1. 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

2. 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

3. 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

4. Sources of Infection for Persons 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

5. Exposures Not Associated with Acquiring HCV Case Control Studies of Acute Hepatitis C, U.S., 1979-1985 CasesControls Exposure (prior 6 months)n=148 n=200 Medical care procedures30.4%29.5% Dental work24.3%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.

6. Limitations of Case Control Studies Will not detect rare events Do not directly measure risk

7. History of Tattooing and Acute Hepatitis C 1982-2000, United States Total (95% CI)18563.2% (2.5-3.8)1.5% (0.9-2.1) 1982-19868392.7%1.8% 1987-19906252.7%1.1% 1991-20003924.3%1.5% Time period of History of tattooing prior 6 mo reported case NAll patients No IDU/BT Source: CDC Sentinel Counties Study

8. History of Body Piercing Acute Hepatitis B and Acute Hepatitis C 1996-2000, United States Acute hepatitis B6032.3%1.5% Acute hepatitis C1343.7%1.0% History of piercing* prior 6 mo Type N All patients No IDU/BT Source: CDC Sentinel Counties Study * Other than ears

9. 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

10. Tattoos and HCV Infection Cross Sectional Studies Donors US (Murphy) 27% (758)5% (1039)NANS US (Conry-Cantilena) 21% (248)6% (233)NANS AU (Kaldor) 30% (220)4% (210)27 (8.4-87) GI clinic (Balasekaran) No IDU/BT43% (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 NegOR*CI * Controlling for other risk factors (e.g., IDU, BT)

11. Ear/body Piercing and HCV Infection Cross 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)infp<.05 VA pts (Briggs) 37% (185)24% (847)NANS Pierced (Total tested)Adj. 95% Group (author)HCV Pos HCV NegOR*CI * Controlling for other risk factors (e.g., IDU, BT)

12. Tattoos, Body Piercing, HBV and HCV Infection Prevalence Studies HCV TattooYes 1% (1652)7% (106)33% (52) No1% (6348) 3% (106) 3.5% (513) Adj. OR* (95% CI).65 (.3-1.5) † NS6.5 (2.9-14.8) Body piercingYes.8% (1372)---- No1% (6534) HBV Adj. OR* (95% CI) TattooYes 7% (1652) 0.81 (0.58-1.11) No10% (6348) Body piercingYes5% (1372)---- No10% (6534) Positive (Total tested) Group (author)CollegeER ptsSpinal Clinic * Controlling for other risk factors (e.g., IDU, BT)

13. Blood Donor Studies of HCV Infection Injecting drug use+++ Transfusion+++ High-risk sex++/-+ Nasal cocaine use+-ND Tattooing--+ Ear/body piercing+/-+ND Acupuncture--ND Incarceration-+- ExposureUS-ARC US-REDS Australia Conry-Cantilena NEJM 1996; Murphy Hepatology 2000; Kaldor Med J Aust 1992

14. Tattoos and HCV Infection GI 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

15. Tattoos and HCV Infection Orthopedic Spinal Clinic, Dallas, TX 1991-1992 Tattoo58%15%41% Beer drinker47%26%23% Injection drug use35%4%17% Male Ancillary HCW23%4%8% Transfusion12%21%-- HCV Pos HCV Neg Exposure n=43 n=583AR* *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

16. Tattoos and HCV Infection Haley 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 “ ”

17. 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?)

18. College Students, 2000-2001, Preliminary Data Total801877 (0.96) Age <191777 2 (0.1) 20-24366814 (0.4) 25-291189 7 (0.6) >3037754 (3.9) p<.001 Race/Ethnicity White238431 (1.3) Black189621 (1.1) Hispanic183912 (0.6)p<.05* Other1725 9 (0.5) Characteristic Total TestedNo. (%) HCV Positive * vs. Whites Hwang et al., unpublished data

19. HCV and HBV Among College Students, 2000-2001 TransfusionYes 337 (4.5)6.2*11.8* No7236 (95.5)0.7 5.6 IDUYes 116 (1.5)22.4*17.1* No7718 (98.5)0.65.7 TattooYes1430 (20.5) 0.3 † 5.3 No5533 (79.5)0.56.2 Body piercingYes1202 (17.4) 0.4 † 3.7 No5701 (82.6)0.46.5 Snorted drugsYes 617 (9.1) 0.6 † 6.8 No6179 (90.9)0.45.9 % Positive Characteristic Total Tested (%)HCV HBV Hwang et al., unpublished data * p<.001 † excluding IDU and transfusion

20. Cosmetic Procedures and HCV Infection Moderate Endemic Countries Tattooing Body Piercing Country HCV PosHCV NegHCV PosHCV Neg Case-control Taiwan 0%0%0%1% Cross-sectional Japan1%0%---- 3%0%---- Pakistan 7%0%7%0%

21. Alternative Medicine and HCV Infection Moderate Endemic Countries Acupuncture Country HCV PosHCV Neg Case-control Taiwan 5% 1% Cross-sectional Japan62%*26% 20%17% * P<.05, performed by unlicensed therapists

22. 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