Descriptive epidemiology of hepatitis C virus among male heroin abusers in Taiwan.Background: The purpose of this study was to explore the epidemiology of hepatitis C virus
abbr. hepatitis C virus HCV 1 Hepatitis C virus, see there 2. Human coronavirus. See Coronavirus. ) infection and to determine the risk factors for HCV infection among heroin abusers in Taiwan. Methods: This was a cross-sectional study cross-sectional study n. See synchronic study. cross-sectional study, n the scientific method for the analysis of data gathered from two or more samples at one point in time. . From November 2004 to February 2005, 577 subjects, including 423 subjects (73.3%) using injectable in·ject·a·ble adj. Capable of being injected. Used of a drug. n. A drug or medicine that can be injected. 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 chi square (kī), n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] test, and multivariate The use of multiple variables in a forecasting model. logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. 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 Needle sharing is the colloquialism for the reuse of syringes by multiple illegal drug users to administer intravenous drugs, and is a primary vector for diseases which can be transmitted through blood, including hepatitis and AIDS. was independently related to HCV infection (odds ratio = 5.25, 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. = 2.48-11.12). Conclusions: The prevalence of anti-HCV antibody positivity among male injecting drug abusers drug abuser n → chi fa uso di droghe is high in Taiwan. Needle sharing is identified as a potential risk factor for HCV infection. Key Words: epidemiology, hepatitis C Hepatitis C Definition Hepatitis C is a form of liver inflammation that causes primarily a long-lasting (chronic) disease. Acute (newly developed) hepatitis C is rarely observed as the early disease is generally quite mild. , heroin abuser, prevalence, needle sharing, tattoo tattoo, the marking of the skin with punctures into which pigment is rubbed. The word originates from the Tahitian tattau [to mark]. The term is sometimes extended to scarification, which consists of skin incisions into which irritants may be rubbed to produce ********** In 2002, chronic liver disease Chronic liver disease is a liver disease of slow process and persisting over a long period of time, resulting in a progressive destruction of the liver. It includes amongst others:
(sirō´sis), n a degenerative disease of the liver in which hepatic tissue is replaced with connective tissue, commonly a result of chronic alcoholism. See jaundice. were the sixth leading causes of death in Taiwan, (1) with hepatitis B Hepatitis B Definition Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the most common chronic and hepatitis C virus (HCV) infections the leading cause of these diseases. (2-4) In Taiwan, HCV infection is mainly transmitted by blood transfusion blood transfusion, transfer of blood from one person to another, or from one animal to another of the same species. Transfusions are performed to replace a substantial loss of blood and as supportive treatment in certain diseases and blood disorders. , IV drug abuse, accidental needle injection, sexual contact, acupuncture acupuncture (ăk`y  pŭng'chər), technique of traditional Chinese medicine, in which a number of very fine metal needles are inserted into the skin at specially designated points. ,
tattoos, and earlobe ear·lobe or ear loben. The soft, fleshy, pendulous lower part of the external ear. piercing. (5-10) Since there is no effective vaccination vaccination, means of producing immunity against pathogens, such as viruses and bacteria, by the introduction of live, killed, or altered antigens that stimulate the body to produce antibodies against more dangerous forms. 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 in·ject·ed adj. 1. Of or relating to a substance introduced into the body. 2. Of or relating to a blood vessel that is visibly distended with blood. injected 1. introduced by injection. 2. congested. heroin and 154 (26.7%) smoked heroin. The study was approved by the ethics committee ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. . The subjects' age, employment, years of education, and marital status marital status, n the legal standing of a person in regard to his or her marriage state. 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 1. condom - The protective plastic bag that accompanies 3.5-inch microfloppy diskettes. Rarely, also used of (paper) disk envelopes. Unlike the write protect tab, the condom (when left on) not only impedes the practice of SEX but has also been shown to have a high failure use, tattoo history, alcohol use, and blood transfusion history. All study subjects underwent testing for hepatitis C virus antibody using the third generation EIA (Electronic Industries Alliance, Arlington, VA, www.eia.org) A membership organization founded in 1924 as the Radio Manufacturing Association. It sets standards for consumer products and electronic components. test. Statistical Analysis Statistical analysis was performed by SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. (Chinese Version 10.0, Sinter sinter Mineral deposit with a porous or vesicular texture (having small cavities). Siliceous sinter is a deposit of opaline or amorphous silica that occurs as an incrustation around hot springs and geysers and sometimes forms conical mounds (geyser cones) or terraces. 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 tattooing /tat·too·ing/ (tah-too´ing) the introduction, by punctures, of permanent colors in the skin. tattooing of cornea permanent coloring of the cornea, chiefly to conceal leukomatous spots. 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 ster·il·ize tr.v. ster·il·ized, ster·il·iz·ing, ster·il·iz·es 1. To make free from live bacteria or other microorganisms. 2. 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 parenteral /pa·ren·ter·al/ (pah-ren´ter-al) not through the alimentary canal, but rather by injection through some other route, as subcutaneous, intramuscular, etc. par·en·ter·al adj. 1. 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 hep·a·to·cel·lu·lar carcinoma n. A carcinoma derived from parenchymal cells of the liver. Also called hepatocarcinoma, malignant hepatoma. : role of viral infection viral infection, n an infection by a pathogenic virus. A virus acts on the cell nucleus, taking over the genetic material within the nucleus and replicating itself. . 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 Chronic hepatitis Long lasting inflammation of the liver due to viruses or other causes. Mentioned in: Tube Compression of the Esophagus and Stomach 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 yang (yang) [Chinese] in Chinese philosophy, the active, positive, masculine principle that is complementary to yin; see yin, under principle. 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 New Mexico, state in the SW United States. At its northwestern corner are the so-called Four Corners, where Colorado, New Mexico, Arizona, and Utah meet at right angles; New Mexico is also bordered by Oklahoma (NE), Texas (E, S), and Mexico (S). , USA. Epidemiol Infect infect /in·fect/ (in-fekt´) 1. to invade and produce infection in. 2. to transmit a pathogen or disease to. in·fect v. 1. 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 opioid /opi·oid/ (o´pe-oid) 1. any synthetic narcotic that has opiate-like activities but is not derived from opium. 2. any of a group of naturally occurring peptides, e.g. 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 seroprevalence Immunology The proportion of a population that is seropositive–ie, has been exposed to a particular pathogen or immunogen; the seropositivity of a population is calculated as the number of individuals who produce a particular antibody divided of hepatitis C in a sample of middle class substance abusers. J Addict Any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or who is so drawn to the use of such narcotic drugs as to have lost the power of self-control with reference to his or her drug use. Dis 1999;18:77-87. 18. Wada K, Greberman SB, Konuma K, et al. HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. 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 non-A, non-B hepatitis n. Abbr. NANB hepatitis Hepatitis that is caused by a virus that is antigenically different from hepatitis viruses A and B. . JAMA JAMA abbr. Journal of the American Medical Association 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 reprint An individually bound copy of an article in a journal or science communication 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
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