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