Background The expansion of the U.S. opioid epidemic has led to significant increases in infections such as infective endocarditis (IE), which is tied to injection behaviors. We aimed to estimate the population-level IE mortality among people who inject opioids and compare the risk of IE death against the risks of death from other causes Methods We developed a microsimulation model of the natural history of injection opioid use. We defined injection behavior profile by both injection frequency and injection techniques. We accounted for competing risks of death and populated the model with primary and published data. We modeled cohorts of 1 million individuals with different injection behavior profiles until age 60. We combined model-generated estimates with published data to project the total expected IE deaths in the U.S. by 2030 Results The probability of death from IE by age 60 years for 20-, 30-, and 40-year-old men with high frequency use with higher infection risk techniques compared to lower risk techniques for IE was 53.8% versus 3.7%, 51.4% versus 3.1%, and 44.5% versus 2.2%, respectively. The predicted population-level attributable fraction of 10-year mortality for IE among all risk groups was 20%. We estimated that approximately 257,800 people are expected to die from IE by 2030 Conclusions The expected burden of IE among people who inject opioids in the U.S. is large. Adopting a harm reduction approach, including expansion of syringe service programs, to address injection behaviors could have a major impact on decreasing the mortality associated with the opioid epidemic

Objective-To estimate the clinical effects and cost-effectiveness of universal prenatal hepatitis C screening, and to calculate potential life expectancy, quality of life, and health care costs associated with universal prenatal hepatitis C screening and linkage to treatment. Methods-Using a stochastic individual-level microsimulation model, we simulated the lifetimes of 250 million pregnant women matched at baseline with the U.S. childbearing population on age, injection drug use behaviors, and hepatitis C virus (HCV) infection status. Modeled outcomes included hepatitis C diagnosis, treatment and cure, lifetime health care costs, quality-adjusted life years (QALY) and incremental cost-effectiveness ratios (ICERs) comparing universal prenatal hepatitis C screening to current practice. We modeled whether infants exposed to maternal hepatitis C virus (HCV) at birth were identified as such. Results-Hepatitis C virus-infected pregnant women lived 1.21 years longer and had 16% lower HCV-attributable mortality with universal prenatal hepatitis C screening, which had an ICER of $41,000 per QALY gained compared to current practice. Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most sensitivity analyses; notable exceptions included ICERs above $100,000 when assuming mean time to cirrhosis of 70 years, a cost greater than $500,000 per false positive diagnosis, or population HCV infection prevalence below 0.16%. Universal prenatal hepatitis C screening increased identification of infants exposed to HCV at birth from 44% to 92%. Conclusions-In our model, universal prenatal hepatitis C screening improves health outcomes in HCV-infected women, improves identification of HCV exposure in infants born at risk, and is cost-effective. PRÉCIS Universal testing for hepatitis C in pregnancy is cost effective and would increase average life expectancy by 1.21 years for infected women.