Epidemiological Studies Evaluating Risk of Viral Hepatitis Infection from

Tattoos and Body Piercing

Miriam J. Alter, Ph.D.Division of Viral Hepatitis

Centers for Disease Control and Prevention

March 14, 2002

Types of Epidemiological Studies Cohort (prospective) - direct estimate of risk– Presence of exposure determined in sample of population– Entire sample followed and incidence of disease compared for those

with and without the exposure Case control (retrospective) - indirect estimate of risk– Sample selected based on presence or absence of disease– Proportion of cases with history of exposure before onset of disease

compared with controls Cross-sectional or prevalence - associations– Presence of disease determined in sample of population

• Proportion of cases with history of exposure compared with non-cases• Prevalence of disease compared for those with and without the exposure

– Temporal sequence of exposure relative to disease unknown

Risk Factors Associated with Acquiring HCV Infection, United States

Transfusion, transplant Injecting drug use Occupational blood exposure (needle sticks) Birth to an infected mother Infected sex partner Multiple heterosexual partners

Cohort and Case Control Studies

Sources of Infection forPersons with Hepatitis C

Sexual 15%

Other* 5%

Unknown 10%

Injecting drug use 60%

Transfusion 10%(before screening)

* Hemodialysis; health-care work; perinatal

Source: Centers for Disease Control and Prevention

Exposures Not Associated with Acquiring HCV Case Control Studies of Acute Hepatitis C, U.S., 1979-1985

Cases ControlsExposure (prior 6 months) n=148 n=200 Medical care procedures 30.4% 29.5%Dental work 24.3% 23.5%Health care work (no blood contact) 4.1% 5.0%Ear piercing 2.7% 3.0%Tattooing 0.7% 0.5%Acupuncture 0 1.0%Incarceration 4.1% 1.0%Foreign travel 4.1% 2.5%Military service 1.3% 4.9%

Source: JID 1982;145:886-93; JAMA 1989;262:1201-5.

Limitations of Case Control Studies

Will not detect rare events Do not directly measure risk

History of Tattooing and Acute Hepatitis C1982-2000, United States

Total (95% CI) 1856 3.2% (2.5-3.8) 1.5% (0.9-2.1)

1982-1986 839 2.7% 1.8%

1987-1990 625 2.7% 1.1%

1991-2000 392 4.3% 1.5%

Time period of History of tattooing prior 6 moreported case N All patients No IDU/BT

Source: CDC Sentinel Counties Study

History of Body Piercing Acute Hepatitis B and Acute Hepatitis C

1996-2000, United States

Acute hepatitis B 603 2.3% 1.5%

Acute hepatitis C 134 3.7% 1.0%

History of piercing* prior 6 moType N All patients No IDU/BT

Source: CDC Sentinel Counties Study

* Other than ears

Identifying Risk Factors from Prevalence Studies Determining specific exposures preceding infection

problematic when onset of infection unknown or many years ago

Substantial differences in methodology– Population-based (NHANES)– Highly selected groups

• Blood donors• Clinic patients• VA patients

Inconsistent results among studies– Under-ascertain some risk factors– Cannot generalize to the rest of the population

Tattoos and HCV InfectionCross Sectional Studies

Donors US (Murphy) 27% (758) 5% (1039) NA NS US (Conry-Cantilena) 21% (248) 6% (233) NA NS AU (Kaldor) 30% (220) 4% (210) 27 (8.4-87)GI clinic (Balasekaran) No IDU/BT 43% (58) 16% (58) 5.9 (1.1-31)VA pts (Briggs) 50% (185) 20% (847) 2.9 (1.7-5.1)

Tattooed (Total tested) Adj. 95%Group (author) HCV Pos HCV Neg OR* CI

* Controlling for other risk factors (e.g., IDU, BT)

Ear/body Piercing and HCV InfectionCross Sectional Studies

Donors US (Murphy) 56% (758) 40% (1039) 2.0 (1.1-3.7) US (Conry-Cantilena) Ear piercing men only 30% (139) 0% (83) inf p<.05

VA pts (Briggs) 37% (185) 24% (847) NA NS

Pierced (Total tested) Adj. 95%Group (author) HCV Pos HCV Neg OR* CI

* Controlling for other risk factors (e.g., IDU, BT)

Tattoos, Body Piercing, HBV and HCV InfectionPrevalence Studies

HCV Tattoo Yes 1% (1652) 7% (106) 33% (52)

No 1% (6348) 3% (106) 3.5% (513) Adj. OR* (95% CI) .65 (.3-1.5)† NS 6.5 (2.9-14.8)Body piercing Yes .8% (1372) -- --

No 1% (6534)HBV Adj. OR* (95% CI) Tattoo Yes 7% (1652) 0.81 (0.58-1.11)

No 10% (6348) Body piercing Yes 5% (1372) -- --

No 10% (6534)

Positive (Total tested)Group (author) College ER pts Spinal Clinic

* Controlling for other risk factors (e.g., IDU, BT)

Blood Donor Studies of HCV Infection

Injecting drug use + + +Transfusion + + +High-risk sex + +/- +Nasal cocaine use + - NDTattooing - - +Ear/body piercing +/- + NDAcupuncture - - NDIncarceration - + -

Exposure US-ARC US-REDS Australia

Conry-Cantilena NEJM 1996; Murphy Hepatology 2000; Kaldor Med J Aust 1992

Tattoos and HCV InfectionGI Clinic, Albuquerque, NM 1995-1996

Limitations Not representative– 40% Hispanic, 40% indigent– Cases – referred for positive HCV test– Controls • One category only - gastroesophageal reflux disease• HCV status not ascertained

History of incarceration not accounted for Attributable fraction for tattooing 0.8%

Source: Balasekaran et al. Am J Gastro 1999;94:1341-6

Tattoos and HCV Infection Orthopedic Spinal Clinic, Dallas, TX 1991-1992

Tattoo 58% 15% 41%Beer drinker 47% 26% 23%Injection drug use 35% 4% 17%Male Ancillary HCW 23% 4% 8%Transfusion 12% 21% --

HCV Pos HCV NegExposure n=43 n=583 AR*

*Attributable risk percentage adjusted for other risk factors and standardized to population

Source: Haley et al. Medicine 2001;80:134-51.

Cross sectional study of 629 patients over-represented by blacks, hispanics, men, middle and low income

Tattoos and HCV InfectionHaley et al.’s Conclusions

Majority of HCV due to tattoos, IDU, and ancillary hospital jobs for men– Tattoos accounted >2 times the infections as IDU

Transfusion a rare means of acquiring HCV– Majority of controlled studies reported no (or inverse)

association between HCV and transfusion. Heavy beer drinking (not wine/liquor) important role Increased prevalence of HCV in black men due

almost entirely to confounding effects of having been a male ancillary HCW and drinking beer heavily

“

”

Haley Study Limitations Population not representative AR calculated from cross-sectional studies controversial Inconsistent with virtually all other studies Dose response relationships inconsistent for tattooing, but

not for IDU IDU likely under-reported– >50% of HCV-positives admit to IDU when re-interviewed after

receiving results Some factors likely surrogates for known risks– Male ancillary HCW (why not females?)– Beer drinking (why not other forms of alcohol?)

College Students, 2000-2001, Preliminary Data

Total 8018 77 (0.96)Age <19 1777 2 (0.1) 20-24 3668 14 (0.4) 25-29 1189 7 (0.6) >30 377 54 (3.9) p<.001Race/Ethnicity White 2384 31 (1.3) Black 1896 21 (1.1) Hispanic 1839 12 (0.6) p<.05* Other 1725 9 (0.5)

Characteristic Total Tested No. (%) HCV Positive

* vs. Whites

Hwang et al., unpublished data

HCV and HBV Among College Students, 2000-2001

Transfusion Yes 337 (4.5) 6.2* 11.8*No 7236 (95.5) 0.7 5.6IDU Yes 116 (1.5) 22.4* 17.1*No 7718 (98.5) 0.6 5.7Tattoo Yes 1430 (20.5) 0.3† 5.3

No 5533 (79.5) 0.5 6.2Body piercing Yes 1202 (17.4) 0.4† 3.7

No 5701 (82.6) 0.4 6.5Snorted drugs Yes 617 (9.1) 0.6† 6.8

No 6179 (90.9) 0.4 5.9

% PositiveCharacteristic Total Tested (%) HCV HBV

Hwang et al., unpublished data

* p<.001† excluding IDU and transfusion

Cosmetic Procedures and HCV InfectionModerate Endemic Countries

Tattooing Body PiercingCountry HCV Pos HCV Neg HCV Pos HCV Neg

Case-controlTaiwan 0% 0% 0% 1%Cross-sectionalJapan 1% 0% -- --

3% 0% -- --Pakistan 7% 0% 7% 0%

Alternative Medicine and HCV InfectionModerate Endemic Countries

AcupunctureCountry HCV Pos HCV Neg

Case-control Taiwan 5% 1%Cross-sectional Japan 62%* 26%

20% 17%* P<.05, performed by unlicensed therapists

Risk of Viral Hepatitis Infection from Tattoos and Body Piercing

Summary Biologically plausible but no evidence for increased risk

for HBV or HCV based on these histories alone May account for small fraction of cases

(epidemiologically insignificant) and be limited to certain settings– prisons, unregulated practitioners, non-US

Routine screening in the general population not warranted– Other considerations may warrant screening selected

populations, e.g., donors