Tattoo practices and risk of hepatitis B and hepatitis C infection in the general population
Authors: Foerster Milena , Zins Marie , Goldberg Marcel , Ribet Céline , Kab Sofiane , Hosseini Bayan , McCarty Rachel , McCormack Valerie , Ezzedine Khaled , Schüz Joachim 
Published: October 2024

Objectives

To prevent hepatitis B (HBV) and hepatitis C (HCV) infections and associated deaths from hepatocellular carcinoma and cirrhosis, better identification of transmission routes is needed. Here, we reassessed the impact of different tattooing practices on viral transmission.

Design

Population based cohort-study.

Setting

Cancer Risk Associated to the Body Art of Tattooing (CRABAT) cohort as part of the ongoing French national cohort study Constances (baseline examination from 2012-2018).

Participants

110,402 participants (60,387 women and 50,015 men), of which 11.6% (12,789) were tattooed as per Constances follow-up questionnaire 2020. Complete exposure data on different exposure settings and countries of tattooing collected via complementary exposure assessment in 2023 (response rate 60%) was available for 7740 tattooed (4930 women and 2810 men) participants.

Main outcome measures

Self-reported HBV and HCV infections that were confirmed by surface antigen testing (HBsAG) and antibody (Anti-HCV) testing, respectively. Associations of different tattoo exposure characteristics (any tattoo; tattooed in/outside tattoo parlours; tattooed in/outside regulating countries; no tattoos (reference)) on subsequent HBV and/or HCV infections were assessed via multivariate logistic regression models, minimally adjusted and adjusted for known hepatitis risk factors, in the population >=45 years. Post-hoc, number of preventable HCV infections due to unsafe tattooing outside tattoo parlours was estimated.

Results

In fully adjusted models, tattooing was associated with increased risk of any hepatitis infection (Odds ratio (OR): 1.46 (95% confidence interval: 1.15; 1.86), with a particularly strong increased risk for HCV (2.26 (1.64; 3.11)) compared to HBV (1.08 (0.77; 1.52)) infection. The increased risk for HCV and to a lesser extend for HBV was due to tattooing outside tattoo parlours (HCV: 4.75 (2.81; 8.03); HBV: 1.88 (0.99; 3.57)) whereas tattooing outside regulating countries was associated with an increased risk for HCV (2.74 (1.00; 7.45) and HBV (1.96 (0.80; 4.84)). Risk of HBV and/or HCV were around 10-fold for tattooing outside tattoo parlours outside regulating countries. The estimated number of preventable HCV infections through safe tattoo practices was around 12,000 in France and over 150,000 in Europe.

Conclusion

The impact of unsafe tattooing practices as a preventable risk factor for HCV transmissions is highly underestimated.

What is already known on the topic?

Tattooing was identified as a potential transmission route for hepatitis infections in the early 1990s.

Hygiene measures were implemented in tattoo parlours throughout (many) European countries to prevent bloodborne infection transmission through tattooing needles.

Current hepatitis prevention strategies rarely/never consider tattooing as a common transmission route.

What this study adds

Unsafe tattooing practices are very common. One in four tattooed people got at least one tattoo outside parlours and one in five got tattooed in a country without strict hygiene regulations.

Unsafe tattooing practices strongly increase the risk of HCV and to a lesser extend for HBV, making it the most important HCV transmission route after injecting drugs.

The study provides evidence that raising awareness on unsafe tattooing and upscaling screening of persons that underwent unsafe tattooing might help to substantially reduce hepatitis infections and related morbidity and mortality.