Journal of Urban Health

, Volume 82, Issue 3, pp 468–478 | Cite as

Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users

  • Stephanie R. Bialek
  • William A. Bower
  • Karen Mottram
  • Dave Purchase
  • T. Nakano
  • Omana Nainan
  • Ian T. Williams
  • Beth P. Bell


During January–April, 2000, 12 cases of acute hepatitis B were reported in Pierce County, Washington, compared with seven in all of 1999. Seven (58.3%) case patients were injection drug users (IDUs), three of whom were coinfected with hepatitis D virus (HDV) and died of fulminant hepatitis. Vaccination clinics were implemented at the local health department and needle exchange program to control the outbreak. We investigated this outbreak to determine risk factors for hepatitis B virus (HBV) transmission among IDUs. Hepatitis B cases were ascertained through routine surveillance and prevaccination testing at vaccination clinics. We conducted a case-control study comparing IDU case patients with HBV-susceptible IDUs identified at the vaccination clinics. Fifty-eight case patients were identified during January–December, 2000, 20 (34.5%) of whom were coinfected with HDV. Thirty-eight case patients (65.5%) reported current IDU. In the case-control study, the 17 case patients were more likely than the 141 controls to report having more than one sex partner [odds ratio (OR)=4.8, 95% confidence interval (CI)=1.5–15.0], injecting more than four times a day (OR=4.5, 95% CI=1.2–15.6) and sharing drug cookers with more than two people (58.8% vs. 14.0%, OR=14.0, 95% CI=2.4–81.5). Results were similar after controlling for syringe sharing in multivariable analysis. IDUs should be vaccinated against hepatitis B and should be advised against sharing drug injection equipment.


Hepatitis B Hepatitis D Intravenous drug abuse 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Centers for Disease Control and Prevention. Hepatitis Surveillance Report 57. Atlanta, GA: CDC; 2000.Google Scholar
  2. 2.
    Garfein RS, Vlahov D, Galai N, et al. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86:655–661.PubMedGoogle Scholar
  3. 3.
    Murrill CS, Weeks H, Castrucci BC, et al. Age-specific seroprevalence of HIV, hepatitis B virus, and hepatitis C virus infection among injection drug users admitted to drug treatment in 6 US cities. Am J Public Health. 2002;92:385–387.PubMedCrossRefGoogle Scholar
  4. 4.
    Dhopesh VP, Taylor KR, Burke WM. Survey of hepatitis B and C in addiction treatment unit. Am J Drug Alcohol Abuse. 2000;26:703–707.CrossRefPubMedGoogle Scholar
  5. 5.
    Lopez-Zetina J, Kerndt P, Ford W, et al. Prevalence of HIV and hepatitis B and selfreported injection risk behavior during detention among street-recruited injection drug users in Los Angeles County, 1994–1996. Addiction. 2001;96:589–595.CrossRefPubMedGoogle Scholar
  6. 6.
    Polish LB, Gallagher M, Fields HA, et al. Delta hepatitis: molecular biology and clinical and epidemiological features. Clin Microbiol Rev. 1993;6:211–229.PubMedGoogle Scholar
  7. 7.
    DesJarlais C, Perlis T, Friedman SR, et al. Behavioral risk reduction in a declining HIV epidemic: injection drug users in New York City, 1990–1997. Am J Public Health. 2000;90:1112–1116.Google Scholar
  8. 8.
    Crofts N, Aitken CK. Incidence of bloodborne virus infection and risk behaviours in a cohort of injecting drug users in Victoria, 1990–1995. Med J Aust. 1997;167:17–20.PubMedGoogle Scholar
  9. 9.
    Cook PA, McVeigh J, Syed Q, et al. Predictors of hepatitis B and C infection in injecting drug users both in and out of drug treatment. Addiction. 2001;96:1787–1797.CrossRefPubMedGoogle Scholar
  10. 10.
    McCoy CB, Metsch LR, Chitwood DD, et al. Parenteral transmission of HIV among injection drug users: assessing the frequency of multiperson use of needles, syringes, cookers, cotton, and water. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:S25-S29.PubMedGoogle Scholar
  11. 11.
    Thiede H, Romero M, Bordelon K, et al. Using a jail-based survey to monitor HIV and risk behaviors among Seattle area injection drug users. J Urban Health. 2001;78:264–278.PubMedGoogle Scholar
  12. 12.
    Hunter GM, Donoghoe MC, Stimson GV, et al. Changes in the injecting risk behaviour of injecting drug users in London, 1990–1993. AIDS. 1995;9:493–501.PubMedGoogle Scholar
  13. 13.
    Hagan H, Thiede H. Changes in injection risk behavior associated with participation in the Seattle needle-exchange program. J Urban Health. 2000;77:369–382.CrossRefPubMedGoogle Scholar
  14. 14.
    Koester S, Hoffer L. “Indirect sharing”: additional HIV risks associated with drug injection. AIDS Public Policy J. 1994;3:100–105.Google Scholar
  15. 15.
    Mansson AS, Moestrup T, Nordenfelt E, et al. Continued transmission of hepatitis B and C viruses, but no transmission of human immunodeficiency virus among intravenous drug users participating in a syringe/needle exchange program. Scand J Infect Dis. 2000;32:253–258.CrossRefPubMedGoogle Scholar
  16. 16.
    Thorpe LE, Ouellet LJ, Hershow R, et al. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol. 2002;155:645–653.CrossRefPubMedGoogle Scholar
  17. 17.
    Centers for Disease Control and Prevention. Hepatitis B vaccination for injection drug users —Pierce County, Washington, 2000. MMWR Morb Mortal Wkly Rep. 2001;50:388–390, 399.Google Scholar
  18. 18.
    Nakano T, Shapiro CN, Hadler SC, et al. Characterization of hepatitis D virus genotype III among Yucpa Indians in Venezuela. J Gen Virol. 2001;82:2183–2189.PubMedGoogle Scholar
  19. 19.
    Nainan OV, Cromeans TL, Margolis HS. Sequence-specific, single-primer amplification and detection of PCR products for identification of hepatitis viruses. J Virol Methods. 1996;61:127–134.CrossRefPubMedGoogle Scholar
  20. 20.
    Nainan OV, Stevens PE, Taylor PE, et al. Hepatitis B virus (HBV) antibody resistant mutants among mothers and infants with chronic HBV infection. In: Rizetto, M, Purcell, RH, Gerin, JL, Verme, G, eds. Viral Hepatitis and Liver Disease. Turin, Italy: Edizioni Minerva Medica; 1997:132–134.Google Scholar
  21. 21.
    Devereux J, Haeberli P, Smithies O. A comprehensive set of sequence analysis programs for the VAX. Nucleic Acids Res. 1984;12:387–395.PubMedGoogle Scholar
  22. 22.
    Abdala N, Reyes R, Carney JM, et al. Survival of HIV-1 in syringes: effects of temperature during storage. Subst Use Misuse. 2000;35:1369–1383.PubMedGoogle Scholar
  23. 23.
    Clatts MC, Heimer R, Abdala N, et al. HIV-1 transmission in injection paraphernalia: heating drug solutions may inactivate HIV-1. J Acquir Immune Defic Syndr. 1999;22:194–199.PubMedGoogle Scholar
  24. 24.
    Shah SM, Shapshak P, Rivers JE, et al. Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a preliminary laboratory report. J Acquir Immune Defic Syndr Hum Retrovirol. 1996;11:301–306.PubMedGoogle Scholar
  25. 25.
    Heimer R, Khoshnood K, Jariwala-Freeman B, et al. Hepatitis in used syringes: the limits of sensitivity of techniques to detect hepatitis B virus (HBV) DNA, hepatitis C virus (HCV) RNA, and antibodies to HBV core and HCV antigens. J Infect Dis. 1996;173:997–1000.PubMedGoogle Scholar
  26. 26.
    Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet. 1981;1:550–551.CrossRefPubMedGoogle Scholar
  27. 27.
    van Bueren J, Simpson RA, Jacobs P, et al. Survival of human immunodeficiency virus in suspension and dried onto surfaces. J Clin Microbiol. 1994;32:571–574.PubMedGoogle Scholar
  28. 28.
    Alter MJ, Hadler SC. Delta hepatitis and infection in North America. Prog Clin Biol Res. 1993;382:243–250.PubMedGoogle Scholar
  29. 29.
    Vlahov D, Junge B, Brookmeyer R, et al. Reductions in high-risk drug use behaviors among participants in the Baltimore needle exchange program. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;16:400–406.PubMedGoogle Scholar
  30. 30.
    Hagan H, DesJarlais DC, Purchase D, et al. An interview study of participants in the Tacoma, Washington, syringe exchange. Addiction. 1993;88:1691–1697.CrossRefPubMedGoogle Scholar
  31. 31.
    Hagan H, Jarlais DC, Friedman SR, et al. Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program. Am J Public Health. 1995;85:1531–1537.PubMedGoogle Scholar
  32. 32.
    Hagan H, McGough JP, Thiede H, et al. Syringe exchange and risk of infection with hepatitis B and C viruses. Am J Epidemiol. 1999;149:203–213.PubMedGoogle Scholar
  33. 33.
    Hutchinson SJ, Goldberg DJ, Gore SM, et al. Hepatitis B outbreak at Glenochil prison during January to June 1993. Epidemiol Infect. 1998;121:185–191.CrossRefPubMedGoogle Scholar
  34. 34.
    Stevenson J, Tannahill M, Biggs V. An outbreak of acute hepatitis B infection among injecting drug users in Inverclyde, Scotland. Commun Dis Public Health. 2001;4:60–63.PubMedGoogle Scholar
  35. 35.
    Streetly A, Perkins A, Tucker KM, et al. An outbreak of hepatitis B among intravenous drug users in Medway. Community Med. 1988;10:147–155.PubMedGoogle Scholar

Copyright information

© Oxford University Press on behalf of the New York Academy of Medicine 2005

Authors and Affiliations

  • Stephanie R. Bialek
    • 1
  • William A. Bower
    • 1
  • Karen Mottram
    • 2
  • Dave Purchase
    • 3
  • T. Nakano
    • 1
  • Omana Nainan
    • 1
  • Ian T. Williams
    • 1
  • Beth P. Bell
    • 1
  1. 1.Unired States Public Health Service, Division of Viral Heparitis, National Center for Infectious DiseasesCenters for Disease Control and PreventionAtlanta
  2. 2.Tacoma Pierce County Health DepartmentWashington, DC
  3. 3.Point Defiance AIDS ProjectsWashington, DC

Personalised recommendations