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Hepatitis C hospitalizations in Spain, 2004-2013: a retrospective epidemiological study

  • R. Boix1Email author,
  • R. Cano1, 2,
  • P. Gallego1,
  • F. Vallejo1, 2,
  • R. Fernández-Cuenca1, 2,
  • I. Noguer1 and
  • A. Larrauri1, 2
BMC Health Services ResearchBMC series – open, inclusive and trusted201717:461

https://doi.org/10.1186/s12913-017-2410-1

Received: 11 October 2016

Accepted: 27 June 2017

Published: 5 July 2017

Abstract

Background

Hepatitis C is an important public health problem about which there is currently scarce epidemiological information. The objective of this study is to describe and analyse the demographic and epidemiological characteristics of hospitalized cases of hepatitis C in the Spanish population between 2004 and 2013.

Methods

The study uses the Hospital Discharge Records Database of the Spanish National Health System. It is a retrospective descriptive epidemiological study. The variables analysed were year of infection, age, sex, diagnostic category, days admitted and co-morbidity.

Results

There have been a total of 351,996 hospitalizations; 225,138 men (64%) and 126,858 women (36%). They are divided between acute hepatitis 8161 (2.3%); chronic hepatitis 325,185 (92.4%) and unspecified hepatitis 18,650 (5.3%). The mean age for men is 53.7 (+/−15.2) and for women 62.3 (+/−17.3). 22.8% also present with an Human immunodeficiency virus (HIV) disease coinfection, and 14.7% with opioid dependencies. The trend is for a gradual increase in cases without statistical significance.

Conclusions

The Hepatitis C cases hospitalized had high levels of chronicity, which entails two distinct patterns of illness in men and women – who are affected in different age ranges.

Keywords

Hepatitis C Hospitalizations Trends Epidemiology

Background

Despite the fact that hepatitis C is a disease of particular relevance to public health, the epidemiological information available remains scarce. This, in part, is due to the intrinsic characteristics of a disease which is difficult to diagnose, remains asymptomatic for many years and becomes chronic in a high percentage of cases. It is estimated that hepatitis C affects 150 million people globally, of which 350,000 to 500,000 die each year as a result. In the World Health Organization (WHO) European Region it is estimated that there are 15 million people infected [1]. In 2013 the European Centre for Disease Prevention and Control (ECDC) was notified of 31,513 cases of hepatitis C in 26 countries [2], of which 569 (1.8%) were acute, 4776 (15.2%) were chronic, and 23,230 (73.7%) were unknown. A number of studies have been undertaken in Spain to evaluate the prevalence of hepatitis C [313], in general they are reviews [3] or local-level studies, carried out in both distinct populations and the general population [48] (with a range of prevalence between 0.74% and 2.6%), school-age children [9] (0.36%), pregnant women [1012] (0.4-1.4%) and the working population [13] (0.6%).

In the recently approved Strategic Plan for Tackling Hepatitis C in the Spanish National Health System [14], it is estimated that 1.7% of the Spanish adult population (688000) have antibodies against hepatitis C and 1.2% of adults have viremia (472000) [15, 16].

In addition to studies on the prevalence, other studies of mortality and disease burden show that when the chronic complications of hepatitis C – like cirrhosis and hepatocellular carcinoma – are taken into account, Hepatitis C leads the list of infectious disease related mortality in Spain [17] and is the leading cause of disability-adjusted-life-years (DALYs) among transmissible diseases in Spain [18].

The Hospital Discharge Records Database of the Spanish National Health System (CMBD in its Spanish acronym) registers the cases in National Health Service hospitals, as well as a number of private hospitals, with a 90% level of coverage at present [19]. The system collects information regarding the patient, the disease and the hospital. The information system based on the CMBD can be a useful tool to better understand the epidemiological pattern of the disease, and the associated assistance required.

The objective of this study is to describe and analyse the demographic and epidemiological characteristics of those cases hospitalized with a diagnosis of hepatitis C and in addition to identifying trends in the hospitalizations. The study uses the CMBD database as an information system.

Methods

This is a descriptive retrospective epidemiological study of the hospitalizations with hepatitis C diagnoses in the Spanish population from 2004 to 2013.

It has used data from the CMBD, which have been coded with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) from the World Health Organisation [20].

CMBD is the Spanish mandatory hospital discharge registry. Similar registries are in place in western countries. In Spain the registry uses the ICD-9 CM for codifying the illnesses and in 2017 will begin to use the International Classification of Diseases, Tenth Revision (ICD-10). The registry does not permit distinguishing between hospitalization and patients. CMBD has been consolidated as the principal source for knowing about the causes of disease which receive treatment in hospitals. Its application to epidemiological studies is shown by many scientific articles [2123].

It has studied all of those hospital admissions in which a primary or secondary diagnosis with one of the following codes appeared: 070.41 (acute hepatitis C with hepatic coma), 070.44 (chronic hepatitis C with hepatic coma), 070.51 (acute hepatitis C without mention of hepatic coma), 070.54 (chronic hepatitis C with no mention of hepatic coma), 070.70 (unspecified viral hepatitis C without hepatic coma), 070.71 (unspecified viral hepatitis C with hepatic coma).

The studied variables were: year of admission (2004-2013), sex (male/female), age, diagnosis (acute, chronic or unspecified hepatitis C) and days hospitalized. Co-morbidity with HIV has been studied (ICD-9-CM: 042, for Human immunodeficiency virus [HIV] disease and V08, for asymptomatic HIV). The database was cleaned to remove any potential duplicates of hospitalizations. The entries without complete values for age and sex were removed, as well as those entries with extreme values – using a refined average stay. From the initial 357,731 entries, 1.6% was eliminated and a total of 351,996 have been analysed.

For the computation of the rates we have used the population estimations of the studied period provided by the Spanish National Statistics Institute. [24]. For the purposes of standardization, the European population has been used [25].

Statistical analysis

A descriptive analysis was carried out, and in order to compare the qualitative variables Pearson’s chi-squared test was used. To compare the quantitative values, Student’s t technique was used for normal distributions, and Mann-Whitney’s U, as a non-parametric test, for non-normal distributions. Values of p < 0.05 were considered statistically significant.

For the statistical analysis we have used IBM-SPSS ver. 22 and for the trend-analysis, Jointpoint Regression Program 4.2.0.2., which, through Poisson regression models, allows the calculation of Annual Percent Change (APC) and the estimation of trend change points.

Results

Our study provides an analysis of 351,996 hospitalizations over a 10-year period, which equates to approximately 35,000 per year.

Table 1 shows the distribution of hospitalizations for the studied period, by sex, year and diagnostic category.
Table 1

Hepatitis C Hospitalizations. Distribution by diagnostic category, sex and year. CMBD Spain 2004-2013

 

Acute

Chronic

Unspecified

Total HC

Year

Men

Women

Both

Men

Women

Both

Men

Women

Both

Men

Women

Both

2004

1041

626

1667

19,527

11,077

30,604

0

0

0

20,568

11,703

32,271

2005

958

589

1547

19,752

11,023

30,775

0

0

0

20,710

11,612

32,322

2006

575

332

907

18,628

10,411

29,039

1081

564

1645

20,284

11,307

31,591

2007

481

247

728

18,883

10,535

29,418

1430

761

2191

20,794

11,543

32,337

2008

520

291

811

19,902

11,468

31,370

1322

771

2093

21,744

12,530

34,274

2009

306

203

509

21,274

12,274

33,548

1488

895

2383

23,068

13,372

36,440

2010

352

194

546

21,873

12,320

34,193

1489

829

2318

23,714

13,343

37,057

2011

294

209

503

22,088

12,101

34,189

1646

954

2600

24,028

13,264

37,292

2012

296

197

493

22,295

12,561

34,856

1750

950

2700

24,341

13,708

38,049

2013

287

163

450

23,843

13,350

37,193

1757

963

2720

25,887

14,476

40,363

Total

5110

3051

8161

208,065

117,120

325,185

11,963

6687

18,650

225,138

126,858

351,996

During the 10 years studied (2004-2013) a total of 351,996 hepatitis C hospitalizations were recorded (64% men; 36% women p = 0.031) with a 1.7 ratio of men to women. By diagnostic category, the cases are distributed between acute hepatitis (8161; 2.3%), chronic hepatitis (325,185; 92.4%) and unspecified hepatitis (18,650; 5.3%), maintaining the same ratios between men and women.

Age presents a bimodal distribution (Figs. 1 and 2, Table 2). The age group with the highest frequency in men is between 40 and 49 years (N 75025; 33.35%) with a smaller peak in the 70–79 age group (N 31363; 13.90%). In women the most frequent age group is 70–79 years (N 34439; 27.10%) with a smaller peak in the 40–49 age groups (N 20752, 16.40%).
Fig. 1

Hepatitis C Hospitalizations. Histogram of age distribution frequency. CMBD Spain 2004-2013. Men. Note. p*value < 0.05 significant value for the mean differences in age by sex, Mann-Whitney’s U p < 0.001

Fig. 2

Hepatitis C hospitalizations. Histogram of age distribution frequency. CMBD Spain 2004-2013. Women. Note. p*value < 0.05 significant value for the mean differences in age by sex, Mann-Whitney’s U p < 0.001

Table 2

Frequency distribution by age group. Hepatitis C Hospitalizations. CMBD Spain 2004-2013

 

Men

Women

Age

N

%

N

%

<1

44

.0

27

.0

1_4

50

.0

51

.0

5_9

107

.0

103

.1

10_14

142

.1

83

.1

15_19

154

.1

201

.2

20_24

704

.3

668

.5

25_29

2866

1.3

1883

1.5

30_34

9204

4.1

4491

3.5

35_39

22,985

10.2

8340

6.6

40_44

37,320

16.6

10,854

8.6

45_49

37,705

16.7

9898

7.8

50_54

25,379

11.3

7297

5.8

55_59

15,224

6.8

7007

5.5

60_64

13,132

5.8

8723

6.9

65_69

13,513

6.0

11,158

8.8

70_74

15,051

6.7

15,628

12.3

75_79

16,312

7.2

18,811

14.8

80_84

10,651

4.7

13,833

10.9

85+

4595

2.0

7802

6.2

Total

225,138

100.0

126,858

100.0

Highest frequency in men occurs at age 45 and in women at 76 years. The median in men is 50 (interquartile range: 42–66) and in women is 66 (interquartile range 47–77). These differences are statistically significant p < 0.001.

A study of co-morbidity highlights that 22.8% of hospitalizations for hepatitis C also presented with HIV and 14.7% presented with opioid addiction. Both are more frequent in men than women p < 0.0001 (Table 3).
Table 3

Hepatitis C Hospitalizations. Distribution of comorbidity with HIV and opioid dependency by age and sex. CMBD Spain 2004-2013

  

Frequency

%

p*

Mean Age

SD

P**

HIV

Men

61,517

17.4

 

43.28

6.78

 

Women

18,882

5.4

 

41.99

6.93

 

Total

80,399

22.8

p < 0.0001

42.98

6.84

p < 0.0001

Opioid dependency

Men

41,395

11.7

 

42.22

6.68

 

Women

10,397

3.0

 

40.60

6.74

 

Total

51,792

14.7

p < 0.0001

41.90

6.72

p < 0.0001

p* <0.05 significant value for the difference between percentages for each sex – chi-square/χ2

p** <0.05 significant value for the difference between mean ages by sex – Student’s t

Hospitalization rates are shown in Fig. 3. They present a slight upward trend, which is statistical not significant, for both men and women – although some change-points can be observed. The trend for men is for an APC of 1.02 (p > 0.05) with a change-point in 2010; for women the APC is 0.81 (p > 0.05) with a change-point in 2007.
Fig. 3

Hepatitis C Hospitalizations. Evolution of hospitalization rates according to sex. CMBD Spain 2004-2013. Note. Adjusted rates per 100,000 inhabitants for the European standard population. Poisson Regression p for trend is not statistically significant Men p > 0.05 Women p > 0.05

Discussion

To the best of our knowledge, this is the first study of hepatitis C hospitalizations at a national level during a recent 10-year period. The results show a high rate of chronicity, with over 90% of cases, and significant differences for sex and age in the epidemiological pattern of the disease.

Of those admitted with this disease 64% are men and 36% are women, although the proportions of hepatitis C types remain similar for both sexes.

When we compare our data with that of the surveillance system of ECDC, we can see that there is a 1.9 ratio of men to women in European cases [2], while in our study it was a little less: 1.7. The majority of the cases recorded in Europe are classified as “unspecified hepatitis”, due to the difficulties in classifying correctly, although it is assumed that the majority are chronic hepatitis, as found in our study. The most numerous group in the European study were 25 to 44 year-olds, somewhat younger than in our study, in which the 40–49 age range in men and 70–79 age range in women were the most numerous.

In our study the age of hospitalization presents a bimodal distribution in men and women with a reversed image with a most frequent age group 40-49 years in men opposite to 70-79 years in women.

The bimodal distribution suggests that two populations with different patterns of the disease can be observed in these findings, a younger population in which men predominate and an older population in which women predominate. This distribution may indicate that the populations have been subjected to different risk factors in the acquisition of the disease, something which other studies have already noted [3]. On one hand, hepatitis C principally affects young men, and in this group the prevalence of co-infection with HIV and that of opioid dependence is much higher than for women. According to a number of studies, the rate of hepatitis C infection in people with HIV is close to 30% [26]. For populations of injection drug users there is a substantial range of infection between 21 and 86% [27, 28]. On the other, for the predominantly more advanced ages in which infection in women is found, it is probable that the infections were a consequence of nosocomial infections in the past, as a result of blood transfusions before 1990 or the use of unsterilized syringes before 1975.

A possible hypothesis is that in the past women could have been subjected to an additional risk-factor, as pregnancy and birth admissions are principal causes of hospitalization. Some studies estimate that nosocomial transmission accounts for 15–25% of cases [29, 30].

The data of hospitalizations in our study are consistent with those found in another study carried out in Spain in which more than 3000 serum samples of patients were analyzed and differences were found in the genotypes related to the age cohort, with differences between those born before and after 1950 being found [31].

Although the trend in women is less noticeable than that in men, as is reflected by the percentage of annual change, we have identified a point of inflection or change in both (in 2010 for men and 2007 for women). Therefore, with less effect there is also a slight increasing trend.

This slight upward trend in hospitalization rates adjusted for age for hepatitis C goes contrary to the trend for general hospital admissions, which have declined during the last few years. In 2013 there was a decrease of 0.47% with respect to 2012 [19], more prominent in women – owing to a decrease in the number of consultations for pregnancy, delivery and puerperium.

However, it is important to highlight a number of limitations with the use of the CMBD related to the fact that it was created for hospital management and therefore its applications in epidemiology can be limited. As CMBD data are anonymous, it is impossible to identify hepatitis C cases being hospitalized more than once for the duration of the disease. We have taken into account new hospitalizations and readmissions, so all hospitalizations are included. Therefore the results should be taken with caution and the number of patients should not be inferred, because in that case it would be somewhat overestimated. We think that this limitation does not affect the disease trend and in the absence of direct incidence data is a good proxy for the behavior of the disease. And in the other hand, the information is easily accessible and the data cover the whole Spanish population, this means that the epidemiological information refers to the whole hospitalized Spanish population and it covers a period of 10 years.

Predictive mathematical models for hepatitis C indicate that, with the current treatment rate, the total number of viral hepatitis C infections could decrease or remain stable. Nevertheless, the number of patients with chronic hepatitis will tend to increase, with a consequent increase in mortality, morbidity and their associated costs. Therefore, alternative strategies are required [32].

The challenge now is to diagnose the unknown cases of hepatitis C, as it is estimated that only 35% of cases have been diagnosed [33].

Conclusions

Hospitalizations for hepatitis C entail a high level of chronicity, and they occur in two distinct patterns for women and men, for whom different age groups are affected. It is our view that the CMBD can be a useful tool to assess the scale of the problem and evaluate trends in hepatitis C. The knowledge of the epidemiological pattern of the disease is of considerable use to help orient health policy.

Abbreviations

APC: 

Annual Percent Change

CMBD: 

Hospital Discharge Records Database

DALYs: 

Disability-adjusted-life-years

ECDC: 

European Centre for Disease Prevention and Control

HIV: 

Human immunodeficiency virus

ICD-10: 

International Classification of Diseases, Tenth Revision

ICD-9-CM: 

International Classification of Diseases, Ninth Revision, Clinical Modification

WHO: 

World Health Organization

Declarations

Acknowledgements

We would like to thank Dr. Iñaki Galán (National Centre of Epidemiology, Madrid, Spain) for his valuable comments and the Institute of Health Information, from the Information and Statistics Department of the Spanish Ministry of Health, Social Services and Equality, which provided the data necessary to complete this study.

Funding

Not applicable.

Availability of data and materials

The data that support the findings of this study are available from Ministry of Health, Social Services and Equality but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon responsible request and with permission of Ministry of Health, Social Services and Equality.

Authors’ contributions

RB and RC designed the study. RB prepared and analysed the databases. All named authors - RB, RC, PG, FV, RFC, IN, AL- contributed to the interpretation of the results. All the signatories - RB, RC, PG, FV, RFC, IN, AL- have participated in the preparation of the manuscript have given their approval to the final version, and share responsibility for the article.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

None.

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Authors’ Affiliations

(1)
National Centre of Epidemiology, Institute of Health Carlos III
(2)
CIBER Epidemiología y Salud Pública (CIBERESP)

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Copyright

© The Author(s). 2017

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