Tattoos, incarceration and hepatitis B and C among street-recruited injection drug users in New Mexico, USA: update

To the Editor:In a previous report [1], we described significant risks for hepatitis B (HBV) and hepatitis C (HCV) positivity associated with receipt of tattoos, particularly while incarcerated, among a street-recruited population of injection drug users (IDUs) in New Mexico, United States from 1995 to 1997. Another recent report in this Journal, based on a study conducted on prisoners in Australia, found tattooing in prison to be an independent risk for HCV [2]. Another report also described a strong association between tattoos and HCV, but found the strongest association to be with commercial tattooing venues [3]. That study found the risk associated with receipt of tattoos in prison elevated, but not statistically significant. That same report reviewed other articles and found a significant risk for HCV infection associated with tattoos in six out of eight studies that had data available. Further, a recent U.S. Centers for Disease Control and Prevention (CDC) document summarized the literature on risks for hepatitis infections in correctional settings and developed extensive control guidelines [4].     

The hepatitis C virus epidemic among injecting drug users.

Given the economic and health costs of hepatitis C virus (HCV) infection, and the ongoing transmission within the injecting drug user (IDU) population, there is a need for improved understanding of HCV epidemiology within this risk group. We employed a recently developed method based on phylogenetic analysis to infer HCV epidemic history and to provide the first estimates of the rate of spread of subtypes 1a and 3a circulating within injecting drug user populations. The data indicates that HCV subtype 1a entered the IDU population on at least three separate occasions. Both subtypes demonstrate exponential population growth during the 20th century, with a doubling time of 7-8 years. The results provide a baseline for prediction of the future course of the HCV epidemic, and its likely response to transmission control policies.     

静脉吸毒共用注射器具方式和性行为与丙型肝炎病毒感染关系的研究

目的 了解四川省凉山州某地区静脉吸毒人群共用注射器具方式及性行为与丙型肝炎病毒(HCV)感染的关系。方法 以社区为基础使用标准化问卷调查静脉吸毒人群人口学特征和静脉吸毒共用注射器具方式、性行为情况;通过检测研究对象的HCV抗体确定是否感染HCV。结果 在静脉吸毒379人中,静脉吸毒人群HCV感染率为对71.0％(269/379)。单因素分析结果显示近3个月共用针头或注射器和既往感染梅毒在HCV感染方面差异有统计学意义。趋势性检验发现随着共用针头或注射器、共用洗针头或注射器水的频率以及共用注射器具伙伴数的增加HCV的感染率也在增加。多因素分析结果显示,近3个月共用针头或注射器。既往感染梅毒是HCV感染的危险因素,其OR值分别为1.468(95％CI:1.045～2.061)和2.914(95％CI:1.327～6.398)。未见性行为对HCV感染的影响。结论 需考虑采用定群血清流行病学研究来进一步阐明静脉吸毒共用注射器具方式及性行为同HCV感染的关系及其联系强度。     

Coinfections by HIV, hepatitis B and hepatitis C in imprisoned injecting drug users

In order to know the prevalence and risk factors for coinfections by human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among injecting drug users (IDUs), a cross-sectional study was carried out in two prisons of the province of Cantabria, northern Spain. Three hundred and sixty-two IDU inmates were recruited. All inmates were interviewed and their blood tested for HIV, HBV and HCV. Crude and multiple risk factor adjusted for (by polychotomous logistic regression) odds ratios were calculated. Prevalence of HBV-HCV coinfection (42.5%) was higher than HIV-HBV-HCV coinfection (37.3%), whereas monoinfections were very uncommon (overall: 13%). Long-term injectors and reincarceration were the foremost risk factors for both coinfections, showing a trend between the degree of association and the number of viruses infecting a patient. No significant relationship between coinfection status and sexual practices was observed. The results related to coinfections are consistent with previous studies of prevalence and risk factors for HIV, HBV and HCV, in indicating that the high rates of coinfections among IDU inmates emphasise the need to harm-reduction policy across prisons in Spain.     

Epidemiology of hepatitis C virus infection among injecting drug users in Australia.

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.     

Rapid transmission of hepatitis C virus among young injecting heroin users in Southern China

BACKGROUND: Hepatitis C virus (HCV) is quickly spread through injection drug use. The prevalence and incidence of HCV in Chinese heroin users has been rarely reported. METHODS: A longitudinal cohort of young injection drug users (IDU) from southern China was established to study the risk factors for blood-borne infections (597 subjects). Individuals underwent analysis for the presence of hepatitis B surface antigen and antibodies to human immunodeficiency virus type 1 (HIV-1), HCV and hepatitis B surface antigen. Using self-reported risk behaviours, multivariate regression analysis was performed for factors associated with HCV prevalence and seroconversion. RESULTS: At baseline, HIV-1 and HCV prevalence was 17% and 72%, respectively. Significant factors associated with HCV seroprevalence included age >25 years (odds ratio [OR] = 1.71) and injection drug use for >2 years (OR = 2.60). HCV prevalence within one year of starting heroin use was 57% for any route of administration, and 80% if restricted to injectors. After two 6-month follow-up visits, 56 out of 159 baseline HCV seronegative individuals (148.9 total person years [py]), underwent seroconversion at an incidence rate of 37.6 per 100 py. Individuals who reported injection drug use were more likely to undergo HCV seroconversion (rate ratio [RR] = 6.59). CONCLUSIONS: HCV infection is rapidly acquired in heroin users who adopt injection in southern China. This study emphasizes the urgent need to implement and expand injection prevention and primary substance abuse prevention programmes in China.     

An outbreak of acute hepatitis B infection among injecting drug users in Inverclyde, Scotland

This large outbreak of acute hepatitis B infection among injecting drug users (IDUs) was precipitated by an increase in injecting heroin use in Inverclyde in the West of Scotland, between 1997 and 1999. Ninety-two cases of hepatitis B infection in residents of Inverclyde were reported to Argyll and Clyde Health Board from January 1996 to December 1999. An investigation of risk factors found 87% (80/92) of the cases were IDUs, of whom four-fifths were men. Fifty six per cent of cases were aged 20-29 years old and 12% were aged 16-19 years old. Further investigations among this close community of young and relatively inexperienced IDUs revealed that many admitted to sharing injecting equipment particularly spoons, water and filters. Only a minority had been using local needle exchange facilities in the area. After public consultation a second needle exchange was opened in 1998 staffed by a dedicated needle exchange development worker who has continued to develop harm reduction services locally.     

Variability in the incidence of human immunodeficiency virus,hepatitis B virus,and hepatitis C virus infection among young injecting drug users in New York City

Cohort studies of young (aged 18-30 years) injecting drug users recruited in 1997-1999 in the Harlem and Lower East Side areas of New York City, New York, were used to assess the incidence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The authors found that HIV incidence was low at both sites: 0.8/100 person-years at the Harlem site and 0/100 person-years at the Lower East Side site. In contrast, HBV incidence was moderate (12.2/100 person-years) at the Harlem site and high (30.7/100 person-years) at the Lower East Side site. Similarly, HCV incidence was moderate (9.3/100 person-years) at the Harlem site and high (34.0/100 person-years) at the Lower East Side site. Results show that high rates of HBV and HCV transmission do not imply high rates of HIV transmission, even within an area of high HIV seroprevalence.     

Sexual risk for hepatitis B virus infection among hepatitis C virus-negative heroin and cocaine users

Hepatitis C virus (HCV) and hepatitis B virus (HBV) are highly prevalent, often co-occurring infections among drug users. We examined HBV prevalence and risk behaviour patterns among a group of HCV-negative heroin and/or cocaine users in order to understand HBV risk and prevention opportunities among this unique group. Of 164 people enrolled, 44% had injected drugs. Overall, 24% of participants tested positive for exposure to HBV; drug injectors (28%) were only slightly and not significantly (P=0.287) more likely to test positive than those who had never injected drugs (21%). HBV exposure was significantly associated with multiple indicators of greater sex risk. HBV status was not associated with any demographic characteristic, but participants who reported longer duration of cocaine use were significantly less likely to test positive to exposure for HBV. It appears that HBV risk among HCV-negative drug users in this cohort is primarily due to sexual behaviour.     

Case-reporting of acute hepatitis B and C among injection drug users

Although public health surveillance system data are widely used to describe the epidemiology of communicable disease, occurrence of hepatitis B and C virus (HBV and HCV, respectively) infections may be misrepresented by under-reporting in injection drug users (IDUs). This study was carried out to examine the relationship between HBV and HCV incidence and case-reporting of hepatitis B and C in Seattle IDUs. Names of participants in a Seattle IDU cohort study who acquired HBV or HCV infection over a 12-month follow-up period were compared to a database of persons with acute bepatitis B and C reported to the bealth department surveillance unit over the same period. Of 2,208 IDUs enrolled in the cohort who completed a follow-up visit, 63/759 acquired HBV infection, 53/317 acquired HCV infection, and 3 subjects acquired both HBV and HCV. Of 113 cohort subjects who acquired HBV or HCV, only 2 (1.5%) cases were reported; both bad acute bepatitis B. The upper 95% confidence limit for case-reporting of bepatitis C in the cohort was 5.7%, and for hepatitis B, it was 7.5%. In this study, reporting of acute bepatitis in IDUs was extremely low, raising questions regarding the use of community surveillance data to estimate underlying incidence in that population group.     

Needle sharing and participation in the Amsterdam Syringe Exchange program among HIV-seronegative injecting drug users.

To enhance the prevention of human immunodeficiency virus infection, factors related to regular participation in the Amsterdam Syringe Exchange and the borrowing of syringes were studied in 131 HIV-seronegative injecting drug users in a 1989-90 survey. A total of 29 percent of the users reported borrowing syringes, that is injecting drugs at least once in the past 4-6 months with a needle or syringe previously used by someone else. Users at increased risk of borrowing are previous borrowers, long term moderate-to-heavy alcohol users, current cocaine injectors, and drug users without permanent housing. Regular clients of the syringe exchange, when compared with other injecting drug users, were found more often to be frequent, long term injectors. They borrowed slightly less often than other users, but this was not statistically significant, even after controlling for frequency of injecting or other potential confounders. The results suggest that, 5 years after the start of the Amsterdam Syringe Exchange, drug use characteristics govern an individual injecting drug user's choice of exchanging or not exchanging syringes. The conclusion is that it seems more important to direct additional preventive measures at injecting drug users with an increased risk of borrowing rather than at users who do not participate in the syringe exchange or who do so irregularly.     

Drug use frequency among street-recruited heroin and cocaine users in harlem and the bronx before and after September 11, 2001

We determined if illicit drug use frequency changes after a disaster by comparing drug use frequency in two street-recruited samples of heroin and cocaine users, ages 15–40 years. The users were interviewed between July 11 and November 11 and divided into before- and after-September 11th groups for analysis. The before and after groups were similar in the mean number of days of drug use per month (sniff cocaine 6.8 days vs. 9.4 days, respectively, P=.17; snorted heroin 13.9 vs. 14.0, respectively, P=.96; smoked crack 16.9 vs. 15.6, respectively, P=.96; and smoked marijuana 17.5 vs. 15.3, respectively, P=.36) and in the proportion of daily users: sniffed cocaine 10% versus 17%, respectively (P=.28); snorted heroin 47% versus 40%, respectively (P=.91); smoked crack 33% versus 37%, respectively (P=.68); and smoked marijuana 47% versus 40%, respectively (P=.41). Among street-recruited heroin and cocaine users in Harlem and the Bronx, the frequency of drug use did not increase following the events of September 11, 2001. Dr. Factor is from the Division of Prevention Research and Analytic Methods in the Epidemiology Program Office at the Centers for Disease Control and Prevention and is assigned to     

注射毒品者丙型肝炎病毒感染率及其危险因素研究

目的了解北京市注射毒品者HCV感染状况及其危险因素,评估注射毒品人群中HIV感染高危行为流行水平,为制定预防和控制艾滋病的策略和措施提供科学依据。方法选择北京市强制戒毒所新收治的注射毒品者和自社区招募的注射毒品者作为研究对象,采用问卷调查的方法进行资料的收集,采集静脉血5ml,实验室检测HCV抗体。资料的分析采用单因素分析、多因素分析。结果北京市注射毒品者的HIV感染率和HCV感染率分别为7.33%和52.59%。多因素分析结果表明HCV感染的危险因素有在强制戒毒所(OR=2.37,95%CI为1.55~5.72)、非北京市户籍(OR=1.94,95%CI为1.05~3.45)和注射次数≥100次(OR=2.60,95%CI为1.54~7.03)。结论北京市注射毒品人群HCV的感染率高达52.59%,标志着HIV感染高危行为在这一人群中广泛存在,应立即采取相应措施控制HIV和HCV感染的进一步扩散。     

Changes in needle sharing behavior among intravenous drug users: San Francisco, 1986-88.

We analyzed data for San Francisco intravenous drug users entering treatment, April 1986-September 1988 (N = 7,660). The proportion of cases reporting any needle sharing in the month preceding treatment decreased from 50 percent in 1986 to 28 percent in 1988. Similar decreases were reported by two longitudinal cohorts (needle sharing by the same individuals) admitted in 1986 and 1987 (n = 303), and in 1986 and 1988 (n = 205). In a multiple logistic regression model four variables predicted needle sharing: earlier time of admission, cocaine use, younger age, and being White rather than Black.     

HIV seroprevalence among street-recruited injection drug and crack cocaine users in 16 US municipalities.

OBJECTIVES: This study deter- mined human immunodeficiency virus (HIV) seroprevalence and factors associated with HIV infection among street-recruited injection drug users and crack cocaine smokers. METHODS: An analysis was performed on HIV serologies and risk behaviors of 6402 injection drug users and 3383 crack smokers in 16 US municipalities in 1992 and 1993. RESULTS: HIV seroprevalence was 12.7% among injection drug users and 7.5% among crack smokers. Most high-seroprevalence municipalities (>25%) were located along the eastern seaboard of the United States. In high-seroprevalence municipalities, but not in others, HIV seroprevalence was higher for injection drug users than for crack smokers. Among injection drug users, cocaine injection, use of speedballs (cocaine or amphetamines with heroin), and sexual risk behaviors were independently associated with HIV infection. Among crack smokers, sexual risk behaviors were associated with HIV infection. CONCLUSIONS: Injection drug users and crack smokers are at high risk for HIV infection.     

Potential biases in estimates of hepatitis C RNA clearance in newly acquired hepatitis C infection among a cohort of injecting drug users

Estimates of hepatitis C virus (HCV) clearance following acute infection range from 14 to 46%. This wide range is likely to be due to the characteristics of the populations studied and analysis methods. This paper examines how differing definitions of clearance parameters affect estimates of viral clearance in a cohort of 85 injecting drug users with newly acquired HCV infection. Kaplan-Meier estimates of time to HCV clearance were determined using varying definitions of eligible cohort, viral clearance, date of infection and date of clearance. Based on which combinations of definitions were used, the number of subjects eligible for analysis ranged from 27 to 75, clearance rate ranged from 14 to 68% and time to achieving 25% clearance ranged from approximately 5 months to 14 months. Standardized definitions and methodologies are required to enable valid comparisons of rates of clearance across newly acquired HCV infection natural history studies.