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Hepatitis C

PEDIATRICS Vol. 111 No. 1 January 2003, pp. 153-157

Prevalence of Hepatitis C Virus Infection and Risk Factors in an Incarcerated Juvenile Population: A Pilot Study

Karen F. Murray, MD*, Laura P. Richardson, MD, MPH{ddagger}, Chihiro Morishima, MD§, James W. M. Owens, MD, MPH|| and David R. Gretch, MD, PhD

* Hepatobiliary Program, Division of Gastroenterology and Nutrition, Department of Pediatrics, Children’s Hospital and Regional Medical Center, Seattle, Washington
{ddagger} Child Health Institute, University of Washington, Seattle, Washington
§ Viral Hepatitis Clinical Research Laboratory, Virology Division, Department of Laboratory Medicine, Harborview Medical Center and University of Washington, Seattle, Washington
|| Echo Glen Children’s Center, Seattle, Washington
Viral Hepatitis Clinical Research Laboratory, Virology Division, Department of Laboratory Medicine, Harborview Medical Center and University of Washington, Seattle, Washington

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   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective. Hepatitis C virus (HCV) infection is the leading cause of liver failure in adulthood. Although the prevalence of HCV is reportedly as high as 80% in incarcerated adult populations, little is known about the prevalence of HCV in incarcerated juvenile populations. The purpose of this study was to determine the prevalence of HCV and high-risk behaviors in a population of incarcerated youths.

Methods. We conducted a cross-sectional prevalence study of HCV infection in youths who were admitted to a juvenile detention center between September 1999 and January 2001. Subjects were asked questions regarding behaviors that might put them at risk for acquiring HCV, and blood was drawn for HCV antibody testing. Qualitative HCV RNA testing was performed on antibody-positive subjects.

Results. Seventy-four percent (n = 305) of youths consented to participate in the seroprevalence study. HCV risk behaviors were common in this population: sexual activity (70%), intravenous drug use (6%), intranasal drug use (32%), body piercing (53%), and tattoos (33%). Six study youths (2%) were HCV antibody positive; 4 of these subjects were also HCV RNA positive. HCV-positive status was significantly associated with history of intravenous drug use and having had a sexually transmitted disease. Only 17% of study participants could correctly identify behaviors that might put them at risk for HCV.

Conclusions. The prevalence of HCV in incarcerated youths is higher than in the general pediatric population but not yet at adult levels of prevalence. Given the high prevalence of risk factors in this population, future studies should address the need for targeted HCV screening and education of incarcerated youths regarding risks for HCV.

Key Words: hepatitis C • chronic hepatitis • chronic hepatitis C • intravenous substance abuse • adolescent behavior

Abbreviations: HCV, hepatitis C virus • IV, intravenous • STD, sexually transmitted disease • EGCC, Echo Glen Children’s Center


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Hepatitis C virus (HCV) is a leading cause of liver failure and liver transplantation in adults. Identified risk factors for HCV infection include intravenous (IV) drug use, exposure to infected blood products, and intranasal drug use.1 High-risk sexual activity (multiple sexual partners, history of sexually transmitted disease [STD]), tattooing, and skin piercing have also been suggested to be associated with increased risk for HCV; however, study results have been contradictory.2 Whereas the overall seroprevalence of HCV among American adults has been estimated to be between 1% and 2%,3 the prevalence of HCV has been shown to be as high as 80% in populations of adults who use IV drugs or are incarcerated.4

During adolescence, many youths experiment with behaviors that might put them at increased risk for HCV infection. From the 1999 United States Youth Risk Behavior Surveillance Survey, 1.8% of students in grades 9 to 12 had injected illegal drugs, and 49.9% had had sexual intercourse, with 8.3% initiating sexual intercourse before 13 years of age.5 In populations of adolescents with similar patterns of risk factors to those reported on the Youth Risk Behavior Surveillance Survey, the prevalence of HCV has been estimated to be between 0.1% and 0.4%.2,6

Incarcerated youths have a higher prevalence of behaviors that might put them at risk for HCV than the general public. In 1 study of youths in 39 juvenile facilities in 5 states conducted in 1991, 10% of male youths and 20% of female youths had used IV drugs, and 89% of youths were sexually active.7 Twenty-one percent of a sample of incarcerated youths from a juvenile detention facility in Australia screened positive for HCV, and 61% of these youths had used IV drugs.8 No HCV prevalence studies have been conducted among incarcerated youths in the United States, and there have not been any recent surveys of risk behaviors in this population. The 3 main goals of this study were to determine the prevalence of high-risk behaviors for HCV and the seroprevalence of HCV in an incarcerated adolescent population and to evaluate general knowledge regarding HCV in this population.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Setting
The Echo Glen Children’s Center (EGCC), located in Snoqualmie, WA, is a residential juvenile correctional facility for boys aged 9 to 15 years and girls aged 9 to 21 years. It has an average daily census of 237 youths. It is the only juvenile facility for female adolescents in Washington State and has specialized programs for individuals with drug addiction, mental health disorders, and a history of sexual offense.

Procedures
Youths who were newly incarcerated between September 1999 and January 2001 were eligible to participate in the study. Exclusion criteria included anticipated stay of <2 weeks (too short for obtaining parental consent) and previous incarceration at EGCC during the study period. As part of the routine intake health assessment, all youths completed an HCV questionnaire. The questionnaire asked, "What factors or activities put people at risk for getting HCV?" and then specific questions about their own risk factors including injection and intranasal drugs, having received blood products, tattoos, body piercing, sexual activity, and history of sexually transmitted diseases. In each case, details regarding frequency, duration, age of onset, and age of most recent behaviors were obtained. Medical staff in the clinic assisted youths with completing these questionnaires.

After consent was obtained, 8 mL of blood was drawn and centrifuged to 4 mL of serum. This serum was separated for future testing needs and stored at -20°C. HCV antibody testing (HCV encoded antigen [recombinant c100–3, HC-31, and HC-34] Abbott HCV EIA 2.0) was initially performed, and the remaining serum was stored at -70°C. Stored serum for HCV antibody-positive subjects was subsequently tested for HCV RNA and HCV genotype.

Qualitative detection of HCV RNA was performed using the polymerase chain reaction-based microwell format Roche Amplicor HCV v. 2.0 kit (Roche Molecular Systems, Inc, Totowa, NJ). This assay is sensitive to 100 IU/mL HCV RNA in serum.9 HCV genotype was determined in viremic specimens using restriction fragment length polymorphism analysis of the 5' noncoding region.

Guardian consent was requested both by mail and by telephone, and all subjects gave assent before participation. For youths who were older than 12 years and for whom guardian consent was unavailable, an advocate, who was not a study investigator, was present during the assent process. For assessing the representativeness of the population who consented to HCV antibody testing, questionnaires without personal identifiers were available for subjects for whom assent to blood testing was not obtained. Study procedures were approved by both the Seattle Children’s Hospital and Regional Medical Center Institutional Review Board and the Washington State Department of Social and Health Services Human Research Review Board.

Basic descriptive statistics were performed using Stata statistical software (Stata Corp, College Station, TX). Prevalence estimates of HCV were generated using HCV-positive youths as a numerator and all tested youths as a denominator. Prevalences of risk factors were generated using data from all consented study participants. {chi}2 tests and t tests were used to assess differences in risk factors between participants and nonparticipants. Mantel-Haenszel methods were used to generate the relative risk of HCV-positive status for each potential risk behavior. Finally, tests of equality of proportions were conducted to compare prevalence of HCV in our study with previously published estimates of prevalence in the general adolescent population.2,6


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Seventy-four percent (305 of 411) of new arrivals consented to participate in the prevalence study. The most common reasons for nonparticipation were inability to obtain consent from parents and youths too young for assent (8%), parents denied consent (24%), subject refused blood draw because of anxiety (51%), and discharge from the facility before blood testing (17%). There were no statistically significant differences in risk factors, demographics, or HCV knowledge level between youths who consented to participate in the study and those who chose not to participate (Table 1). Female participants (mean age: 15.5 years; range: 11–18 years) were on average 2 years older than male participants (mean age: 13.5 years; range: 10–18 years) in the study sample.


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  		TABLE 1. Demographics and Risk Behaviors in Study Participants and Nonparticipants

 
High-risk behaviors were common in our study population (Table 2). The mean age of onset of sexual intercourse was 11.7 years (standard deviation: 1.7 years) for male participants and 12.6 years (standard deviation: 2.6 years) for female participants. More than one third of sexually active youths had a history of at least 5 sexual partners, and 15% had a history of 10 or more sexual partners. Eighteen percent of sexually active adolescents had a history of diagnosed STD, and one quarter of these youths had a history of 2 or more infections. IV drug use was more common in female than male participants, occurring in 3% of male participants and 10% of female participants. One third of IV drug users and 48% of intranasal drug users reported having shared equipment in the past. The average age of onset of IV drug use was 14.5 years (range: 12–17 years) and of intranasal drug use was 13.1 years (range: 8–17 years). The duration of IV drug use was relatively short in this population: 61% of IV drug users had started using IV drugs in the past year, and only 1 youth had used drugs for >2 years.


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  		TABLE 2. Subcategories of Risk Factors in 305 Study Participants*

 
Six subjects of the 305 tested (2%) were positive for HCV antibody. Of these, 4 were positive for HCV RNA. Genotypes present were 1a, 1b, 2a, and 2b. All but 1 of the HCV antibody-positive individuals reported 2 or more risk factors, and all of the HCV RNA-positive subjects had 2 or more risk factors (Table 3). Youths who had a history of IV drug use were at significantly increased risk for having HCV (relative risk: 15.9; 95% confidence interval [CI]: 3.5–73.5) as were youths who had a history of STD (relative risk: 14.5; 95% CI: 2.5–76.4). There was no significant association between HCV-positive status and any of the other risk factors studied. On a 1-sample test of proportions, this observed prevalence of 2% (95% CI: 0.42–3.5) was statistically significantly higher than previously observed prevalence of 0.4% in a sample of adolescents from the general population.2


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  		TABLE 3. Risk Behaviors in HCV Antibody-Positive Subjects

 
Only 17% of study participants were able to identify correctly behaviors that would put them at risk for HCV on an open-ended question before administration of the questionnaire. Responses accepted as correct included IV drug use, sexual activity, blood exposure, tattoo, like hepatitis B, like HIV, and sharing needles. Five percent could identify HCV as a liver disease or had a family member with HCV but did not identify any risk behaviors.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The prevalence of HCV in this incarcerated juvenile sample was significantly higher than the previously observed prevalence of HCV in the general adolescent population. Despite the high prevalence of other potential risk factors, only IV drug use and previous STD infection were significantly associated with being HCV positive in our study population.

The finding of an association between IV drug use and HCV-positive status is consistent with other samples of high-risk youths in the United States, Australia, and Canada (Table 4). When these studies are examined in combination, the prevalence of HCV seems to rise in parallel with the prevalence of IV drug use. An additional factor that may play a role in the acquisition of HCV in IV drug users is the duration of exposure to drugs. In adults, the risk of HCV acquisition has been shown to increase with increasing number of years of reported IV drug use.10–14 Although no longitudinal studies have been conducted to test the risk of HCV acquisition in incarcerated populations, the overall observation of increasing prevalence with increasing age of incarcerated populations studied would be consistent with this explanation.8,13


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  		TABLE 4. Summary of HCV Prevalence and IV Drug Use Prevalence in Studies of High-Risk Adolescent Populations

 
In our sample, most IV drug users had begun using IV drugs within the previous year, and half of them had used IV drugs <5 times, indicating a relatively brief window of exposure. Despite this brief exposure, 3 (17%) of 18 IV drug users in our sample were already positive for HCV antibody. Because young age at first drug use has been shown to be a strong predictor of future risk of drug abuse,15 adolescent users in our sample may be at very high risk for continued drug use and continued potential exposure to HCV.

Sexual promiscuity has also been suggested to be associated with increased risk for acquisition of HCV in adult populations.16,17 In our study, history of STD was associated with increased risk for HCV antibody positivity. This finding must be interpreted with caution as 3 of 4 of the HCV-positive youths who had a history of STD in our study also had used IV drugs. Thus, the separate effects of history of STD without history of IV drug use could not be assessed.

This study has 3 main limitations. First, this study was conducted in a sample from a single juvenile detention center in Washington State. These findings may not be generalizable to other settings or incarcerated populations. Second, all behaviors were obtained by self-report, which is vulnerable to reporting bias and may result in misclassification of exposure status in affected youths. Finally, the small number of affected youths and a high degree of overlap of risk behaviors prevented the assessment of specific risk behaviors controlling for the presence of other factors.

Despite these limitations, we believe that this study has important public health implications. The seroprevalence of HCV in this incarcerated juvenile population is higher than in the general adolescent population but not as high as in incarcerated adult populations. Incarcerated youths have been shown to have a recidivism rate of as high as 69%,18 and youths who begin to use drugs early are at high risk for continued drug use (estimated to be 40%–50% in the EGCC population). Thus, incarcerated youths may be at very high risk for acquisition of HCV in the future. Despite this risk, only 17% of surveyed youths were able even tangentially to identify activities that could put them at risk for contracting HCV. Hence, national and local HCV educational campaigns are not reaching this young population. Although we cannot specifically determine causative factors using this survey method, our pilot study does suggest that youths who have a history of IV drug use or STD might be at highest risk for the acquisition of HCV. Education efforts that targeted screening for HCV in at-risk youths and magnified counseling to encourage discontinuation of high-risk behaviors might help curtail the rise in HCV infection in incarcerated populations.


   ACKNOWLEDGMENTS
 
This publication was supported by an award from Children’s Hospital and Regional Medical Center’s General Research Endowment.

We thank the staff and youth advocates at the Echo Glen Children’s Center for support of this project.


   FOOTNOTES
 
Received for publication Jun 10, 2002; Accepted Aug 1, 2002.

Reprint requests to (K.F.M.) Hepatobiliary Program, Division of Gastroenterology and Nutrition, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way, NE, Box 5371/CH-24, Seattle, WA 98105-0371. E-mail: kmurra{at}chmc.org


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 DISCUSSION
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics



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