Fact Sheet Series > Viral Hepatitis and Injection Drug Users

Viral Hepatitis and Injection Drug Users
September 2002

Viral Hepatitis is an Important Health Issue for the Nation

Hepatitis, literally an “inflammation of the liver,” has a number of causes. Viral infection is one of them. The most common types are hepatitis A, hepatitis B, and hepatitis C.

Viral hepatitis affects millions.

Hepatitis C virus (HCV) infection occurs when blood (or to a lesser extent, other body fluids such as semen or vaginal fluid) from an infected person enters the body of an uninfected person. Injection drug use is the major risk factor for HCV infection. About 3.9 million Americans have been infected with HCV and 2.7 million have chronic HCV infection. Hepatitis C disproportionately affects people of color: 3.2% of African Americans and 2.1% of Mexican Americans are infected with HCV, compared to 1.5% of non- Hispanic whites. These numbers underestimate the actual impact because they do not include infections in prisoners or the homeless. In 2000, about 30,000 new infections occurred. Most of these infections occurred among young adults 20-39 years old.

Hepatitis B virus (HBV) infection occurs when blood or body fluids from an infected person enter the body of an uninfected person. High-risk sexual behaviors (unprotected sex with multiple partners) and injection drug use are the major risk factors. About 5% of people in the U.S. have evidence of past infection with HBV and approximately 1.25 million people have chronic HBV infection. Like hepatitis C, hepatitis B disproportionately affects people of color. An estimated 73,000 new HBV infections occurred in 2000. Most infections occurred in young adults, aged 20-39 years. Hepatitis B can be prevented through immunization.

Hepatitis A virus (HAV) is primarily transmitted through the fecal-oral route, when a person puts something in his or her mouth (such as food or a beverage) that has been contaminated with the feces of a person infected with HAV. Outbreaks occur more easily in overcrowded areas where poor sanitary conditions exist. Outbreaks of hepatitis A also have been reported among IDUs. About one-third of Americans have evidence of past infection with HAV. Hepatitis A can be prevented through immunization.

The medical and health care costs of viral hepatitis are high.

Each year, 8,000 to 10,000 people die from the complications of liver disease caused by hepatitis C and about 5,000 die from complications caused by hepatitis B. Chronic liver disease is currently the 10th leading cause of death, and liver failure due to hepatitis C is the leading reason for liver transplants. Annual health care costs and lost wages associated with hepatitis-related liver disease are estimated to be $600 million for hepatitis C and $700 million for hepatitis B. The costs to individuals and society of illness related to hepatitis A are also substantial.

Viral hepatitis can be insidious. Frequently, symptoms of newly acquired (acute) infection are mild or nonexistent, so people may not even be diagnosed as having viral hepatitis. Those who do have symptoms might experience “flu-like” symptoms, fatigue, nausea, pain in the upper abdomen, and sometimes jaundice.

People who get HAV infection are able to clear the virus from their bodies and recover fully. They develop a lifelong immunity to the virus. The situation is different with hepatitis B and hepatitis C:

• The majority of people who acquire HBV infection after age 5 are able to clear the virus from their bodies. However, about 2%-6% are not able to clear the virus and go on to become chronically infected. A much higher percentage of those who acquire HBV infection as infants (90%) or young children (30%) become chronically infected.
• About 75%-85% of people with HCV infection are unable to clear the virus and become chronically infected.

Many people with chronic infection – 60% of those with HBV infection and 70% of those with HCV infection – develop chronic liver disease, a situation in which the virus damages the liver. The damage may progress to severe disease, including cirrhosis, liver cancer, and liver failure. This progressive liver disease usually develops slowly over 20 to 30 years. Because symptoms are so frequently mild or nonexistent, the majority of people with chronic HBV and HCV infections do not know they are infected and can unknowingly transmit the virus to others. For many, signs and symptoms appear only when liver disease is advanced and treatments are less effective.

Hepatitis C is a particular concern.

• So many people have been infected with HCV. During the 1960s, 1970s, and early 1980s, the number of new cases every year was very high, averaging an estimated 240,000 per year during the 1980s. Because many were unaware they were infected, the risks of transmitting the infection to others were extremely high. Since then, the incidence of HCV infection has declined dramatically (only 30,000 new infections estimated in 2000). Most of this decline has occurred among IDUs. The reasons are not fully understood but may be due to safer injection practices resulting from intensive HIV prevention programs and to the very high proportion of drug users already infected.
• Most people with HCV infection develop chronic infection, which frequently leads to chronic liver disease.
• The impact of HCV infection may explode over the next 10-20 years. Because it takes 20-30 years for chronic liver disease, cirrhosis, and liver cancer to develop, it is conservatively estimated that illness and deaths from HCV-related liver disease among the millions of people infected during earlier years will increase 2- to 3-fold over the next two decades. Direct medical costs may range from $6.5 to $13.6 billion, with even larger indirect and societal costs.
• No vaccine to prevent HCV infection is available.

Viral Hepatitis is a Very Significant Problem Among IDUs

Because HBV and HCV are transmitted through exposure to infected blood and body fluids, IDUs are at very high risk of acquiring and transmitting both viruses. For example, it is estimated that 60%, or 17,000, of the 30,000 new cases of HCV that occurred in 2000 occurred among IDUs. Is it estimated that 17%, or 13,000 of the 73,000 new cases of hepatitis B that occurred in 2000, occurred among IDUs.

Hepatitis A, B, and C at a Glance Virus Risk of Transmission Course of Infection Does Protective Immunity Develop? Vaccine Available?   Injecting Transfusion/ Transplant Sex Fecal-Oral Occupational       A low* high high high none acute->resolved yes yes B high low high none high unless immune due to hepatitis B immunization or previous infection acute -> chronic in 90% of infants, 30% in children aged 1-5, 2%-6% of older children and adults yes yes C high low low none low acute ? chronic in 75%-85% of adults no no * Hepatitis A outbreaks occur among IDUs; mechanisms of transmission are not known with certainty but are related to poor hygiene and sharing drugs, drug solution, syringes, and drug preparation equipment (water, drug solution containers, cotton filters).

HBV and HCV infections are also acquired relatively rapidly among IDUs. Within 5 years of beginning injection drug use, 50%-70% of IDUs become infected with HBV. Between 50%-80% of IDUs become infected with HCV within 5 years of beginning injection drug use; it is usually the first bloodborne virus they acquire. Several factors favor the rapid spread of HCV infection among IDUs:

• Viral factors – HCV is transmitted efficiently through blood exposure.
• Host factors – A large number of individuals are infected and this provides multiple opportunities for transmission to others.
• IDU factors – IDUs often jointly purchase drugs and prepare the drug solution together; this solution is divided among users. Sharing the drug solution, syringes, or other drug preparation equipment (such as water, drug mixing containers, and cotton filters) all increase the risk of transmission if any of these components are infected with HCV.
• Other circumstances also contribute to the heavy impact of viral hepatitis on IDUs:
• IDUs are at very high risk of coinfection with HIV and HCV.
• Many IDUs drink alcohol, which damages the liver and accelerates the progression of liver disease.
• HAV infection can be severe and very dangerous in those who already have liver disease from chronic hepatitis B or chronic hepatitis C.
• Treatment of chronic hepatitis B or chronic hepatitis C can be complicated and adherence difficult for infected IDUs because many have other conditions (HIV, mental illness, alcoholism, other illnesses), are poor, and have unstable living situations. The stigma surrounding injecting drugs also means that many IDUs are marginalized and have little or no contact with health care providers.

Agencies and Providers Face a Number of Pressing Issues in their Efforts to Address Viral Hepatitis

In many ways, the current challenges of viral hepatitis, especially hepatitis B and hepatitis C, resemble those of HIV in the late 1980s and early 1990s. Awareness of viral hepatitis as an important public health issue is growing, but agencies, providers, communitybased organizations, and others who work with those at risk must address several key issues:

• Prevention.Viral hepatitis is not inevitable for IDUs and others at risk. All three strains of viral hepatitis can be prevented. HAV and HBV infections can be prevented through immunization. All IDUs should be immunized against HAV and HBV infections unless they have already had the infection. Reducing or eliminating high-risk sexual and drug-use behaviors can help prevent HAV, HBV, and HCV infections. Substance abuse treatment is an important way to help IDUs reduce or eliminate drug use.
• Transmission. Because symptoms of viral hepatitis are often mild or nonexistent, many people do not know they’re infected. This means that a very large pool of individuals with chronic HBV and HCV infections may not be using any measures to reduce the possibility of transmitting these infections to others.
• Treatment. Antiviral therapies for chronic hepatitis B and chronic hepatitis C are expensive, only moderately effective, and not appropriate for everyone infected with these viruses. Determining whether to begin treatment, and monitoring and adjusting treatment over time for those who do begin antiviral therapy can be difficult.
• Capacity. Currently, public health agencies, community-based organizations, and health care professionals are limited in their ability to respond to needs in viral hepatitis. For example, fewer than half of state and local public health laboratories are able to perform tests to determine HCV infection. Many health care facilities (such as emergency rooms) that treat IDUs and others at increased risk do not routinely provide immunizations against hepatitis A and hepatitis B. In addition, primary care physicians may not have the training or expertise to diagnose or medically manage chronic hepatitis B or chronic hepatitis C. Staff of HIV and sexually transmitted disease (STD) clinics, substance abuse treatment programs, and correctional facilities have limited training and expertise in viral hepatitis issues.
• Education.The need to educate, train, and reach the general public, groups at increased risk, and health care professionals is enormous. This effort needs to:
  • improve the understanding of viral hepatitis and its risk factors so that individuals can reduce their chances of acquiring or transmitting the infections and providers can better serve infected and at-risk individuals;
  • encourage high-risk groups to be tested for HCV infection, receive pre- and post-test counseling, and receive medical treatment if appropriate;
  • improve hepatitis A and hepatitis B immunization rates by encouraging high-risk groups to get vaccinated;
  • integrate viral hepatitis prevention messages and interventions into existing HIV, STD, substance abuse treatment, and criminal justice initiatives; and
  • work to reduce bias and stigma toward groups at increased risk of infection.

The National Hepatitis C Prevention Strategy is One Key Response In 2001, in collaboration with other federal, state, and private sector agencies, the Centers for Disease Control and Prevention (CDC) launched the National Hepatitis C Prevention Strategy. This effort is aimed at lowering the incidence of acute HCV infections in the U.S. and reducing the disease burden from chronic hepatitis C. The principal components of this effort are:

• education of health care and public health professionals;
• education of the public and individuals at increased risk of infection;
• clinical and public health activities to identify, counsel, and test persons at risk and to improve medical evaluations and referrals to care;
• outreach and community-based prevention programs;
• surveillance to monitor viral hepatitis trends; and
• • research.

For more information about the Strategy, visit: CDC's Hepatitis C Strategy

To Learn More About This Topic

Visit websites of the Centers for Disease Control and Prevention and the Academy for Educational Development for these and related materials:

• Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach, which provides extensive background information on HIV and viral hepatitis infection in IDUs and the legal, social, and policy environment, and describes strategies and principles of a comprehensive approach to addressing these issues.
• Interventions to Increase IDUs’ Access to Sterile Syringes, a series of six fact sheets.
• Drug Use, HIV, and the Criminal Justice System, a series of eight fact sheets.
• Substance Abuse Treatment and Injection Drug Users, a series of six fact sheets. Visit the CDC’s Viral Hepatitis website for information materials and on-line training for health professionals.

Visit these websites for additional information on viral hepatitis:

• The American Liver Foundation
• The National Institute of Diabetes & Digestive & Kidney Diseases
• Hepatitis Foundation International
• Hepatitis C Support Project
• National AIDS Treatment Advocacy Project
• Check out these sources of information:

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Alter MJ, Moyer LA. The importance of preventing hepatitis C virus infection among injection drug users in the United States. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S6-S10.

Armstrong GL, Alter MJ, McQuillan GM, Margolis HS. The past incidence of hepatitis C virus infection: implications for the future burden of chronic liver disease in the United States. Hepatology 2000;31(3):777-782.

Centers for Disease Control and Prevention (CDC). National hepatitis C prevention strategy. Summer 2001.

Centers for Disease Control and Prevention (CDC). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCVrelated chronic disease. Morbidity and Mortality Weekly Report 1998;47(RR19):1-39.

Centers for Disease Control and Prevention (CDC). Epidemiologic notes and reports: hepatitis A among drug abusers. Morbidity and Mortality Weekly Report 1988;37(19):297-300, 305.

Garfein RS, Doherty MC, Monterroso ER, et al. Prevalence and incidence of hepatitis C virus infection among young adult injection drug users. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1): S11-S19.

Gunn RA, Murray PJ, Ackers ML, et al. Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic – rationale for integrating services. Sexually Transmitted Diseases 2001;28(3):166-170. Hagan H, McGough JP, Thiede H, et al. Syringe exchange and risk of infection with hepatitis B and C viruses. American Journal of Epidemiology 1999;149(3):203-213.

Hagan H, Thiede H, Weiss NS, et al. Sharing of drug preparation equipment as a risk factor for hepatitis C. American Journal of Public Health 2001;91(1):42-46. Hagan H, Des Jarlais DC. HIV and HCV infection among injecting drug users. The Mount Sinai Journal of Medicine 2000;67(5-6):423-428.

Hutin Y, Sabin KM, Hutwagner LC, et al. Multiple modes of hepatitis A virus transmission among methamphetamine users. American Journal of Epidemiology 2000;152(2):186-192.

Margolis HS, Alter MJ, Hadler SC. Hepatitis B: evolving epidemiology and implications for control. Seminars in Liver Disease 1991;11(2):84-92.

National AIDS Treatment Advocacy Project (NATAP). Current review and update on hepatitis C and HIV/HCV coinfection. New York: NATAP; Summer 2001.

National Institutes of Health (NIH). Management of hepatitis C: 2002. Consensus Development Statement #116. June 10-12, 2002.

Novick DM. The impact of hepatitis C virus infection on methadone maintenance treatment. (PDF 36 KB, 7 pages) The Mount Sinai Journal of Medicine 2000;67(5-6): 437-443.

O’Donovan D, Cooke RPD, Joce R, et al. An outbreak of hepatitis A amongst injecting drug users. Epidemiology and Infection 2001;127(3):469-473.

Ompad DC, Fuller CM, Vlahov D, Thomas D. Lack of behavior change after disclosure of hepatitis C virus infection among young injection drug users in Baltimore, Maryland. Presented at 128th Annual Meeting of the American Public Health Association. Boston, MA. November 12-16, 2000.

Thorpe LE, Ouellet LJ, Hershow R, et al. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. American Journal of Epidemiology 2000;155(7):645- 653.

Vento S, Garofano T, Renzini C, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. New England Journal of Medicine 1998; 338(5):286-290.

Wong JB, McQuillan GM, McHutchison JG, Pynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. American Journal of Public Health 2000;90(10); 1562-1569.

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