Journal of Viral Hepatitis, 2015, 22, 238–244
doi:10.1111/jvh.12295
Hepatitis C virus infection in China: an emerging public health issue Qianqian Qin,1* M. Kumi Smith,1,2* Lu Wang,1 Yingying Su,1 Liyan Wang,1 Wei Guo,1 Lan Wang,1 Yan Cui1 and Ning Wang1 1National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; and 2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA Received April 2014; accepted for publication June 2014
SUMMARY. Hepatitis C virus now represents a global viral
pandemic and is the fourth most commonly reported infectious disease in China. Information on China’s national HCV epidemic was limited to cross -sectional seroprevalence studies of special populations, and a national surveillance effort had been launched to inform prevention and control. We analysed novel data from two national databases: (i) China’s national medical HCV case report system and (ii) the national disease sentinel surveillance system. Between 1997 and 2012, reporting incidence of medical cases for HCV infection rose from 0.7 to 15.0 cases per 100 000 with the largest burden of disease concentrated among individuals over 35 years of age, rural residents and those tested as part of routine screening. Between 2010 and 2012, disease sentinel surveillance identified the highest HCV seropositive rates among persons who use
INTRODUCTION Hepatitis C virus [HCV] infection was a major and growing public health problem in both developing and developed countries. The World Health Organization estimated that about 150 million persons currently lived with HCV infection, roughly five times the number of those infected with HIV [1]. Seventy-four to 86% of newly infected persons will develop chronic infection characterized by liver fibrosis, with some cases developing into cirrhosis and hepatocellular carcinoma [2]. Blood transfusion from unscreened donors and unsafe injection drug use were thought to have driven the majority of global transmission to date, although wide geographical differences in prevalence rates Abbreviations: CDC, Center for Disease Control; HCV, Hepatitis C virus. Correspondence: Ning Wang, MD PhD, National Center for AIDS/ STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China. E-mail: [email protected] *These authors contributed equally to the work.
drugs and haemodialysis patients, with far lower but not negligible rates among sexually active population. The concentration of cases among older age groups is consistent with past studies of age-specific prevalence rates in Asia. Differences across regions and testing modes suggest diverse biological and social forces driving the spread of HCV in China. Surveillance data show ongoing transmission, particularly among persons who use drugs and persons undergoing invasive medical treatments, particularly haemodialysis. Improvements in case detection and data reporting systems will be critical for understanding current drivers of transmission and identifying key areas for prevention. Keywords: China, disease surveillance, hepatitis C virus infection, medical case reports.
suggest different epidemiologic patterns across regions [3,4]. As of 2012, HCV infection was the fourth most commonly reported infectious disease in China after hepatitis B virus infection, pulmonary tuberculosis and dysentery [5]. Global seroprevalence comparisons suggested that HCV infection may be hyperendemic in China as in the rest of the Asia [4]. Knowledge of China’s HCV epidemic to date was largely informed by surveys of special populations [6–8] and HCV subtype analyses among chronically infected individuals [9,10], groups whose experiences may not be representative of the general population. Several large-scale seroprevalence studies had reported estimates in large samples of asymptomatic Chinese ranging from 0.39 to 3.2% [11,12], but the heterogeneity of sampling strategies and time periods limit the comparability of rates across these studies. Moreover, the voracity of conclusions drawn from HCV seroprevalence estimates was weakened by the limitation of antibody testing for confirming active infection or for distinguishing between past and current infection. National level prevalence studies using alternative detection methods such as HCV RNA testing and more rigorous sampling strategies were needed but are costly and time-consuming to conduct. © 2014 John Wiley & Sons Ltd
Hepatitis C virus in China In the meantime, this report represents the most comprehensive investigation of China’s HCV epidemic to date, using novel data from its national HCV case report and disease sentinel surveillance systems. Insights from this analysis seek to shape China’s future HCV control efforts, particularly at a time of increasing political consensus on this issue’s importance. Its ongoing injection drug use epidemic, rapidly expanding healthcare infrastructure and large population size made HCV control in China a global public health priority.
MATERIALS AND METHODS Medical case report system China’s medical case report system requires mandatory reporting of laboratory confirmed cases of HCV infection to the China Center for Disease Control [CDC] by hospitals, disease control stations and other qualified healthcare facilities at every administrative level in China’s 31 provinces, municipalities and autonomous regions. In 2004, the paper-based medical case report system was replaced by a web-based system, which allowed real-time reporting to the national CDC. Unlike case reports compiled during the paper-based system, electronically filed reports contain individual level information on patients (name, residential address and personal ID number), demographical information (sex, age and occupation), the reporting health facility and HCV test mode (‘active testing’ for those presenting clinically vs ‘passive testing’ such as routine screening for pre-operative or antenatal procedures or for state administered health exams). For this reason all stratified analyses are restricted to after 2004 when individual level information first became available. Laboratory testing specifications for case reports of HCV infection are issued by the national reference laboratory of the China CDC. Samples that test positive for anti-HCV antibodies are rescreened with the same reagent using the double aperture method or with a different reagent from a second manufacturer. Those with double positive or discordant results undergo confirmation testing using (i) Western blot or (ii) a qualitatively assessment of HCV viremia levels according to anti-HCV signal-to-cut-off ratios, followed by Western blot for those with low S/CO ratios (high S/CO ratios are considered positive). Samples determined to be positive at this final stage of testing are considered reportable as anti-HCV antibody positive. Guidelines for HCV RNA detection also exist, although capacity to conduct reliable and consistent PCR and fluorescence quantitative PCR testing is limited to a small number of specialized laboratory facilities in China, and at the time of writing are therefore considered supplementary, but not primary criteria for confirming case reports for HCV infection. Case criteria for reportable cases of HCV infection are dictated by the China CDC [13] and require all confirmed © 2014 John Wiley & Sons Ltd
239
positive anti-HCV antibody tests to meet at least one of the following epidemiological or clinical criteria. Epidemiological criteria include patients’ reported contact with any blood, blood products or human tissue; history of any invasive medical procedures, haemodialysis, organ transplants or unsafe injections (including that of illicit drugs); history of commercial blood donation or sexual contact with a HCV-infected person and children born to HCV-infected mothers. Clinical criteria include fatigue, loss of appetite, nausea and right upper quadrant pain (for all stages of HCV infection); signs of splenomegaly or hepatomegaly (for chronic or advanced HCV infection) and development of varices in the oesophagus and other collateral sites from portal hypertension (for advanced HCV infection). Other clinical criteria include elevated levels of serum aspartate aminotransferase, alanine aminotransferase or bilirubin; histological evidence of chronic hepatitis including lobular and periportal inflammation and progressive fibrosis. If available, B-mode ultrasounds, CT scans or MRI imaging indicative of splenomegaly and hepatomegaly (for all stages of HCV infection), damage to the liver parenchyma (for chronic and advanced HCV infection) or widening of the portal vein (for advanced HCV infection) can also be used as case defining criteria. Although clinicians may use the above-mentioned to differentiate among acute, chronic and advanced cases of HCV infection to inform treatment and management decisions, they are not required to report symptoms or disease stage in the case reports they file, nor do they indicate the type of laboratory testing (antibody or RNA testing) conducted for the diagnosis.
Sentinel surveillance A national sentinel surveillance system to monitor the HCV epidemic in China was established in 2010. Annual cross-sectional surveys are conducted at fixed times and sites, using target sample sizes for key populations including voluntary blood donors, kidney haemodialysis patients, patients undergoing invasive medical procedures such as surgery, endoscopy or routine injections. HCV antibody test results conducted for routine health exams for events such as employment, marriage registration, university enrolment or immigrant residence registration are also included in national surveillance databases to represent rates in the lower risk general population. In addition to this, HCV antibody testing was introduced into the panel of laboratory testing conducted as part of China’s routine HIV surveillance work in 2010. The HIV surveillance system – described previously by Sun et al. [14] – consists of 1888 sentinel sites that monitor HIV in subpopulations including persons who use drugs, female sex workers, men who have sex with men [MSM] and patients presenting at sexually transmitted disease clinics, all of whom may have elevated risk for HCV infection. HIV
240
Q. Qin et al.
surveillance is also conducted on lower risk groups such as university students and women in antenatal care, HCV testing results of which are also included in this analysis. HCV testing for blood samples collected for HCV and HIV sentinel surveillance follow the same laboratory testing specifications as for HCV case reporting.
Statistical analysis Crude rates per 100 000 populations were calculated using resident population census data from National Bureau of the Census in China from 2005 to 2012. Case numbers and reporting incidence of HCV infection were analysed by year, age groups, county of residence, testing mode (active vs passive) and type of residence (village, township and city). Trends in HCV seroprevalence from the surveillance data were tested over time using the Cochran–Armitage trend test.
Role of funding source The sponsors had no role in the data collection, data analysis, data interpretation or writing of this report. The corresponding author is responsible for the content of the report and had final responsibility for the decision to submit for publication.
RESULTS
Age-specific trends in annual incidence of reported cases of HCV infection differ greatly across testing modes (Fig. 2). Older age groups had consistently higher reporting incidence rates as compared to younger age groups, for both types of testing mode. However, whereas rates remained stable over time for all age groups who were tested actively, rates of those detected through passive testing show great heterogeneity across age groups. Particularly among those over 35, reporting incidence for those tested passively has increased steadily over time (Fig. 2, right panel); in 2012, the reporting incidence among persons over 60 was 4.7 per 100 000 in those testing actively vs 24.6 in those testing passively. Figure 3 shows the geographical distribution of the reported cases per 100 000 persons, grouped by patients’ counties of residence in 2005, 2007, 2009 and 2011. By 2011, 91.3% of China’s roughly 3000 counties had reported at least one case of HCV infection, and 17 provinces were reporting over 10 cases per 100 000 in a single year. The 35 counties with the highest reporting incidence (over 100 cases per 100 000) in 2011 were concentrated in Henan, Hebei, Gansu, Xinjiang, Inner Mongolia and Jilin Provinces. The distribution of reported cases according to the type of residence – village (rural), township (peri-urban) and city (urban) – suggests that rural residents may be bearing an increasingly large burden of HCV infection in China. The upward trend for townships is not as steep as for villages, but higher than cities (Fig. 4).
Medical case reports Sentinel surveillance data The national sentinel surveillance data in Table 1 shows that between 2010 and 2012, anti-HCV antibody rates were highest among surveyed drug users among whom rates averaged 42.1% with no statistically significant trend across the 3 years. Seroprevalence rates among haemodialysis patients were also notably high with a 3 year average
180 000
16.0
160 000
14.0
Reported cases
140 000
12.0 TransiƟon to web-based reporƟng system. When acƟve and passive cases began to be disƟnguished.
120 000 100 000 80 000
10.0 8.0 6.0
60 000
4.0
40 000
2.0
20 000 0
ReporƟng incidence (per 100 000)
The reporting incidence of HCV medical cases reports has increased over time, rising from 0.7 to 15.0 cases per 100 000 from 1997 to 2012, the latter year in which 201 622 cases were reported (Fig. 1). In 2004, when the paper-based reporting system was replaced with a webbased system, cases were distinguished for the first time based on the testing method of confirmed cases.
0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Year Paper based Paper based
AcƟve tesƟng (web based) AcƟve tesƟng (web based)
Passive tesƟng (web based) Passive tesƟng (web based)
Fig. 1 Medical case reports for HCV infection, 1997–2012. © 2014 John Wiley & Sons Ltd
30
ReporƟng incidence (per 100 000)
Fig. 2 Age distribution of reported case reports for active testing (left) and passive testing (right), by 10-year age groups, 2005–2012.
ReporƟng incidence (per 100 000)
Hepatitis C virus in China AcƟve tesƟng
25 20 15 10 5 0 2005 2006 2007 2008 2009 2010 2011 2012 0–14 15–24 25–34
241
Passive tesƟng
30 25 20 15 10
35–44
5 0 2005 2006 2007 2008 2009 2010 2011 2012 45–54 55–64 65+
2005
2007
2009
2011
051050100-
Fig. 3 Incidence of reported HCV cases by county, 2005–2011.
100 000 90 000
Reported cases
80 000 70 000 60 000 50 000 40 000 30 000 20 000 10 000 0
Fig. 4 Number of reported cases by patient residence, 2005–2012.
2005
of 6.6%, although rates fluctuated over this time. Among all the remaining groups’ rates remained under 1% but were markedly higher in MSM and higher risk heterosexu© 2014 John Wiley & Sons Ltd
2006 City
2007
2008
Township
2009
2010
Village
2011
2012
Unknown
als as compared to voluntary blood donors, persons undergoing medical procedures and members of the general population. Trends in the seroprevalence rates for every
group except for drug users were statistically significant over the 3-year period.
0.0177 0.059
doi:10.1111/jvh.12295
Hepatitis C virus infection in China: an emerging public health issue Qianqian Qin,1* M. Kumi Smith,1,2* Lu Wang,1 Yingying Su,1 Liyan Wang,1 Wei Guo,1 Lan Wang,1 Yan Cui1 and Ning Wang1 1National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; and 2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA Received April 2014; accepted for publication June 2014
SUMMARY. Hepatitis C virus now represents a global viral
pandemic and is the fourth most commonly reported infectious disease in China. Information on China’s national HCV epidemic was limited to cross -sectional seroprevalence studies of special populations, and a national surveillance effort had been launched to inform prevention and control. We analysed novel data from two national databases: (i) China’s national medical HCV case report system and (ii) the national disease sentinel surveillance system. Between 1997 and 2012, reporting incidence of medical cases for HCV infection rose from 0.7 to 15.0 cases per 100 000 with the largest burden of disease concentrated among individuals over 35 years of age, rural residents and those tested as part of routine screening. Between 2010 and 2012, disease sentinel surveillance identified the highest HCV seropositive rates among persons who use
INTRODUCTION Hepatitis C virus [HCV] infection was a major and growing public health problem in both developing and developed countries. The World Health Organization estimated that about 150 million persons currently lived with HCV infection, roughly five times the number of those infected with HIV [1]. Seventy-four to 86% of newly infected persons will develop chronic infection characterized by liver fibrosis, with some cases developing into cirrhosis and hepatocellular carcinoma [2]. Blood transfusion from unscreened donors and unsafe injection drug use were thought to have driven the majority of global transmission to date, although wide geographical differences in prevalence rates Abbreviations: CDC, Center for Disease Control; HCV, Hepatitis C virus. Correspondence: Ning Wang, MD PhD, National Center for AIDS/ STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China. E-mail: [email protected] *These authors contributed equally to the work.
drugs and haemodialysis patients, with far lower but not negligible rates among sexually active population. The concentration of cases among older age groups is consistent with past studies of age-specific prevalence rates in Asia. Differences across regions and testing modes suggest diverse biological and social forces driving the spread of HCV in China. Surveillance data show ongoing transmission, particularly among persons who use drugs and persons undergoing invasive medical treatments, particularly haemodialysis. Improvements in case detection and data reporting systems will be critical for understanding current drivers of transmission and identifying key areas for prevention. Keywords: China, disease surveillance, hepatitis C virus infection, medical case reports.
suggest different epidemiologic patterns across regions [3,4]. As of 2012, HCV infection was the fourth most commonly reported infectious disease in China after hepatitis B virus infection, pulmonary tuberculosis and dysentery [5]. Global seroprevalence comparisons suggested that HCV infection may be hyperendemic in China as in the rest of the Asia [4]. Knowledge of China’s HCV epidemic to date was largely informed by surveys of special populations [6–8] and HCV subtype analyses among chronically infected individuals [9,10], groups whose experiences may not be representative of the general population. Several large-scale seroprevalence studies had reported estimates in large samples of asymptomatic Chinese ranging from 0.39 to 3.2% [11,12], but the heterogeneity of sampling strategies and time periods limit the comparability of rates across these studies. Moreover, the voracity of conclusions drawn from HCV seroprevalence estimates was weakened by the limitation of antibody testing for confirming active infection or for distinguishing between past and current infection. National level prevalence studies using alternative detection methods such as HCV RNA testing and more rigorous sampling strategies were needed but are costly and time-consuming to conduct. © 2014 John Wiley & Sons Ltd
Hepatitis C virus in China In the meantime, this report represents the most comprehensive investigation of China’s HCV epidemic to date, using novel data from its national HCV case report and disease sentinel surveillance systems. Insights from this analysis seek to shape China’s future HCV control efforts, particularly at a time of increasing political consensus on this issue’s importance. Its ongoing injection drug use epidemic, rapidly expanding healthcare infrastructure and large population size made HCV control in China a global public health priority.
MATERIALS AND METHODS Medical case report system China’s medical case report system requires mandatory reporting of laboratory confirmed cases of HCV infection to the China Center for Disease Control [CDC] by hospitals, disease control stations and other qualified healthcare facilities at every administrative level in China’s 31 provinces, municipalities and autonomous regions. In 2004, the paper-based medical case report system was replaced by a web-based system, which allowed real-time reporting to the national CDC. Unlike case reports compiled during the paper-based system, electronically filed reports contain individual level information on patients (name, residential address and personal ID number), demographical information (sex, age and occupation), the reporting health facility and HCV test mode (‘active testing’ for those presenting clinically vs ‘passive testing’ such as routine screening for pre-operative or antenatal procedures or for state administered health exams). For this reason all stratified analyses are restricted to after 2004 when individual level information first became available. Laboratory testing specifications for case reports of HCV infection are issued by the national reference laboratory of the China CDC. Samples that test positive for anti-HCV antibodies are rescreened with the same reagent using the double aperture method or with a different reagent from a second manufacturer. Those with double positive or discordant results undergo confirmation testing using (i) Western blot or (ii) a qualitatively assessment of HCV viremia levels according to anti-HCV signal-to-cut-off ratios, followed by Western blot for those with low S/CO ratios (high S/CO ratios are considered positive). Samples determined to be positive at this final stage of testing are considered reportable as anti-HCV antibody positive. Guidelines for HCV RNA detection also exist, although capacity to conduct reliable and consistent PCR and fluorescence quantitative PCR testing is limited to a small number of specialized laboratory facilities in China, and at the time of writing are therefore considered supplementary, but not primary criteria for confirming case reports for HCV infection. Case criteria for reportable cases of HCV infection are dictated by the China CDC [13] and require all confirmed © 2014 John Wiley & Sons Ltd
239
positive anti-HCV antibody tests to meet at least one of the following epidemiological or clinical criteria. Epidemiological criteria include patients’ reported contact with any blood, blood products or human tissue; history of any invasive medical procedures, haemodialysis, organ transplants or unsafe injections (including that of illicit drugs); history of commercial blood donation or sexual contact with a HCV-infected person and children born to HCV-infected mothers. Clinical criteria include fatigue, loss of appetite, nausea and right upper quadrant pain (for all stages of HCV infection); signs of splenomegaly or hepatomegaly (for chronic or advanced HCV infection) and development of varices in the oesophagus and other collateral sites from portal hypertension (for advanced HCV infection). Other clinical criteria include elevated levels of serum aspartate aminotransferase, alanine aminotransferase or bilirubin; histological evidence of chronic hepatitis including lobular and periportal inflammation and progressive fibrosis. If available, B-mode ultrasounds, CT scans or MRI imaging indicative of splenomegaly and hepatomegaly (for all stages of HCV infection), damage to the liver parenchyma (for chronic and advanced HCV infection) or widening of the portal vein (for advanced HCV infection) can also be used as case defining criteria. Although clinicians may use the above-mentioned to differentiate among acute, chronic and advanced cases of HCV infection to inform treatment and management decisions, they are not required to report symptoms or disease stage in the case reports they file, nor do they indicate the type of laboratory testing (antibody or RNA testing) conducted for the diagnosis.
Sentinel surveillance A national sentinel surveillance system to monitor the HCV epidemic in China was established in 2010. Annual cross-sectional surveys are conducted at fixed times and sites, using target sample sizes for key populations including voluntary blood donors, kidney haemodialysis patients, patients undergoing invasive medical procedures such as surgery, endoscopy or routine injections. HCV antibody test results conducted for routine health exams for events such as employment, marriage registration, university enrolment or immigrant residence registration are also included in national surveillance databases to represent rates in the lower risk general population. In addition to this, HCV antibody testing was introduced into the panel of laboratory testing conducted as part of China’s routine HIV surveillance work in 2010. The HIV surveillance system – described previously by Sun et al. [14] – consists of 1888 sentinel sites that monitor HIV in subpopulations including persons who use drugs, female sex workers, men who have sex with men [MSM] and patients presenting at sexually transmitted disease clinics, all of whom may have elevated risk for HCV infection. HIV
240
Q. Qin et al.
surveillance is also conducted on lower risk groups such as university students and women in antenatal care, HCV testing results of which are also included in this analysis. HCV testing for blood samples collected for HCV and HIV sentinel surveillance follow the same laboratory testing specifications as for HCV case reporting.
Statistical analysis Crude rates per 100 000 populations were calculated using resident population census data from National Bureau of the Census in China from 2005 to 2012. Case numbers and reporting incidence of HCV infection were analysed by year, age groups, county of residence, testing mode (active vs passive) and type of residence (village, township and city). Trends in HCV seroprevalence from the surveillance data were tested over time using the Cochran–Armitage trend test.
Role of funding source The sponsors had no role in the data collection, data analysis, data interpretation or writing of this report. The corresponding author is responsible for the content of the report and had final responsibility for the decision to submit for publication.
RESULTS
Age-specific trends in annual incidence of reported cases of HCV infection differ greatly across testing modes (Fig. 2). Older age groups had consistently higher reporting incidence rates as compared to younger age groups, for both types of testing mode. However, whereas rates remained stable over time for all age groups who were tested actively, rates of those detected through passive testing show great heterogeneity across age groups. Particularly among those over 35, reporting incidence for those tested passively has increased steadily over time (Fig. 2, right panel); in 2012, the reporting incidence among persons over 60 was 4.7 per 100 000 in those testing actively vs 24.6 in those testing passively. Figure 3 shows the geographical distribution of the reported cases per 100 000 persons, grouped by patients’ counties of residence in 2005, 2007, 2009 and 2011. By 2011, 91.3% of China’s roughly 3000 counties had reported at least one case of HCV infection, and 17 provinces were reporting over 10 cases per 100 000 in a single year. The 35 counties with the highest reporting incidence (over 100 cases per 100 000) in 2011 were concentrated in Henan, Hebei, Gansu, Xinjiang, Inner Mongolia and Jilin Provinces. The distribution of reported cases according to the type of residence – village (rural), township (peri-urban) and city (urban) – suggests that rural residents may be bearing an increasingly large burden of HCV infection in China. The upward trend for townships is not as steep as for villages, but higher than cities (Fig. 4).
Medical case reports Sentinel surveillance data The national sentinel surveillance data in Table 1 shows that between 2010 and 2012, anti-HCV antibody rates were highest among surveyed drug users among whom rates averaged 42.1% with no statistically significant trend across the 3 years. Seroprevalence rates among haemodialysis patients were also notably high with a 3 year average
180 000
16.0
160 000
14.0
Reported cases
140 000
12.0 TransiƟon to web-based reporƟng system. When acƟve and passive cases began to be disƟnguished.
120 000 100 000 80 000
10.0 8.0 6.0
60 000
4.0
40 000
2.0
20 000 0
ReporƟng incidence (per 100 000)
The reporting incidence of HCV medical cases reports has increased over time, rising from 0.7 to 15.0 cases per 100 000 from 1997 to 2012, the latter year in which 201 622 cases were reported (Fig. 1). In 2004, when the paper-based reporting system was replaced with a webbased system, cases were distinguished for the first time based on the testing method of confirmed cases.
0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Year Paper based Paper based
AcƟve tesƟng (web based) AcƟve tesƟng (web based)
Passive tesƟng (web based) Passive tesƟng (web based)
Fig. 1 Medical case reports for HCV infection, 1997–2012. © 2014 John Wiley & Sons Ltd
30
ReporƟng incidence (per 100 000)
Fig. 2 Age distribution of reported case reports for active testing (left) and passive testing (right), by 10-year age groups, 2005–2012.
ReporƟng incidence (per 100 000)
Hepatitis C virus in China AcƟve tesƟng
25 20 15 10 5 0 2005 2006 2007 2008 2009 2010 2011 2012 0–14 15–24 25–34
241
Passive tesƟng
30 25 20 15 10
35–44
5 0 2005 2006 2007 2008 2009 2010 2011 2012 45–54 55–64 65+
2005
2007
2009
2011
051050100-
Fig. 3 Incidence of reported HCV cases by county, 2005–2011.
100 000 90 000
Reported cases
80 000 70 000 60 000 50 000 40 000 30 000 20 000 10 000 0
Fig. 4 Number of reported cases by patient residence, 2005–2012.
2005
of 6.6%, although rates fluctuated over this time. Among all the remaining groups’ rates remained under 1% but were markedly higher in MSM and higher risk heterosexu© 2014 John Wiley & Sons Ltd
2006 City
2007
2008
Township
2009
2010
Village
2011
2012
Unknown
als as compared to voluntary blood donors, persons undergoing medical procedures and members of the general population. Trends in the seroprevalence rates for every
group except for drug users were statistically significant over the 3-year period.
0.0177 0.059
