Back HCV Epidemiology Deaths Due to Hepatitis C Likely Undercounted

Deaths Due to Hepatitis C Likely Undercounted


Hepatitis C is "under-documented" on death certificates of people who die with the disease, according to a report in the February 12 advance edition of Clinical Infectious Diseases. Only about 20% of people with HCV-related chronic liver disease had this listed as a cause of death, even though a majority had evidence of moderate or advanced liver fibrosis. A related study in New York City found that people with hepatitis C were at increased risk of dying, and of dying at younger ages.

The number of people dying with HCV-related liver disease has been rising as people in the Baby Boomer age cohort (born 1945-1965) -- which has the highest prevalence of chronic hepatitis C in the U.S. -- experiences long-term disease progression. But actual rates and causes of death have not been extensively studied.

Mortality among People with HCV

Reena Mahajan from the Centers for Disease Control and Prevention (CDC) and colleagues looked at disease-specific, liver-related, and non-liver-related mortality among people with HCV in the observational Chronic Hepatitis Cohort Study (CHeCS) at 4 U.S. health care systems. They compared this to Multiple Cause of Death (MCOD) data from 12 million death certificates recorded in 2006-2010.


  • Among 2,143,369 adult patients seen at CHeCS sites during 2006-2010, a total of 11,703 (0.5%) had been diagnosed with chronic HCV and 1590 (14%) died.
  • Most (75%) of the CHeCS participants who died were born between 1945-1965, 68% were men, and half were white.
  • The mean age of death was 59 years -- 15 years younger than the average age of MCOD deaths.
  • The age-adjusted mortality rate for liver disease among CHeCS participants was 12 times higher than the MCOD rate.
  • Before death, 63% of CHeCS participants who died had evidence in their medical records of chronic liver disease, 76% had elevated FIB-4 scores (a non-invasive liver fibrosis biomarker index), and 70% of those who underwent liver biopsy had moderate or worse liver fibrosis.
  • However, only 19% of all people who died in the CHeCS cohort and only 30% of those with recorded liver disease had hepatitis C listed on their death certificates.

"HCV infection is greatly under-documented on death certificates," the study authors summarized. "The 16,622 persons with HCV listed in 2010 may represent only one-fifth of about 80,000 HCV-infected persons dying that year, at least two-thirds of whom (53,000 patients) would have pre-mortem indications of chronic liver disease."

"Data from this study suggests a much greater role of HCV on mortality in the United States than has been previously understood based on analyses of death certificate data," they continued in their discussion. These data "contradict prevalent views that, perhaps because of its long incubation period (30 years), HCV infection is an indolent infection that is not of urgent concern."

These results may still be conservative, as recent studies indicate that only about half of all people with HCV have been diagnosed, they suggested. Even among the 156 HCV positive CHeCS patients who had liver transplants, only 46 (29%) had HCV noted on their death certificate.

"[E]ven if we exclude other diseases associated with HCV infection such as diabetes and non-Hodgkin lymphoma,it appears that most are dying not just with HCV but in possibly from HCV," the authors concluded. "These considerations are especially important because identifying and treating HCV patients in an era of rapidly evolving and effective, curative therapies could have a major public health impact."

New York City Death Rates

Jessie Pinchoff and colleagues analyzed surveillance data from 2000-2010 and mortality data from 2000-2011 maintained by the New York City Department of Health and Mental Hygiene, looking at causes and factors associated with death among adults with hepatitis C.

Between 2000 and 2011 a total of 13,307 HCV monoinfected adults and 5475 HIV/HCV coinfected adults died. People who died with HCV alone were more likely to have died of liver cancer (odds ration [OR] 9.2, or 9 times higher likelihood), drug-related causes (OR 4.3), and cirrhosis (OR 3.7) compared to people with neither infection. Coinfected people were more likely to have died of liver cancer (OR 2.2) and drug-related causes (OR 3.1). Among coinfected people, 54% of deaths were attributed to HIV/AIDS. Most deaths (94%) occurred prematurely, before age 65.

"HCV-infected adults were at increased risk of dying and of dying prematurely, particularly from conditions associated with HCV, such as HIV/AIDS or drug use," the researchers concluded. "The short interval between HCV report and death suggests a need for earlier testing and improved treatment."



R Mahajan, J Xing, SJ Liu, et al. Mortality among Persons in Care with Hepatitis C Virus Infection -- The Chronic Hepatitis Cohort Study (CHeCS), 2006-2010. Clinical Infectious Diseases. February 12, 2014 (Epub ahead of print).

J Pinchoff, K Bornschlegel, S Braunstein, et al. Deaths among People with Hepatitis C in New York City, 2000-2011. Clinical Infectious Diseases. February 12, 2014 (Epub ahead of print).

K Rose. Determining the Effect of Hepatitis C on Mortality: Sorting the Signal From the Noise.Clinical Infectious Diseases. February 12, 2014 (Epub ahead of print).