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Miriam J. Alter, Ph.D. Division of Viral Hepatitis Centers for Disease Control and Prevention

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. Types of Epidemiological Studies. Cohort (prospective) - direct estimate of risk

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Miriam J. Alter, Ph.D. Division of Viral Hepatitis Centers for Disease Control and Prevention

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  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 forPersons 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)n=148n=200 Medical care procedures 30.4% 29.5% Dental 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 1982;145:886-93; JAMA 1989;262:1201-5.

  6. Limitations of Case Control Studies • Will not detect rare events • Do not directly measure risk

  7. History of Tattooing and Acute Hepatitis C1982-2000, United States Time period of History of tattooing prior 6 mo reported caseNAll patientsNo 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 C1996-2000, United States History of piercing* prior 6 mo TypeNAll patientsNo 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 InfectionCross Sectional Studies Tattooed (Total tested) Adj. 95% Group (author)HCV Pos HCV NegOR* 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 InfectionCross Sectional Studies Pierced (Total tested) Adj. 95% Group (author)HCV Pos HCV NegOR* 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<.05 VA pts (Briggs) 37% (185) 24% (847) NA NS * Controlling for other risk factors (e.g., IDU, BT)

  12. Tattoos, Body Piercing, HBV and HCV InfectionPrevalence 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 ExposureUS-ARCUS-REDS Australia Injecting drug use + + + Transfusion + + + High-risk 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 InfectionGI Clinic, Albuquerque, NM 1995-1996Limitations • 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 1999;94:1341-6

  15. Tattoos and HCV InfectionOrthopedic 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 Exposuren=43n=583 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 2001;80:134-51.

  16. Tattoos and HCV InfectionHaley 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 CharacteristicTotal TestedNo. (%) HCV Positive Total 8018 77 (0.96) Age <19 1777 2 (0.1) 20-24 3668 14 (0.4) 25-29 1189 7 (0.6) >30 377 54 (3.9) p<.001 Race/Ethnicity White 2384 31 (1.3) Black 1896 21 (1.1) Hispanic 1839 12 (0.6) p<.05* Other 1725 9 (0.5) * vs. Whites Hwang et al., unpublished data

  19. HCV and HBV Among College Students, 2000-2001 % Positive CharacteristicTotal 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* No 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 * p<.001 † excluding IDU and transfusion Hwang et al., unpublished data

  20. Cosmetic Procedures and HCV InfectionModerate Endemic Countries Tattooing Body Piercing CountryHCV PosHCV NegHCV PosHCV Neg Case-control Taiwan 0% 0% 0% 1% Cross-sectional Japan 1% 0% -- -- 3% 0% -- -- Pakistan 7% 0% 7% 0%

  21. Alternative Medicine and HCV InfectionModerate Endemic Countries Acupuncture CountryHCV PosHCV Neg Case-control Taiwan 5% 1% Cross-sectional Japan 62%* 26% 20% 17% * P<.05, performed by unlicensed therapists

  22. Risk of Viral Hepatitis Infection from Tattoos and Body PiercingSummary • 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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