Hepatitis C & Injection Drug Use — A Focus On Youth

The Hepatitis C Virus

• Hepatitis C is a virus (HCV). The virus was first identified in 1989.¹
• HCV affects the liver. It causes hepatitis (inflammation in the liver), which can progress to cirrhosis (extensive scarring so the liver cannot perform its normal functions).
• Most newly infected persons (60 to 70%) have no symptoms and are unaware of their infection. Nonetheless, they are still infectious to others.²
• Approximately 15 to 25% of all persons infected with HCV appear to resolve their infection.¹⁷
• Approximately 75 to 85% of all persons infected with HCV progress to chronic infection. The course of the chronic disease is generally slow, without symptoms for two or more decades after infection.³
• Approximately 3 to 20% of infected persons will develop cirrhosis of the liver after 20 years of infection.²
• At present, there is no vaccine available.⁴
• There are at least six types, and more than 90 subtypes of HCV.^4,5
• The current recommended treatment for HCV infection is a combination of the drugs interferon and ribavirin.⁶
• Presently, treatment is not effective in all infected people.⁶
• It is possible to become re-infected with HCV.

Rates of Hepatitis C

• It is estimated that approximately 240,000 persons in Canada are infected with HCV, with rates higher among males than females.^3,9
• To date, HCV infection rates are very low in infants and children, gradually climbing to a peak rate among those 30-39 years of age and declining thereafter.³
• It is estimated that 4,000 new cases of HCV infection will occur in Canada each year, 63% of which will be related to injection drug use.³

Transmission of Hepatitis C

• HCV is primarily transmitted through exposure to infected blood.
• Compared to HIV, HCV is 10 to 15 times more highly transmissible by blood.⁸

At Greatest Risk

• Sharing needles, syringes, swabs, filters, spoons, tourniquets and water for injection drug use represents the highest risk behaviour.⁵

At Lower Risk

• Sexual transmission of HCV is estimated between 0 to 10%. Having multiple sexual partners may increase the risk of infection.²
• Infection of infants from an infected mother occurs in about 5 to 10% of cases.²
• Evidence shows that HCV can be transmitted through tattooing.⁷
• There is a potential risk of infection through the sharing of household articles that may be contaminated with blood (e.g., toothbrushes, razors).⁷
• Transfusion of blood or blood products account for approximately 10% of existing cases. However, the risk of infection through blood has been substantially reduced by the introduction of universal testing of blood donors in May 1990. The current risk of infection is estimated to be approximately 1 in 100,000 units.²
• Canadian Blood Services and Héma Québec are currently investigating a new blood screening method that is expected to decrease the risk of HCV transmission to 1 in 500,000 units.¹⁰

Injection Drug Use

• It is estimated that 63% of new HCV infections in Canada each year are related to sharing needles, syringes, swabs, filters, spoons, tourniquets and water related to injection drug use.^2,7
• It has been estimated that there are up to 125,000 people in Canada who inject drugs.¹¹
• People involved in injection drug use are geographically and socially diverse.¹¹
• Currently, a young, single person at the low end of the economic scale is characteristic of those at greater risk of sharing needles and other drug equipment.¹¹
• HCV spreads quickly. Consistently, research shows high rates of HCV among short-term users of injection drugs who share drug-injecting equipment.^12,13
• Worldwide estimates of HCV infection range from 50 to 100% among drug-injecting populations. People who inject drugs are central to the persistence of HCV in Canada.⁸
• A 1996 study of injection drug users in British Columbia showed that 88% were infected with HCV. The results also revealed high levels of needle sharing, with 40% of participants having lent used needles and 40% having borrowed used needles.¹⁴
• The use of cocaine poses particular health risks. Cocaine use often involves up to 20 injections per day. This increases the likelihood that drug equipment will be shared.¹⁵
• There are various injection practices that increase the risk of transmission. For example, in a practice called 'front loading or back loading', the drug is mixed in one syringe and then divided by squirting some of the solution into one or more syringes. Although the needle is not shared, HCV can be transmitted if the syringe used for mixing has been previously contaminated.¹⁶
• Limited research suggests that people with a history of intra nasal or inhaled drug use may be at risk for HCV. Because users of cocaine often have nasal erosions and ulcers, sharing of cocaine straws can transmit HCV. Dehydrated and cracked lips, another common side effect of injection drug use, makes pipe sharing a potential risk.¹⁷
• People living in Canada who inject drugs are stigmatized and often rejected by society. This has significant implications for efforts to reach this population.¹⁸

Youth

• While there are great variations in the ages of individuals involved in injection drug use, substantial numbers are under the age of 20 years. A 1994 study of injection drug users in Quebec City showed that one in four individuals were under the age of 20 years.¹⁹
• Research with young users of injection drugs suggests that females are being initiated into injection drug use at an earlier age than males. Females are more likely than males to be influenced to inject drugs and less able to resist pressure by their male partners to share needles.¹¹
• The use and misuse of drugs in general, and injection drug use in particular, is high among street-involved youth.
• A 1995/96 Montreal study of street-involved youth (aged 15 to 22 years) showed that 36% had never used injection drugs and 23% had injected in the previous six months. The proportion infected with HCV was 12.6%. The majority (67%) had shared injecting equipment.²⁰
• A 1998 Winnipeg study of persons that inject drugs showed that 22% had injected with a used needle the first time they injected. At the time of first injection, 49% were under 20 years of age. These results highlight the young age at which people are becoming involved in injection drug use and engaging in risky injection practices.²¹
• Young injection drug users are often involved in multiple drug use, with their daily activities revolving around the acquisition and use of drugs. Involvement in illegal activities is often a means of meeting the financial demands of their drug use, frequently to the detriment of basic subsistence needs.²²

Personal Safety

• Never share needles, syringes, swabs, filters, spoons, tourniquets and water related to injection drug use.
• Exchange all used needles.
• Do not share toothbrushes, razors or other personal care articles as they may have blood on them.
• Consider the health risks in tattooing, body piercing or other personal services that involve breaking the skin and that may not follow recommended guidelines.

Prevention Efforts

• Discouraging individuals from being initiated into injection drug use is critical to preventing the spread of HCV infection.
• Using peer networks, where those involved with injection drug use provide education and intervention to others, has produced positive outcomes.²³
• Harm reduction strategies such as needle exchange programs and methadone maintenance programs reach a population that is difficult to access through more traditional channels. Such contact allows for the provision of education regarding the effects of harmful drug practices, and provides an opportunity to link individuals to other social and health services.
• Strategies directed at people who inject drugs need to use a comprehensive prevention and harm reduction approach that gives attention to the psycho social factors associated with injection drug use, the environment in which unsafe behaviour occurs, and the provision of basic life necessities.
• Street youth indicate that they have important basic needs. A stable long-term living arrangement has been identified as a primary factor in making a successful transition from the street. Secondary elements include educational upgrading, job training and personal counselling.^24,25

April 2001

---

References

1. Choo, Q.L., Kuo, G., Wiener, A.J., et al. (1989). Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science, 244, 359-362.

2. Canadian Liver Foundation (2000). Hepatitis C: medical information update. Canadian Journal of Public Health, 91, 1, S4-S9.

3. Zou, S., Tepper, M. & Giulivi, A. (2000). Current status of hepatitis C in Canada. Canadian Journal of Public Health, 91, 1, S10-S15.

4. Medical Research Council of Canada (MRC) (1999). Identification of a Research Agenda for the Diagnosis, Care and Prevention of Hepatitis C in Canada. Report to the Minister of Health.

5. Laboratory Centre for Disease Control (LCDC) (1999). Hepatitis C Prevention and Control: A Public Health Consensus. Health Canada.

6. Menard, D. (2000). Clinical Application of the Canadian Consensus Conference Guidelines for HCV. www.hepnet.ca

7. Patrick, D.M., Buxton, J.A., Bigham, M., et al. (2000). Public health and hepatitis C. Canadian Journal of Public Health, 91, 1, S18-S21.

8. Heintges, T. & Wands, J.R. (1997). Hepatitis C virus: epidemiology and transmission. Hepatology, 26, 521-526.

9. Remis, R., Hogg, R., Krahn, M.D., et al. (1998). Estimating the number of blood transfusion recipients infected by hepatitis C virus in Canada, 1960-85 and 1990-92. Report to Health Canada.

10. Canadian Blood Services (1999). Nucleic Acid Amplification Testing for Hepatitis C. Scientific Paper.
http://www.bloodservices.ca/CentreApps/Internet/
UW_V502_MainEngine.nsf/9749ca80b75a038585256aa20060
d703/708f54b29790a54585256abe0050069d?OpenDocument

11. Wiebe, J. & Single, E. (2000). Hepatitis C and Injection Drug Use in Canada: A Discussion Paper. Prepared for Hepatitis C Prevention, Support and Research Program, Health Canada.

12. Chang, C.J., Lin, C.H., Lee, C.T., et al. (1999). Hepatitis C virus infection among short-term intravenous drug users in southern Taiwan. European Journal of Epidemiology, 15, 597-601.

13. Van Beek, I., Dwyer, R., Dore, G.J., et al. (1998). Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study. British Medical Journal, 17, 433-437

14. Strathdee, S., Patrick, D., Currie, S., et al. (1997). Needle exchange is not enough: lessons from Vancouver injecting drug use study. AIDS, 11, F59-F65.

15. McAmmond and Associates (1997). Care, Treatment and Support for Injection Drug Users Living with HIV/AIDS. Report prepared for Health Canada.

16. Riehman, K. (1996). Injecting Drug Use and AIDS in Developing Countries: Determinants and Issues for Policy Consideration. Background paper for the Policy Research Group Confronting AIDS. World Bank, Policy Research Department.

17. Centres for Disease Control (1998). Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Mortality and Morbidity Weekly Report, 47, 1-39.

18. Millar, J. (1998). Hepatitis and injection drug use in British Columbia - Pay Now or Pay Later. Vancouver: BC Ministry of Health.

19. Belanger, D., Alary, M., Godin, G., et al. (1996). Identification of Subgroups of High Risk of Sharing used Needles among Injection Drug Users Participating in a Needle-exchange Program. University of Laval: unpublished paper

20. Roy, E. et al. (1997). Hepatitis B and C among street youth in Montreal - final report. Submitted to LCDC, Division of HIV/AIDS and Division of Bloodborne Pathogens.

21. Elliot, L. & Blanchard, J. (1999). The Winnipeg Injection Drug Epidemiology (W.I.D.E.) Study: A Study of the Epidemiology of Injection Drug Use and HIV Infection in Winnipeg, Manitoba. Epidemiology Unit, Manitoba Health.

22. Martinez, T., Gleghorn, A., Marx, R., et al. (1998). Psycho social histories, social environment, and HIV risk behaviors of injection and non injection drug using homeless youths. Journal of Psychoactive Drugs, 30, 1-10.

23. Hunt, N., Stillwell, G., Taylor, G., et al. (1998). Evaluation of a brief intervention to prevent initiation into injecting. Drugs: Education, Prevention and Policy, 5, 185-194.

24. Anderson, J. (1993). A Study of Out-of-the-Mainstream Youth in Halifax, Nova Scotia. Ottawa: Minister of Supply and Services.

25. Smart, R.G., Adlaf, E.M., Walsh, G.W., et al. (1992). Drifting and Doing: Changes in Drug Use Among Toronto Street Youth, 1990-1992. Toronto: Addictions Research Foundation.