European Journal of Public Health, Vol. 15, No. 5, 464–466 Ó The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cki145 Advance Access published on August 10, 2005
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Infectious Diseases
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Prevalence of hepatitis A among drug users in north-eastern Italy Is vaccination necessary in low prevalence areas? Fabio Lugoboni1, Gianluca Quaglio1, Benedetta Pajusco1, Maurizio Foroni2, Gianstefano Blengio2, Giorgio Talamini3, Paolo Mezzelani1, Don C. Des Jarlais4 Background: The authors report on the prevalence of, and risk factors for, hepatitis A virus (HAV) in a group of drug users in Italy. Methods: 404 heroin users were recruited and compared with a control group of 107 subjects in the general population. Results: Drug users born in north-eastern Italy have a prevalence of anti-HAV similar to the control group. A much higher prevalence was found in drug users born in southern Italy. Conclusion: The similar prevalence of anti-HAV in drug users born in north-eastern Italy and in the general population, suggests that their lifestyle does not involve a substantial additional risk of HAV. The much higher prevalence found in drug users born in southern Italy is more likely to be related to infection during infancy. Keywords: HAV infection, heroin users, HAV vaccination
............................................................................................................ nfection with hepatitis A virus (HAV) causes an acute infec-
I tion of the liver. The infection is usually self limiting, but
typically produces fever, malaise, anorexia, nausea and abdominal discomfort. The severity of disease and mortality increases in older age groups. Complications of HAV infection can include fulminant hepatitis, cholestatic hepatitis and relapsing hepatitis.1 HAV infection is highly correlated with poor social and economic conditions. Oral-faecal is the most common mode of transmission, with parenteral [shared needles among drug users (DUs), transfusions, contaminated drug solutions], sexual (especially anal) and vertical transmission occurring less frequently.1–3 Hepatitis A can also be potentially spread among DUs by contamination from rectally carried drugs.4,5 The seropositive rates in this population is significantly higher than in a matched control population.6–9 Because persons who use illicit psychoactive drugs are at increased risk for HAV infection, there have been multiple recommendations for HAV vaccination for DUs.1–3,6–10 Italy has low to intermediate endemic levels of hepatitis A, with frequent outbreaks of epidemics in the south, where HAV antibody prevalence levels are greater than in the north.11–13 In this paper, we report on the prevalence of, and risk factors for, HAV antibody in DUs and in the general population in the Veneto region of Italy.
withdrawal, short-term detoxification with low-dose methadone, methadone maintenance programmes, psychotherapy and so on. Moreover, these centres deal with medical problems related to addiction such as vaccination against HAV, HBV, HIV testing, etc.14 The data collected for each patient were: age, sex, duration of drug use and place of birth. The patients were categorized into three groups for place of birth: (i) those born in the province of Verona, (ii) those born in north Italy but not in Verona, (iii) those born in the south of Italy. A comparison group of 107 subjects was recruited from persons reporting to District Healthcare Centres for the health certification required of all public authority employees. The comparison group was chosen on the basis of place of birth (all inside the province of Verona) and age (similar to DUs). All subjects gave their informed consent to participate in the study. Blood samples were collected to test for anti-HAV antibodies (EIA, Roche Laboratories, Mannheim, Germany). A single laboratory performed all the tests, without knowing whether the sample was from a DU or a comparison subject. Analysis of variance was used to study continuous variables. Bonferroni correction was applied where multiple comparisons were performed. Fisher exact or x2 tests were used to compare categoricalvariables.Multiplelogisticregressionwasusedtoassess the statistical independence of risk factor variables. SPSS release 10.0 (SPSS Inc., Chicago, IL) was used for statistical analyses.15
Methods Between January 1997 and December 2000, 404 heroin users were recruited. All were voluntarily in care at a Public Health Authority Centre for Drug Users (PHCDU) in the Veneto Region, and all resided in the province of Verona. These publicly funded PHCDUs provide counselling, treatment for drug
............................................................. 1 Medical Service for Addictive Disorders, Department of Internal Medicine, University of Verona, Italy 2 Department of Hygiene and Public Health, ASL 22 Villafranca, Verona, Italy 3 Department of Internal Medicine, University of Verona, Italy 4 Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, NY, USA Correspondence: Fabio Lugoboni MD, Medical Service for Addictive Disorders, University of Verona, Policlinico GB Rossi, 37134 Verona, Italy, e-mail:
[email protected]
Results Of the 404 heroin users recruited for the study, 81% reporting injecting as their primary route of administration and 19% reporting sniffing. The majority were receiving either methadone or buprenorphine treatment. Table 1 shows the demographic characteristics of the DU groups and the comparison group. Of the 404 DUs, 305 (75.4%), were born in the Verona province, 55 (13.6%) in other regions in northern Italy and 44 (10.9%) in southern Italy. Among the DUs as a whole, the prevalence of anti-HAV was 28.7%. The study of the association between HAV positivity and the variables analysed shows that for DUs: the prevalence in males is 30.6% compared to 19.7% for females (P ¼ 0.042); the mean age of HAV-positive DUs is 36.9 years (S.D. 4.9) versus 31.0 for
HAV infection in heroin users
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Table 1 Prevalence of HAV, mean age and length of drug use among drug users and comparison subjects
Total
Total no
Males (%)
Females (%)
Age (years) mean (S.D.)
HAVþ no (%)
Years of drug use mean (S.D.)
404
333 (82.4)
71 (17.6)
32.7 (5.9)
116 (28.7)
13.0 (6.6)
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a
c
Born in South Italy
44
40 (90.9)
4 (9.1)
33.0 (6.2)
28 (63.6)
e
11.5 (7.0)c
Born in North Italy
55
37 (67.3)a
18 (32.7)a
32.0 (6.7)c
13 (23.6)
&
Born in Verona
305
256 (83.9)a,b
49 (16.1)a,b
32.8 (5.7)c,d
75 (24.6)e,f
13.5 (6.3)c
Control group
107
63 (58.9)b
44 (41.1)b
30.1 (6.1)d
25 (23.4)f
–
.............................................................................................................................. 12.5 (7.3)c
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a: x , P < 0.003; b: x 2, P ¼ 0.001; c: ANOVA: P ¼ n.s; d: ANOVA: P < 0.001; e: x 2, P < 0.001; f: x 2, P ¼ n.s. Table 2 Multivariate analysis of anti-HAV positivity and some characteristics of drug users Variable
OR
95% CI
P
Mean age
1.28
1.18–1.39
