of Death Among People with Hepatitis B and C
Deaths due to most liver-related causes dropped among people
with hepatitis B, and people with hepatitis C were less likely
to die of drug-related causes, but mortality due to hepatocellular
carcinoma remained stable, according to a large Australian
study. Coinfection with HIV increased mortality significantly.
time chronic hepatitis B virus (HBV)
and hepatitis C virus (HCV) infection
can progress to advanced liver disease, including life-threatening
liver failure and hepatocellular carcinoma (HCC), a form of liver
cancer. These viruses are often transmitted through shared drug
injection equipment and people with hepatitis B and C are therefore
also at elevated risk for death due to drug-related causes such
a retrospective study described in the May
11, 2011, Journal of Hepatology, Scott Walter and colleagues
analyzed specific causes of death among a population-based cohort
of people with hepatitis B or C to examine trends in mortality
and identify areas of excess risk.
study authors looked at medical records of people with hepatitis
B or C in New South Wales, Australia, between 1992 and 2006. New
South Wales is the most populous state in Australia, including
almost one-third of the country's population.
data from the state's Notifiable Diseases Database, the researchers
determined trends in mortality among people with HBV monoinfection,
HCV monoinfection, HBV/HCV coinfection, HIV/HBV
coinfection, and HIV/HBV/HCV triple infection. Australia law
mandates reporting of HIV, HBV, and HCV diagnoses, allowing the
opportunity to conduct an accurate population-based assessment
of people living with these diseases.
previous population-based study found large increases in rates
of death among people with hepatitis B and an alarmingly jump
in mortality among people with hepatitis C. The high HCV-related
mortality was largely attributed to deaths due to drug-related
causes, outnumbering deaths caused by liver disease. In the current
study, the researchers extended their previous work to examine
recent trends in HBV- and HCV-related deaths, including the impact
The study looked at medical records of 128,726 patients:
people (63.7%) with HCV monoinfection;
people (33%) with HBV monoinfection;
people (2.6%) with HBV/HCV coinfection;
people (0.2%) with HIV/HBV coinfection;
people (0.5%) with HIV/HCV coinfection; and
people (< 0.1%) with HIV/HBV/HCV triple infection.
cohort included 60% men and 40% women; 90% of people with HIV
were men, and 72% of those coinfected with HBV/HCV were men. All
patients had been diagnosed with viral hepatitis between 1994
and 2002. If an individual died within 6 months of diagnosis,
he or she was excluded from the analysis (1367 people).
total of 6201 people died between 1992 and 2006, with mortality
rates differing widely across groups:
HCV monoinfection: 6%;
leading cause of death for the HBV monoinfected group was
neoplasms (tumors), most frequently HCC, followed by lung
cancer and lymphoid cancer.
rates were significantly higher among people with HBV monoinfection
than among those with HCV monoinfection.
with HBV were significantly more likely to have HCC than those
contrast, the leading cause of death in the HCV monoinfected
group was not specifically liver-related -- 72% of deaths
were the result of drug overdose or suicide.
rate of all-cause mortality was significantly higher for the
HCV monoinfected group than for the HBV monoinfected group.
taking into account age and sex, people with HCV monoinfection
had a 2.5 times higher mortality rate compared with the overall
population of New South Wales.
the number of drug-related deaths among people with HCV in
2002 was approximately half that seen prior to 2000, and rates
have since remained low and stable.
deaths of people with HCV during 2002-2006 were significantly
lower than those reported during 1997-2001.
women with HBV or HCV, the risks of death due to drug-related
causes and, significantly, liver disease, was higher than
it was for men.
of liver-related death increased with age in both the HBV
monoinfected and HCV monoinfected groups.
people with HBV/HCV coinfection, rates of all-cause death
were considerably higher than among people with HBV or HCV
with the overall population of New South Wales, the mortality
rate for people with coinfection (HBV/HCV, HIV/HBV, or HIV/HCV)
was 4 to 24 times higher.
coinfected with HIV also had a markedly higher risk of death
compared to other infected groups.
with HIV/HBV coinfection had a mortality rate 10 times
higher than those with HBV monoinfection.
with HIV/HCV coinfection were at least 3 times more
likely to die than their HCV monoinfected counterparts.
deaths among HIV/HBV and HIV/HCV coinfected people were HIV-related
(70% and 61%, respectively).
with HIV/HBV/HCV triple infection had by far the highest rate
of death due to all causes.
their discussion of their analysis, the researchers described
the supply and purity of opiates that contributed to drug-related
deaths, specifically the shortage and higher price of heroin in
late 2000 and early 2001. The decrease in the supply of heroin
and its high price has been credited with fewer drug-related deaths
during that period. However, the researchers noted, "[O]ur
study found that rather than return to pre-2001 levels, rates
of drug-related deaths have remained low in 2002 to 2006."
reaching interventions such as the needle and syringe exchange
programs (NSPs) and harm reduction campaigns delivered through
the NSPs may also have contributed to the maintenance of improved
drug-related mortality since 2001 among those infected with HCV,"
addition, they wrote, "The moderate decline in non-HCC liver
disease mortality among people with HBV monoinfection and the
decline in age-specific rates of liver-related death with younger
cohorts suggest that improved HBV antiviral therapy may have reduced
the risk of death from decompensated cirrhosis."
authors suggested that the availability of antiviral drugs for
the treatment of hepatitis B may also have contributed to a decrease
in hepatocellular carcinoma, although this did not reach statistical
significance. "The study identified a positive trend in non-HCC
liver-related deaths among those infected with HBV, consistent
with improvements in HBV treatment and uptake."
pegylated interferon was only licensed in Australia in 2006, so
most people with hepatitis C were either not on treatment or on
thrice-weekly conventional interferon plus ribavirin. Lack of
the latest state-of-the-art treatment -- which now includes direct-acting
antiviral agents as well as pegylated interferon/ribavirin --
may have contributed to the high rate of death among people with
affiliations: National Centre in HIV Epidemiology and Clinical
Research, The University of New South Wales, Sydney, Australia;
New South Wales Department of Health, Sydney, Australia; Storr
Liver Unit, Westmead Hospital and Westmead Millennium Institute,
University of Sydney, Sydney, Australia; Australian Government
Department of Health and Ageing; NSW Cancer Council STREP Grant
Walter, H Thein, J Amin, et al. Trends in mortality after diagnosis
of hepatitis B or C infection: 1992-2006. Journal of Hepatology