|
Amir Houshang
Mohammad Alizadeh, Research Center for Gastroenterology and
Liver Disease, Shaheed Beheshti University of Medical Sciences,
Tehran, Iran
Seyed Moayed Alavian, Baghiatalah University of Medical
Sciences, Tehran, Iran
Khalil Jafari, Nastaran Yazdi, Hamedan University of Medical
Sciences, Hamedan, Iran
Correspondence to: Amir Houshang Mohammad Alizadeh, Research
Center for Gastroenterology and Liver Disease, Shaheed Beheshti
University of Medical Sciences, 7th
Floor, Taleghani Hospital, Yaman Str., Evin, Tehran 19857, Iran.
article@rcgld.org
Telephone: +98-21-2418871
Fax: +98-21-2402639
Received: 2004-10-12
Accepted: 2004-10-26
Abstract
Aim: Recent
studies in Iran has shown that prevalence of hepatitis C virus (HCV)
infection among Iranian prisoners is high, in spite of low HCV
seroprevalence in general population.
Methods: This
study was carried out in the central prison of Hamedan - Iran, in
year 2002. Inmates were interviewed using a standard questionnaire
including demographic, imprisonment history and HCV-related risk
behaviors items. Thereafter, the sera drawn from the participants
were tested for anti-HIV and anti-HCV antibodies.
Results: A
total number of 427 drug abuser inmates participated in our study.
Three hundred and ninety-seven (93%) were men and 30 (7%) were
women. Total number of IV drug abusers (IDA) and non-IV drug abusers
(NIDA) was 149 (34.9%) and 278 (65.1%), respectively. The overall
rate of antibody positivity among inmates was 0.9% for HIV and 30%
for HCV. Of all IDAs, 31.5% and of NIDAs, 29.1% had serological
evidence of HCV infection.
Conclusion: The
seroprevalence of HCV infection among drug abuser prisoners in
comparison with the general population in Iran, is very high (30% vs
in italics 0.2%). Our results indicate the importance of policies to
prevent transmission of HCV infection during and following
incarceration.
?/span> 2005
The WJG Press and Elsevier Inc. All rights reserved.
Key words: Hepatitis C virus; Prisoners; Drug abusers; Iran
Alizadeh AHM, Alavian SM, Jafari K, Yazdi N. Prevalence of hepatitis
C virus infection and its related risk factors in drug abuser
prisoners in Hamedan - Iran. World J Gastroenterol
2005; 11(26): 4085-4089
http://www.wjgnet.com/1007-9327/11/4085.asp
INTRODUCTION
Hepatitis C virus (HCV) infection is increasingly recognized as a
major health care problem throughout the world. Approximately 85% of
individuals infected with HCV will develop chronic HCV infection[1,2].
Identified risk factors for HCV infection include intravenous drug
use, exposure to infected blood/blood products, and intranasal drug
use[3].
Surveys of HCV infection among IDU have reported prevalence rates as
high as 70-90%[4-6]
among habitual injectors. High risk sexual activity (multiple sexual
partners), history of sexually transmitted disease, tattooing, and
skin piercing have also been suggested to be associated with
increased risk for HCV; however, study results have been
contradictory[7].
Whereas the overall seroprevalence of HCV among Iranian blood
donors has been estimated to be 0.12%[8]
the prevalence of HCV has been shown to be
as high as 45% in populations of incarcerated IV drug users[9].
HCV seropr-evalence among prison inmates varies markedly from
country to country[10,11].
Worldwide hepatitis C data similarly report significant prevalence
figures in high risk populations ranging from 30% to 50%, with
intravenous drug use being the predominant risk factor[12-15].
High risk populations are indivi-duals most at risk for hepatitis C,
including those medically underserved, have a history of IV drug
injection and high-risk behaviors. A dramatic growth in the number
of prisoners associated with high-risk behaviors and high rates of
community re-entry emphasizes the need for detection and treatment
of hepatitis C virus infection in this unique group.
This study could be of particular interest, as in
comparison with worldwide hepatitis C data, the seroprevalence of
hepatitis C infection among Iranian general population is low.
However, recent studies in Iran has shown that the level of
hepatitis C infection among Iranian prisoners is as high as HCV
seroprevalence in incarcerated population of countries with high
prevalence of HCV infection in their general population.
MATERIALS AND METHODS
This study was carried out in the central prison of Hamedan (one of
the largest penal institutions in Iran), from mid-June to
mid-September 2002. The study protocol conforms to the ethical
guideline of the 1975 Declaration of Helsinki, as revised in 1983.
The sample was selected by drawing the numbered individual prison
files, available to investigators, in intervals determined by a
random number generator. There were 427 drug abuser inmates in our
study. Participation in this study was voluntary and confidentiality
was guaranteed. All inmates were counseled about the study and they
were required to provide signed informed consent. Thereafter,
inmates were interviewed using a standard questionnaire including
demographic items, specific questions relative to their imprisonment
history and HCV-related risk behaviors such as intravenous drugs
abuse, having received blood and/or blood products, tattoos, body
piercing, sexual activity, and history of sexually transmitted
diseases.
Physical examination was performed on all
participants and afterward 8 mL of blood was taken. The sera were
tested for anti-HIV and anti-HCV antibodies by using an
enzyme-linked immunosorbant assay (ELISA) 3rd generation (for anti-HCV
antibodies we used HCV 3.0 ELISA Test System with Enhanced SAVe;
ORTHO, Raritan, NJ, USA). All anti-HCV Ab positive sera were
retested, using recombinant immunoblot assay (RIBA) 2nd
generation (HCV Blot 3.0; Genelabs Diagnostics, Singapore) as a
complementary test. Patients with both ELISA and RIBA positive
reports were considered to be infected with HCV.
Microsoft Access 2000 database software was used
(Microsoft Corp., Redmond, WA, USA). Basic descriptive statistics
were performed using SPSS for Windows (version 11.0; SPSS Inc.,
Chicago, IL, USA) software. Risk factors prevalences were generated
using data from all consented study participants. Standard c2
and c2
trend tests were performed to assess the
univariate relationship of demographic and behavioral variables and
HCV seroprevelance. Univariate ORs were computed with 95% confidence
intervals (CIs) for each risk factor.
RESULTS
A total number of 427 drug abuser inmates participated in our study.
Three hundred and ninety-seven (93%) were men and 30 (7%) were
women. Total number of IV drug abusers (IDA) was 149 (34.9%). The
remaining 278 individuals (65.1%) were non-IV drug abusers (NIDA).
Demographic characteristics of drug abuser inmates are depicted in
Table 1.
The overall rate of antibody positivity among
inmates for HIV was 0.9% (4/427) and for HCV was 30% (128/427). Of
all IDAs, 31.5% (47/149) had serological evidence of HCV infection
and in NIDAs seropositivity for HCV was 29.1% (81/278). There were
no significant statistical differences for HCV seropositivity
between the two groups.
About HIV infection in the two groups, only one
inmate (out of 149, 0.67%) was seropositive for HIV in IDA group and
in NIDA we found three inmates with anti-HIV antibodies (3/278,
1.07%). Because the number of HIV infected participants was small,
no statistical comparisons were conducted. Among three HIV positive
individuals, all were male and their ages were between 30 and 49
(mean 37.5), one was IV drug abuser for 36 mo, one reported history
of tattoos and one had received blood transfusion, they spent 2-26
mo in prison.
As shown in Table 1, the pattern of HCV antibody
prevalence differed within each demographic characteristic.
The mean?/span>SD
of participants was 37.9?/span>9.7 (range
15-77 years old). Most participants belonged to 30-39 years old age
group (34.7%) and HCV seropositivity in ≤20
years and 40-49 years old age group was highest (40% and 31.6%,
respectively; P = 0.70).
None of the inmates had high risk job
(health-care related) be infected by HCV or HIV. 42.6% of HCV
seropositive participants were labourers and 41% had private
business, 8.2% were farmers, 6.6% housekeepers, and 1.6% were
unemployed (no significant difference, P = 0.4).
As depicted in Table 2, we studied the
association between some behavioral characteristics and HCV
seropositivity. The seroprevalence of HCV was associated with
duration of imprisonment (P = 0.02). Remarkably, 100% of the
individuals who reported 108-119 mo of imprisonment were infected
with HCV.
Table 1 Demographic
characteristics and their association with HCV seropositivity among
drug abuser inmates, Hamedan, Iran
| Variable |
Total
(n = 427) |
HCV
positive1
(n = 128)2 |
| n |
% |
n |
% |
| Sex |
|
|
|
|
| Male |
397 |
93 |
119 |
93 |
| Female |
30 |
7 |
9 |
7 |
| Age
group (yr) |
|
|
|
|
| <20 |
5 |
1.2 |
2 |
1.6 |
| 20-29 |
83 |
19.6 |
26 |
20.4 |
| 30-39 |
148 |
34.9 |
45 |
35.1 |
| 40-49 |
136 |
32.1 |
43 |
33.5 |
| 50-59 |
41 |
9.7 |
11 |
8.6 |
| 60
or more |
11 |
2.6 |
1 |
0.8 |
| Marital
status |
|
|
|
|
| Single |
136 |
31.9 |
48 |
37.5 |
| Married |
291 |
68.1 |
80 |
62.5 |
| Education
level |
|
|
|
|
| Uneducated |
141 |
33 |
32 |
25 |
| Primary
school |
191 |
44.8 |
60 |
46.9 |
| High
school |
89 |
20.8 |
33 |
25.8 |
| University |
6 |
1.4 |
3 |
2.3 |
| Total |
427 |
100 |
128 |
30 |
1We
found no significant statistical difference. 2Basis
of numbers and %s may be slightly smaller due to missing values.
Table 2
(PDF) Behavioral characteristics and their association with
HCV seropositivity among drug Abuser prisoners in Hamedan, Iran
DISCUSSION
High risk populations are individuals most at risk of contracting
hepatitis C, including those who come from medically underserved and
minority communities and /or have a history of IV drug injection,
alcohol abuse, and multiple sex partners[16].
IV drug abusing remains the predominant mode of HCV transmission
risk in prison systems[17].
In this study we evaluated the seroprevalence of HCV and HIV among
drug abuser inmates (IV drug abusers (IDA) and non-IV drug abusers (NIDA)).
Prevalence of HCV antibody positivity among all participants was
30%. HCV seroprevalence in IDA and NIDA groups was 31.5% and 29.1%,
respectively, and confirms the high prevalence of blood borne
disease in those with imprisonment history[18-20].
Different studies have estimated the seroprevalence of HCV antibody
among the general population (blood donors, mostly) to be about
0.16-6% world-wide[8,21-24].
In high risk population in comparison to the general population, IV
drug abusing, sharing needles and tattooing may increase risk
status.
We found only one published similar investigation
on Iranian prisoners. In Zali et al. study[9],
the seroprevalence of HCV among IDAs was 45%. In the studies on
prisoners of Australia, Brazil, France, India, Ireland, UK and
United States the HCV seroprevalence were about 38%, 6.3%, 30%, 16%,
37%, 30%, and 41%, respectively[25-28,10,12,13].
According to other investigations worldwide, hepatitis C antibody
positivity prevalence in high risk ranges from 31% to 50%, while
intravenous drug abuse is the predominant risk factor[11,29-33].
Limited available data indicate the majority of
HCV infections are acquired before incarceration[16].
Blood serum evaluations among 265 male prison inmates in Maryland
(USA) revealed a hepatitis C prevalence of 38% at intake[34].
In our study, the overall rate of HIV antibody
among prisoners was 0.9% (4/427). In IDA and NIDA groups, we found
0.67% and 1.07% positive HIV antibodies. The HCV prevalence rate in
our study was higher than HIV prevalence. However, the findings are
in accordance with those in many countries - including Germany,
Nederland, Switzerland and Australia[35,36].
In Iran we have no similar investigation on HIV seroprevalence of
prisoners in comparison with our results.
Prevalence of antibodies of HIV in Irish and
Brazilian prisoners was 2% and 3.2%, respectively[13,26].
The HIV prevalence reported in prison studies from other developed
countries is similar[37-40].
Some limitations of our study should be
considered. As with any convenience sample, this study had the
limitation of being a self-selected group and may not be a
representative of all Iranian prisoners. In addition, because of
religious beliefs and security problems of prisons, many individuals
could not respond properly to the questions containing sex behavior
characteristics. Therefore we excluded the sex behavior related risk
factors from statistical analysis. Because of financial problems we
couldn't
perform PCR on our samples.
In our investigation we studied some risk factors
related to HCV and HIV infection. Participants who had spent more
time in prison, however, and those who had history of
hospitalization were significantly more likely to be positive for
antibodies to HCV. Being in prison in Iran may be an independent
risk factor for hepatitis C infection. We found no statistical
association between HCV and other risk factors and there was no
significant difference in HCV seropositivity prevalence between IV
drug abusers and non IV drug abusers recommending the possibility of
some other unknown etiologic factors. The high percentage of HCV
positive cases with no apparent risk factor further emphasizes the
need for further investigation on the routes of transmission and
other factors, which have not yet been concerned. It should be noted
that in some investigations, there were considerable numbers of HCV
infected cases with no apparent risk factors, depicting the complex
nature of HCV transmission[41-45].
Although the inmates participating in this study
cannot be considered representative of all prisoners in Iran, the
results obtained have important implications for penal and public
health administrators, indicating the importance of policies to
prevent transmission of these infections during and following
incarceration. These policies must include primary concern on not
only identification of those most at risk but also on provision of
appropriate treatment[8,12,16,26].
Specific harm-reduction strategies directed toward preventative
education and counselling are also crucial. In addition, testing
programs in prisons, which should be seen as an opportunity to
improve the health outcome of those infected and prevent further
transmission of infectious agents[46-48].
There are few studies involving large multicentre
sampling that provided epidemiological aspects of HCV infection
among prison inmates in Iran. In conclusion, prospective studies
with meticulous assessment of confounding risk factors are required
to assess the potential risk factors of HCV and HIV infections in
prisons of Iran, effectively.
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