the health department’s surveillance database. Of the 113 study participants who became infected, only two cases of those identified in the study were picked up by the state’s surveillance system (Hagan et al., 2002). None of the 65 acute HCV infections in IDUs was reported.

Enhanced sero-surveillance studies, such as the National Health and Nutrition Examination Survey (NHANES), which are often used to provide supplemental data and prevalence estimates when surveillance systems are inadequate or incomplete, have serious limitations when addressing viral hepatitis. For example, NHANES, the study most commonly used to estimate the disease burden of chronic HBV and HCV infections, excludes or underrepresents populations that are most at risk for HBV and HCV infections. Those populations include homeless persons, institutionalized and incarcerated persons, and persons of Asian and Pacific Island descent. About 1.5 million people are in state or federal prisons in the United States (Department of Justice, 2009). CDC estimated chronic HBV prevalence in the adult prison population to be around 1–3.7%, and the prevalence of chronic HCV infection has been reported to vary from 12–35% (CDC, 2003c). Thus, the national estimate of 2.7–3.9 million people chronically infected with HCV (CDC, 2009b; Daniels et al., 2009a) potentially excludes several hundred thousand cases. Similarly, Asians, Pacific Islanders, American Indian, and Alaska Native people are undersampled among NHANES participants (Coleman et al., 1998). Given the higher prevalence of HBV in those populations, NHANES underreports the number of chronic HBV cases in the national estimates (Kim, 2007).

A supplemental HIV surveillance project funded by CDC’s Division of HIV/AIDS Prevention is the National HIV Behavioral Surveillance System. The system surveys persons at high risk for HIV infection in cities with high rates of AIDS diagnoses to determine their risk behavior, testing behavior, and use of prevention services. Even though IDUs are one of the targeted populations studied through the system (CDC, 2009d), HCV testing has not been included systematically as part of the study design, and this leads to missed opportunities to define the injection and injection-related behaviors as they apply to HCV and HCV prevention.

Case Evaluation, Followup, and Partner Services

The reporting of a case of hepatitis B or hepatitis C by a public test site or private clinic provides an opportunity for public-health followup. Part of the followup generally involves ensuring that the persons with the reported diagnoses and their partners receive proper medical evaluation, counseling, vaccination, and referrals to support services as needed (Fleming et al.,



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