标题：Epidemiology of Hepatitis C Virus in Pennsylvania State Prisons, 2004–2012: Limitations of 1945–1965 Birth Cohort Screening in Correctional Settings
摘要：Objectives. We described hepatitis C virus antibody (anti-HCV) prevalence in a state prison system and retrospectively evaluated the case-finding performance of targeted testing of the 1945 to 1965 birth cohort in this population. Methods. We used observational data from universal testing of Pennsylvania state prison entrants (June 2004–December 2012) to determine anti-HCV prevalence by birth cohort. We compared anti-HCV prevalence and the burden of anti-HCV in the 1945 to 1965 birth cohort with that in all other birth years. Results. Anti-HCV prevalence among 101 727 adults entering prison was 18.1%. Prevalence was highest among those born from 1945 to 1965, but most anti-HCV cases were in people born after 1965. Targeted testing of the 1945 to 1965 birth cohort would have identified a decreasing proportion of cases with time. Conclusions. HCV is endemic in correctional populations. Targeted testing of the 1945 to 1965 birth cohort would produce a high yield of positive test results but would identify only a minority of cases. We recommend universal anti-HCV screening in correctional settings to allow for maximum case identification, secondary prevention, and treatment of affected prisoners. HCV is the most common blood-borne viral infection in the United States, with an estimated 4.1 million persons having been exposed to the virus, and 3.2 million people, or about 1.3% of the population, having chronic HCV infection. 1 Although overall HCV prevalence in the United States is declining, 2 recently there have been multiple reports of outbreaks among young people, predominantly in suburban and rural areas. 3–5 The primary mode of HCV transmission is injection drug use, 6 and as a result, HCV disproportionately affects people in contact with the criminal justice system. 7 An estimated 17.4% of US state prisoners were HCV antibody positive (anti-HCV positive) in 2006, and perhaps 28.5% to 32.8% of the US case burden was in contact with the criminal justice system in that year. 8 People may be infected with HCV for several decades without symptoms. At least half of the affected individuals in the United States are unaware of their infection 9 and thus are unable to receive treatment. Without treatment, HCV infection can lead to cirrhosis, chronic liver disease, and hepatocellular carcinoma. 10–12 At current treatment rates, HCV will kill nearly 380 000 people in the United States by 2030 and more than 1 million by 2060. 13 Until recently, the Centers for Disease Control and Prevention (CDC) recommended HCV testing only for people with known or at high risk for past or current HCV exposure, including people who had ever injected drugs, who had certain medical conditions, or who had received blood transfusions or blood products before HCV screening of such products became routine. 14 In recognition of the urgent need to diagnose and treat extant infections and reduce HCV-related mortality, in 2012 the CDC also recommended 1-time HCV testing of all people born between 1945 and 1965. 14 This birth cohort was selected on the basis of findings from the National Health and Nutrition Examination Survey (NHANES). NHANES is an ongoing nationally representative survey of the civilian, noninstitutionalized population. NHANES data from 1999 to 2008 indicated that 81.6% of anti-HCV–positive people in the United States were born between 1945 and 1965. 15 However, an acknowledged limitation of the NHANES data in assessing the epidemiology of HCV is the exclusion of incarcerated people from the sample. 1 As such, it is unclear how applicable the 1945 to 1965 birth cohort screening recommendation may be for prisoner populations. The Federal Bureau of Prisons now recommends HCV antibody testing for all inmates who request a test or report risk factors for infection. 16 This approach assumes that inmates will reliably report a history of injection drug use, but concerns about self-incrimination and confidentiality may prevent this disclosure. Although 1 study has reported success in using risk-based testing to identify acute HCV in an incarcerated population, 17 that study did not assess the proportion of all chronic HCV cases identified by risk-based testing. Analysis of data from a large representative sample of prison entrants found that testing only those inmates who reported injection drug use would have identified 56% of anti-HCV–positive women and just 35% of anti-HCV–positive men. 18 Given the high anti-HCV prevalence and limited case-finding performance of risk-based HCV screening in correctional settings, universal screening has been suggested as an alternative approach. 19 If, however, HCV infection in the correctional population is concentrated in the 1945 to 1965 birth cohort, targeting testing toward this group may be an efficient and cost-effective approach to HCV case finding. 20 Limited recent epidemiological data on HCV prevalence in correctional settings hamper evaluation of these different approaches to HCV testing. We present data from universal HCV screening on entry to state prisons in Pennsylvania and consider the case-finding performance of the CDC 1945 to 1965 birth cohort recommendation in this setting.
