title: Delta hepatitis within the Veterans Affairs medical system in the United States: Prevalence, risk factors, and outcomes.
abstract: OBJECTIVE
  Low hepatitis delta prevalence estimates in the United States are likely biased due to low testing rates. The objectives of this study were to quantify the prevalence of testing and identify factors associated with hepatitis D positive status among chronic hepatitis B patients in the Veterans Health Administration.
  
  
  METHODS
  We performed a nationwide retrospective study of all veterans who tested positive for HBsAg from October 1999 to December 2013. Hepatitis D antibody testing results were used to stratify patients into three groups: HDV-positive, HDV-negative, and HDV-not tested. Demographics, comorbidities, additional laboratory data and clinical outcomes were compared across these groups of patients using standard statistical approaches.
  
  
  RESULTS
  Among 25,603 patients with a positive hepatitis B surface antigen, 2175 (8.5%) were tested for HDV; 73 (3.4%) patients tested positive. Receiving HDV testing was associated with receipt of testing for HBV, HIV, and HCV. Predictors of positive HDV results included substance abuse and cirrhosis. Fitting a predefined high-risk profile (abnormal ALT with suppressed HBV DNA titers) was strongly associated with testing positive for HDV (OR 3.2, 95%CI 1.4-7.5). Most (59%) of HDV-positive patients were HCV co-infected. HDV-positive subjects had higher risks of all-cause mortality. Incidence rates of HCC were 2.9 fold higher in HDV-positive relative to HDV-negative individuals (p=0.002). In adjusted analyses, HDV was independently associated with HCC (OR 2.1, 95%CI 1.1-3.9).
  
  
  CONCLUSIONS
  Testing rates for hepatitis delta in chronic hepatitis B patients in the United States are inappropriately low. Approaches to increase testing for HDV particularly in high-risk subsets should be explored.
authors.affiliation: Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Tatyana
authors.initials: T
authors.lastname: Kushner
authors.affiliation: Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.
authors.forename: Marina
authors.initials: M
authors.lastname: Serper
authors.affiliation: Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States. Electronic address: dakaplan@mail.med.upenn.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Kaplan
mesh_terms: D000328:Adult; D000368:Aged; D060085:Coinfection / Q000453:epidemiology; D005260:Female; D006508:Hepatitis Antibodies / Q000097:blood; D006514:Hepatitis B Surface Antigens / Q000032:analysis; D003699:Hepatitis D / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D003698:Hepatitis Delta Virus / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D014728:Veterans
chemical_list: D006508:Hepatitis Antibodies; D006514:Hepatitis B Surface Antigens
keywords: Database; Hepatitis B; Hepatitis D; Hepatocellular carcinoma