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Descriptive epidemiology of hepatitis C virus among male heroin abusers in Taiwan.
http://www.thefreelibrary.com/Descriptive+epidemiology+of+hepatitis+C+virus+among+male+heroin+...-a0145561557
Background: The purpose of this study was to explore the epidemiology of hepatitis C virus (HCV) infection and to determine the risk factors for HCV infection among heroin abusers in Taiwan.

 

Methods: This was a cross-sectional study. From November 2004 to February 2005, 577 subjects, including 423 subjects (73.3%) using injectable heroin and 154 subjects (26.7%) using smoked heroin from one male prison located in Taiwan, were enrolled in this study. The mean age was 33.3 [+ or -] 7.9 years (age range 19-65 years). Anti-HCV antibody was tested. A face-to-face interview focusing on sociodemographic information and risk behaviors was addressed. The t test, [chi square] test, and multivariate logistic regression were used.


Results: The overall prevalence of anti-HCV antibody positivity was 74.9%, with 89.8% among injecting heroin abusers and 33.8% among smoking heroin abusers (P < 0.0001). The multivariate logistic regression analysis demonstrated that needle sharing was independently related to HCV infection (odds ratio = 5.25, 95% confidence interval = 2.48-11.12).

Conclusions: The prevalence of anti-HCV antibody positivity among male injecting drug abusers is high in Taiwan. Needle sharing is identified as a potential risk factor for HCV infection.

Key Words: epidemiology, hepatitis C, heroin abuser, prevalence, needle sharing, tattoo

**********

In 2002, chronic liver disease
and liver cirrhosis were the sixth leading causes of death in Taiwan, (1) with hepatitis B and hepatitis C virus (HCV) infections the leading cause of these diseases. (2-4) In Taiwan, HCV infection is mainly transmitted by blood transfusion, IV drug abuse, accidental needle injection, sexual contact, acupuncture, tattoos, and earlobe piercing. (5-10) Since there is no effective vaccination to prevent HCV infection, intervention consists of avoidance techniques only. After screening for HCV antibodies in blood donors was instituted in Taiwan in July 1992, the transmission of the HCV virus via blood transfusion was effectively interrupted. (11,12)

HCV is a common infection among injecting drug abusers. (2,13) In the study by Chang et al, (8) the prevalence of anti-HCV antibody positivity was 66.4% among injecting drug abusers. Policies and programs to prevent HCV infection remain uncertain in these high risk people.

We hope to make a dent in the rising epidemic of HCV infection by monitoring HCV infection rates, as a means of showing the effectiveness of various interventions. This study used data collected from heroin abusers to explore the following questions: (1) what are the sociodemographic patterns and the prevalence of HCV infection in heroin abusers? (2) what are the risk factors for HCV infection in heroin abusers?

Materials and Methods

Study Population

This was a cross-sectional study. The study was undertaken at a male prison in Taiwan from November 2004 to February 2005. All new sentenced prisoners received a structured questionnaire interview. A total of 577 men were enrolled in the study. Of that group, 423 (73.3%) injected heroin and 154 (26.7%) smoked heroin. The study was approved by the ethics committee. The subjects' age, employment, years of education, and marital status were included. A face-to-face interview inquired about the age of first heroin use, frequency of use, duration of use, and needle sharing. Other risk factors included the number of female sexual partners, frequency of condom use, tattoo history, alcohol use, and blood transfusion history. All study subjects underwent testing for hepatitis C virus antibody using the third generation EIA test.

Statistical Analysis

Statistical analysis was performed by SPSS (Chinese Version 10.0, Sinter Information Corp, Taiwan). The t test, [chi square] test and multivariate logistic regression were used. Relative risks were estimated by the odds ratio (OR) using a multivariate logistic regression and were expressed with 95% confidence interval (CI). A P value less than 0.05 was considered statistically significant.

Results

Sociodemographic characteristics of this study population are listed in Table 1. The mean age was 33.3 [+ or -] 7.9 years (age range 19-65 years). Among 68.9% of these abusers, the age of the first heroin use was less than 30 years old. Eighty percent of the abusers were employed full time, 60.3% had less than 9 years of education, and 58.2% were unmarried.

The related factors of HCV infection are listed in Table 2. The overall prevalence of anti-HCV antibody positivity was 74.9%. The prevalence of anti-HCV antibody positivity was higher among injecting heroin abusers than among smoking heroin abusers, with statistical significance (89.8% versus 33.8%), P < 0.0001). The subjects with anti-HCV antibody positivity were younger than those who were anti-HCV antibody negative, with statistical significance (32.8 versus 34.9 years old, P = 0.005). The prevalence of anti-HCV positivity did not increase with age (P = 0.169).

The mean age of first heroin use and history of needle sharing were significantly associated with anti-HCV positivity. The mean age of the first heroin use was 26.8 years for the anti-HCV positive subjects, and 28.7 years for the anti-HCV negative subjects (P = 0.007). Also, 93.1% of those with a needle sharing history were anti-HCV positive, compared with 70.8% of those who did not share needles. (P < 0.0001).

The employment status, years of education, marital status, frequency of use, duration of use, number of female sex partners, condom use, tattoo history, alcohol use, and blood transfusion history were not significantly associated with anti-HCV positivity.

The predictors of HCV infection are exhibited in Table 3. In the final model, multivariate logistic regression revealed that needle sharing was the only strong risk factor for HCV infection. That is, the prevalence of anti-HCV positivity increased 5.25-fold for heroin abusers with a history of needle sharing (95% confidence interval = 2.48-11.12, P < 0.0001).

Discussion

Our study revealed that HCV is a common infection among injecting heroin abusers. The prevalence of anti-HCV positivity was 89.8% among male injecting heroin abusers. Several studies have reported similar results. The prevalence of anti-HCV positivity among injecting drug abusers was 66.4% in southern Taiwan, (8) 82% in the US, (14) and 75.3% in Australia. (15) In contrast, the prevalence of anti-HCV positivity among male smoking heroin abusers was 33.8% in our study and 14.4% among noninjecting drug abusers in southern Taiwan. (8) The prevalence of anti-HCV positivity was 3.9% in a hospital-based study of healthy men. (16) Although there are variations in prevalence, HCV infection among injecting drug abusers is a critical public health threat.

Our study also confirmed that needle sharing was an independent risk factor for HCV infection (OR = 5.25, 95% CI = 2.48-11.12). Several studies have consistently observed this association between needle sharing and HCV infection. (17-20) Hence, risk reduction programs, including use of sterile needles, is of great concern.

We also found the mean age of the first heroin use for the subjects with anti-HCV positivity was younger than those who were anti-HCV negative (26.8 versus 28.7 years old, P = 0.007). We also noted that the cumulative prevalence of anti-HCV positivity reached an apparently high level (82.2%) before 40 years of age. Due to the fact that the number of heroin users with anti-HCV positivity was highest among those who began using before age 30, and among those with less education, risk reduction counseling must be directed at these specific sociodemographic groups.

Surprisingly, we identified that tattooing was not associated with anti-HCV positivity in the [chi square] test (P = 0.225). So far, no consistent data exist for the association between tattooing and HCV infection. In the study by Alter et al, (21) no association was found between tattooing and HCV infection. In contrast, however, several researchers have illustrated a remarkable association between tattooing and HCV infection. (5,6,8-10) Ko et al also suspected that unhygienic tattooing with improperly sterilized needles could obviously introduce an increased risk for HCV infection in Taiwan. (22)

Limitations

Due to the small sample size, this is not a thorough representation of all Taiwanese heroin abusers. However, 70.8% of those without a needle sharing history were also anti-HCV positive. Thus, there is un urgent need to investigate the other routes of transmission of HCV. Hence, a larger detailed study is necessary for a more accurate description of risk factors.

Conclusion

The prevalence of anti-HCV positivity among male injecting drug abusers is predominantly high. The parenteral route, mainly by needle sharing, is the most common transmission route of HCV infection. Intervention to improve the availability of sterile needles is a critical public health topic with regard to reducing HCV infections in Taiwan. Moreover, we sincerely hope this study could provide the background data for further decision making in public health care policy.

References

1. Main Causes of Deaths in Taiwan in 2002, Department of Health, Taiwan. Available at: http://www.doh.gov.tw/ufile/Doc/S02/9101-eng.xls. Accessed February 23, 2006.

2. Chen DS, Wang JT, Chen PJ, et al. Hepatitis C virus infection in Taiwan. Gastroenterol Jpn 1991; 26(suppl 3):164-166.

3. Tsai JF, Chang WY, Jeng JE, et al. Hepatitis C virus infection as a risk factor for non-alcoholic liver cirrhosis in Taiwan. J Med Virol 1993; 41:296-300.

4. Tai DI, Chen CH, Chang TT, et al. Eight-year nationwide survival analysis in relatives of patients with hepatocellular carcinoma: role of viral infection. J Gastroenterol Hepatol 2002;17:682-689.

5. Chen TZ, Wu JC, Yen FS, et al. Injection with nondisposable needles as an important route for transmission of acute community-acquired hepatitis C virus infection in Taiwan. J Med Virol 1995;46:247-251.

6. Li CP, Hwang SJ, Lu CL, et al. Risk factor analysis of patients with chronic hepatitis C in Taiwan. Zhonghua Yi Xue Za Zhi (Taipei) 1996;58:275-280.

7. Wang CS, Chang TT, Chou P. Differences in risk factors for being either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan. J Clin Epidemiol 1998;51:733-738.

8. Chang CJ, Ko YC, Liu HW. Seroepidemiology of hepatitis C virus infection among drug abusers in southern Taiwan. J Formos Med Assoc 1998;97:826-829.

9. Sun CA, Chen HC, Lu CF, et al. Transmission of hepatitis C virus in Taiwan: prevalence and risk factors based on a nationwide survey. J Med Virol 1999;59:290-296.

10. Lee PL, Wang JH, Tung HD, et al. A higher than expected recovery rate from hepatitis C infection amongst adolescents: a community study in a hepatitis C-endemic township in Taiwan. Trans R Soc Trop Med Hyg 2004;98:367-372.

11. Wang JT, Wang TH, Lin JT, et al. Effect of hepatitis C antibody screening in blood donors on post-transfusion hepatitis in Taiwan. J Gastroenterol Hepatol 1995;10:454-458.

12. Chang TT, Young KC, Yang YJ, et al. Incidence of post-transfusion hepatitis in Taiwan before and after introduction of anti-HCV testing. Liver 1996;16:201-206.

13. Lee SD, Chan CY, Wang YJ, et al. Seroepidemiology of hepatitis C virus infection in Taiwan. Hepatology 1991;13:830-833.

14. Samuel MC, Doherty PM, Bulterys M, et al. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect 2001;127:475-484.

15. Hallinan R, Byrne A, Amin J, et al. Hepatitis C virus prevalence and outcomes among injecting drug users on opioid replacement therapy. J Gastroenterol Hepatol 2005;20:1082-1086.

16. Lai SW, Ng KC, Li CI. Descriptive analysis of HBsAg and HCV antibody prevalence in patients receiving health checkups: a hospital-based study. Mid Taiwan J Med 2004;9(suppl 1):s64-s69.

17. Abraham HD, Degli-Esposti S, Marino L. Seroprevalence of hepatitis C in a sample of middle class substance abusers. J Addict Dis 1999;18:77-87.

18. Wada K, Greberman SB, Konuma K, et al. HIV and HCV infection among drug users in Japan. Addiction 1999;94:1063-1069.

19. Habib SE, Lovejoy FH, Aspin C. Hepatitis C prevalence and risk behavior of injecting drug users in Sydney: a continuing concern. Southeast Asian J Trop Med Public Health 2001;32:823-834.

20. Herring BL, Tsui R, Peddada L, et al. Wide range of quasispecies diversity during primary hepatitis C virus infection. J Virol 2005;79:4340-4346.

21. Alter MJ, Coleman PJ, Alexander WJ, et al. Importance of heterosexual activity in the transmission of hepatitis B and non-A, non-B hepatitis. JAMA 1989;262:1201-1205.

22. Ko YC, Ho MS, Chiang TA, et al. Tattooing as a risk of hepatitis C virus infection. J Med Virol 1992;38:288-291.

Kuan-Fu Liao, MD, Chen-Yuang Peng, MD, PHD, Shih-Wei Lai, MD, Wu-Long Chang, MS, and Nan-Yung Hsu MD, MS

From the Departments of Internal Medicine, Family Medicine, and Surgery, China Medical University Hospital, and the Department of Health, Taichung Prison, Taichung, Taiwan.

Reprint requests to Shih-Wei Lai, Department of Family Medicine, China Medical University Hospital, No 2, Yuh-Der Road, Taichung, 40447, Taiwan. Email: wei@www.cmuh.org.tw

Accepted January 18, 2006.

 

RELATED ARTICLE: Key Points

* Hepatitis C virus (HCV) infection is the second cause of chronic liver diseases in Taiwan.

* The prevalence rate of anti-HCV positivity is high among injecting heroin abusers.

* Needle sharing is identified as a potential risk factor for HCV infection.

Table 1. Sociodemographic characteristics of male heroin abusers
 
Variable                          Male heroin abusers (%)
 
Type of use
  Smoking                         154 (26.7%)
  Injecting                       423 (73.3%)
Age (years) (mean [+ or -] SD)     33.3 [+ or -] 7.9
Age of first use (years) (a)
  <20                              46 (9.5)
  20-29                           288 (59.4)
  30-39                           123 (25.4)
  40-49                            21 (4.3)
  [greater than or equal to]50      7 (1.4)
Employment status(a)
  Unemployed                       67 (12.3)
  Part time                        42 (7.7)
  Full time                       435 (80.0)
Educational years (a)
  [less than or equal to]9 years  342 (60.3)
  >9 years                        225 (39.7)
Marital status (a)
  Unmarried                       335 (58.2)
  Married                         146 (25.3)
  Divorced/separated               95 (16.5)
 
(a) Imprecise summation of total subjects was due to missing data.
 
Table 2. Related factors of HCV infection by chi-square test
 
                                HCV antibody    HCV antibody    P value
Variable                        negative (%)    positive (%)
 
Age (years) (mean [+ or -] SD)   34.9 [+ or -]   32.8 [+ or -]   0.005
                                  7.9             7.8
Age of first use (years)         28.7 [+ or -]   26.8 [+ or -]   0.007
  (mean [+ or -] SD)              7.2             6.8
Type of use                                                     <0.0001
  Smoking                       102 (66.2)       52 (33.8)
  Injecting                      43 (10.2)      380 (89.8)
Age groups (years)                                               0.169
  <20                             0 (0)           2 (100.0)
  20-29                          48 (21.3)      177 (78.7)
  30-39                          57 (24.5)      176 (75.5)
  40-49                          33 (35.1)       61 (64.9)
  50-59                           6 (30.0)       14 (70.0)
  [greater than or equal to]60    1 (33.3)        2 (66.7)
Employment status (a)                                            0.491
  Unemployed                     14 (20.9)       53 (79.1)
  Part time                      13 (31.0)       29 (69.0)
  Full time                     106 (24.4)      329 (75.6)
Educational years (a)                                            0.804
  [less than or equal to]9       85 (24.9)      257 (75.1)
    years
  >9 years                       58 (25.8)      167 (74.2)
Marital status"                                                  0.361
  Unmarried                      77 (23.0)      258 (77.0)
  Married                        41 (28.1)      105 (71.9)
  Divorced/separated             27 (28.4)       68 (71.6)
Frequency of use                                                 0.358
  Non-daily                     126 (25.7)      365 (74.3)
  Daily                          16 (20.8)       61 (79.2)
Duration of use (years)                                          0.570
  [less than or equal to]5      112 (24.8)      339 (75.2)
  >5                             22 (27.8)       57 (72.2)
Female sex partners (a)                                          0.447
  0                               3 (33.3)        6 (66.7)
  1                              24 (20.7)       92 (79.3)
  [greater than or equal to]2    92 (25.8)      264 (74.2)
Condom use (a)                                                   0.475
  Never                          31 (22.1)      109 (77.9)
  Sometimes                      65 (27.2)      174 (72.8)
  Always                         23 (22.8)       78 (77.2)
Needle sharing                                                  <0.0001
  No                            126 (29.2)      305 (70.8)
  Yes                             8 (6.9)       108 (93.1)
Tattoo                                                           0.225
  No                             53 (28.2)      135 (71.8)
  Yes                            91 (23.5)      296 (76.5)
Alcohol use                                                      0.330
  Never                          82 (23.6)      265 (76.4)
  Quit                            7 (38.9)       11 (61.1)
  Yes                            28 (25.7)       81 (74.3)
Blood transfusion                                                0.156
  No                            107 (26.2)      302 (73.8)
  Yes                             7 (16.3)       36 (83.7)
 
(a) Imprecise summation of total subjects was due to missing data.
 
Table 3. Risk factors of HCV infection by multivariate logistic
regression
 
Variable                        EP(SE)        OR    95% CI
 
Intercept                        1.64 (0.45)
Age (years)                     -0.02 (0.01)  0.98  0.95-1.00
Needle sharing (never            1.66 (0.38)  5.25  2.48-11.12 (a)
  needle sharing as reference)
 
EP, estimated parameter; SE, standard error; OR, odds ratio; CI,
confidence interval.
(a) P<0.0001