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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

  1. CDC. Hepatitis B--New Bern, North Carolina. MMWR 1979;28:373-4.

  2. CDC. Unpublished data.

  3. Cherubin CE, Hargrove RL, Prince AM. The serum hepatitis related antigen (SH) in illicit drug users. Am J Epidemiol 1970;91:510-7.

  4. Rosenstein BJ. Viral hepatitis in narcotics users. An outbreak in Rhode Island. JAMA 1967;199:698-700.

  5. Dismukes WE, Karchmer AW, Johnson RF, et al. Viral hepatitis associated with illicit parenteral use of drugs. JAMA 1968;206:1048-52.

  6. 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.

  7. CDC. Delta hepatitis--Massachusetts. MMWR 1984;33:493-4.

  8. 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.

  9. 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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