# Presentation: 769315

## 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 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**

- Source: Sentinel Counties, CDC

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

**	****Cases****	****Controls**
_**Exposure (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 C1982-2000, 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 mo**
_**reported 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 mo**
_**Type**_**	**** ****	****	****       **_**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 InfectionCross 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 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)****	****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 InfectionPrevalence 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****	****+****	****-****	****ND**
**Tattooing****	****-****	****-****	****+**
**Ear/body piercing****	****+/-****	****+****	****ND**
**Acupuncture****	****-****	****-****	****ND**
**Incarceration****	****-****	****+****	****-**

_**Exposure**_**	****	****	**_**US-ARC**_**  ****	**_**US-REDS **_**   **_**Australia**_

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

## 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**

## 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 Neg**
_**Exposure**_**	****	****      ****	**_**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 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**

**“**

**”**

## 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<.001**
**Race/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****	**** 5.6**
**IDU****	****Yes****	****  116 (1.5)****	****22.4*****	****17.1*****	****	****No****	****7718 (98.5)****	****0.6****	****5.7**
**Tattoo****	****Yes****	****1430 (20.5)**** ****	****0.3****†****	****5.3**
**	****No****	****5533 (79.5)****	****0.5****	****6.2**
**Body piercing****	****Yes****	****1202 (17.4)**** ****	****0.4****†****	****3.7**
**	****No****	****5701 (82.6)****	****0.4****	****6.5**
**Snorted drugs****	****Yes****	****  617 (9.1)**** ****	****0.6****†****	****6.8**
**	****No****	****6179 (90.9)****	****0.4****	****5.9**

**	****	****	****	****	****	**** ****% Positive**
_**Characteristic**_**	****   **_**Total Tested (%)**_**	**_**HCV     HBV**_

**Hwang et al., unpublished data**

*** p<.001**
**†**** ****excluding IDU and transfusion**

## Cosmetic Procedures and HCV InfectionModerate Endemic Countries

**	****	**** ****	****      ****	****       ****Tattooing****	****      Body Piercing**
_**Country**_**	****	****	**_**HCV Pos**_**	**_**HCV Neg**_**	****	**_**HCV Pos**_**	**_**HCV Neg**_
**Case-control**
**Taiwan****	****	****  ****	****	****0%****	****	****0%****	****	****	****0%****	****	****	****1%**
**Cross-sectional**
**Japan****	****	****	****	****1%****	****	****0%****	****	****	****--****	****	****	****--**
**	****	****	****	****	****3%****	****	****0%****	****	****	****--****	****	****	****--**
**Pakistan ****	****	****	****	****7%****	****	****0%****	****	****	****7%****	****	****	****0%**

## Alternative Medicine and HCV InfectionModerate Endemic Countries

**	****	****   ****	****	****	****	****          ****Acupuncture**
_**Country**_**	****	****	****	****	**_**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 **