Understanding the Changing Hepatitis B and Hepatitis C Epidemics Open Access

Hall, Eric (Summer 2020)

Permanent URL: https://etd.library.emory.edu/concern/etds/2227mq790?locale=en


In the United States, over 3 million people are currently infected with hepatitis B virus (HBV) or hepatitis C virus (HCV), two major causes of liver disease, liver cancer and liver-related death. After decades of substantially decreasing disease incidence, new cases of HBV and HCV are on the rise in the United States, partially because of increased transmission among persons who inject drugs. Despite these recent trends, advancements in prevention and treatment interventions have the public health community strategizing to eliminate viral hepatitis transmission.

In the first study, we modeled county-level HCV death rates and estimated HCV mortality trends. Although many health jurisdictions have experienced declines in HCV mortality since 2013, the magnitude and composition of those declines has differed by place. These data provide a better understanding of geographic differences in HCV mortality and can be used by local jurisdictions to evaluate HCV mortality in their areas.

In the second study, we developed a novel longitudinal metric that summarizes the relationship between opioid prescribing practices and drug overdose mortality, and then assessed trends in this metric by characteristics of place. Opioid prescribing practices and drug overdose mortality both continue to be ongoing public health challenges, but how they interact differs by geography and place. This novel summary metric provides an additional data point that can used in future research to enhance our understanding of the shift in overdose mortality away from prescription opioids to other drugs.

In the third study, we conducted an economic evaluation of a universal hepatitis B vaccination recommendation for all U.S. adults. We found that a universal adult HBV vaccination strategy may be appropriate for reducing new HBV infection and improving health outcomes, particularly in scenarios that result in high vaccination coverage among high-risk adults. These results can be used by vaccine policy makers to reevaluate HBV vaccination guidance.

Our findings result in new data that improve our understanding of current viral hepatitis epidemics and potential interventions. We provide granular data relevant to local health department prevention planning, a new opioid metric, data relevant to national policy makers and an informative framework for future research.   

Table of Contents

Chapter 1: Background and Significance. 1

Natural History. 1

Transmission. 3

Epidemiology. 4

Prevention and Treatment 6

Recent Trends in Incidence. 9

Public Health Priority: Elimination of HCV and HBV.. 11

Research Opportunities 14

Specific Dissertation Aims 15

Structure of Dissertation. 15

Chapter 2: County-Level Variation in Hepatitis C Virus Mortality and Trends in the United States, 2005-2017. 16

Abstract 16

Introduction. 17

Methods 18

Results 21

Discussion. 27

Chapter 3: Describing the Changing Relationship between Opioid Prescribing Rates and Overdose Mortality: A Novel County-Level Metric. 33

Abstract 33

Introduction. 34

Methods 37

Results 41

Discussion. 48

Chapter 4: Economic Evaluation of Universal Hepatitis B Vaccination among Adults 53

Abstract 53

Introduction. 54

Methods 56

Results 68

Discussion. 72

Chapter 5: Conclusions and Public Health Implications 77

Review of Major Findings 77

Innovation. 79

Relevance and Public Health Impact 80

Future Directions 85

References 88

Appendices 100

Appendix A: Supplemental Material for Chapter 2. 100

Appendix B: Supplemental Material for Chapter 3. 178

Appendix C: Supplemental Material for Chapter 4. 183

Appendix C1. Description of Susceptible to Infection/Currently Infected Markov Processes 183

Appendix C2. Risk of Acute HBV Infection Calculation. 188

Appendix C3. Supplemental Results 191

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