International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi POSTER PRESENTER
An Overview of HIV, HBV, and HCV Infections among Tattooed People in Cimahi Patricia Gita Naully*, Diki Hilmi, Miftah Muhamad Homis, Oktaviani Indah Permata, Rinzani Nurlaili Soviayani Department of Medical Laboratory Technology, Stikes Jenderal A. Yani Cimahi *Email:
[email protected]
Abstract Cases of Human Immunodeficiency Virus (HIV) infections are rising in Cimahi; where 100 HIV infections were identified in 2015 and 2016. Although Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection rate in Cimahi is not the highest in Indonesia, they posess a prevalence rate of 0.2%. HIV, HBV, and HCV can be transmitted through pregnancy, sexual interaction, blood transfusion, drug use, and tattooing. This study aims to determine the overview of HIV, HBV, and HCV infections of tattooed people in Cimahi. Here, serum from 30 tattooed people in Cimahi were taken. These people met criterias as follows; having a permanent tattoo, not are not injection drug user, never having a free sexual interaction, never having a blood transfusion, and filled an informed consent. Presence of anti-HIV, HBsAg, and anti-HCV was detected by immunochromatography. All testing steps was done in accordance with Regulation of the Minister of Health of the Republic of Indonesia Number 15 Year 2015 on HIV and Opportunistic Infection Testing Laboratory Services. Among the 30 tattooed people (16.7% female, 83.3% male, age range: 17 to 48 years old), 2 persons (6.7%) tested positive for HIV, 2 persons (6.7%) tested positive for HBV, and 1 person (3.3%) tested positive for HCV. Key words: Anti-HCV, Anti-HIV, HBsAg, Tattoo
Introduction According to WHO, 36.7 million people estimated are living with HIV and about 325 million people infected with HBV or HCV (Cohen, 2017). As a developing country with large population, Indonesia faces the same problem. Based on a data from Ministry of Health, Indonesia experienced increase in HIV cases with cumulative HIV patients until June 2016 was 208.902 people (Ministry of Health, 2016). Indonesia also have the second highest hepatitis B patients in Southeast Asian, after Myanmar. Based on the results of the Regional Health Research on the study and blood donor screening of PMI, donors estimated among 100 Indonesians, there are 10 people who have been infected with Hepatitis B or C (Ministry of Health, 2017). The increase in HIV cases also occurred in Cimahi, there were 100 cases were identified in 2015 and 2016 (Cimahi City Health Office, 2017). In contrast to the ever-increasing case of HIV every year, cases of HBV and HCV infection in Cimahi are not too numerous. However, it does not mean residents of Cimahi are free from infection of both viruses. According to the Department of Health, the prevalence of HCV infection in Cimahi is 0.2% (Cimahi City Health Office, 2016). HIV is a virus in Retroviridae group that attacks the immune system, especially CD4 T cells. HBV is a virus that belongs to the group Hepadnaviridae whereas HCV is included in the group Flaviridae, but they both attack the liver cells (Rees, 2014). Although these three viruses have differences in genetic material and the attacked cells, they have similar transmission paths. All three viruses can be transmitted vertically from mother to child and horizontally through sexual interactions, blood transfusions, injecting drug use, and tattooing using contaminated needles (Patel et al., 2014).
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International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi
Tattoos are the result of a needle puncture where a number of inks with various colors are injected beneath the skin surface. The larger the size of the tattoo, the more necessary injection. This results in an increased risk of infection. Each injection exposes the needle into the blood and a contaminated injection of the pathogen can spread the infection in people who use the instrument simultaneously. The Shahri et al. (2016) study proved that of 63 patients tattooed in one of the hospitals in Iran, there were four (6.3%) patients positive on HBsAg and PCR-HBV examinations, seven (11%) positive HCV and five people (7.9%) were HIV positive. In addition, as many as 8.45% of tattooed people were shown to have chronic HBV infection (Jahangirnezhad et al., 2011). Through his research, Pallas et al. (1999) proved that of 167 people tattooed in one prison in Spain, there were 43 people who had two infections at once i.e. HIV-HBV and HIV-HCV. The development of tattoos in Indonesia is quite rapid. The art of drawing pictures in body is not only popular inyoung people but also by the adults. Formerly tattoos commonly used by men as one way of expressing themselves, but now is also a make-up trend for women (Wardhani, 2017). Usually tattooed body parts are hands, feet, or back, but now make tattoos on the armpits trend is developing (Gusri, 2017). Trend of tattooing also hit the city of Cimahi. Given the everincreasing case of HIV in the city of Cimahi and the growing trend of tattooing, this study aims to determine the picture of HIV infection, HBV, and HCV in people tattooed in Cimahi.
Methods This study used cross sectional study method. The research was conducted at Stikes Jendral Achmad Yani Cimahi Laboratory and data was collected from February to March 2017. Before the analysis, all respondents in this study were asked to fill out and sign the informed consent states that the respondents were willing to have their blood checked without any coercion.
Collection of samples and speciments Sample collection is done by disseminating interview form to group of tattooed people domiciled in Cimahi. The interview form contains questions such as age, gender, education, type of tattoo, number of tattoos, tattooing places, and others. The dissemination of interview forms was conducted to get 30 respondents who fulfilled the following criteria: have a permanent tattoo, do not use intravenous drugs, do not engage in free sexual activity, and never had a blood transfusion. A 3 cc specimen of venous blood was taken with a syringe. Blood is transferred into the tube and centrifuged at 3000 rpm for 15 minutes to obtain serum.
HIV Laboratory Testing This study uses a laboratory HIV testing strategy II in accordance with Regulation of the Minister of Health of the Republic of Indonesia Number 15 Year 2015 on HIV and Opportunistic Infection Testing Laboratory Services. In the first stage, anti-HIV testing was performed by immunocromatography of HIV MONOTES 1/2 with sensitivity of 99.5%. If the first stage examination shows reactive results, then a second phase of examination using INTEC HIV 1/2 immunochromatography has a specificity of 100%.
HBV Laboratory Testing The presence of serum HBsAg was detected using MONOTES immunocromatography having 99.3% sensitivity and 98.3% specificity. If the HBsAg test results are positive, follow-up is done with Immunocromatography Answer which has 99% specificity.
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International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi HCV Laboratory Testing The presence of anti-HCV in serum was detected using MONOTES immunochromatography which had a sensitivity of 98.1% and a specificity of 98.9%. Specimens that showed positive results were re-examined with BIOLINE SD immunochromatography that had 100% sensitivity and 99.4% specificity.
Processing and Analysis of Data Data from laboratory tests for HIV, HBV, and HCV is processed using the formula (Dahlan, 2016):
Y= Where: Y X N
x 100 %
= Percentage of positive or negative samples = Number of positive or negative samples = Total number of samples
Results The sample in this study consisted of 25 people (83.3%) male and 5 (16.7%) women, ranged between 17 - 48 years old, and the majority of which finished senior high school (36.67%) (Table 1). Of the 30 people, as many as 19 people (40%) make tattoos more than once and 11 people like to switch between tattoo studios. Based on interviews, there were only 8 respondents (26.67%) who knew that HIV and HBV could be transmitted through the production of unsterile tattoos. Table 1. Characteristics of Research Sample
Variable
HIV (+)
HBV (+)
HCV (+)
n (%)
n (%)
n (%)
Total (%)
Number of Subject
30 (100)
2 (6,67)
2 (6,67)
1 (3,33)
Gender Male Female
25 (83,3) 5 (16,7)
2 (6,67) 0 (0)
2 (6,67) 0 (0)
1 (3,33) 0 (0)
Age Group 15-25 year old 26-35 year old 36-45 year old ≥ 46 year old
16 (53,33) 5 (16,7) 5 (16,7) 3 (10)
1 (3,33) 1 (3,33) 0 (0) 0 (0)
0 (0) 1 (3,33) 1 (3,33) 0 (0)
0 (0) 0 (0) 1 (3,33) 0 (0)
Education Background Elementary School Junior High School Senior High School
8 (26,67) 10 (33,3) 11 (36,67)
0 (0) 1 (3,33) 1 (3,33)
0 (0) 2 (6,67) 0 (0)
0 (0) 0 (0) 1 (3,33)
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International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi University
1 (3,33)
0 (0)
0 (0)
0 (0)
Number of tattooing 1 time 2 times More than 2 times
11 (36,67) 7 (23,33) 12 (40)
0 (0) 0 (0) 2 (6,67)
0 (0) 1 (3,33) 1 (3,33)
0 (0) 0 (0) 1 (3,33)
Tattoo Studio Same Changing
19 (63,33) 11 (36,67)
0 (0) 2 (6,67)
0 (0) 2 (6,67)
0 (0) 1 (3,33)
Knowledge about HIV or HBV Transmission Have Don‘t have
8 (26,67) 22 (73,33)
0 (0) 2 (6,67)
0 (0) 1 (3,33)
0 (0) 1 (3,33)
Laboratory testing results showed two positive (6.67%) positive respondents on anti-HIV testing, two (6.67%) positive on HBsAg examination, and one (3.33%) positive on HCV testing.
Discussion Respondents who had HIV, HBV, and HCV infection in this study were all male with age range from 25-45 years old. From the results it cannot be concluded that men have a higher risk of HIV, HBV and HCV infection than women, because in this study the number of female respondents is less. However, in the study of Shahri et al. (2016) mentioned that men have a higher risk of HIV infection than women with a ratio of 2: 1. Other studies have also shown that the prevalence of HIV and HCV infection is higher in males (11.6%) than in women (9.4%) (Muriuki et al., 2013). According to Jahangirnezhad et al. (2011), men tend to have more tattoos than women because of the freer lifestyle, more easily influenced, and regard the tattoo as a symbol of masculinity and the pride of himself. In addition, according to Shahri et al. (2016), men pay less attention to the cleanliness of the tools used during tattooing. Based on these facts then there is a possibility that men have a risk of HIV infection, HBV, and HCV through the production of tattoos that are higher than women. Viewed from the side of respondents' general knowledge and formal education, respondents who have HIV infection, HBV, and HCV only finished junior high and high school. In addition, they do not have sufficient knowledge of how HIV, HBV, and HCV are transmitted. Similar results were also obtained by Jafari et al. (2012). In his research he mentioned that people who are less educated and do not have knowledge about the dangers of tattoos tend to acquire various diseases through tattooing. Sarma and Oliveras (2013) also mentioned that knowledge and behavior of a person to a disease is one factor that can affect the prevention of the disease. Judging from the number and place of tattoo studio, respondents who had HIV infection, HBV, and HCV had more than one permanent tattoo and often alternated tattoo studio. Quite a few studies have proven that the risk of HIV infection, HBV, and HCV will increase with the increase in the number of tattoos a person has (Jafari et al., 2012; Jahangirnezhad et al., 2011; Samuel et al., 2001; Shahri et al., 2016). The more surface covered skin tattoo the higher the risk of infection. Jafari et al. (2010) proved that relative risk (RR) for the tattoo relationship with hepatitis risk in people with tattoo area 1-4 cm2 was 5.0 while for tattoo area 20 cm2 was 12.2. Frequently changing tattoo studios can increase the risk of HIV, HBV, and HCV infections because not all tattoo studios apply the correct tattooing procedure as practiced by professionals and use sterile tools (Weild et al., 2000).
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International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi
From the overall results, it can be seen that the lack of knowledge, the large number of tattoos, and frequent alternating tattoo studios can increase the risk of HIV, HBV, and HCV infections. Therefore, to prevent the increase of these three infections cases, people need educational programs in the community, especially among young people about the dangers of tattooing. When trying to make a tattoo, consumers should be wary of tools that are not sterile. HIV, hepatitis virus, and other blood-spreading pathogens can be transmitted if the tattoo tool used is not sterile (Shahri et al., 2016). In addition, transmission of various types of pathogens through tattooing can be caused by tattoo artists who do not follow well controlled infection procedures such as hand washing, using latex gloves, and cleaning and soaking tattoo tools with disinfectants (Jafari et al., 2010). Therefore, an educational program for tattoo artists that emphasizes the importance of cleanliness of the tools used and the potential spread of infection through contaminated tattoo needles. Owners of tattoo studios and tattoo artists should inform their customers about the risks of tattooing and report any adverse events associated with tattooing to authorized health personnel.
Conclusion Of 30 respondents consists of 16.7% women and 83.3% of men with age range between 17-48 years old, 2 people (6.7%) were positive infected with HIV, 2 people (6.7% ) were positively infected with HBV, and 1 person (3.33%) were positively infected with HCV. Therefore, it can be concluded that in the collection of tattooed people in Cimahi there are cases of HIV infection, HBV, and HCV. References Cimahi City Health Office. 2016. Profil Kesehatan Kota Cimahi Tahun 2016. Cimahi: Dinas Kesehatan Pemerintah Kota Cimahi. pp. 86-88. Cimahi City Health Office. 2017. Profil Kesehatan Kota Cimahi Tahun 2017. Cimahi. Dinas Kesehatan Pemerintah Kota Cimahi. pp. 163-165. Cohen, J. 2017. New Report Halves The Number of People Infected with Hepatitis C Worldwide. Available at: http://www.sciencemag.org/news/2017/04/ new-report-halves-numberpeople-infected-hepatitis-c-worldwide [date accessed 28 July 2017, 23.49 WIB]. Dahlan, M.S. 2016. Statistik untuk Kedokteran dan Kesehatan: Deskriptif, Bivariat, dan Multivariat. Jakarta: Epidemiologi Indonesia. pp. 32-33. Gusri, L. 2017. Unik, Tato Bunga di Ketiak yang Kekinian. Available at: http://lifestyle.liputan6.com/read/3026406/unik-tato-bunga-di-ketiak-yang-keki nian. [date accessed 27 June 2017, 15.21 WIB]. Jafari, S., Copes, R., Bahalou, S., Etminan, M., Buxton, J. 2010. Tattooing and The Risk of Transmission of Hepatitis C: A Systematic Review and Meta-analysis. International Journal of Infectious Diseases 14, 928-940. Jafari, S., Buxton, J.A., Afshar, K., Copes, R., Baharlou, S. 2012. Tattooing and Risk of Hepatitis B: A Systematic Review and Meta-analysis. Canadian Journal of Public Health 103(3), 207-212. Jahangirnezhad, M., Hajiani, E., Makvandi, M., Jalali, F. 2011. A Study on Risk Factor of Chronic Hepatitis B Carriers. Jun-dishapur Journal of Microbiology 4(4), 267-272. Ministry of Health. 2016. Situasi Penyakit HIV AIDS di Indonesia. Jakarta: Pusat Data dan Informasi Kementerian Kesehatan Republik Indonesia. pp. 2-8. Ministry of Health. 2017. Situasi dan Analisis Hepatitis. Jakarta: Pusat Data dan Informasi Kementerian Kesehatan Republik Indonesia. pp. 2-8. Muriuki, B.M., Gicheru, M.M., Wachira, D., Nyamache, A.K., Khamadi, S.A. 2013. Prevalence of Hepatitis B and C Viral Co-Infections among HIV-1 Infected Individuals in Nairobi, Kenya. BMC Research Notes 6, 363-369. Pallas, J., Alvarez, C.F., Prieto, D., Llorca, J., Rodriguez, M.D. 1999. Risk Factor for Monoinfections and Coinfections with HIV, Hepatitis B and Hepatitis C Viruses in Northern Spanish Prisoners. Epidemiology Infections. 123, 95-102. Patel, P., Borkowf, C.B., Brooks, J.T., Lasry, A., Lansky, A., Mermin, J. 2014. Estimating Per-Act HIV Transmission Risk: A Systematic Review. AIDS. 28(10), 1509-1519.
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International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi Rees, R.C. 2014. Tumor Immunology and Immunotherapy. UK: Oxford University Press. pp. 88. Regulation of the Minister of Health of the Republic of Indonesia Number 5 Year 2015 on HIV and Opportunistic Infections Testing Laboratory Service Samuel, M.C., Doherty, P.M., Bulterys, M., Jenison, S.A. 2001. Association Between Heroin Use, Needle Sharing and Tattoos Received in Prison with Hepatitis B and C Positivity among Street-recruited Injecting Drug Users in New Mexico, USA. Epidemiol. Infect. 127, 475-484. Sarma, H and Oliveras, E. 2013. Implementing HIV/AIDS Education: Impact of Teachers‘ Training on HIV/AIDS Education in Bangladesh. J. Health. Popul. Nutr. 31(1), 20-27. Shahri, S.M.H., Mood, B.S., Metanat, M., Salehi, M., Sharifi, R. 2016. Blood-Borne Infections in Tattooed People. International Journal Infections 3(2), 944-948. Wardhani, A.T. 2017. Tato Temporer Menjadi Tren Make Up Terbaru yang Unik. Available at: http://lifestyle.liputan6.com/read/2941919/tato-temporer-jaditren-makeup-terbaru-yang-unik. [date accessed 27 July 2017, 15.21 WIB]. Weild, A.R., Gill, O.N., Bennett, D., Livingstone, S.J.M., Parry, J.V., Curran, L. 2000. Prevalence of HIV, Hepatitis B, and Hepatitis C Antibodies in Prisoners in England and Wales: A National Survey. Commun. Dis. Public. Health. 3(2), 121-126.
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