Hepatitis B among Parenteral Drug Abusers -- North Carolina
Since 1983, an increased incidence of hepatitis B (HB) has been
observed in Durham County, North Carolina, primarily involving
parenteral drug abusers (PDAs) and their sexual contacts.
Eighty-six
cases (including 50 cases among PDAs or their sexual contacts) were
reported in 1985, compared with 24 cases in 1984 and eight in 1983.
Of the 1985 patients, nine were hospitalized, and two died.
Seventy-six patients who could be located were interviewed
regarding
risk factors for HB, and serum samples were obtained from 64 (74%)
patients to confirm the diagnosis of HB and to test for evidence of
coinfection with the delta agent.
Of the 86 cases, 56 (65%) were among males. Sixty-five (76%)
were
black; 20 (23%) were white; and one was Asian. Ages ranged from 9
months to 54 years (median 26 years). Forty-six (61%) of 76
patients
on whom detailed data were obtained were known PDAs; six others
were
sexual contacts or infants of PDAs; and four were males who had had
(or were suspected of having had) sexual relations with another
male.
Of 33 reporting self-injection of drugs within the last 6 months,
30
(91%) admitted sharing intravenous (IV) needles, and 20 (61%)
reported
recently injecting cocaine. Other drugs injected included
methamphetamine, heroin, hydromorphone, and phenmetrazine. None
reported using 3,4-methylene diamphetamine (MDA), a drug implicated
in
fulminant HB deaths among PDAs in North Carolina in 1979 (1). Of
47
persons assayed, seven (15%) had markers for delta virus exposure.
All seven with delta virus infection were PDAs. Ninety-six percent
of
the patients had lived in Durham over 10 years; the majority were
employed. Fifty-three percent resided within a 1-mile radius of
downtown Durham; in this area, the HB attack rate for 1985 was
365/100,000 persons in the 15- to 49-year age group, compared with
national attack rates of 17/100,000 persons in the same age group
(2).
Reported by IF Hoffman, JD Stratton, MD, Durham County Health Dept,
SM
Lemon, MD, Div of Infectious Diseases, Dept of Internal Medicine,
Memorial Hospital, University of North Carolina, Chapel Hill, RA
Meriwether, MD, Communicable Disease Control Br, JN MacCormack, MD,
State Epidemiologist, Div of Health Svcs, North Carolina Dept of
Human
Resources; Div of Field Svcs, Epidemiology Program Office,
Hepatitis
Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Many HB outbreaks have been described among PDAs
over
the last 2 decades, and serologic surveys have demonstrated that HB
virus (HBV) infection is highly prevalent in this group (1,3-7).
More
recently, combined HBV and delta virus infection has been
recognized
to cause hepatitis outbreaks with unusually high mortality in PDAs
(7). Combined HBV-delta virus infection (either coinfection with
both
viruses or delta superinfection of HBV carriers) is associated with
higher frequency of fulminant hepatitis than HBV infection alone.
Delta superinfection of HBV carriers frequently causes
transformation
from no or mild chronic liver disease to severe, progressive
chronic
active hepatitis. In the United States, infection with the delta
agent has been observed previously among persons with frequent
blood
and blood-product exposures, i.e., PDAs and hemophiliacs. PDAs can
serve as a source of HB and delta agent infections that can
disseminate to lesser-risk groups, e.g., sexual contacts and
health-care workers (7). In the United States, although only
10%-15%
of persons reported with HB infection have been identified as PDAs,
control of HB among PDAs and persons in other risk groups is
critical
for limiting the spread of HB and delta agent in the general
population.
Control of HB outbreaks among PDAs has proven difficult. In
previous outbreaks, several strategies have been tried, including
public education programs, tracking and identification of contacts,
and, in one instance, an HB vaccine campaign. An HB vaccine
program
attempted among PDAs during a large outbreak of HB and delta
hepatitis
in Worcester, Massachusetts, had limited success, principally due
to a
lack of perceived danger among otherwise healthy PDAs and the lack
of
patient compliance in completing vaccination (8). The highly
publicized program offered free serologic testing and vaccinations
to
PDAs and their regular sexual contacts at local community clinics
and
to PDAs attending drug abuse clinics or undergoing incarceration.
During this ongoing project, only 27% of the approximately 300
participants were susceptible to HB, including only 5% of PDAs who
had
used parenteral drugs for longer than 5 years and who represented
the
majority of participants. Of HB-susceptible PDAs, only 58% and 31%
returned to receive the second and third vaccine doses,
respectively.
Because Worcester has a large PDA population and an overall
population
of 160,000, the successful vaccination of a relatively small number
of
susceptible PDAs has not visibly affected the course of the
outbreak.
Because of difficulty in delivering HB vaccine to PDAs, other
control tactics have been suggested (9). Educational efforts
directed
at behavior modification, including avoidance of parenteral drug
abuse, or at least avoidance of sharing IV needles, are presently
being mounted in Durham County. Because HB is also a sexually
transmitted disease, sexual behaviors need to be emphasized also to
help PDAs minimize their number of sexual partners, to use
appropriate
barrier methods, and to encourage their partners to seek HB
vaccination. A program to vaccinate susceptible PDAs in Durham
County
is also being considered.
References
CDC. Hepatitis B--New Bern, North Carolina. MMWR
1979;28:373-4.
CDC. Unpublished data.
Cherubin CE, Hargrove RL, Prince AM. The serum hepatitis
related
antigen (SH) in illicit drug users. Am J Epidemiol
1970;91:510-7.
Rosenstein BJ. Viral hepatitis in narcotics users. An
outbreak
in Rhode Island. JAMA 1967;199:698-700.
Dismukes WE, Karchmer AW, Johnson RF, et al. Viral hepatitis
associated with illicit parenteral use of drugs. JAMA
1968;206:1048-52.
Cates W Jr, Warren JW. Hepatitis B in Nuremberg, Germany.
Epidemiology of a drug-associated epidemic. Among US Army
soldiers. JAMA 1975;234:930-4.
Lettau LA, Schatz GC, Hadler SC, et al. Vaccination as a
control
measure in an outbreak of hepatitis B among parenteral drug
abusers, Massachusetts (Abstract). Atlanta, Georgia: Epidemic
Intelligence Service Conference, April 1985.
Des Jarlais DC, Hopkins W. "Free" needles for intravenous drug
users at risk for AIDS: current developments in New York City
(Letter). N Engl J Med 1986;313:1476.
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