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10/11/2013

Premature Mortality in HCV-infected Individuals Reported at ID Week 2013


With the impending approval of new directly-acting antivirals, treatment of HCV will undergo dramatic changes, making a cure possible in many more patients. About half of the estimated 3-4 million cases in the US are undiagnosed. To improve diagnosis and facilitate linkage to care, the CDC and USPSTF have endorsed routine testing of all persons aged 45-65 (‘baby boomers”) who have the highest HCV prevalence in the US. Individuals with HCV infection suffer from both liver-related and non-liver related morbidity and mortality. Identifying more individuals through expanded testing and linkage to care could have profound effects on health outcome in HCV-infected individuals. Investigators from the New York City (NYC) Department of Health cross-matched reportable disease and vital statistics databases to identify premature death (at age <65) and cause of death among individuals with HCV, HIV/HCV co-infection or neither, who died in NYC between 2000 and 2011 [1]. The median age at death was 52, 59, and 78 for the HIV/HCV, HCV, and neither infection groups. Two-thirds of deaths in the HCV mono-infection group and 95% in the co-infection group were premature. Compared to the group with neither infection, those with HCV mono-infection had an 8.7-and 3.5-fold increase in risk of death due to liver cancer and cirrhosis, respectively. Still, only a quarter of all deaths in the HCV mono-infection group were attributed to liver-related causes. Cardiovascular disease and non-liver cancer were the most commonly reported causes of death. Drug-related deaths were increased in both the HCV and HIV/HCV groups. The HIV co-infected group had a 2.2-fold increased risk of death due to liver cancer, but not cirrhosis. However, competing mortality was extremely high in the co-infection group, as 53% of deaths were attributed to HIV/AIDS. In a related abstract, CDC investigators assessed mortality and cause of death from 2006-2010 in the Chronic Hepatitis Cohort Study, a cohort with almost 12,000 chronic HCV patients, comparing it to a large database of 12 million US death certificates [2]. All cause mortality was increased 12-fold and median age of death was 15 years younger in patients with HCV. As expected, liver-related causes of death were increased markedly (6-86-fold) in the hepatitis cohort, but many other causes, including circulatory, respiratory, digestive and genitourinary diseases, diabetes, trauma and mental health disorders were also significantly increased compared to the compared to the general population.

These studies document the high rate of premature mortality in HCV-infected individuals, and especially with HIV/HCV co-infection. Deaths due to liver disease are increased but premature deaths due to other causes still predominate. Programs to increase diagnosis and linkage to care, and the lure of simple new treatments that cure most infections will bring many new HCV-infected individuals into care. This will create new a unique opportunity to reduce not only liver-related mortality but also to reduce premature deaths due to many other preventable and treatable conditions such as cardiovascular disease, chronic pulmonary disease, non-liver cancer diabetes and psychiatric illness and drug abuse.

References:
1. Mahajan R, Xing J, Liu S,et al. Rates and Causes of Mortality among People in Care with Hepatitis C Virus Infection — Chronic Hepatitis Cohort Study (CHeCS), 2006– 2010. ID Week 2013, San Francisco, CA, October 2-6, 2013, abstract 1774.
2. Pinchoff J, Drobnik A, Fuld J, et al. Trends in HCV and Liver Related Causes of Death among People with HCV Infection in NYC, 2000 to 2010. ID Week 2013, San Francisco, CA, October 2-6, 2013, abstract 1777.


Source: Reporting from San Francisco fro PRN News: David H Shepp. MD