By Clarisse A. Tsang, Julius Tonzel, Hasan Symum, Harvey W. Kaufman, William A. Meyer III, Ademola Osinubi, William W. Thompson and Carolyn Wester. Morbidity and Mortality Weekly Report (MMWR).
In brief
- Known: hepatitis C is deadly but curable. U.S. goals call for at least 80% of people with it to clear the virus by 2030.
- New: in 2013–2022 data from a large national commercial laboratory, the share who cleared the virus ranged from 10% to 51% by state — below goal everywhere.
- So what: state-by-state data show where testing, treatment and prevention are falling short.
Background
About 2 million U.S. adults had hepatitis C during January 2017–March 2020, and new infections roughly doubled from 2013 to 2022, mostly linked to injection drug use. Untreated, it can cause advanced liver disease, liver cancer and death; screening is recommended for all adults.
An 8–12-week course of oral direct-acting antivirals (DAAs) clears the virus in 95% or more of cases. The HHS Viral Hepatitis National Strategic Plan for 2021–2025 aims for at least 58% cleared by 2025 and 80% by 2030.
The clearance cascade
A clearance cascade tracks people through five steps:
- Ever infected — any positive hepatitis C test.
- Viral testing — an HCV RNA test, which tells past from current infection.
- Initial infection — detectable virus.
- Cured or cleared — virus later undetectable, from treatment or on its own.
- Persistent infection or reinfection — virus back after clearing.
CDC published guidance for such cascades in 2021, but many state surveillance systems cannot track people's lab results over time. So this study used ten years (January 1, 2013–December 31, 2022) of results from Quest Diagnostics across all 50 states and DC — the first state-level cascades from national laboratory data.
Results
Of 1,631,609 people ever infected, 1,627,170 (99.7%) could be placed in a state.
State-level estimates at each step of the cascade, 2013–2022. Chart: CDC.
| Step | Median across states | Range |
|---|---|---|
| Viral testing (of those ever infected) | 91% | 51% (Hawaii) to 99% (South Dakota) |
| Initial infection (of those tested) | 73% | 59% (New York) to 96% (South Dakota) |
| Cured or cleared (of those infected) | 29% | 10% (West Virginia) to 51% (Connecticut) |
| Persistent infection or reinfection (of those cleared) | 5% | 2% (Oklahoma, Maine) to 11% (California) |
- Below average: 37 states cured or cleared fewer than the national estimate of 35%. Five of the seven lowest were in southern Appalachia (West Virginia) or the north and central U.S. (Michigan, Minnesota, Nebraska, Ohio) — regions with high rates of new infection from injection drug use.
- All below goal: every jurisdiction was below the 2025 goal of 58% and far below the 2030 goal of 80%.
- Numbers vary: people ever infected ranged from 125 in North Dakota to 338,715 in California, reflecting population, lab coverage and prevalence.
Percentage cured or cleared, by jurisdiction, against the HHS 2025 and 2030 goals. Chart: CDC.
What it means
- Testing is mostly done right: the 91% median for viral testing reflects the best practice of automatically running an RNA test on every positive antibody test.
- Treatment is the gap: low clearance matches other studies showing low DAA treatment rates.
- Reinfection: the cascade cannot tell persistent infection (such as treatment failure) from reinfection (such as ongoing risk without access to syringe services); both need study.
- Ideally, every state would run its own complete surveillance registry, including all labs, people who moved or died, and links to treatment and prevention.
Limitations
- Only people with a positive test were counted, not everyone infected.
- One laboratory may not represent a state, and people tested elsewhere are missing.
- People with no follow-up RNA test are missed, which may understate clearance or recurrence.
For public health
The findings give every state data regardless of its surveillance capacity. Recommended action: more testing wherever people with hepatitis C get care, unrestricted access to treatment regardless of insurance, and full harm-reduction services for people who use and inject drugs.
Sources
Based on "State-Specific Hepatitis C Virus Clearance Cascades — United States, 2013–2022," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; MMWR material is in the public domain. Its full state-by-state table is in the article PDF. Two authors are affiliated with Quest Diagnostics, whose data were used; the report discloses their stock ownership and consulting fees.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
1
0
0
0
Comments
