Research Article| Volume 68, ISSUE 3, P393-401, March 2018

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The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study

Published:October 26, 2017DOI:


      • Alcohol use disorder is a major contributor to HCV-related liver disease burden.
      • Alcohol use could reduce individual and population level benefits of HCV treatment.
      • Impact of alcohol use on liver disease should be monitored in the DAA era.
      • World Health Organization has set a 65% HCV mortality reduction target by 2030.
      • To achieve this target, strategies are needed to manage the use and impact of alcohol.

      Background & Aims

      The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings.


      HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995–2011/2012/2013, respectively) were linked to hospital admissions (2001–2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed.


      Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76–2.10), New South Wales (aHR 3.68; 95% CI 3.38–4.00) and Scotland (aHR 3.88; 95% CI 3.42–4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively.


      Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved.

      Lay summary

      The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.

      Graphical abstract


      Linked Article

      • Reply to: “‘Who killed JR’: Chronic hepatitis C or alcohol use disorders?”
        Journal of HepatologyVol. 68Issue 5
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          We appreciate the correspondence of Schwarzinger, Rehm, and Mallet on our study ‘‘The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study”.1 They make important points in relation to limitations of using administrative data for epidemiological research, including misclassification bias. We have discussed these limitations at length in our paper; however, we believe the generalizability of our findings (given the large sample sizes and extensive study periods) take precedence over such limitations.
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      • “Who killed JR”: Chronic hepatitis C or alcohol use disorders?
        Journal of HepatologyVol. 68Issue 5
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          Alavi and colleagues recently found that alcohol use disorders (AUDs) were a major contributor to decompensated cirrhosis in patients with chronic hepatitis C in Canada (British Columbia), Australia (New South Wales), and Scotland.1 This international study corroborates our previous results for France.2 However, cross-country comparisons are puzzling (Fig. 1), with population attributable fractions (PAFs) of decompensated cirrhosis associated with AUDs ranging from 13% in Canada (British Columbia) to 72% in France.
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