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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Snorting drugs and Hepatitis C transmission- where's the link?

Robert Fieldhouse

In some studies, hepatitis C infection has been associated with a history of intranasal cocaine use (snorting coke).

Transmission of HCV could take place through sharing blood-contaminated straws, notes or bullets to snort drugs.

It is unclear whether intranasal drug use is an independent risk factor or, rather, an indication that a person practices both injecting drug use and snorting of drugs with shared notes or straws that could get contaminated with blood.

Research in the UK among HIV positive gay men who have recently acquired hepatitis C has shown intranasal cocaine use to exist alongside other potential risk factors for hepatitis C transmission, including unprotected sex and having untreated sexually transmitted infections.

People who use drugs may be reluctant to report their injection drug use, so it is possible that some hepatitis C transmission may have occurred as a result of injection drug use rather than drug snorting but remain unreported.

A study conducted among volunteer blood donors in the United States independently associated HCV infection with a history of intranasal cocaine use. (The mode of transmission could be through sharing contaminated straws.)

This study showed that among volunteer blood donors, in addition to blood transfusion and a history of injection drug use, other factors associated with a significant risk for HCV infection were intranasal cocaine use, sexual promiscuity, and ear piercing among men.

However, compounding this issue was that the large percentage of people who admitted to intravenous drug use had denied such use when questioned directly at the time of their blood donations. However, when privately administered a separate questionnaire about recreational drug use, 68% admitted to or recalled the use of illegal drugs in their lifetime. (1)

Data from NHANES III (The National Health and Nutrition Examination Surveys, conducted by the National Center for Health Statistics, Centers for Disease Control (NCHS/CDC), designed to assess the health and nutritional status of adults and children in the United States through interviews and direct physical examinations) indicated that 14% of the general population have used cocaine at least once. (2)

Although NHANES III data also indicated that cocaine use was associated with HCV infection, injecting-drug use histories were not ascertained.

Data from another study in the United States showed young low-income women in San Francisco and Alameda County to be infected with the potentially deadly hepatitis C (HCV) at more than double the national average, according to a study from the University of California-San Francisco (UCSF). In addition to the high infection rates among poor women ages 18 to 29, the researchers found a possible connection to herpes and non-injection drug use, namely cocaine snorting. (3)

The research covered 1,707 women in four counties -- San Francisco, Alameda, San Joaquin and San Mateo. It showed that 4.3 percent of the women studied in San Francisco and 3.8 percent of those in Alameda County were infected with hepatitis C -- well above the national average of 1.8 percent. Young women in two other counties -- San Joaquin and San Mateo -- had infection rates below the national average at 1.4 percent and zero, respectively.

In total 17.5% of the total sample reported snorting cocaine.

This study highlights the need to extend hepatitis C prevention beyond simply blood-to-blood transmission. It seems pertinent to address both STI prevention and treatment as well as risk reduction when snorting drugs.

More studies are necessary to clarify the role of cocaine use in the acquisition and transmission of HCV infection.

In a study of 276 people who had ever smoked crack or who sniffed or snorted cocaine or heroin, published last year, 4.7 percent were infected with HCV.

Participants who sniffed or snorted heroin and cocaine together were most likely to be infected with HCV. The reason for the increased risk of HCV infection among those participants may possibly be related to the damaging effects of the drugs on the nasal mucosal lining. (4)

Currently, the strength of the association between intranasal cocaine use and HCV infection means that the US Centers for Disease Control does not support routine hepatitis testing based solely on this risk factor. In the case of the outbreak in the UK snorting drugs appears not to exist in isolation to other risk factors such as unprotected sex or sex involving blood exchange.

The role of drug snorting in London hepatitis C outbreak

Researchers from the Royal Free Hospital found evidence to suggest both sexual and intranasal transmission of HCV.

In a paper presented to the 54th Annual Meeting of the American Association for the Study of Liver Diseases in Boston, Massachusetts in late 2003, the authors reported that unprotected sexual intercourse was the sole risk factor reported by all men in the cohort, 16 subjects (70%) reported group sex and fisting, 15 (65%) reported intranasal drug use, and four (17%) reported injected drug use.

The hypothesis of sexual transmission was supported by the fact that 10 (43%) had a documented STI (seven syphilis and one gonorrhoea) including two patients with acute HIV seroconversion in the six months prior to hepatitis C diagnosis. At the time of the presentation last October, five isolates had been sequenced and three appeared related by phylogenetic analysis, suggesting a common source. Work is continuing to elucidate further possible links.