.

Limitations: Incarcerated and homeless persons were not included in the

survey.

Conclusions: Many Americans are infected with HCV. Most were born between

1945 and 1964 and can be identified with current screening criteria. History

of injection drug use is the strongest risk factor for infection.

Editors' Notes

Context

The Third National Health and Nutrition Examination Survey (NHANES III),

conducted between 1988 and 1994, indicated that 1.8% of people in the United

States had been infected with hepatitis C virus (HCV), 70% of whom had

chronic infection. Most anti-HCV–positive individuals were between 30 and 49

years of age.

Contribution

Data from the recent NHANES (1999–2002) show little change in anti-HCV

prevalence, but peak prevalence has shifted to individuals between 40 and 49

years of age. More than 85% of HCV RNA–positive individuals may be

identified through targeted testing of 18% of adults between 20 and 59 years

of age: persons with abnormal serum alanine aminotransferase levels, those

who have used injection drugs, and those who received blood transfusions

before 1992.

Cautions

Incarcerated and homeless people were not included in the survey.

Implications

Despite a decrease in new HCV infections, aging of chronically infected

individuals may presage an imminent increase in complications.

—The Editors

Author and Article Information

From National Center for Infectious Diseases, Centers for Disease Control

and Prevention, Atlanta, Georgia, and National Center for Health Statistics,

Centers for Disease Control and Prevention, Hyattsville, land.

Grant Support: None.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: L. Armstrong, MD, Division of Viral

Hepatitis, Centers for Disease Control and Prevention, Mailstop G-37, 1600

Clifton Road NE, Atlanta, GA 30333; e-mail, GArmstrong@....

Current Author Addresses: Drs. Armstrong and Wasley and Mr. Simard: Division

of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop

G-37, 1600 Clifton Road NE, Atlanta, GA 30333.

Dr. McQuillan: Centers for Disease Control and Prevention, National Center

for Health Statistics, Division of Health and Nutrition Examination Surveys,

3311 Toledo Road, Room 4204, Hyattsville, MD 20782.

Dr. Kuhnert: Division of Viral Hepatitis, Centers for Disease Control and

Prevention, Mailstop A-33, 1600 Clifton Road NE, Atlanta, GA 30333.

Dr. Alter: Division of Viral Hepatitis, Centers for Disease Control and

Prevention, Mailstop D-66, 1600 Clifton Road NE, Atlanta, GA 30333.

Author Contributions: Conception and design: G.L. Armstrong, G.M. McQuillan,

M.J. Alter.

Analysis and interpretation of the data: G.L. Armstrong, A. Wasley, E.P.

Simard, G.M. McQuillan, W.L. Kuhnert, M.J. Alter.

Drafting of the article: G.L. Armstrong, G.M. McQuillan.

Critical revision of the article for important intellectual content: G.L.

Armstrong, A. Wasley, E.P. Simard, G.M. McQuillan, M.J. Alter.

Final approval of the article: G.L. Armstrong, A. Wasley, E.P. Simard, G.M.

McQuillan, M.J. Alter.

Provision of study materials or patients: G.M. McQuillan.

Statistical expertise: G.L. Armstrong.

Obtaining of funding: M.J. Alter.

Administrative, technical, or logistic support: W.L. Kuhnert.

Collection and assembly of data: A. Wasley, E.P. Simard, G.M. McQuillan.

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