Background: The rising clinical burden of alcohol related liver disease in the U.S. has been exacerbated by COVID-19 pandemic-related increases in high-risk alcohol use. Veterans and racial/ethnic minorities are two vulnerable populations that may be especially susceptible to pandemic-related increases in alcohol use leading to severe liver disease complications. We aim to evaluate long-term national trends in rates of alcohol associated hepatitis (AH) among Veterans in the U.S., with a focus on racial/ethnic differences.
Methods: All Veterans utilizing Veterans Affairs healthcare facilities in the U.S. from January 1, 2010 to August 31, 2023 with at least one clinical encounter each year were included. AH was defined based on prior studies: >1 AH-related ICD-9/10 diagnosis code (571.1, K70.10, or K70.11) plus >3 of the following laboratory criteria (ALT or AST > 50 IU/L; AST:ALT ratio > 2; INR > 2; and/or bilirubin > 3.0 mg/dL) within +/- 30 days. Rates of AH (per 100,000 person-years (py)) were calculated annually and were stratified by race/ethnicity. Comparison of AH trends utilized the trends test, and comparisons of rates between groups utilized the z-statistic.
Results: Among a cohort of 3.0 million Veterans, rates of AH increased steadily from 31.6 per 100,000-py in 2010 to 392.6 per 100,000-py in 2023 (average annual percent change (AAPC) +81.6%, p-trend < 0.05). When stratified by race/ethnicity, similar trends in the alarming rise in AH from 2010 to 2023 were observed across all groups, but was most pronounced among American Indian/Alaska Natives, the group with consistently highest rates of AH (Figure 1). From 2010 to 2023, rates of AH increased from 43.6 to 775.9 per 100,000-py (AAPC +120.0%, p-trend < 0.05) in American Indian/Alaska Natives; from 37.0 to 418.5 per 100,000-py (AAPC +73.6%, p-trend < 0.05) in black/African Americans; from 36.9 to 398.0 per 100,000-py (AAPC +69.9%, p-trend < 0.05) in Hispanics; from 31.1 to 391.1 per 100,000-py (AAPC +82.7%, p-trend < 0.05) in non-Hispanic whites; from 19.0 to 170.4 per 100,000-py (AAPC +56.9%, p-trend < 0.05) in Asian/Pacific Islanders. In 2023, rates of AH were significantly higher among American Indian/Alaska Natives vs. blacks/African Americans, the group with the second highest rate of AH (775.9 vs. 418.5 per 100,000-py, p<0.001).
Conclusion: Among a national cohort of U.S. Veterans, there is a steady and alarming rise in rates of AH that persists beyond the third year post-COVID-19 pandemic, and this alarming rise has not peaked. Similarly concerning, significant racial/ethnic disparities in AH trends were observed, with ethnic minorities, particularly American Indian/Alaska Natives, most impacted. Greater awareness of the dangers of high-risk alcohol use among Veterans and ensuring timely linkage to resources and treatment for those at risk of alcohol use disorder is critical.

Terry Yip

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