Viral hepatitis and the drug cult: a brief socio-epidemiological study in Sydney

Estimating the cost-effectiveness of needle-syringe programs in Australia

OBJECTIVE

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

DESIGN/METHODS

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

RESULTS

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19 000-77 000 cases) during 2000-2010, leading to 20 000-66 000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

CONCLUSION

Australia's early introduction and high coverage of NSPs has significantly reduced the prevalence of HIV and HCV among IDUs. NSPs are a cost-effective public health strategy and will result in substantial net cost savings in the future.

Hepatitis B immunity in a population of drug and alcohol users

The objective of this study was to determine the level of immunity from Hepatitis B infection in an Australian population of drug and alcohol users, and the validity of self-reported immune status. A cross-sectional survey was employed of drug and alcohol users presenting for treatment, who were clients of De Paul House, a community-based drug and alcohol withdrawal service in Victoria. Outcome measures were: hepatitis B serology and personal reports of hepatitis B immunity. A total of 118 people were enrolled; 22% were injecting drug users and 48% reported past injecting drug use, while 55% were alcohol users; 51% had no general practitioner; 73% of participants were unaware of whether they were protected from hepatitis B infection, while 19.5% believed they were protected. However, serology demonstrated that 52.2% of those who believed they were protected were not immune. Only 21% of participants were immune. This is the first study in an Australian setting since the 1970s to examine the effectiveness of vaccination targeted to this population, and demonstrates low rates of immunity. New strategies are needed to deliver vaccination to this group. These will need to take account of the often chaotic nature of their lives, the poor validity of self-reported immunity, and the lack of primary care links.

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.

Hepatitis A outbreak amongst intravenous amphetamine abusers in Finland

This article describes a widespread outbreak of hepatitis A virus (HAV) infection amongst drug abusers in Finland. Although attempts to demonstrate the virus in amphetamines failed, the infection was assumed to be linked to intravenous use of the drug. The unusual mode of transmission prompted us to analyse possible atypical clinical features as well as the spread of the virus to the general population, nowadays practically without protective immunity. Serologically verified cases that occurred in Helsinki were interviewed, their hospital records were analysed and their contacts were serology tested. Amphetamine lots, as well as faecal samples from patients, were examined with RT-PCR. Detailed information was obtained from 238 subjects, among whom 131 admitted drug abuse and 67 cases were classified as secondary cases. Phylogenetic analysis of virus strains from HAV-infected cases suggested a common origin, and epidemiological observations linked it with particular lots of amphetamine. Three cases died, and 3 presented with severe clinical disease. Icterus was more common among i.v. drug abusers than others. Infection with hepatitis A virus was probably related to the faecal contamination of amphetamine associated with the transportation of the drugs in the gastrointestinal tract.

The incidence of hepatitis B infection in Australia: an epidemiological review

Hepatitis B virus (HBV) infection in Australia remains a significant problem despite the availability of an inexpensive vaccine. National information about incidence, prevalence, morbidity and the extent of vaccine coverage is incomplete; improved surveillance would allow for better targeting and evaluation of prevention activities. Our estimates indicate that 75%-90% of cases of vertical transmission of HBV are preventable through vaccination of newborns whose mothers are carriers.

An autopsy survey of hepatitis B in Sydney

AIM

1) To determine the prevalence of hepatitis B in Sydney autopsies and 2) to determine the relationship between seroprevalence, hepatitis B risk factors and histological changes in the liver.

METHODS

One hundred autopsy subjects were studied for evidence of past or present hepatitis B infection, using RIA to detect the HBV antigens and antibodies in the serum and peroxidase-antiperoxidase technique to detect HBsAg and HBcAg in the liver. Both serum and liver were examined for the presence of HBV DNA.

RESULTS

Markers of hepatitis B virus infection were detected in either serum and/or liver of 29 subjects. Four subjects (4%) were seropositive for HBsAg. Eight subjects had been recently infected, 7 were chronically infected and 14 had recovered.

CONCLUSION

The 29% prevalence of HBV infection is higher than expected. In four cases the serum was either free of HBV markers or showed conventional evidence of recovery, yet the liver still contained HBsAg. There were few histopathological changes despite the presence of HBsAg in the liver. The only epidemiological factors possibly predisposing to HBV infection were tattooing and drug abuse.

Clinical, biochemical, serological, histological and ultrastructural features of liver disease in drug abusers

Heroin abusers are frequently found to have abnormal liver function tests and hepatic histology. Hepatitis viruses A, B, and NANB, other drugs or drug contaminants and excessive alcohol consumption are factors thought to contribute. One hundred and sixteen heroin abusers attending a London treatment centre were studied. Sixty two (53%) had a raised aspartate transaminase. This was not explained by current infection with hepatitis A and B, cytomegalo or Epstein-Barr viruses, excessive alcohol consumption (greater than 80 g/day) or concomitant drug taking. Abnormal liver function tests were as frequent in those with markers of current or past HBV infection as those without and there was evidence that both HBV infection and the cause of the abnormal liver function tests were acquired in the first few years of intravenous drug abuse. Liver biopsies from eight patients showed chronic hepatitis with a mild lobular and portal inflammatory infiltrate, fatty change and prominent sinusoidal cells. Electron microscopy showed cytoplasmic trilaminar tubular structures and dense fused membranes in dilated endoplasmic reticulum. These clinical, biochemical, serological, and histological features would suggest a major role for NANB virus infection in the aetiology of hepatitis in heroin abusers.

Viral hepatitis among parenteral drug addicts attending a Danish addiction clinic

100 parenteral drug abusers attending an addiction clinic were studied for past or present infection with hepatitis A and B virus (HAV and HBV) by sensitive serological assays for hepatitis B surface and e-antigen and antibodies to HBsAg, HBeAg, HBcAg and HAV. 44% of the individuals had past HAV infection, which is 4 times as high compared to the general population in Denmark. 83% had evidence of past or present HBV infection with no difference between men and women. This is 30 times higher than in the general population in Denmark. 18% of the subjects studied were positive for HBsAg and/or anti-HBc alone, but only 3 of these were positive for HBeAg (3%). Serum transaminase values were often elevated but this finding could not differentiate between patients with or without HBV infection. Infection with HBV appeared to take place during the first year of the drug addict's career, and to eliminate this major reservoir of HBV infection the main objective will be to prevent new susceptible individuals in getting addicted.

Viral hepatitis: a four-year hospital and general-practice study in Sydney 1. Epidemiological features, natural history, and laboratory findings

We studied 761 patients admitted to hospital with viral hepatitis between 1971 and 1974, and 53 patients with viral hepatitis seen in general practice in Sydney, following up some of them for one to two years. We evaluated factors contributing to each type of hepatitis. We noted differences in the patterns in hepatitis A, B and non-A non-B between Anglo-Saxon and non-Anglo-Saxon sectors of the community. All patients with hepatitis A regained normal liver function within 20 months of the acute illness. Of 115 hepatitis B patients seen at 12 months, 6% had chronic hepatitis Bs antigenaemia, 60% had developed anti-HBs antibodies, and 7.3% still had abnormal liver function. Of 20 non-A non-B patients followed for 12 months, liver function was still abnormal in three, but one of these had developed hepatitis B. The case fatality rate for the whole series was 0.66%.