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Notes from the Field : Hepatitis C Virus Infections Among Young Adults — Rural Wisconsin, 2010

During November 2010, Wisconsin Division of Public Health (DPH) staff members noted the number of hepatitis C virus (HCV) infections reported annually among persons aged <30 years in six contiguous rural counties of Wisconsin had increased from an average of eight cases per year during 2004–2008 to an average of 24 cases per year during 2009–2010. To understand factors associated with this increase, DPH, local health departments, and CDC investigated the epidemiologic and laboratory characteristics of 25 cases reported during 2010 among adults aged <30 years who resided in these six counties.

Among the 25 patients investigated, medical records of 21 were reviewed, 17 were interviewed, and 16 provided blood samples for quasispecies analysis (1) to assess relatedness of their HCV. Of the 25 patients, seven (28%) had symptoms of jaundice, consistent with acute HCV infection. All 25 patients had antibodies to HCV by enzyme immunoassay; 21 were confirmed to have HCV by having an enzyme immunoassay with an appropriate signal-to-cutoff ratio for a given assay or by having the presence of HCV RNA by polymerase chain reaction. Sixteen (94%) of 17 interviewed patients admitted to sharing hypodermic needles, drug preparation equipment, or drug snorting equipment. Sixteen (94%) of 17 interviewed patients admitted to either injecting drugs (12 patients), snorting illicit drugs (16 patients), or both (12 patients). Three of eight patients who reported injecting opioid pain relievers started injecting prescription opioids and switched to injecting heroin or methamphetamine after a median of 3 years (range: 1–4 years). Six specimens could be analyzed at CDC for variations in the NS5B region, and four of them were genetically similar in that region. These underwent quasispecies analysis but were unrelated, suggesting that patients were infected through unrelated networks of HCV transmission and that many other undetected cases might exist.

Although most U.S. reports of acute HCV infections before 2001 occurred among persons aged 30–49 years, the highest age-adjusted reported incidence is now among persons aged 20–29 years (2), as observed and reported recently from Massachusetts (3). In Wisconsin, although most reported HCV infections have occurred among persons aged 45–54 years, 2009–2010 surveillance data suggests that incidence has been stable among this age group but has been increasing among younger persons, consistent with national trends (4). This investigation sheds light on a growing burden of hepatitis C in rural areas (3) and describes a transition among users from injection of prescription opioid drugs to injection of heroin, as noted elsewhere (5).

Public health practitioners should be mindful of the growing prevalence of hepatitis C in rural communities, which typically are harder to reach for prevention efforts. CDC recently awarded funds to seven state and local health departments to investigate risk factors and understand drug use behaviors associated with HCV transmission among adolescents and young adults. Efforts to improve monitoring and control of opioid prescribing and targeted interventions, including HCV education, access to new, sterile syringes, and improved access to opioid agonist treatment programs have been shown to reduce the incidence of HCV infection (6).*

Reported by

Marisa M. Stanley, MPH, Sheila Guilfoyle, James M. Vergeront, MD, Jeffrey P. Davis, MD, Wisconsin Div of Public Health. Anil Suryaprasad, MD, Dale J. Hu, MD, Yury Khudyakov, PhD, Div of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Marisa M. Stanley,, 608-266-0463.


  1. Ramachandran S, Xia G, Ganova-Raeva LM, Nainan OV, Khudyakov Y. End-point limiting-dilution real-time PCR assay for evaluation of hepatitis C virus quasispecies in serum: performance under optimal and suboptimal conditions. J Virol Methods 2008;151:217–24.
  2. CDC. Viral hepatitis surveillance—United States, 2009. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at Accessed May 9, 2012.
  3. CDC. Hepatitis C virus infections among adolescents and young adults—Massachusetts, 2002–2009. MMWR 2011;60:537–41.
  4. Wisconsin Hepatitis C Program. Wisconsin hepatitis C statistical reports. Madison, WI: Wisconsin Department of Health Services; 2010. Available at Accessed May 9, 2012.
  5. CDC. Notes from the field: risk factors for hepatitis C virus infections among young adults—Massachusetts, 2010. MMWR 2011;60:1457–8.
  6. Hagan H, Enrique R, Pouget E, Des Jarlais D. A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. J Infect Dis 2011;204:74–83.

* In December 2011, Congress reinstated a ban on the use of federal funds for carrying out any program of distributing sterile needles or syringes for hypodermic injection of illegal drugs.

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