Disparities are evident in viral hepatitis morbidity, mortality, and outcomes. Disparities are considered an outcome of social determinants of health (SDoH), as systemic differences in the conditions in which people are born, grow, live, work, and age can lead to differences in health outcomes and access to health care services among population groups.1,2 Disparities in viral hepatitis incidence and mortality are described in surveillance reports 3 and the literature4,5; however, an examination of the influence of SDoH on disparities in viral hepatitis incidence, mortality, and outcomes is missing from the literature. This gap in the literature could be a direct result of limitations in viral hepatitis surveillance data in capturing relevant measures. However, examining data on social, economic, physical, and political environments of people affected by viral hepatitis is important for understanding the incidence and outcomes of the disease, developing interventions, and assessing progress toward achieving health equity. 1 This commentary discusses existing disparities in viral hepatitis, explores how SDoH may contribute to these disparities, and highlights opportunities to examine the influence of SDoH on viral hepatitis outcomes.
Disparities in Viral Hepatitis
Disparities in viral hepatitis exist, with unequal effects on different populations. The rates of infection, complications, and death vary substantially among population groups. According to the 2022 Viral Hepatitis Surveillance Report, 3 non-Hispanic Black people had the highest rate of acute hepatitis B virus (HBV) infection in 2022, and non-Hispanic Asian/Pacific Islander people had the lowest rate. 3 Historically, people aged 30 to 59 years and men have had the highest rates of acute HBV infection. 3 Chronic HBV infection follows a similar pattern of disparities, with the highest rates of infection found among non-Hispanic Asian/Pacific Islander people followed by non-Hispanic Black, non-Hispanic American Indian/Alaska Native, non-Hispanic White, and Hispanic people in 2022. 3 People aged 30 to 59 years and men had the highest rates of chronic HBV infection in 2022. 3 The disparity extends to hepatitis B–related deaths: non-Hispanic Asian/Pacific Islander and non-Hispanic Black people had significantly higher mortality rates than non-Hispanic White people in 2022. 3 Lastly, hepatitis B–related mortality rates were also highest among adults aged >55 years and men. 3
HBV transmission can occur via sexual contact, from mother to child during pregnancy or birth, and through injection drug use, which was the most commonly reported risk behavior among risk behaviors and exposures identified in 2022. 3 The concerning trend of disparities observed in HBV infection rates is not isolated. Similar patterns of disparities exist when examining rates of hepatitis C virus (HCV) infection and death.
HCV transmission can occur perinatally, through sexual contact, or through injection drug use, which is the most commonly reported risk behavior. 3 In 2022, the estimated number of acute HCV infections was highest among non-Hispanic American Indian/Alaska Native people and lowest among non-Hispanic Asian/Pacific Islander people. 3 Since 2010, people aged 20 to 49 years have consistently had the highest rates of acute HCV infection, similar to the age group with the highest rate of fatal overdoses in the United States. 6 The picture becomes more complicated when examining chronic HCV infection, the long-term form of the infection. Non-Hispanic Black people had the highest rate of infection in 2022, and non-Hispanic Asian/Pacific Islander people had the lowest rates. 3 Chronic HCV infection rates were significantly higher among adults aged ≥20 years compared with people aged <19 years. 3 The consequences of HCV are most severe for adults aged 55 to 74 years; this group also had the highest rates of HCV-related deaths in 2022. 3 Lastly, men have had consistently higher rates of infection than women for both acute and chronic HCV infection and HCV-related deaths. 3
These findings underscore the urgent need for targeted interventions to address HCV across racial and ethnic populations, age groups, and genders. Differences in viral hepatitis incidence and mortality may reflect differences in screening, immunization, and treatment access and use among racial and ethnic groups. SDoH factors such as poverty, access to quality health care, and language barriers can affect a person’s ability to take preventive steps such as screening and vaccination and access to potentially life-saving treatment. While we know the role that SDoH play in health outcomes, further research is needed to determine the ways that various SDoH contribute to disparities in viral hepatitis infection. By understanding these disparities and their potential causes, we can develop more effective strategies to achieve the public health goal of eliminating viral hepatitis in the United States.
Influence of SDoH on Disparities
SDoH have emerged in recent decades as a critical area of research, highlighting the unequal distribution of factors that shape health across populations. One SDoH that influences health disparities is economic stability. Economic stability plays a critical role in influencing health disparities by shaping access to key resources (eg, employment, food security, housing stability) necessary for maintaining good health. 7 Racial and ethnic minority populations often have high rates of unemployment 8 and poverty,9 -11 which can affect their ability to access and afford health care. Employer-sponsored health insurance is a major source of coverage in the United States, 12 and a lack of health insurance coverage can leave people without access to adequate health care, leading to potential health risks and financial hardship. Fortunately, for people who do not have employer-sponsored health insurance, alternative options for health insurance exist, including health insurance marketplaces, private health insurance companies, and government-sponsored plans (eg, Medicaid). Medicaid provides health insurance coverage for low-income people and families; however, having this type of coverage can prove to be a problem for people who require hepatitis C treatment.
Although all patients diagnosed with hepatitis C may have cost-related barriers to treatment, Medicaid beneficiaries—a group with low socioeconomic status, a high proportion of people from racial and ethnic minority groups, and high prevalence of HCV infection compared with the general population—are particularly affected.13,14 Some state Medicaid programs restrict access to treatment for hepatitis C (eg, direct-acting antivirals [DAAs]) based on clinical, administrative, or behavioral criteria. 14 As of February 2024, only 28 states and the District of Columbia had removed Medicaid prior-authorization requirements for hepatitis C treatment. 15 These restrictions limit a person’s ability to receive timely treatment for hepatitis C. 14 A recent analysis of claims and encounters data found that the adjusted odds of DAA treatment initiation were lower among adults with Medicaid than among adults with private health insurance. 16 In addition, among people with Medicaid, those residing in states that restrict access to hepatitis C treatment had lower odds of DAA treatment initiation than those living in states without hepatitis C treatment restrictions. 16 These disparities in DAA treatment initiation highlight how restrictive policies can exacerbate inequities in viral hepatitis outcomes.
The intersection of systemic racism with factors such as health care access, 17 incarceration, 18 and drug use19,20 has profoundly affected people from racial and ethnic minority groups. One way this intersection manifests is through the criminal justice system, where Black people, indigenous people, and people from other racial and ethnic minority groups are disproportionately represented in incarcerated populations. 21 This disportionate representation can be attributed to numerous factors, such as an enduring legacy of racial subordination, biased policies and practices (eg, police harrassment, unlawful engagement by police, pretrial detention of people from racial and ethnic minority groups due to income inequality, disproportionate charging of Black defendants compared with White defendants under state habitual offender laws), and structural disadvantages associated with poverty, employment, housing, and family differences.22,23 HCV infection is highly prevalent among incarcerated populations, 23 particularly among those who engage in high-risk behaviors such as injection drug use, sexual activity, and tattooing, 24 and even more prevalent among incarcerated people who inject drugs. 25 Although research on incarcerated populations suggests that hepatitis C antibody prevalence is highest among non-Hispanic White people compared with other racial and ethnic populations, 26 because of disparities in incarceration rates, people in racial and ethnic minority groups comprise the majority of both incarcerated people and incarcerated people who are anti–HCV positive. 26 The disproportionately higher incarceration rates among these groups not only disrupt community and family structures but also contribute to the higher prevalence of hepatitis and other communicable diseases because of limited access to prevention measures in carceral facilities.27,28 DAA treatment is indicated for all people with hepatitis C; however, because of various barriers (eg, budget constraints, varying lengths of stay), few carceral systems offer treatment to people who are incarcerated. 29
While effective tools exist to prevent hepatitis A and B and treat hepatitis C, access to these resources is uneven. Economic hardship can hinder access to preventive measures such as vaccines, while restrictive policies, such as prior-authorization requirements for hepatitis C DAA treatment among Medicaid recipients, can exacerbate disparities in health care access. This complex interplay between SDoH and access to care contributes to disparities in viral hepatitis disease rates among diverse populations.
Addressing Disparities in Viral Hepatitis Through SDoH
Although it is important to understand the role of SDoH in contributing to disparities in viral hepatitis disease rates, limitations exist when using viral hepatitis surveillance data to examine SDoH. National viral hepatitis surveillance is performed under the umbrella of the National Notifiable Diseases Surveillance System (NNDSS). NNDSS is a nationwide collaboration in which each state and territory mandates which conditions and diseases are reportable by law in their jurisdiction and voluntarily submits notifications of those conditions and diseases to the Centers for Disease Control and Prevention. 30 Routine information submitted to the system includes geographic information (eg, state, county) and demographic characteristics (eg, age, sex, race, ethnicity). Additional information may include laboratory test results, clinical features, risk behaviors (eg, injection drug use, international travel), and affected population groups (eg, men who have sex with men). 31 However, viral hepatitis surveillance is limited in the amount and type of SDoH data submitted by contributing state and territorial jurisdictions. This limitation makes it difficult to determine which SDoH directly contribute to disease progression, complications, or mortality and create evidence-based policy or interventions necessary for effectively addressing viral hepatitis disparities. Given this limitation, a methodological approach that extends beyond individual-level analyses is necessary to comprehensively assess the role of SDoH on viral hepatitis outcomes.
One such approach is ecological analyses, which allow for the examination of relationships between environmental factors and population health outcomes on a broad scale. 32 Studies with data aggregated at granular geographic levels, such as neighborhoods, census tracts, or counties, can reveal geospatial patterns of health disparities and support the targeting of interventions to address social and environmental factors that contribute to health disparities in communities. Geographic identifiers in the NNDSS can be merged with contextual data from various sources to characterize differences among populations with viral hepatitis and examine associations between viral hepatitis outcomes and SDoH. In addition, states and territories have access to granular levels of geographic data (eg, zip code) that can allow for analyses at the census tract or neighborhood level. Examples of contextual data that can be merged to aggregated surveillance data include the percentage of people with a high school education, the percentage of people employed, the percentage of people with home ownership (US Census), area-level health professional shortage areas (Health Resources and Services Administration Data Warehouse), and the proportion of housing units with moderate or severe physical problems (US Department of Housing and Urban Development American Housing Survey).
For example, to understand community-level drivers of opioid-related and HCV-related health outcomes, Gezer et al 33 performed an ecological analysis using hospitalization encounter data (South Carolina Revenue and Fiscal Affairs Office) that were linked to demographic, socioeconomic, and structural barrier data (US Census Bureau American Community Survey) and the Social Vulnerability Index (Agency for Toxic Substances and Disease Registry at the Centers for Disease Control and Prevention). The study identified area-level barriers, such as higher proportions of people without health insurance, higher Social Vulnerability Index score, greater poverty, lower median annual household income, and rurality, that were associated with the highest risk of opioid-related and HCV-related hospitalizations in South Carolina. 33 Findings of the study can be used to identify areas that may benefit from targeted interventions (eg, mobile health clinics). Additional studies aimed at analyzing and understanding SDoH and hepatitis C mortality, 34 hepatitis C screening and positivity, 35 and HCV transmission risk 36 have reported independent associations with census tract–level poverty in New York City, 34 residential ethnic segregation in Philadelphia, 35 and households without transportation in North Carolina. 36 These studies can be used to identify and prioritize medically underserved communities with high disease incidence for delivery of field-level interventions and allocation of resources needed to address the needs of those communities. However, one limitation of ecological analyses is the difficulty in generalizing results to other areas (eg, neighborhoods, census tracts, cities, counties). In addition, contextual data may not be available for areas with low-density populations. However, a strength of ecological analyses is that they allow for an examination of SDoH and health outcomes at levels of geography that are more granular than at the national, state, and county levels. This granularity is often essential for local decision makers, as analyses at the state or national level may lack the specificity needed for targeted interventions. This granular analysis allows for a more precise identification of SDoH that affect health outcomes in specific geographic areas, guiding subsequent research and resource allocation efforts.
Summary
National viral hepatitis surveillance is essential in monitoring trends in disparities that can inform planning, implementation, and evaluation needed to advance viral hepatitis policy and practice. 3 However, efforts are needed to provide a complete picture of factors that influence viral hepatitis prevalence, incidence, and mortality. Analyses incorporating SDoH can identify and quantify the relative contributions of SDoH that influence viral hepatitis health outcomes and inform resource allocation and intervention efforts.37,38 Approaches to incorporating SDoH into existing data streams are needed to guide efforts to advance health equity. Merging contextual information into comprehensive surveillance systems such as NNDSS provides a more comprehensive picture of viral hepatitis to support decisions about the public health response to viral hepatitis and guide the formulation of effective policies and programs to reduce health disparities and promote health equity.
Footnotes
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Karon C. Lewis, DrPH, MSBMS
https://orcid.org/0000-0002-1370-1151
Donna Hubbard McCree, PhD, MPH, RPh
https://orcid.org/0000-0002-5600-2270
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