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Epidemiological Studies Evaluating Risk of Viral Hepatitis Infection from Tattoos and Body Piercing

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Majority of HCV due to tattoos, IDU, and ancillary hospital jobs for men ... Dose response relationships inconsistent for tattooing, but not for IDU ... – PowerPoint PPT presentation

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Title: Epidemiological Studies Evaluating Risk of Viral Hepatitis Infection from Tattoos and Body Piercing


1
Epidemiological Studies Evaluating Risk of Viral
Hepatitis Infection from Tattoos and Body Piercing
March 14, 2002
  • Miriam J. Alter, Ph.D.
  • Division of Viral Hepatitis
  • Centers for Disease Control and Prevention

2
Types of Epidemiological Studies
  • Cohort (prospective) - direct estimate of risk
  • Presence of exposure determined in sample of
    population
  • Entire sample followed and incidence of disease
    compared for those with and without the exposure
  • Case control (retrospective) - indirect estimate
    of risk
  • Sample selected based on presence or absence of
    disease
  • Proportion of cases with history of exposure
    before onset of disease compared with controls
  • Cross-sectional or prevalence - associations
  • Presence of disease determined in sample of
    population
  • Proportion of cases with history of exposure
    compared with non-cases
  • Prevalence of disease compared for those with and
    without the exposure
  • Temporal sequence of exposure relative to disease
    unknown

3
Risk Factors Associated with Acquiring HCV
Infection, United States
Cohort and Case Control Studies
  • Transfusion, transplant
  • Injecting drug use
  • Occupational blood exposure (needle sticks)
  • Birth to an infected mother
  • Infected sex partner
  • Multiple heterosexual partners

4
Sources of Infection for Persons with Hepatitis C
Injecting drug use 60
Sexual 15
Transfusion 10 (before screening)
Other 5
Unknown 10
Hemodialysis health-care work perinatal
Source Centers for Disease Control and Prevention
5
Exposures Not Associated with Acquiring HCV Case
Control Studies of Acute Hepatitis C, U.S.,
1979-1985
Cases Controls Exposure (prior 6 months) n148
n200 Medical care procedures 30.4 29.5 Denta
l work 24.3 23.5 Health care work (no blood
contact) 4.1 5.0 Ear piercing 2.7
3.0 Tattooing 0.7 0.5 Acupuncture 0
1.0 Incarceration 4.1 1.0 Foreign travel
4.1 2.5 Military service 1.3 4.9
Source JID 1982145886-93 JAMA 19892621201-5.
6
Limitations of Case Control Studies
  • Will not detect rare events
  • Do not directly measure risk

7
History of Tattooing and Acute Hepatitis
C 1982-2000, United States
Time period of History of tattooing prior
6 mo reported case N All patients No
IDU/BT
Total (95 CI) 1856 3.2 (2.5-3.8) 1.5
(0.9-2.1) 1982-1986 839 2.7 1.8 1987-1990 625 2.
7 1.1 1991-2000 392 4.3 1.5
Source CDC Sentinel Counties Study
8
History of Body Piercing Acute Hepatitis B and
Acute Hepatitis C 1996-2000, United States
History of piercing prior 6 mo Type
N All patients No IDU/BT
Acute hepatitis B 603 2.3 1.5 Acute hepatitis
C 134 3.7 1.0
Other than ears
Source CDC Sentinel Counties Study
9
Identifying Risk Factors from Prevalence Studies
  • Determining specific exposures preceding
    infection problematic when onset of infection
    unknown or many years ago
  • Substantial differences in methodology
  • Population-based (NHANES)
  • Highly selected groups
  • Blood donors
  • Clinic patients
  • VA patients
  • Inconsistent results among studies
  • Under-ascertain some risk factors
  • Cannot generalize to the rest of the population

10
Tattoos and HCV Infection Cross Sectional Studies
Tattooed (Total tested) Adj. 95 Group
(author) HCV Pos HCV Neg OR CI
Donors US (Murphy) 27 (758) 5 (1039) NA NS US
(Conry-Cantilena) 21 (248) 6 (233) NA NS AU
(Kaldor) 30 (220) 4 (210) 27 (8.4-87) GI clinic
(Balasekaran) No IDU/BT 43 (58) 16 (58) 5.9
(1.1-31) VA pts (Briggs) 50 (185) 20 (847) 2.9
(1.7-5.1)
Controlling for other risk factors (e.g., IDU,
BT)
11
Ear/body Piercing and HCV Infection Cross
Sectional Studies
Pierced (Total tested) Adj. 95 Group
(author) HCV Pos HCV Neg OR CI
Donors US (Murphy) 56 (758) 40 (1039) 2.0
(1.1-3.7) US (Conry-Cantilena) Ear piercing
men only 30 (139) 0 (83) inf p(Briggs) 37 (185) 24 (847) NA NS
Controlling for other risk factors (e.g., IDU,
BT)
12
Tattoos, Body Piercing, HBV and HCV
Infection Prevalence Studies
Positive (Total tested) Group
(author) College ER pts Spinal Clinic
HCV Tattoo Yes 1 (1652) 7 (106) 33
(52) No 1 (6348) 3 (106) 3.5 (513) Adj.
OR (95 CI) .65 (.3-1.5) NS 6.5
(2.9-14.8) Body piercing Yes .8
(1372) -- -- No 1 (6534) HBV Adj. OR (95
CI) Tattoo Yes 7 (1652) 0.81
(0.58-1.11) No 10 (6348) Body piercing Yes 5
(1372) -- -- No 10 (6534)
Controlling for other risk factors (e.g., IDU,
BT)
13
Blood Donor Studies of HCV Infection
Exposure US-ARC US-REDS Australia
Injecting drug use Transfusion High-r
isk sex /- Nasal cocaine use - ND Tattooing
- - Ear/body piercing /- ND Acupuncture - -
ND Incarceration - -
Conry-Cantilena NEJM 1996 Murphy Hepatology
2000 Kaldor Med J Aust 1992
14
Tattoos and HCV Infection GI Clinic, Albuquerque,
NM 1995-1996 Limitations
  • Not representative
  • 40 Hispanic, 40 indigent
  • Cases referred for positive HCV test
  • Controls
  • One category only - gastroesophageal reflux
    disease
  • HCV status not ascertained
  • History of incarceration not accounted for
  • Attributable fraction for tattooing 0.8

Source Balasekaran et al. Am J Gastro
1999941341-6
15
Tattoos and HCV Infection Orthopedic Spinal
Clinic, Dallas, TX 1991-1992
Cross sectional study of 629 patients
over-represented by blacks, hispanics, men,
middle and low income
HCV Pos HCV Neg Exposure
n43 n583 AR
Tattoo 58 15 41 Beer drinker 47 26 23
Injection drug use 35 4 17 Male Ancillary
HCW 23 4 8 Transfusion 12 21 --
Attributable risk percentage adjusted for other
risk factors and standardized to population
Source Haley et al. Medicine 200180134-51.
16
Tattoos and HCV Infection Haley et al.s
Conclusions
  • Majority of HCV due to tattoos, IDU, and
    ancillary hospital jobs for men
  • Tattoos accounted 2 times the infections as IDU
  • Transfusion a rare means of acquiring HCV
  • Majority of controlled studies reported no (or
    inverse) association between HCV and transfusion.
  • Heavy beer drinking (not wine/liquor) important
    role
  • Increased prevalence of HCV in black men due
    almost entirely to confounding effects of having
    been a male ancillary HCW and drinking beer
    heavily


17
Haley Study Limitations
  • Population not representative
  • AR calculated from cross-sectional studies
    controversial
  • Inconsistent with virtually all other studies
  • Dose response relationships inconsistent for
    tattooing, but not for IDU
  • IDU likely under-reported
  • 50 of HCV-positives admit to IDU when
    re-interviewed after receiving results
  • Some factors likely surrogates for known risks
  • Male ancillary HCW (why not females?)
  • Beer drinking (why not other forms of alcohol?)

18
College Students, 2000-2001, Preliminary Data
Characteristic Total Tested No. () HCV
Positive
Total 8018 77 (0.96) Age 20-24 3668 14 (0.4) 25-29 1189 7 (0.6)
30 377 54 (3.9) pWhite 2384 31 (1.3) Black 1896 21 (1.1)
Hispanic 1839 12 (0.6) p(0.5)
vs. Whites
Hwang et al., unpublished data
19
HCV and HBV Among College Students, 2000-2001
Positive Characteristic Total Tested
() HCV HBV
Transfusion Yes 337 (4.5) 6.2 11.8 No 7236
(95.5) 0.7 5.6 IDU Yes 116 (1.5) 22.4 17.1 N
o 7718 (98.5) 0.6 5.7 Tattoo Yes 1430 (20.5)
0.3 5.3 No 5533 (79.5) 0.5 6.2 Body
piercing Yes 1202 (17.4) 0.4 3.7 No 5701
(82.6) 0.4 6.5 Snorted drugs Yes 617 (9.1)
0.6 6.8 No 6179 (90.9) 0.4 5.9
pHwang et al., unpublished data
20
Cosmetic Procedures and HCV Infection Moderate
Endemic Countries
Tattooing Body
Piercing Country HCV Pos HCV Neg HCV Pos HCV
Neg Case-control Taiwan 0 0 0 1 Cros
s-sectional Japan 1 0 -- -- 3 0
-- -- Pakistan 7 0 7 0
21
Alternative Medicine and HCV Infection Moderate
Endemic Countries
Acupuncture Country HCV
Pos HCV Neg Case-control Taiwan 5
1 Cross-sectional Japan 62 26
20 17
P 22
Risk of Viral Hepatitis Infection from Tattoos
and Body Piercing Summary
  • Biologically plausible but no evidence for
    increased risk for HBV or HCV based on these
    histories alone
  • May account for small fraction of cases
    (epidemiologically insignificant) and be limited
    to certain settings
  • prisons, unregulated practitioners, non-US
  • Routine screening in the general population not
    warranted
  • Other considerations may warrant screening
    selected populations, e.g., donors
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