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From the Centers for Disease Control and Prevention
December 14, 2011

Notes From the Field: Risk Factors for Hepatitis C Virus Infections Among Young Adults—Massachusetts, 2010

JAMA. 2011;306(22):2448. doi:

MMWR. 2011;42:1457-1458

During 2002-2009, rates of newly diagnosed hepatitis C virus (HCV) infection increased from 65 to 113 cases per 100,000 population among persons aged 15-24 years in Massachusetts.1 Accordingly, the Massachusetts Department of Public Health (MDPH) and CDC interviewed persons aged 18-24 years with HCV infection reported to MDPH during July 1–December 31, 2010, to elicit detailed information regarding demographic, clinical, and risk characteristics.

Of the 394 patients indentified, 193 (49%) had a valid telephone number; of those 193 patients, 101 (52%) did not answer after three call attempts, 19 (10%) were either in a drug treatment facility or incarcerated, 19 (10%) refused to participate, 31 (16%) agreed to participate but did not come on the scheduled interview day, and 23 (12%) completed the interview. An additional five persons aged 18-24 years with diagnosed HCV infection during July 1–December 31, 2010, but not reported to MDPH, were interviewed in a correctional facility, where they were incarcerated.

Mean age of the 28 respondents was 21.9 years (range: 19-24 years); 15 (54%) patients were female, 23 (82%) were white, nine (32%) did not finish high school, nine (32%) were unemployed, and 25 (89%) had health insurance. Twenty-six (93%) had used drugs; of these, 100% reported marijuana use, with a median age of initiation of 13 years (range: 9-17 years); 92% reported opioid analgesic abuse (oxycodone and/or Oxycontin), with a median age of initiation of 17 years (range: 12-23 years); and 89% reported heroin use, with a median age of initiation of 18 years (range: 14-21 years). Nearly all respondents (95%) used opioid analgesics before switching to heroin. During the preceding 6 months, the most frequently injected drugs among respondents were heroin (50%) and opioid analgesics (30%).

Medical record reviews showed that five respondents had visited emergency departments on multiple occasions complaining of pain and were prescribed opioid analgesics. Most respondents (70%) reported sharing syringes and drug paraphernalia within networks of injection drug users that included persons with known HCV infection (43%). One in four respondents reported never being informed of their HCV infection by their health-care provider, and 11 (39%) were tested for HCV in a drug treatment program or during incarceration.

The findings in this report are subject to at least three limitations. First, only a small number of persons agreed to be interviewed, which limits the ability to generalize these findings. The low response rate might be attributed, in part, to the characteristics of the targeted population (young injection drug users) coupled with lack of provision of incentives. Second, comparison of the demographic and clinical characteristics of persons who were interviewed with those who could not be interviewed was not possible because information was lacking for nearly 60% of the 394 hepatitis C cases reported during July 1–December 31, 2010. However, of those cases with available information, 229 (58%) occurred among females and approximately 80% occurred among whites, which is consistent with the demographic characteristics of interviewed respondents. Finally, persons with HCV infection who were in drug rehabilitation centers could not be interviewed because of federal confidentiality regulations specific to these centers.

Consistent with other studies, most respondents reported opioid analgesics abuse before switching to heroin (which is less expensive).2,3 Health-care providers should routinely ask about prescription and illicit drug use and screen all persons with risk factors for HCV infection, regardless of age.4 They also need to be aware of warning signs of prescription opioid and drug abuse, such as frequent complaints of pain and request for opioids. Drug treatment programs and prisons are potential venues for education regarding the risk for hepatitis C from sharing needles and other injection paraphernalia and for providing vaccination against hepatitis A and B. School and community-based education programs also are needed to prevent initiation of illicit and prescription drug use.5 Several harm reduction interventions have been conducted to assess the effectiveness of reducing incidence of both human immunodeficiency virus and HCV infection. Overall results from a recent meta-analysis did not indicate a statistically significant decrease in incident HCV infection from a single programmatic strategy; however, the results did indicate that combined interventions were effective.6 Thus, combining current interventions and identifying new evidence-based approaches to preventing drug use and unsafe injection practices in young adults are needed to control and prevent HCV infections.

Reported by: Daniel Church, MPH, Kerri Barton, MPH, Franny Elson, MS, Alfred DeMaria, MD, Kevin Cranston, MDiv, Massachusetts Dept of Public Health. Norma Harris, PhD, Stephen Liu, MPH, Dale Hu, MD, Deborah Holtzman, PhD, Scott Holmberg, MD, Div of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Rania A. Tohme, MD, EIS Officer, CDC. Corresponding contributor: Rania A. Tohme, rtohme@cdc.gov, 404-718-8577.

References
1.
Centers for Disease Control and Prevention (CDC).  Hepatitis C virus infection among adolescents and young adults: Massachusetts, 2002-2009.  MMWR. 2011;60(17):537-541PubMed
2.
Lankenau SE, Teti M, Silva K, Bloom JJ, Harocopos A, Treese M. Initiation into prescription opioid misuse amongst young injection drug users [published ahead of print June 19, 2011]. Int J Drug PolicyPubMed
3.
Grau LE, Dasgupta N, Harvey AP,  et al.  Illicit use of opioids: is OxyContin a “gateway drug”?  Am J Addict. 2007;16(3):166-173PubMedArticle
4.
Centers for Disease Control and Prevention (CDC).  Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease.  MMWR Recomm Rep. 1998;47(RR-19):1-39PubMed
5.
National Institute on Drug Abuse.  Preventing drug use among children and adolescents: a research-based guide for parents, educators, and community leaders. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 2003. Available at http://www.drugabuse.gov/prevention/index.html. Accessed October 25, 2011
6.
Hagan H, Pouget ER, Des Jarlais DC. A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs.  J Infect Dis. 2011;204(1):74-83PubMedArticle
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