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

Prevalence of injecting drug use and associated risk behavior among regular ecstasy users in Australia

BACKGROUND

The aim of the study was to investigate the prevalence of injecting drug use and associated risk behaviour among a sentinel sample of ecstasy users.

METHODS

Cross-sectional surveys were conducted with regular ecstasy users as part of an annual monitoring study of ecstasy and related drug markets in all Australian capital cities.

RESULTS

Twenty-three percent of the sample reported having ever injected a drug and 15% reported injecting in the 6 months preceding interview. Independent predictors of lifetime injection were older age, unemployment and having ever been in prison. Completion of secondary school and identifying as heterosexual was associated with a lower likelihood of having ever injected. Participants who had recently injected typically did so infrequently; only 9% reported daily injecting. Methamphetamine was the most commonly injected drug. Prevalence of needle sharing was low (6%), although half (47%) reported sharing other injecting equipment in the preceding 6 months.

CONCLUSIONS

Ecstasy users who report having injected a drug at some time appear to be demographically different to ecstasy users who have not injected although neither are they typical of other drug injectors. The current investigation suggests that ongoing monitoring of injecting among regular ecstasy users is warranted.

Protective immunity against hepatitis C virus infection

There is increasing evidence that a small percentage of individuals exposed to the hepatitis C virus have the capacity to generate a strong cellular immune response against the virus and avoid persistent infection, and perhaps do so repeatedly after re-exposure. This article reviews the evidence that the responses identified in this unique group of individuals represent the protective immunity that will need to be elicited by hepatitis C virus vaccines.

"The first shot": the context of first injection of illicit drugs, ongoing injecting practices, and hepatitis C infection in Rio de Janeiro, Brazil

The context of first drug injection and its association with ongoing injecting practices and HCV (hepatitis C virus) infection were investigated. Injection drug users (IDUs) (N = 606) were recruited in "drug scenes" (public places, bars) in Rio de Janeiro, Brazil, interviewed, and tested for HCV. Sharing of needles/syringes was more prevalent at the first injection (51.3%) than at the baseline interview (36.8%). Those who shared syringes/needles at first injection were more likely to be currently engaged in direct/indirect sharing practices. Among young injectors (< 30 years), those reporting sharing of needles/ syringes at the first injection were about four times more likely to have been infected by HCV. Hepatitis C virus prevalence among active IDUs (n = 272) was 11%. Prison history and longer duration of drug injection were identified as independent predictors of HCV infection. To effectively curb HCV transmission among IDUs and minimize harms associated with risk behaviors, preventive strategies should target individuals initiating drug injection beginning with their very first injection and discourage the transition from non-injecting use to the self-injection of illicit drugs.

Risk profile of individuals who provide assistance with illicit drug injections

BACKGROUND

Assisted injection is a common practice among injection drug users (IDU) that carries significant risk for health-related harm. However, little is known about the individuals who provide assistance with injections.

METHODS

We evaluated factors associated with providing help injecting among participants enrolled in the Vancouver Injection Drug User Study (VIDUS) using univariate and logistic regression analyses. We also examined self-reported relationships between the provider and the receiver of assisted injection, if compensation was provided for assistance, and what type of compensation was given.

RESULTS

Of the 704 IDU eligible for this analysis, 193 (27.4%) had provided help injecting during the last 6 months. Variables independently associated with providing help injecting included: lending one's own syringe (adjusted odds ratio [AOR] = 3.99, p = 0.004); frequent heroin injection (AOR = 3.75, p < 0.001); unstable housing (AOR = 2.15, p < 0.001); binge drug use (AOR = 2.01, p = 0.012); frequent cocaine injection (AOR = 1.95, p = 0.002); and frequent use of crack cocaine (AOR = 1.85, p = 0.002). Help was most often provided to a casual (47.2%) or a close friend (41.5%). Of the 96 (49.7%) individuals who received compensation for providing help, the most common forms of compensation were drugs (89.6%) and money (45.8%).

CONCLUSION

Providing help injecting was common among IDU in this cohort and was associated with various high-risk behaviours, including elevated levels of syringe lending. These findings indicate the need for interventions that offset the risks associated with this dangerous practice.

Molecular epidemiology of hepatitis C among drug users in Flanders, Belgium: association of genotype with clinical parameters and with sex- and drug-related risk behaviours

The aim of this study was to determine the genotypic variation of hepatitis C among drug users in Flanders and to relate the distribution of genotypes to the characteristics of the population. Hepatitis C virus RNA (HCV-RNA) quantification and genotyping was performed on stored samples from 161 anti-HCV-positive injecting and non-injecting drug users. Information on sociodemographic status, drug-related risk behaviour and sexual risk behaviour was available for each drug user. HCV-RNA was present in 152 of 161 samples (94.4%). Genotype 1 was predominant (48.7%), followed by genotype 3 (41.2%), genotype 4 (8.8%) and genotype 2 (1.4%). In the multivariate analysis, lack of a history of injecting drug use was confirmed as a statistically significant predictor for infection with genotype 1. Predictors for infection with genotype 3 were the presence of anti-HBc antibodies and a history of injecting drug use. Being tattooed emerged as a statistically significant predictor for infection with genotype 4. The 94.4% prevalence of HCV-RNA among anti-HCV-positive drug users was considerably higher than the 54-86% chronicity rate found globally among HCV-infected patients. The results of this study suggest the existence of separate transmission networks for injecting drug users and non-injecting drug users. Finally, the results suggest that tattooing practices play a role in the spread of HCV among drug users.

Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990-2001

OBJECTIVE

To assess trends in HIV, hepatitis C virus (HCV) and HIV/HCV infection among injecting drug users (IDU) from 1990 to 2001 in New York City. The 1990-2001 time period included a very large expansion of syringe exchange in New York City, from 250,000 to 3,000,000 syringes exchanged annually.

METHODS

Cross-sectional seroprevalence surveys of IDU entering drug abuse treatment in New York City, with sample sizes for HCV of 72 in 1990-1991 and 412 in 2000-2001. A structured risk behavior questionnaire was administered, and HIV and HCV testing were conducted. HCV testing was performed on de-linked stored serum samples.

RESULTS

Over the 1990-2001 period, HIV prevalence declined from 54 to 13%. HCV prevalence declined from 80 to 59% among HIV-seronegative individuals, and from 90 to 63% overall. The estimated HCV incidence in 2000-2001 among new injectors was 18 per 100 person-years at risk.

CONCLUSIONS

The large-scale expansion of syringe exchange was temporally associated with large reductions in both HIV and HCV prevalence. The prevalence and incidence of HCV, however, still remain at high levels among IDU in New York City.

Unsafe sex and increased incidence of hepatitis C virus infection among HIV-infected men who have sex with men: the Swiss HIV Cohort Study

BACKGROUND

Data on the incidence of hepatitis C virus (HCV) infection among human immunodeficiency virus (HIV)-infected persons are sparse. It is controversial whether and how frequently HCV is transmitted by unprotected sexual intercourse.

METHODS

We assessed the HCV seroprevalence and incidence of HCV infection in the Swiss HIV Cohort Study between 1988 and 2004. We investigated the association of HCV seroconversion with mode of HIV acquisition, sex, injection drug use (IDU), and constancy of condom use. Data on condom use or unsafe sexual behavior were prospectively collected between 2000 and 2004.

RESULTS

The overall seroprevalence of HCV infection was 33% among a total of 7899 eligible participants and 90% among persons reporting IDU. We observed 104 HCV seroconversions among 3327 participants during a total follow-up time of 16,305 person-years, corresponding to an incidence of 0.64 cases per 100 person-years. The incidence among participants with a history of IDU was 7.4 cases per 100 person-years, compared with 0.23 cases per 100 person-years in patients without such a history (P<.001). In men who had sex with men (MSM) without a history of IDU who reported unsafe sex, the incidence was 0.7 cases per 100 person-years, compared with 0.2 cases per 100 person-years in those not reporting unsafe sex (P=.02), corresponding to an incidence rate ratio of 3.5 (95% confidence interval, 1.2-10.0). The hazard of acquiring HCV infection was elevated among younger participants who were MSM.

CONCLUSIONS

HCV infection incidence in the Swiss HIV Cohort Study was mainly associated with IDU. In HIV-infected MSM, HCV infection was associated with unsafe sex.

What's in a virus? Folk understandings of hepatitis C infection and infectiousness among injecting drug users in Kings Cross, Sydney

Background

To explore folk understandings of blood borne virus infection and infectiousness among injecting drug users in Kings Cross, Sydney.

Methods

Observational fieldwork was conducted in Kings Cross over a four month period. In-depth interviews with 24 current injectors and 4 key informants recruited from King Cross were undertaken.

Results

Hepatitis C (HCV) generated different meanings from HIV. HIV was considered "the dreaded" and generated fear of infection and dire disease progression. Whereas HCV was considered non-desirable but less threatening than HIV. The risks of transmitting HCV through sharing injecting paraphernalia was poorly understood. Some believed HCV infection was linked to poor hygiene and dirty water. Jaundice was mistakenly thought to indicate HCV infection and was used to gauge infectiousness. Many were confused about their current hepatitis C serostatus. Some participants thought they had a "dormant antibody" or that they had a "mild case" of infection. Participants were unsure what this meant for their own health or for their potential to infect others.

Conclusion

Participants displayed confusion about transmission risks for hepatitis C, conflating blood awareness and hygiene health promotion messages. Participants' reliance on the symptom of jaundice to gauge serostatus places them at risk of transmitting and contracting HCV. Participants were confused about what a positive HCV diagnosis meant for their own health and their ability to infect others. Education is needed to debunk misconceptions about jaundice and clarify medical terms such as 'antibody' at the time of diagnosis. Further clarification of messages about injecting hygiene and blood awareness are also required.

Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose

OBJECTIVE

To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.

DESIGN

Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.

PARTICIPANTS AND SETTING

155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.

MAIN OUTCOME MEASURES

Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.

RESULTS

The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.

CONCLUSION

IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Preventing hepatitis C: 'common sense', 'the bug' and other perspectives from the risk narratives of people who inject drugs

There is little published research about how people who inject drugs are responding to the hepatitis C epidemic. This study seeks to address the prevention of hepatitis C using qualitative interviews with people who inject drugs in London. We explored narratives about risk reduction and hepatitis C in the social and historical context of other risks such as HIV, vein damage and overdose. Themes of the narratives included: the importance of autonomy in the acquisition of safer injecting skills; that safer injection was regarded as 'common sense', normalised and predicated on the risk of HIV; that hepatitis C risk was relativised with HIV risk and thereby seen as less important; and that hepatitis C infection was also seen as unavoidable. These narrative forms represent significant challenges for the management of the hepatitis C epidemic, both in terms of the existing risk reduction efforts designed for HIV and in terms of the articulation of risk reduction for injectors with general public health policy.

Molecular epidemiologic analysis of hepatitis C virus infection in injecting drug users with acute hepatitis C in Japan

BACKGROUND AND AIM

The aim of this study was to examine whether particular hepatitis C virus (HCV) subtypes are spreading among injecting drug users (IDUs) in Yamaguchi prefecture, on the south-western tip of the island of Honshu in Japan, as found in European countries.

METHODS

We prospectively enrolled acute hepatitis C patients from January 2001 to March 2003. E2 gene sequences of HCV isolates from IDUs with acute hepatitis C were phylogenetically compared to those from 30 chronic hepatitis C patients with the same HCV subtypes who had or did not have a history of intravenous drug use.

RESULTS

Nine of 11 patients (82%) with acute hepatitis C were IDUs. The HCV subtypes were 2a in four and 2b in five, which contrasted with the high prevalence of subtype 1b in patients with chronic liver diseases in Japan. IDUs with acute hepatitis C (22.0 +/- 2.4 years old) were significantly younger than those with chronic hepatitis C (49.5 +/- 9.5 years old) for subtype 2a (P = 0.0005), but not for subtype 2b (25.6 +/- 5.4 vs 28.1 +/- 2.4 years old). Some HCV isolates of subtype 2b from IDUs with acute hepatitis C were phylogenetically related to those from IDUs with chronic hepatitis C. By contrast, there was no phylogenetic segregation of HCV in IDUs with subtype 2a. HCV isolates from non-IDUs were genetically divergent from each other and those from IDUs, irrespective of the HCV subtype.

CONCLUSION

Hepatitis C virus of the non-1b subtype, particularly subtype 2b, seemed to be transmitted between IDUs very recently in Yamaguchi prefecture, Japan.

Randomized controlled trial of a brief behavioural intervention for reducing hepatitis C virus risk practices among injecting drug users

AIM

To develop and evaluate a brief intervention for reducing risk behaviours associated with HCV transmission in injecting drug users (IDU).

DESIGN

Randomized controlled trial of an individually tailored brief behavioural intervention (BBI) (experimental) versus a standardized educational intervention (control).

SETTING

Specialist drug treatment facility in Melbourne, Australia.

PARTICIPANTS

One hundred and forty-five IDU (aged 18 or over, injecting at least weekly in the preceding 6 months) recruited and randomized to the experimental condition (n = 73) or the control condition (n = 72).

INTERVENTIONS

The BBI was based on the Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ)-a standardized blood-borne virus risk assessment instrument comprising injecting risk, sexual risk and other skin penetration risk subscales. The BBV-TRAQ was used to identify individual HCV risk practices and to tailor the 30-minute experimental BBI. Control participants received a standardized HCV educational session, using current educational materials.

MAIN OUTCOME MEASURES

BBV-TRAQ subscale and total scores and measures of participant satisfaction.

RESULTS

One hundred and twenty-four participants (86%) were followed-up at 4 weeks (+/-7 days). Analyses revealed a significant reduction in HCV risk behaviours for both groups at 1-month follow-up, with participants in the experimental BBI condition reporting higher overall satisfaction with the intervention compared to the control group.

CONCLUSIONS

Both groups reported significant reductions in risk behaviour, indicating that while BBI methods hold promise for HCV education and prevention, they were not demonstrated to be more effective than the provision of standard educational materials. Future research could evaluate the efficacy of the BBV-TRAQ as a risk behaviour intervention and counselling tool in clinical, NSP and peer education settings.

Treatment of chronic hepatitis C in patients with drug dependence: time to change the rules?

AIMS

Approximately 170 million people world-wide are chronically infected with the hepatitis C virus (HCV). While the seroprevalence in the general population ranges between 0.2 and 2%, 50-90% of injection drug users are chronically HCV-infected. However, most patients who are drug abusers are still excluded from treatment of chronic HCV infection with interferon (IFN)-alpha. Due to the recent treatment advances resulting in sustained response rates between 50 and 80%, it becomes increasingly important to reflect the still existing contraindications and restrictions for IFN-alpha treatment, especially for patients with intravenous drug use (IDU) with or without psychiatric comorbidity.

METHODS

We reviewed clinical trials that focus on the treatment of chronic hepatitis C in patients with drug addiction published between 1987 and 2003.

FINDINGS

Only seven clinical trials investigating HCV treatment among drug users were found: four open prospective uncontrolled trials and three controlled trials. Thus far, no trials using pegylated IFN-alpha have been conducted. Data about sustained response and adherence in HCV-infected methadone substituted patients were either comparable to control groups or to representative clinically controlled trials using the same treatment regimen (IFN-alpha monotherapy or combined with ribavirin). Patients with former or present drug abuse seem more likely to discontinue treatment early. HCV-infected IDUs tended to be older with higher inflammatory activity and stage of fibrosis when interferon treatment was started. Psychiatric comorbidity did not negatively influence adherence or treatment outcome.

CONCLUSIONS

There is no clinical evidence suggesting that HCV treatment with IFN-alpha should be limited to IDUs or methadone substituted patients. However, more prospective controlled trials on HCV treatment for patients with IDU are needed to establish and apply new rules and guidelines.

[Evaluation of drug addicts with associated pathology. Clinical and therapeutic aspects of the integral attention]

We review the evaluation and treatment of patients with drug addictions complicated by other acute or chronic diseases from the perspective of the hospital setting. The spectrum of drug addiction's complications is broad and in many instances it is predetermined by the abuse substance and its administration route. Some complications of intravenous drug addiction have dramatically decreased in the last few years as a result of a better knowledge of hygienic customs and after the implementation of some health interventions such as the provision of sterile injectable devices. Two highly prevalent infections --HIV/AIDS and hepatitis C-- remain from the period in which most HIV infections owed to the intravenous use of heroin. Of note, these two infections largely account for the survival and quality of life of those who quit their addiction. On the other hand, it is still common the hospitalization of patients with both alcohol dependence and intercurrent diseases in whom their drug addiction may pass unnoticed. Other common situations include the treatment of acute patients with cocaine addiction and psychiatric comorbidity, patients under methadone therapy and, in general, all those cases in which, in emergency, ordinary hospital wards and specialized units, a wide differential diagnosis is raised when there is a coexistence of signs and symptoms common to an addiction, infection and/or intoxication. An integral vision of drug addiction and its complications, as well as the clinical evaluation of all health problems, is fundamental for the prognosis and treatment of these patients.

Hepatitis C and its risk management among drug injectors in London: renewing harm reduction in the context of uncertainty

AIM

Recognizing the dearth of qualitative research on hepatitis C virus (HCV) infection associated with injecting drug use in the UK, this paper summarizes qualitative insights from a study exploring the social relations of HCV risk management among drug injectors in London.

METHOD

Adopting an inductive approach to data collection and analysis, 59 depth tape-recorded qualitative interviews were undertaken in 2001 with drug injectors recruited via drug user networks.

RESULTS

While access to injecting equipment was reportedly good, needle and syringe sharing continued in exceptional circumstances and in the context of 'trust relationships'. Analyses of drug injectors' accounts of variations of 'I never share' showed that this construction denoted less a descriptor of actual risk behaviour than presentation of perceived risk status. Paraphernalia sharing, including spoons and filters, was common. There was much confusion and uncertainty concerning HCV knowledge, including its medical and transmission risks. Injectors were aware of the provisionality and partiality of their HCV knowledge. Confusion also surrounded the meaning of HCV antibody test results, with some feeling that their positive diagnosis had been 'trivialized' by their experiences of HCV testing. Injectors tended to make sense of HCV risk in relation to HIV. With most viewing HCV prevalence as high and HCV transmission as an inevitable consequence of injecting, HCV risk was perceived as ubiquitous and unavoidable.

CONCLUSIONS

There is an urgent need to renew UK policies of harm reduction in order to support perceptions that HCV is avoidable and preventable.

Blood-borne viruses and their survival in the environment: is public concern about community needlestick exposures justified?

BACKGROUND

More than 30 million needle syringes are distributed per year in Australia as a component of harm-reduction strategies for injecting drug users (IDU). Discarded needle syringes create considerable anxiety within the community, but the extent of needlestick injuries and level of blood-borne virus transmission risk is unclear. We have undertaken a review of studies of blood-borne virus survival as the basis for advice and management of community needlestick injuries.

METHODS

A Medline review of published articles on blood-borne virus survival and outcome from community injuries.

RESULTS

Hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) can all survive outside the human body for several weeks, with virus survival influenced by virus titer, volume of blood, ambient temperature, exposure to sunlight and humidity. HBV has the highest virus titers in untreated individuals and is viable for the most prolonged periods in needle syringes stored at room temperature. However, prevalence of HBV and HIV are only 1-2% within the Australian IDU population. In contrast, prevalence of HCV is 50-60% among Australian IDUs and virus survival in needle syringes has been documented for prolonged periods. There have been no published cases of blood-borne virus transmission following community needlestick injury in Australia.

CONCLUSION

The risk of blood-borne virus transmission from syringes discarded in community settings appears to be very low. Despite this, procedures to systematically follow up individuals following significant needlestick exposures sustained in the community setting should be developed.

Surveillance for newly acquired hepatitis C in Australia

BACKGROUND

The purpose of the present paper was to determine recent patterns of hepatitis C virus (HCV) transmission in Australia through a national system of enhanced surveillance of newly acquired hepatitis C.

METHODS

Demographic, clinical, and risk behavior information on newly acquired hepatitis C cases from 1997 to 2000 was collected. Newly acquired hepatitis C included cases of HCV antibody sero-conversion within a 12 month period and acute clinical hepatitis C cases.

RESULTS

Nine hundred and twelve cases of newly acquired hepatitis C were identified, representing 2.8% of all HCV notifications for this period. The majority of cases (72%) were diagnosed in people aged between 20 and 39 years. Injecting drug use was reported in the vast majority of cases (93%), with sexual transmission (2%) and tattooing (2%) reported in small numbers. HCV antibody sero-conversion was the mode of diagnosis in most cases (78%).

CONCLUSIONS

Injecting drug use is the main route of HCV transmission in Australia. As only a small proportion of HCV infections are detected as newly acquired, enhanced surveillance procedures, including increased regular HCV testing of at-risk populations are required to more effectively monitor recent patterns of transmission.

Modelling hepatitis C virus incidence, prevalence and long-term sequelae in Australia, 2001

BACKGROUND

To plan an appropriate public health response to the hepatitis C virus (HCV) epidemic requires that estimates of HCV incidence and prevalence, and projections of the long-term sequelae of infection, are as accurate as possible. In this paper, mathematical models are used to synthesize data on the epidemiology and natural history of HCV in Australia to estimate HCV incidence and prevalence in Australia to end 2001, and project future trends in the long-term sequelae of HCV infection.

METHODS

Mathematical models of the HCV epidemic in Australia were developed based on estimates of the pattern of injecting drug use. Estimates of HCV infections due to injecting drug use were then adjusted to allow for HCV infections resulting from other transmission routes. Projections of the long-term sequelae of HCV infection were obtained by combining modelled HCV incidence with estimates of the progression rates to these outcomes.

RESULTS

It was estimated that there were 210 000 (lower and upper limits of 157 000 and 252 000) people in Australia living with HCV antibodies at the end of 2001, with HCV incidence in 2001 estimated to be 16 000 (11 000-19 000). It was estimated that 6500 (5000-8000) people were living with HCV-related cirrhosis in 2001, that 175 (130-210) people developed HCV-associated liver failure, and that there were 50 (40-60) incident cases of HCV-related hepatocellular carcinoma (HCC). It was estimated that in 2001 22 500 quality adjusted life years were lost to chronic HCV infection, the majority (77%) in people with early (stage 0/1) liver disease.

DISCUSSION

Model-based estimates were broadly consistent with other sources of information on the HCV epidemic in Australia. These models suggest that the prevalence of HCV-related cirrhosis and the incidence of HCV-related liver failure and HCC will more than triple in Australia by 2020.

Epidemiology of hepatitis C virus antibodies in blood donors from the province of Latina, Italy

In order to calculate the incidence of hepatitis C virus (HCV) antibodies in blood donors and to verify the efficacy of the pre-donation method (testing blood samples of potential donors at least 3 months in advance of their first donation), we performed a retrospective cohort study in 1995 and in the period 1996-2000 at the blood transfusion unit in Latina (Italy). Third generation ELISA method as well as RIBA-3 were used. 5,978 donors in 1995 and 20,741 in the 1996-2000 period were analysed. The age of donors (prevalently male, 78.5%) was between 18 and 65 (median 38). A total of 110 borderline and 62 positives were found with ELISA, of which 75 borderlines and 42 positives in 1995, and the remaining in the 1996-2000 period (p > 0.5). Percentage of HCV antibodies dropped from 8.5% in 1995 to 5.45% in the 1996-2000 period. The non reactivity and undetermined status were found in 82.1 and 9.4% respectively in 1995, and 69.1 and 25.45% respectively in the 1996-2000 period. The incidence of HCV antibodies was 167.28 cases per 100,000 person-years in 1995 and 4.13 per 100,000 person-years in the 1996-2000 period, 2.5 times lower than the national one. There was a statistically significant association between dental care and RIBA positivity (RR: 2.63; p = 0.045). This study, moreover, evidences how pre-donation practices, if extended to a national basis, may be able to nullify the dangers associated with post-transfusional hepatitis and to reduce the number of false positives and of blood packs donated but either unused or destroyed.

Intracerebral haemorrhage and hepatitis C treatment

We report 3 episodes of intracerebral haemorrhage in a population of 1460 hepatitis C infected patients. We suggest the possibility of a link between HCV and its treatment and the occurrence of this serious complication.

Epidemiology of hepatitis C virus infection in Australia

BACKGROUND

Since the discovery in 1989 of hepatitis C virus (HCV) as the infectious agent responsible for the vast majority of post-transfusion non-A non-B hepatitis the patterns of transmission and clinical consequences of this highly prevalent flavivirus have been widely studied.

OBJECTIVE

This paper reviews available evidence on the epidemiology of HCV infection in Australia, including HCV notification data obtained through public health surveillance systems, HCV seroprevalence surveys among high risk populations, and models for estimating and projecting HCV transmission and long-term consequences of chronic HCV infection.

RESULTS

Over the period 1990-2000 approximately 160,000 notifications of HCV infection were received by State and Territory health jurisdictions making it the most commonly notified communicable disease in Australia. Approximately 210,000 people are estimated to be living with HCV infection in Australia, with an estimated 80% having acquired their infection through injecting drug use. Less than 500 cases of newly acquired HCV infection are notified each year, however, an estimated 16,000 new infections occur annually. Despite the widespread introduction of needle and syringe programmes in the late 1980s, HCV transmission continues at high levels among current injecting drug users (IDUs) with incidence and prevalence estimates of 10-20/100 person years and 50-55%, respectively. Levels of HCV transmission are particularly high in both younger and incarcerated IDUs. In contrast to HCV infection, prevalence of HIV among current IDUs has remained below 2% since 1995. Although a small minority of people with chronic HCV infection will develop liver failure or hepatocellular carcinoma, the incidence of these advanced disease complications is estimated to double over the next decade.

CONCLUSION

The epidemic of HCV infection continues to escalate in Australia, predominantly through transmission related to injecting drug use. As the population of people with chronic HCV infection and progressive liver disease expands the public health burden of advanced disease complications will be considerable.

Psychometric properties of the Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ)

AIMS

To develop a standard measure of blood-borne virus transmission risk behaviour, and examine the underlying psychometric properties.

DESIGN

The Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) was developed over three consecutive phases of the original BBV-TRAQ study in adherence to classical scale development procedures, culminating in the recruitment of a development sample of current injecting drug users via convenience and snowball sampling.

SETTING

Needle and syringe programmes (NSPs), medical clinics, alcohol/drug agencies, peer-based and outreach organizations across inner and outer metropolitan Melbourne.

PARTICIPANTS

Two hundred and nine current injecting drug users. The mean age was 27 years, 68% were male, 65% unemployed, 36% with prison history and 25% in methadone maintenance.

MEASUREMENTS

BBV-TRAQ items cover specific injecting, sexual and skin penetration risk practices. BBV-TRAQ characteristics were assessed via measures of internal and test-retest reliability; collateral validation; and principal components analyses.

FINDINGS

The BBV-TRAQ has satisfactory psychometric properties. Internal (a=0.87), test-retest (r=0.84) and inter-observer reliability results were high, suggesting that the instrument provides a reliable measure of BBV risk behaviour and is reliable over time and across interviewers. A principal components analysis with varimax rotation produced a parsimonious factor solution despite modest communality, and indicated that three factors (injecting, sex and skin penetration/hygiene risks) are required to describe BBV risk behaviour.

CONCLUSIONS

The BBV-TRAQ is reliable and represents the first risk assessment tool to incorporate sufficient coverage of injecting, sex and other skin penetration risk practices to be considered truly content valid. The questionnaire is indicated for use in addictions research, clinical, peer education and BBV risk behaviour surveillance settings.

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 hepatitis B and C reported to the health 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 had acute hepatitis B. The upper 95% confidence limit for case-reporting of hepatitis C in the cohort was 5.7%, and for hepatitis B, it was 7.5%. In this study, reporting of acute hepatitis in IDUs was extremely low, raising questions regarding the use of community surveillance data to estimate underlying incidence in that population group.

The association between knowledge of hepatitis C virus status and risk behaviors in injection drug users

AIMS

The three primary objectives of this study were (1) to document the prevalence of the hepatitis C virus (HCV) and awareness of one's status in a sample of street-recruited injection drug users (IDUs); (2) to compare the drug use and HCV risk behaviors of IDUs who reported that they were HCV infected with those who were unaware of their status and subsequently tested positive for HCV antibodies; and (3) to assess associations between risk factors and HCV status by comparing those who tested positive with those who tested negative.

DESIGN

IDUs responded to structured interview questions assessing HCV risk behaviors and were offered a free HCV test.

SETTING

Subjects were recruited through street outreach in Denver, CO, USA.

PARTICIPANTS

Participants were current, out-of-treatment IDUs.

MEASUREMENTS

A modified version of the Risk Behavior Assessment (RBA) and HCV test results were used.

FINDINGS

Of the 197 participants, 20% had been diagnosed previously with HCV. Of those who did not know their status, 61% tested positive for HCV antibodies. Those who knew they were positive had been injecting longer but engaged in fewer HCV risk behaviors than those who did not know their status. Compared to those who tested negative, those who tested positive were more likely to be male, non-white and older. They also had been injecting longer, were more likely to use heroin and/or crack cocaine and consumed more alcohol.

CONCLUSIONS

In this study, a very large proportion of injection drug users who had hepatitis C were unaware of it, and they were engaging in more risk behaviors than those who were aware of their positive status. Risk factors associated with positive HCV status were identified so that those who are most at-risk for HCV might be targeted for testing and subsequent prevention or care.

Infection with hepatitis C virus among intravenous-drug users: prevalence, genotypes and risk-factor-associated behaviour patterns in Thailand

Hepatitis C virus (HCV) infection, a major problem worldwide, is usually transmitted parenterally or by use of contaminated needles among intravenous-drug users (IVDU). In a cross-sectional study, demographic data were collected and behaviour patterns investigated in interviews with 453, consenting IVDU. Blood samples were collected from each interviewee and checked for anti-HCV antibodies and, in a PCR-based assay, for the RNA of HCV. Almost all (92.5%) of the IVDU investigated were found positive for anti-HCV and/or the viral RNA. Most (73.5%) of those positive for HCV RNA were found to be infected with genotype 3a alone, the rest being infected with 1b (17.9%), 6a (3.5%), 3b (1.4%), 1a (1.0%), or both 3a and 6a (2.1%) or having non-typable infections (0.6%). Curiously, 26.0% of those who appeared seronegative for anti-HCV were positive for HCV RNA. The longer an interviewee had been using intravenous drugs, the more likely he or she was to be infected with HCV. Among the IVDU, the sharing of needles, syringes and/or other drug-related paraphernalia appeared to be the behaviour carrying the highest risk of HCV infection, giving an adjusted odds ratio and (95% confidence interval) of 4.84 (1.88-12.43). Programmes of needle and syringe exchange should probably be implemented among IVDU in Thailand and elsewhere, to slow the transmission of HCV.

Bystander resuscitation attempts at heroin overdose: does it improve outcomes?

STUDY OBJECTIVE

To document the characteristics and effectiveness of cardiopulmonary resuscitation (CPR) at non-fatal heroin overdose events in Melbourne, Australia.

METHODS

A retrospective analysis of a computerised database of ambulance attendance records at non-fatal heroin overdose cases for the period 1/12/1998 to 31/7/2000 was undertaken.

MAIN OUTCOME MEASURES

The main outcome measure was the rate of patient hospitalisation. The rate of CPR administration at heroin overdose cases was also examined, along with characteristics of the attendance, such as the age and sex of the overdose case, the relationship of person providing CPR to the overdose case as well as the location, time and date of the event.

RESULTS

CPR was administered prior to ambulance arrival in 579 heroin overdose cases (9.4% of total heroin overdose cases attended) between 1/12/98 and 31/7/2000. A greater proportion of female overdose cases were administered CPR than males and CPR administrations were evenly distributed across attendances occurring in private and public locations. Bystander administration of CPR prior to ambulance attendance resulted in a significantly lower rate of heroin user hospitalisation (14.5%) compared to cases where bystander CPR was not administered (18.8%).

CONCLUSIONS

While CPR administration prior to ambulance attendance at heroin overdose events is relatively uncommon (especially compared to out-of-hospital cardiac arrest), such administration was associated with a statistically significant improvement in clinical outcomes in cases of non-fatal heroin overdose. These findings suggest that the provision of CPR training to people likely to come into contact with heroin overdose events may be an effective strategy at minimising consequent overdose-related harm.

Seroprevalence of hepatitis C markers among intravenous drug users in western European countries: a systematic review

Currently, the most important risk factor for hepatitis C virus (HCV) infection in Europe is intravenous drug use. To establish a better insight into the epidemiology of hepatitis C among intravenous drug users (IVDUs) in western European countries a systematic review on the prevalence of hepatitis C markers and their determinants was performed. Reports were identified by searches on Medline and on the internet and by screening reference lists of selected papers. The prevalence rates of anti-HCV in western European IVDUs reported in the 66 studies selected for analysis, ranged between 37 and 98%. No relation was found between prevalence rates and mean age, mean duration of intravenous drug use, geographical area, setting of the study, method of recruitment or the year(s) of collection of samples. Eleven studies concerning the prevalence of HCV-RNA in hepatitis C-infected IVDUs were selected for analysis. Prevalence rates ranged from 26 to 86%. Based on five studies, a statistically significant positive linear relation was found between the mean age of study population and the prevalence of HCV-RNA. Our analysis revealed considerable variation in prevalence rates of hepatitis C markers among IVDUs in western Europe. We found no conclusive explanation for this variability. Further research investigating the dynamics of the hepatitis C epidemic in IVDUs is necessary.

Pumping iron, risking infection? Exposure to hepatitis C, hepatitis B and HIV among anabolic-androgenic steroid injectors in Victoria, Australia

AIMS

To measure exposure to the hepatitis C and B viruses and HIV among Victorian steroid injectors and evaluate associations between exposure and risk behaviour, and report other characteristics of the study group.

DESIGN

Seroprevalence study using a convenience sample.

SETTING

Victoria, Australia.

PARTICIPANTS

Current injectors of illicit anabolic steroids.

MEASUREMENTS

Prevalences of exposure to HIV and the hepatitis B and C viruses; associations of characteristics and behaviours with exposure; descriptive statistics for the sample.

FINDINGS

Six of 63 blood samples (9.5%) contained hepatitis C virus antibodies; 12.0% tested positive for hepatitis B core antibody; none contained anti-HIV. Hepatitis C virus exposure was associated with heroin injection, imprisonment, sharing needles to inject other drugs, number of tattoos, and hepatitis B virus exposure. No significant differences existed in the steroid-related risk behaviour of exposed and non-exposed individuals. Hepatitis B virus exposure was associated only with hepatitis C virus exposure, past imprisonment and age of first injection.

CONCLUSIONS

Exposure to the hepatitis B and C viruses was detected; hepatitis C virus exposure was at much lower prevalence than normally found among other drug injectors. Factors other than steroid injecting were associated with exposure. Nonetheless, the hepatitis C-exposed reported many steroid-related and other risk behaviours which could spread the virus. Steroid injectors should not be neglected in blood-borne virus prevention efforts.

Immunopathogenesis of hepatitis C virus infection

Hepatitis C virus, a recently identified member of the family Flaviviridae, is an important cause of chronic viral hepatitis and cirrhosis. There are similarities in the nature of the immune response to this pathogen with immunity in other flavivirus and hepatotropic virus infections, such as hepatitis B. However, the high rate of viral persistence after primary hepatitis C infection, and the observation that neutralizing antibodies are not protective, would suggest that there are a number of important differences between hepatitis C, other flaviviruses, and hepatitis B. The phenomenon of quasispecies evolution and other viral factors have been proposed to contribute to immune evasion by hepatitis C virus. In the face of established persistent infection, virus-specific cytotoxic T lymphocytes may exert some control over viral replication. However, these same effectors may also be responsible for the progressive liver damage characteristic of chronic hepatitis C infection. The nature of protective immunity, including the role of innate immune responses early after hepatitis C exposure, remains to be defined.

A serological re-evaluation of acute non-A non-B hepatitis from the early 1970s

BACKGROUND

The epidemiology and natural history of recently discovered viruses, which may be responsible for cases of seronegative infectious hepatitis, are currently being investigated. Retrospective studies of stored sera can provide a historical perspective of these infections.

AIMS

To re-evaluate the serological, demographic and clinical characteristics of patients hospitalised in the early 1970s with acute hepatitis.

METHODS

The stored sera of 57 patients hospitalised between 1971 and 1974 with acute hepatitis, designated at that time as non-A non-B (NANB) hepatitis, were re-tested using commercially available enzyme-linked immunosorbent assays (ELISAs) for the presence of anti-hepatitis A virus (HAV) IgM, hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (HCV) IgG, and anti-hepatitis E virus (HEV) IgG. Stored sera from a group of 57 patients concurrently hospitalised for other conditions were also tested. Detailed records of the original epidemiological interviews were examined to compare patient demographics, risk factors for infectious hepatitis and clinical data for the NANB hepatitis group and an original control group of 604 hospitalised patients.

RESULTS

Serum from 15 of the 57 (26%) previously designated NANB hepatitis cases had elevated anti-HAV IgM and are likely to represent missed cases of hepatitis A. Thirteen (23%) of cases previously designated as NANB hepatitis had positive hepatitis C antibody tests. These patients were younger and significantly more likely to have used intravenous drugs than control patients. Three NANB hepatitis and two hospital control patients were anti-HEV IgG antibody positive. All of these individuals were born in, or had travelled to, developing countries. Serum from 27 (47%) of the NANB hepatitis patients were negative on all tests. These hepatitis non-A-E cases included children and elderly adults, but as a group were significantly more likely to have used intravenous drugs than hospitalised control patients.

CONCLUSION

Both HCV and probable non-A-E virus(es) were important causes of acute NANB hepatitis during the early 1970s.

A study of the patterns and correlates of substance use among adolescents applying for drug treatment

OBJECTIVE

To inform planners by providing a psychosocial and drug-use profile of adolescents who have applied for a drug-treatment program.

METHOD

The setting was a residential drug-treatment program in Sydney for adolescents from NSW and the ACT. The design was a descriptive study of consecutive program applicants over 18 months. Study participants were 14-18 years, 53% were male. Most assessments were telephone interviews. The instrument incorporated the Opiate Treatment Index, Adolescent Drug Abuse Diagnosis, Severity of Dependence Scale and Symptom Checklist 90-Revised (SCL-90-R).

RESULTS

Study participants tended to be poly-substance users, mostly using cannabis, heroin and/or alcohol. Heavy use in terms of frequency and amounts of use were reported, e.g. 50% of the sample used heroin daily and the mean number of standard drinks consumed on the last day of drinking was 18. High levels of problems in the areas of social functioning, criminal activity, psychological distress, physical health, HIV risk and substance dependence were reported. For example, most participants were unemployed and 88% had committed a crime in the previous month. Higher rates of some problems were identified among females, heroin users and benzodiazepine users.

CONCLUSIONS

The sample reported a high level of involvement in substance use and associated problems. The profile suggested that improvements might be difficult to achieve and to maintain.

IMPLICATIONS

A comprehensive, intensive, longer-term drug-treatment program to address the number and extent of substance-related problems for such adolescents is recommended.

Assessment of long-term outcomes of community-acquired hepatitis C infection in a cohort with sera stored from 1971 to 1975

The aim of this study was to examine the long-term effects of hepatitis C virus (HCV) infection on a cohort of patients admitted with acute viral hepatitis from 1971 through 1975. The availability of stored sera from this time enabled testing to identify those who were anti-HCV-positive on admission. Sixteen percent (n = 238) of the cohort tested anti-HCV-positive. The unexposed group was selected from those who were anti-HCV-negative. Systematic approaches were used to locate the cohort and health outcomes assessed by a study-specific questionnaire and clinical, serological, virological, and biochemical assessment. Complete follow-up was achieved on 98 anti-HCV-positive individuals and 201 negatives. Injecting drug use (IDU) was the presumed route of infection. At a mean of 25 years' follow-up, 54% of the anti-HCV-positive group had evidence of chronic HCV infection (both anti-HCV- and HCV-RNA-positive); the remainder were HCV-RNA-negative. Sixty-nine percent of those chronically infected had elevated serum alanine transaminase (ALT) levels, but only 8% had progressed to overt cirrhosis, and no cases of hepatocellular carcinoma (HCC) were identified. In summary, anti-HCV-positive subjects were 8 times more likely to have died from suicide or drug overdose than from HCV-related disease. Anti-HCV-positive study subjects were at increased risk of liver-related pathology after 25 years' follow-up, but few had progressed to overt cirrhotic liver disease. Excess mortality in this group was not the result of liver disease. This suggests that the natural history of community-acquired HCV may be more benign than previously thought.

Syringe availability as HIV prevention: a review of modalities

This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities-such as pharmacy sale, injector-specific packs, mass distribution, and vending machines-and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.

Hepatitis C prevalence among Australian injecting drug users in the 1970s and profiles of virus genotypes in the 1970s and 1990s

OBJECTIVES

To examine the seroprevalence of hepatitis C virus (HCV) in the Australian injecting drug-using community in the 1970s, and to compare the profile of HCV genotypes with that seen in the 1990s.

DESIGN

Investigation of stored sera that were collected from injecting drug users in the 1970s and comparison with sera collected in the 1990s.

SETTING

Inner Sydney, 1974-1975 and 1994-1996.

PATIENTS

The 1970s group comprised 141 consecutive injecting drug users who attended the Brisbane Street Methadone Clinic. The 1990s group comprised 88 consecutive, injecting drug users of European origin who were HCV antibody-positive and attended a primary healthcare facility (the Kirketon Road Centre).

MAIN OUTCOME MEASURES

HCV antibody prevalence (1970s); profile of HCV serotypes (1970s and 1990s); and serological evidence of hepatitis A and B.

RESULTS

84% of the 1970s group were HCV antibody-positive, of whom 92% were infected with HCV serotype 1 and 1% with serotype 3. In contrast, in the 1990s group, 69% were infected with HCV serotype 1 and 25% with serotype 3. The HCV-positive subjects from the early group were more likely than those from the recent group to have serological evidence of previous HBV infection.

CONCLUSIONS

The high prevalence of HCV among injecting drug users in the 1970s in Australia confirms an epidemic that has been present for at least 25 years. Over this period, the proportion of HCV genotype 1 infections has decreased and genotype 3 infections have emerged.

Public health surveillance of hepatitis C: can it identify incident cases?

OBJECTIVES

To evaluate a follow-up system to identify incident cases among individuals notified with the hepatitis C virus (HCV).

METHOD

A cross-sectional survey of medical practitioners treating individuals notified to the NSW Health Department as having HCV between August 1996 and August 1997 was conducted.

RESULTS

Five hundred and fifty-four new notifications were received during the study period (70.7 per 100,000 people). Ninety-six per cent of notifications were followed up with 54 individuals (9.7%) identified as incident cases. Incident cases were significantly younger than prevalent cases (median age 30 vs. 39, p < 0.001) with drug and alcohol notifications being more likely to be incident cases.

CONCLUSION

HCV transmission is continuing at relatively high levels with incident cases being significantly younger than prevalent cases.

IMPLICATIONS

An efficient notification follow-up strategy that identifies incident cases could be routinely used to assess the effectiveness of population-based initiatives aimed at reducing HCV transmission.

Prevalence of hepatitis C virus infection among injecting drug users in Glasgow 1990-1996: are current harm reduction strategies working?

OBJECTIVES

To determine the prevalence of HCV antibodies among injecting drug users and to gauge the effectiveness of needle/syringe exchange in preventing the transmission of HCV infection.

METHODS

Between 1990-1994 and in 1996, annual cross-sectional surveys of injecting drug users in Glasgow were conducted. In order to ensure as representative a sample as possible, the 1949 respondents were recruited from both 'in-treatment' and 'out-of treatment' settings. Injectors were interviewed about their risk behaviours for blood-borne viruses and provided a saliva sample which was initially tested, anonymously, for HIV antibodies, and subsequently tested for hepatitis C infection.

RESULTS

Among 1949 injectors, the prevalence of salivary antibodies, indicative of hepatitis C viraemia, was 61%(95%, confidence interval (CI) 59%-63%): the estimated prevalence of serum antibody positivity was 72%. Length of injecting, year of commencing drug injecting and the number of times in prison were predictive of antibody positivity. Thirty-one per cent of injectors who commenced their injecting after 1992, following the full establishment of needle/syringe exchange in the city, were salivary antibody positive, and the majority of their infections were acquired outside the prison setting. Respondents who began injecting after the introduction of needle/syringe exchange in the city were significantly less likely to test HCV antibody positive than those who commenced injecting prior to the advent of needle/syringe exchange, after adjusting for length of injecting career.

CONCLUSION

The prevalence of HCV among injectors in Glasgow has decreased during the era of needle/syringe exchange. However, there is evidence to suggest that the incidence of infection remains high. Since the prevalence of hepatitis C viraemia among the city's injecting population is extremely high, ongoing transmission is inevitable unless more effective interventions are identified and implemented urgently.

Hepatitis C in injecting drug-using women during and after pregnancy

BACKGROUND

A high proportion of female injecting drug users (IDU) have evidence of hepatitis C virus (HCV) infection. We undertook a prospective study of patients attending a clinic for pregnant IDU to determine the impact of pregnancy on the course of HCV infection and whether pregnancy is affected by HCV infection.

METHODS

One hundred and thirty-one IDU were recruited and followed up with liver function tests, HCV serology and HCV-RNA tests.

RESULTS

Of 131 patients, 125 had HCV antibodies (anti-HCV positive) at delivery, and of these 62% were HCV-RNA positive. The anti-HCV-negative women were younger and had a shorter duration of drug use than the anti-HCV-positive women. There were no differences between viraemic and non-viraemic women with respect to age, ethnicity, duration of injecting drug use, methadone maintenance dose, hepatitis B exposure or reported high-risk behaviour. Alanine aminotransferase (ALT) levels were higher and the proportion with ALT > 55 IU/L higher in viraemic women. Viraemia persisted in all 55 women who were viraemic at term. Eleven had an ALT flare post-partum that was unrelated to viral load and was clinically unsuspected. Four had concurrent elevated gamma-glutamyltranspeptidase and were considered to be drinking alcohol at hazardous levels. Four of 23 women who were HCV-RNA negative at term became positive during follow up.

CONCLUSIONS

Pregnancy does not adversely affect the course of hepatitis C. A modest rebound in ALT levels, but not HCV-RNA, occurs after delivery in some viraemic women. This supports the theory that immune mechanisms rather than direct viral cytopathology are involved in hepatocyte injury during HCV infection. Hepatitis C infection did not influence pregnancy complications and outcomes.

Hepatitis C virus antibody prevalence among injecting drug users at selected needle and syringe programs in Australia, 1995-1997. Collaboration of Australian NSPs

OBJECTIVES

To describe point prevalence of HCV antibody and relevant risk behaviour among people who inject drugs and who attended selected needle and syringe programs throughout Australia in 1995, 1996 and 1997.

DESIGN AND SETTING

Repeated cross-sectional surveys of one week's duration were carried out in 21, 20 and 23 needle and syringe program sites throughout Australia in 1995, 1996 and 1997, respectively.

PARTICIPANTS

All clients attending participating sites during the designated survey week were asked to complete a self-administered questionnaire and provide a finger-prick blood sample for HCV antibody testing.

MAIN OUTCOME MEASURES

Prevalence of HCV antibody.

RESULTS

Survey response was 41% (n = 979) in 1995, 51% (n = 1463) in 1996 and 48% (n = 1699) in 1997. HCV prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (P < 0.001). Among respondents who reported injecting for less than three years, prevalence declined from 22% in 1995 to 13% in 1996 and 1997 (P < 0.001). Reported use of needles and syringes after someone else in the previous month declined from 31% in 1995 and 28% in 1996 to 15% in 1997 (P < 0.001).

CONCLUSIONS

Despite an apparent decline in HCV prevalence, carriage rates of HCV antibody remain high.

Hepatitis C: public health strategies

Hepatitis C virus (HCV) is a major global public health problem. As with many recently discovered diseases, there is still considerable controversy within the scientific community regarding the prevalence, incidence and socio-economic burden of acute and chronic hepatitis C. New infections continue to occur. Given the substantial morbidity and mortality attributable to HCV-related chronic liver disease, each country, irrespective of its economic status, should develop an HCV-related public health plan for the prevention of new HCV infections. The source of HCV infection includes transfusion of blood or blood products from unscreened donors, transfusion of blood products that have not undergone viral inactivation, parenteral exposure to blood through the use of contaminated and inadequately sterilized instruments and needles used in medical, dental and "traditional" medicine, individuals undergoing procedures such as haemodialysis, persons who participate in high risk sexual practices, household or sexual contacts with HCV-infected persons and infants of HCV-infected mothers. In many countries, the relative contribution of the various sources of infection has not been defined with population-based epidemiological studies. Wherever possible, such studies should be performed to enable countries to prioritise their preventive measures and to make the most appropriate use of available resources.

Risk factors for hepatitis C transmission in the Victorian population: a telephone survey

OBJECTIVE

To measure knowledge and prevalences of risk factors for hepatitis C infection in the Victorian community.

METHOD

Telephone survey of 757 Victorian householders aged 15+ years, March 1996.

RESULTS

An estimated 2.2% of Victorians have injected illicit drugs; 4.8% have tattoos and 49.6% have skin piercings; 11.4% received a blood transfusion before screening for HCV was introduced; 10.9% have had a test for HCV antibody. A majority of respondents perceived sexual contact and receipt of a transfusion to be risks for HCV transmission.

CONCLUSIONS

Risk factors associated with the spread of HCV are widespread in the Victorian community; however, the most important risk factor--injecting drug use--has low prevalence. Considerable uncertainty exists about risk factors for hepatitis C.

IMPLICATIONS

A very small percentage of Victorians are injecting drug users and therefore at highest risk of hepatitis C infection, therefore transmission control programs can be efficiently focused on this group. The Victorian community needs to be better educated about risk factors for hepatitis C, in particular that transfusions and blood donations are safe.

Severity of liver disease in hepatitis C infection contracted through injecting drug use

BACKGROUND

Injecting drug use (IDU) is currently the most common route of hepatitis C virus (HCV) transmission in Australia and many other Western countries. Most reports on the natural history of HCV have examined populations that included patients from all risk groups, but it is possible that this increasingly important subgroup is different.

AIMS

To assess the severity of liver disease in individuals who acquired HCV through IDU.

METHODS

Three hundred and forty-six patients with confirmed HCV infection and a history of IDU, who had had a liver biopsy performed were recruited from a liver clinic. Demographic data, liver function tests and hepatitis B serology were obtained on all patients. A detailed drug use history and HCV viral studies were also available in a subgroup of 142 patients.

RESULTS

Mean age of the group was 34 years and 73% were male. Mean duration of HCV infection was 14.6 years. Forty one per cent were infected with genotype 3a, 19% - 1a, 17% - 1 (nonsubtypable), 14% - 1b and 4% - 2b. Cirrhosis was present in 12% of patients. Patients with cirrhosis (38 years) were older than those with chronic hepatitis (34 years; p=0.0003) and had a longer duration of infection (17.2 vs 14.3 years; p=0.003). On multivariate analysis, however, patient age was the only factor independently associated with cirrhosis (odds ratio 4.2; 95% confidence interval 1.4-12.6).

CONCLUSION

While cirrhosis is less common in this group than in other HCV infected populations, its prevalence may increase as these patients are followed over a longer period of time.