Prevalence and Risk Factors for Hepatitis C Virus Infection Among Adolescents in Detention

Objective  To assess the prevalence and correlates of hepatitis C virus infection in a sample of detained adolescents.

Design/Setting/Participants  Cross-sectional prevalence study with 10- to 18-year-old adolescents who were consecutively admitted to a juvenile detention center in San Antonio, Tex.

Main Outcome Measures  The prevalence of hepatitis C virus infection and associated risk factors.

Results  Of the 1002 participants, 75% were Hispanic and the mean age was 15 years. Twenty adolescents had laboratory data consistent with hepatitis C virus infection, giving an overall prevalence of 2.0% (95% confidence interval, 1.2-3.1). All adolescents infected with hepatitis C virus were Hispanic (13 boys and 7 girls). Although a high proportion of the participants reported having had intranasal drug use (55.6%), tattooing (50.5%), or body piercing (25.3%), the only factor significantly associated with hepatitis C virus infection was having a history of injection drug use. Injection drug use was reported by 5.3% of the participants but by 95% (19/20) of those infected with the hepatitis C virus.

Conclusions  This study indicates that injection drug use was linked with the majority of hepatitis C virus infections in this population of detained adolescents, similar to findings in adults. These adolescents reported a high frequency of other behaviors that could potentially pose a risk for contracting bloodborne infections. Effective prevention and awareness programs in a detention setting need to be comprehensive and include screening, hepatitis A and B immunizations, and risk-reduction counseling.

Hepatitis C virus (HCV) infection is a major public health concern in the United States with an estimated prevalence of 1.8% in the general population.¹ The prevalence of HCV infection increases with age in the general population and is lower among adolescents (0.4%) than among adults (2.5%).¹ Studies of adolescents in selected health care settings have also reported lower prevalence rates.^2-5

Among prison inmates in Texas, the seroprevalence of HCV infection has been reported to be 27%.⁶ Among incarcerated adolescents, only 1 other HCV infection prevalence study has been conducted in the United States; the 305 subjects enrolled in the Pacific Northwest had an HCV infection prevalence rate of 2%.⁷ In a study of homeless adolescents, the prevalence of HCV infection was 5.0% and was associated with injection drug use (IDU).⁸ A history of IDU is the most common risk factor for HCV infection in adults, and HCV is acquired soon after initiating injection behavior. Recent studies have shown that an average of 30% of new drug injecting individuals become infected with HCV within the first 36 months of instituting IDU.^9,10

Other behavioral factors, including tattooing, piercing, and intranasal cocaine use,^11-13 have been suggested to place individuals at increased risk for acquiring infections with bloodborne pathogens. These behaviors are commonly reported in juvenile detainees, who also have a high prevalence of sexually transmitted infections.^14-18 The goal of this study was to determine the prevalence of and risk factors for HCV infection in a large sample of predominantly Hispanic detained adolescents. Determining the epidemiology of HCV infection in adolescents with high-risk behaviors is critical for preventing viral hepatitis infections in this age group.

The study site is a short-term detention center in San Antonio, Tex, for adolescents aged 10 to 18 years. The medical clinic within the center provides routine physical examinations and medical care. The screening physical examination, routinely performed on all incoming adolescents within 1 week of their admission, includes the collection of demographic information, medical history, and risk behaviors history. Adolescents seen consecutively at the medical clinic for a physical examination between August 21, 2000, and August 8, 2001, were invited to enroll in this cross-sectional prevalence study. Written informed consent was obtained from those who agreed to participate. There were no exclusion criteria. This study was approved by the institutional review board of the University of Texas Health Science Center at San Antonio.

An extensive risk factor history was obtained by confidential interview of those adolescents enrolled in the study. Information on risk factors included a detailed history of injection and other illegal drug use, tattooing and body piercing, and sexual practices.

Serum samples from study participants were tested for HCV antibody (anti-HCV) by the laboratory at the San Antonio Metropolitan Health District using a third-generation enzyme immunoassay (Ortho HCV Version 3.0 ELISA Test System; Ortho-Clinical Diagnostics, Raritan, NJ). Repeatedly reactive samples were tested using the recombinant immunoblot assay (RIBA 3.0; Chiron Corporation, Emeryville, Calif). Only samples that had positive results by RIBA were considered anti-HCV positive.

All adolescents with anti-HCV positive test results were informed of their results in a confidential setting and counseled about the potential significance of positive results. The adolescents who were anti-HCV positive were provided subsequent measurement of liver enzyme levels, vaccinations to hepatitis A and hepatitis B (if not already done), and referral to a gastroenterologist for medical evaluation. When released from the detention system, adolescents who were anti-HCV positive were counseled to continue medical follow-up with a health care provider and to abstain from the use of hepatotoxic substances, including alcohol and illicit drugs.

Univariate analysis and logistic regression were conducted on the data collected. Using univariate analysis, the prevalence of HCV infection was compared among those with and without each variable of interest. Prevalence ratios were used to measure the strength of each association, and 95% confidence intervals were calculated. The logistic regression model predicting HCV infection included demographic variables such as age and ethnicity, potential risk factor variables with P<.10 by univariate analyses, and interaction terms. Initial analyses revealed no significant interaction terms; therefore, they were removed from the model. A P value of less than .05 was considered significant.

Seventy-eight percent (1002 of 1288 adolescents) of new detainees during the study period consented to participate in this prevalence study. Reasons for refusal included anxiety related to venipuncture, competing detention activities, and disinterest in the study. The demographic characteristics of those who refused were similar to those of the study population (data not shown). The mean age of participants was 15 years, ranging from 10 to 18 years. The majority of the sample was male (72.1%) and Hispanic (75.1%) (Table). High-risk behaviors were commonly reported in this population: IDU (5.3%), intranasal drug use with cocaine or heroin (55.6%), tattoos (50.5%), pierced body parts other than ears (25.3%), at least 1 sexual partner (85.4%), and 5 or more lifetime sexual partners (38.1%) (Table). Of those sexually active, 50.5% reported not using a condom at last intercourse, and 13.1% reported having at some time engaged in anal intercourse.

The overall seroprevalence of HCV infection was 2.0%, and all 20 of these adolescents were Hispanic (Table). Univariate analysis indicated that the prevalence of HCV infection was significantly related to older age (16-18 years vs 10-15 years) and having a history of IDU, a history of intranasal drug use, a tattoo, or anal intercourse (Table). Although most tattoos were administered in noncommercial settings (93.3%), neither the number of tattoos or piercings received nor the type of setting in which they were administered was found to be statistically significant. Multivariate analysis indicated that among these risk factors only a history of IDU remained significantly associated with HCV infection (Table). Stratifying by IDU showed that virtually all of the adolescents who were HCV positive and had a history of tattooing, body piercing, or intranasal cocaine use also had a history of IDU.

This study aimed to provide the prevalence and correlates of HCV infection in adolescent detainees. Our findings revealed that the seroprevalence of HCV infection among adolescents in this juvenile detention facility was significantly higher than that among adolescents in the general population. This seroprevalence of 2% approaches that of the adult population, where HCV infection is a leading cause of liver failure. In addition, our study found that HCV infection in these high-risk adolescents is primarily related to IDU, which is similar to the report from Murray et al⁷ and studies of incarcerated adults.^19-21

Several cross-sectional studies of select groups of adults have reported an association between HCV infection and tattooing.^22-25 Although 50% of the adolescents in this study had a history of receiving a tattoo, tattooing was not independently associated with HCV infection. Among adolescents with a tattoo, only those who also reported IDU tested positive for HCV. Case-control studies of acute hepatitis C cases found no associated risk with tattooing or body piercing, and few persons with acute hepatitis C disease report having received either of these during their exposure period.^26,27 Regardless, persons who are considering tattooing or body piercing should be informed of the potential infectious disease risks of these procedures.²⁸ State regulations promote infection control in commercial tattoo and piercing establishments; however, most of the adolescents in this study had these procedures performed in noncommercial settings.

The univariate association with intranasal illegal drug use also was confounded by IDU. A significant association between HCV infection and intranasal cocaine use was identified in 1 cross-sectional study of volunteer blood donors.²⁹ This association was not confirmed by at least 3 other cross-sectional studies.^30-32

Although potential exposures to blood such as might occur through tattooing, body piercing, or intranasal drug use could plausibly result in HCV transmission, there are no consistent data indicating they are related to an increased risk for acquiring HCV infection in the United States. Among persons who deny IDU, these characteristics are not reliable indicators for identifying persons likely to test positive for HCV.

Detainment in a juvenile detention facility provides an opportunity to screen for risk factors, test those at risk for HCV infection, and provide risk reduction counseling. Our study indicates that juvenile detainees with an IDU history are at high risk of being HCV positive and should be targeted for assessment and referral. The importance of targeting early preventive interventions, and, in particular, focusing on those at risk of starting IDU, cannot be overstated.

Some limitations to this study must be noted. First, behavioral data were collected using self-report, which introduces the possibility of error. In addition, detained adolescents more commonly report engaging in high-risk behaviors, limiting the generalization of these results to other adolescent populations. However, the relatively large sample size of this study does support the reliability of applying these study results to other high-risk groups of adolescents.

Correspondence: Rita M. Bair, MD, MPH, Indiana University School of Medicine, Section of Adolescent Medicine, 575 N West Dr, Room XE070, Indianapolis, IN 46202 (rmbair@iupui.edu).

Accepted for Publication: May 20, 2005.

Funding/Support: This study was supported by a research grant and cooperative agreement No. U50-CCU614390 through the Expanded Laboratory Capacity Program, Centers for Disease Control and Prevention, Atlanta, Ga.

Acknowledgment: We thank Kathleen Cobb, RN, for data collection and Roger Sanchez, BS, and the San Antonio Metropolitan Health Department for processing the samples. We also acknowledge the residents; Yolanda Valdez, RN; and all the detention staff.