Hep C infection among youth

------Also from the National Commission on Correctional Health Care----

NCCHC CorrectCare: Juvenile Voice

HCV Infection in Youth and Young Adults

by Gale R. Burstein, MD, MPH

Hepatitis C virus infection is the most common chronic bloodborne infection in the United States, present in approximately 3.2 million persons. Seventy percent of new HCV cases are asymptomatic or have mild clinical illness. Chronic HCV infection develops in 70% to 85% of HCV-infected persons, and 60% to 70% of chronically infected persons have evidence of active liver disease. Although many are unaware of their infection, HCV-infected persons serve as a source of transmission to others and are at risk for chronic liver disease or other HCV-related chronic diseases decades after infection.

HCV is most efficiently transmitted through large or repeated percutaneous exposure to infected blood (such as through use of injecting drugs or unscreened blood product transfusion). Although much less frequent, occupational, perinatal and sexual exposures also can result in HCV transmission.

Epidemiology
Little is known about HCV in U.S. adolescents and young adults. This may be an artifact of lack of screening. Studies find that high-risk persons are underscreened for HCV compared with the far less prevalent HIV infection. Among a community sample of 86 Rhode Island injection drug users (IDUs) aged 18-25 years, 87% reported ever testing for HIV, but only 51% reported ever testing for HCV, which is far more prevalent in this population.

HCV seroprevalence studies conducted in juvenile detention facilities have generally found a 2% HCV prevalence rate with drug use identified as the major risk factor. A study conducted among detainees aged 10-18 years in a Texas juvenile detention facility found many engaging in high-risk behaviors, such as sex with multiple partners (85%) or anal intercourse (13%), intranasal cocaine or heroin use (56%) and obtaining tattoos from noncommercial settings (51%) or pierced body parts other than ears (25%). Only 5% reported IDU. The overall HCV prevalence rate was 2.0% and a history of IDU was the only significant risk factor (IDU among 95% of HCV-infected detainees).

Among adolescent and young adult IDUs, the HCV prevalence and incidence rates are very high. A study in San Francisco that tested IDUs less than 30 years old (median age 22) found a prevalence rate of 39%. HCV-negative participants were invited to retest at a later date. Incidence among 195 initially HCV-negative IDUs was 25.1/100 person-years. Sharing drug paraphernalia, pooling money to buy drugs and exchanging sex for money were risk factors.

Studies demonstrate that narcotic use begins at an early age; a progression from marijuana to narcotic pills from a physician, the home or a friend quickly transitions when that source is exhausted to purchasing narcotic pills on the street. When the young person realizes the expense of this habit, he or she begins smoking or inhaling heroin. Heroin’s purity has improved from previous levels so users can now snort or smoke rather than inject for a lower cost than purchasing narcotic pills on the street. Unfortunately, some crave more and begin injecting. In a nationally representative survey of high school students, in 12th grade 10% reported Vicodin use and 5% reported Oxycontin use. Most (75%) reported receiving prescription drugs free of charge from a friend or relative and only 19% reported purchasing from a stranger.

Evaluation and Management
Primary care providers are in a key position to identify patients at risk, use appropriate diagnostic testing, provide vaccination to protect against HAV and HBV, and coordinate HCV and substance use treatment and counseling.

Conducting thorough HCV risk assessments for all adolescent and young adults patients is recommended (see table below). All at-risk patients should be tested for HCV antibody using an enzyme immunoassay (EIA) screening test. Confirmatory tests must be performed to identify false-positive test results and to determine patient management. Detection of HCV RNA in blood is the currently accepted “gold standard” for diagnosis of active HCV infection and is recommended by most gastroenterologists. Therefore, a positive EIA should be followed by either a qualitative or quantitative test for HCV RNA in the blood. A qualitative HCV RNA test will confirm active HCV infection; a quantitative test will determine the HCV viral load and assist for treatment eligibility.

Relative Risk Factors for Hepatitis C Transmission
High risk	• Injection drug use • Blood or blood product transfusion or transplantation prior to 1992
Moderate risk	• High-risk sexual activity* • Vertical transmission from mother to baby
Low risk	• Occupational exposure • Sexual activity between long-term spouses/sexual partners
Very low/no risk	• Casual contact • Household contact
* Sexual transmission of HCV is not clearly understood. However, certain high-risk sexual behaviors have been associated with HCV transmission; these include anal sex, sex with trauma, sex in the presence of a sexually transmitted disease and sex without a condom.

Adolescent opioid addiction and HCV are chronic diseases and, similar to diabetes and asthma, need appropriate ongoing management. For addiction, patients must be referred for treatment, either inpatient or outpatient. For HCV infection, patients should be referred to a gastroenterologist or a hepatologist. Many specialists will not treat HCV infection in patients who continue to use illicit substances because their impaired judgment may result in noncompliance with a complicated intravenous treatment regimen that causes many side effects and requires rigorous follow up laboratory testing. (See table for a list of provider resources.)

Provider Resources for Evaluation and Management of Adolescent and Young Adult HCV and Illicit Substance Addiction
Resource	Description
Drug Strategies	Information on adolescent drug treatment facilities, hotlines and research articles
American Society of Addiction Medicine	Patient Placement Criteria (guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems
American Academy of Pediatrics	Policy Statement: Indications for Management and Referral of Patients Involved in Substance Abuse
American Gastroenterology Association	GI Locator Service

— About the author: Gale R. Burstein, MD, MPH, is assistant clinical professor of pediatrics, Women and Children’s Hospital, Buffalo, NY.

[This article first appeared in the Summer 2009 issue of CorrectCare.]