Delta hepatitis within the Veterans Affairs medical system in the United States: Prevalence, risk factors, and outcomes

Abstract

Background & Aims Low hepatitis delta prevalence estimates in the United States are likely biased due to low testing rates. The objectives of this study were to quantify the prevalence of testing and identify factors associated with hepatitis D positive status among chronic hepatitis B patients in the Veterans Health Administration Methods We performed a nationwide retrospective study of all veterans who tested positive for HBsAg from October 1999 to December 2013. Hepatitis D antibody testing results were used to stratify patients into 3 groups: HDV-positive, HDV-negative and HDV-not tested. Demographics, comorbidities, additional laboratory data and clinical outcomes were compared across these groups of patients using standard statistical approaches. Results Among 25,603 patients with a positive hepatitis B surface antigen, 2,175 (8.5%) were tested for HDV; 73 (3.4%) patients tested positive. Receiving HDV testing was associated with receipt of testing for HBV, HIV, and HCV. Predictors of positive HDV results included substance abuse and cirrhosis. Fitting a predefined high-risk profile (abnormal ALT with suppressed HBV DNA titers) was strongly associated with testing positive for HDV (OR 4.2, 95%CI 1.9–9.3). Most (59%) of HDV-positive patients were HCV co-infected. HDV-positive subjects had higher risks of all-cause mortality. Incidence rates of hepatocellular carcinoma were 2.9 fold higher in HDV-positive relative to HDV-negative individuals (p=0.002). In adjusted analyses, HDV was independently associated with HCC (OR 2.1, 95%CI 1.1–3.9). Conclusions Testing rates for hepatitis delta in chronic hepatitis B patients in the United States are inappropriately low. Approaches to increase testing for HDV particularly in high-risk subsets should be explored.

Hepatitis delta-associated mortality in HIV/HBV-coinfected patients

“…The prevalence of HDV infection in our cohort was similar to the findings from the EuroSIDA collaboration but slightly higher than the estimate reported in cohort studies from France and North America 17,18 . As false-positive HDV screening results seem to be frequent in the setting of HIV-infection 19 , we performed a confirmatory serology in all patients with a negative HDV RNA in order to strengthen our HDV prevalence estimate.…”

Hepatitis C Guidance 2019 Update: American Association for the Study of Liver Diseases–Infectious Diseases Society of America Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

“…These patterns do not commonly occur outside of the acute phase of HCV infection . Patients suspected of having acute HCV infection also require laboratory evaluation to exclude other or coexisting causes of acute hepatitis (e.g., HAV, HBV, hepatitis delta virus superinfection if chronically infected with HBV, hepatitis E virus [in the correct clinical scenario], and autoimmune hepatitis) . HIV testing is also recommended.…”

New epidemiology of hepatitis delta

“…However, only 12% of the 1007 HBsAg‐positive patients were tested for anti‐HDV . Furthermore, in a retrospective Veterans Administration study, 7.8% of HBsAg‐positive patients were tested for HDV and 3.6% of them were found to have HDV infection …”