Hepatitis C by Tattoos and Piercings

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Hepatitis C by Tattoos and Piercings

Concerns about body piercing get more than lip service
THE NEW YORK TIMES
At a tattoo and piercing establishment on St. Marks Place in Manhattan recently, Young-Cho, an experienced tattoo artist, applied a small winged horse to Mara Fallon's shoulder.

He dipped his buzzing instrument into a small plastic cup of blue ink and then appeared to draw with the electric needle on Fallon's shoulder.

"It feels like when you pull hairs out when you rip off a Band-Aid," Fallon said.

In another cubicle, Tino, a piercer, disinfected the skin on a young woman's abdomen and marked two dots on either side of her navel. He held her flesh with forceps and pierced the marks with a hollow needle, then threaded a surgical steel rod through the four holes and attached two small steel spheres to each end, making the jewelry into a tiny barbell.

Tattoos and body piercings have become so common, they hardly attract notice. One recent study of 7,960 college students in Texas found that one in five had at least one tattoo or piercing of a body part other than an earlobe.

But health officials say they are increasingly worried about the risks posed by such body modification practices, including physical disfigurement and bacterial and viral infections, and not only from needles that draw blood in potentially unsanitary conditions.

The primary concern is infection with blood-borne pathogens such as HIV and hepatitis C and B. But doctors say that tongue and genital piercings can also provide channels for bacteria and viruses to enter the bloodstream after the piercing procedure.

Bacteria that live on the skin, including some penicillin-resistant forms of staphylococcus, are easily spread by unsterilized instruments or ungloved hands. And bacterial infections, or the body's reaction to the insertion of a foreign object, can cause deformities at piercing sites.

Last month, Sen. Charles Schumer, D-N.Y., expressed concern about a growing number of hepatitis C cases, linking the increase in part to body piercings and tattoos. The potentially fatal virus can live in the body for decades without symptoms.

Studies have not conclusively demonstrated a connection between body modification and hepatitis C. The Texas study, sponsored by the federal Centers for Disease Control and Prevention, found that college students with piercings, tattoos or both were no more likely than other students to have been exposed to the hepatitis C virus.

But an earlier study reported that of 626 patients at an orthopedic clinic, those with tattoos were seven to eight times more likely to have subclinical hepatitis C infections.

"Regardless of whether or not we can demonstrate that bacteria or viruses are spread in this manner, anything that pierces the skin and has blood on it can potentially spread an infection," said Dr. Miriam Alter, associate director for science at the Centers for Disease Control's division of viral hepatitis and the agency's lead scientist on the Texas study. "The moment you pierce the skin barrier, there is risk for transmission of a disease."

Licensing requirements for tattoo and piercing establishments, the growth of professional organizations for practitioners and the growing sophistication of Internet-educated consumers have increased safety. Most people seeking tattoos know they should see the artist remove a new needle and tube setup from sealed plastic and that fresh ink from disposable containers should be used.

But Dr. David Graham said it is impossible to police everyone.

"There will always be someone driven by profit who will avoid regulatory guidelines and licensing fees," he said. And even establishments that use fresh needles and surgical gloves, spray disinfectants and heat-sterilizing autoclaves are of concern, scientists say.

It is estimated that one piercing in 10 becomes infected. Staphylococcus bacteria, which can live on the skin and in the nose, are a frequent cause, said Dr. Scott Hammer, professor of medicine at Columbia College of Physicians and Surgeons.

"If you disinfect the surface of the skin but use a forceps that has not been sterilized, you are risking spreading infection," Hammer said. "You don't need a puncture; you only need an abrasion for the organism to cause an infection."

Unlike most tattoos, which heal in one to two weeks, piercings can pose problems in the long haul. Nipple piercings that go too deep have damaged tissue and led to problems in breast-feeding after the jewelry was removed.

Stud earrings can become embedded in nipples, navels or elsewhere when the body tries to "heal over" the piercing site. Clothing can catch on navel jewelry, causing infections. Keloids, the overgrowth of scar tissue, can also cause disfigurement, including tumorlike growths.

Some styles of mouth and genital piercing carry other dangers. Dr. Jay Gohel, a dentist at the Smile Institute in Manhattan, said tongue rings could cause trauma and breakage of the upper teeth, including the lingual cuspids and molars.

"Every time you move the tongue, it's banging on the teeth," Gohel said. "It's like tapping on glass over and over again. It finally breaks."

Gohel and other experts have also seen infections from tongue piercings. One study reported on the case of a 25-year-old man with a potentially fatal disease of the heart's inner lining that was traced to his tongue piercing.

Many people use antibiotics as a preventive measure before dental surgery because of congenital heart disease, heart defects or repaired heart valves. Dr. Nieca Goldberg, chief of women's cardiac care at Lenox Hill Hospital in New York, said that people in high-risk categories might not realize that they should also take protective medication before piercings.

"You may think of a piercing as cosmetic, but if you have . . . conditions that require antibiotics before dentistry, you should be treating a piercing the same way," Goldberg said.

Contact the Omaha World-Herald newsroom
http://www.omaha.com/index.php?u_np=0&u_pg=1642&u_sid=1327920

Hepatitis C Acquired Through Tattooing Often Asymptomatic

NEW YORK (Reuters Health) Jun 02 - People who become infected with the hepatitis C virus when getting a tattoo may be less likely to develop symptoms than people who become infected in other ways, according to Texas researchers.

In a small study, both people with tattoos and those with a history of injection-drug use were more likely than others to be infected with hepatitis C. But unlike subjects who had injected drugs, individuals who had a tattoo were less likely to develop acute hepatitis symptoms, such as jaundice, vomiting and fatigue.

According to Dr. Robert W. Haley, lead author of the study, a tattoo needle carries a smaller viral load than a standard hypodermic needle and it does not inject the virus directly into the bloodstream.

As a consequence, it takes longer for the virus to enter the bloodstream and make its way to the liver and cause symptoms, Dr. Haley, from the University of Texas Southwestern Medical Center in Dallas, told Reuters Health.

In the study, Dr. Haley and Dr. R. Paul Fischer, from Presbyterian Hospitals of Dallas, re-analyzed data collected in the early 1990s on 626 patients seeing a physician for back problems. Patients were asked about risk factors for hepatitis C, and were screened for the virus after the interview.

The findings are published in the May 12th issue of the Archives of Internal Medicine.

Researchers found that those who had a tattoo had a 6.5-fold higher risk of testing positive for hepatitis C than other subjects. However, infected subjects with tattoos were not at increased risk for acute hepatitis symptoms compared with their peers without tattoos.

In contrast, people with a history of IV drug use were 7.2-times more likely to be infected with the hepatitis C virus than other subjects and 5.9-times more likely to have experienced acute hepatitis symptoms.

Arch Intern Med 2003;163:1095-1098.

Jury sides with hepatitis C victim
By Guillermo Contreras
San Antonio Express-News
Web Posted : 12/04/2003 12:00 AM

A Bexar County jury awarded a woman $551,600 Wednesday after finding she likely contracted hepatitis C from a San Antonio-area business that performs permanent cosmetic applications.

While medical studies have linked the often-fatal virus to tattoo parlors and related permanent cosmetic businesses, the lawsuit is believed to be the first time nationally that the issue has gone to trial, allowing a jury to make the link, state and national health experts said.

"We have no confirmed records of hepatitis C being transmitted at a licensed studio, so we're certainly interested in this case," said John Gower, director of programs for drugs and cosmetics at the Texas Department of Health in Austin.

The jury found John Shumate, owner of Permanent Cosmetics by John Shumate at 6111 Broadway, and his daughter Julie negligent for infecting Deborah Anderson, who received a series of permanent coloring touch-ups to her lips at the studio, mostly in 1999.

Anderson, 52, learned she had hepatitis C in February 2000 when a blood bank rejected her donation, according to her lawyers.

During an earlier donation, she did not have the virus.

She complained to the state Department of Health, and an inspection of the business found several violations, including dirty floors in the tattooing area, employees not washing their hands between applications, and incorrect or insufficient labeling of sterilized equipment.

"The jury has sent out a message to the public about the seriousness of the health issues involved with tattooing," said LoAn Vo, one of Anderson's lawyers.

Neither Shumate nor his attorney, John Wennermark, returned calls seeking comment.

Roger Sanchez, an epidemiologist with the San Antonio Metropolitan Health District, said getting hepatitis C from a business is rare.

He added that "it's difficult to prove, but it's not impossible."

The case bolsters a study done 10 years ago by researchers at the University of Texas Southwestern Medical Center in Dallas that found most hepatitis C cases in Texas — 30 percent — were transmitted through commercial tattooing.

Dr. Robert Haley, an epidemiologist who formerly worked for the Centers for Disease Control and Prevention, said the state uses a different standard in determining infections. A person may not know for years after his initial infection that he is carrying hepatitis C, and he can't isolate the tattooing as the likely cause, he said.

"This was the perfect case because you have a lady with no other risk factors," said Haley, who testified for the plaintiff and was the author of the study. "She has a very low-risk lifestyle ... so she has no (other) reason to get hepatitis C."

At trial, Anderson's lawyers introduced evidence of violations at Shumate's studio. A state investigator noticed topical drugs to numb pain that required a prescription or licensed medical practitioner to apply them. Shumate does not have a medical license, according to the state report.

The inspector also observed three tattoo artists providing services for three hours, but none washed his or her hands between tattoo applications on separate clients, the investigator's report said.

The report also noted Shumate complained about the inspection process.

"Mr. Shumate stated that this is just another way that big government is trying to put him out of business," the report said. "He stated that there are some things that the government has no business regulating."

CDC's Position on Tattooing and HCV Infection
Although some studies have found an association between tattooing and HCV infection in very selected populations, it is not known if these results can be generalized to the whole population. Any percutaneous exposure has the potential for transferring infectious blood and potentially transmitting bloodborne pathogens (e.g., HBV, HCV, or HIV); however, no data exist in the United States indicating that persons with exposures to tattooing alone are at increased risk for HCV infection.

For example, during the past 20 years, less than 1% of persons with newly acquired hepatitis C reported to CDC's sentinel surveillance system gave a history of being tattooed. Further studies are needed to determine if these types of exposures, and the settings in which they occur, are risk factors for HCV infection in the United States. CDC is currently conducting a large study to evaluate tattooing as a potential risk.

www.cdc.gov/ncidod/diseases/hepatitis/c/tattoo.htm

2004.12.14: CDC's Activities to Prevent Hepatitis C Infection
... of infection from intranasal cocaine use, tattooing, and body ... He joined CDC in 1987 as an Epidemic ... of Viral Hepatitis in a variety of positions including Chief ...
www.hhs.gov/asl/testify/t041214.html - 21k - Feb 3, 2005

Testimony
Statement by Rima Khabbaz, M.D.
Associate Director for Epidemiologic Science
National Center for Infectious Diseases
Centers for Disease Control and Prevention

Department of Health and Human Services on CDC's Activities to Prevent Hepatitis C Infection
before the Committee on Government Reform U.S. House of Representatives

December 14, 2004
Good afternoon Mr. Chairman and Members of the Committee. I am Dr. Rima Khabbaz, Associate Director for Epidemiologic Science of the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). I am accompanied today by Dr. Eric Mast, Acting Director of CDC's Division of Viral Hepatitis. We are pleased to be here today to describe the activities CDC has undertaken with partners to implement the National Hepatitis C Prevention Strategy, which this Committee was instrumental in initiating in 1998.

Background

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have this disease. Although hepatitis C can lead to cirrhosis or scarring of the liver, to liver failure, and liver cancer, the consequences of chronic liver disease from hepatitis C may not become apparent for 10 to 20 years, so many individuals infected with HCV are not aware of their infection. HCV infection is spread primarily by exposures that involve direct passage of blood through the skin, and it is the most common chronic bloodborne infection in the United States. About 4 million Americans have already been infected, of whom approximately 3 million are chronically infected, and about 30,000 Americans become newly infected each year. Unlike hepatitis A and hepatitis B, there is no vaccine to prevent infection with HCV.

Risk Factors Associated with HCV Infection

Before blood donor testing for non-A, non-B hepatitis became available beginning in the mid-1980s, and then a specific test for HCV infection beginning in 1990, blood transfusions accounted for 10-25 percent HCV infections. However, specific testing of blood donors has reduced the risk of infection from a unit of blood to less than one in 1,000,000 units transfused.

Injection drug use is now the risk factor for infection among about 50 percent of persons with past HCV infection, and since the mid-1980s, injection drug use accounts for approximately two-thirds of new infections among Americans. Of persons injecting drugs for at least 5 years, 60-80 percent are infected with HCV, a risk that is 2 to 3 times higher than for the human immunodeficiency virus (HIV). This high rate of infection accounts for the 15-30 percent prevalence of HCV infection that has been found among inmates of correctional facilities. Other risk factors for infection include occupational exposure to blood through a needle stick from an infected person, transmission to an infant from an infected mother, and less efficiently through sex with an infected sex partner.

Consequences of Infection with HCV

Approximately 75-85 percent of persons with an acute hepatitis C virus infection develop a chronic infection, and about 60-70 percent of those persons develop chronic hepatitis. Lower rates of chronic infection and liver disease appear to occur among persons who were infected as children.

Over a period of 20 to 30 years, cirrhosis of the liver occurs in 10-20 percent of persons with chronic hepatitis C virus infection and liver cancer developing in 1-5 percent of them. Surveillance studies conducted by CDC and the National Institutes of Health (NIH) show that HCV accounts for 40-60 percent of chronic liver disease in the United States. Chronic liver disease is the tenth leading cause of death among adults in the United States, and HCV causes between 8,000 and 10,000 of these deaths each year. HCV is the most frequent indication for liver transplantation in this country; the number of patients on transplant waiting lists has doubled in the past 5 years, and about 50 percent of these patients die while awaiting liver transplant.

About one quarter of HIV-infected persons in the United States are also infected with HCV. HCV is transmitted primarily by large or repeated direct exposures to contaminated blood. Therefore, coinfection with HIV and HCV is common among HIV-infected injection drug users (IDUs). Coinfection is also common among persons with hemophilia who received clotting factor concentrates before concentrates were effectively treated to inactivate both viruses (i.e., products made before 1987). As highly active antiretroviral therapy (HAART) and preventive treatment of opportunistic infections increase the life span of persons living with HIV, HCV-related liver disease has become a major cause of hospital admissions and deaths among HIV-infected persons. Persons living with HIV who are not already coinfected with HCV can adopt measures to prevent acquiring HCV. Such measures will also reduce the chance of transmitting their HIV infection to others.

Treatment of Chronic HCV Infection

Current antiviral treatment completely eliminates HCV infection in 50-55 percent of selected patients, with 95 percent of those remaining virus free for at least 5 years. While antiviral therapy is indicated for many patients with chronic HCV infection, treatment is less effective and may not be indicated for patients with severe liver disease. Also, alcohol abuse appears to worsen the outcome of HCV, and antiviral treatment is more difficult among persons with ongoing abuse.

In addition to the benefits of antiviral treatment, patients with chronic HCV infection can benefit from counseling, immunizations, and other services to prevent progression of chronic liver disease. Because alcohol use is one of the most important contributing factors to progression of chronic liver disease in HCV-infected persons, it is important to identify infected persons as early as possible so that they can be counseled to limit alcohol consumption. In addition, persons with HCV should be vaccinated against diseases, including hepatitis A and hepatitis B, that may produce further liver injury or increase their risk of death.

CDC's Current Prevention and Control Efforts

Identification of HCV-infected persons and prevention of new infections are the major objectives of the National Hepatitis C Prevention Strategy. Identification of infected persons provides the opportunity for medical evaluation to: 1) determine the extent of their chronic liver disease, 2) determine if they are candidates for antiviral therapy, 3) determine if they need treatment for other conditions such as alcohol or drug abuse that will worsen their HCV, and 4) provide health education about how to prevent HCV transmission to others.

Identification of HCV infected persons, as well as persons at risk of HCV infection, is best achieved through the integration of hepatitis prevention services into community-based clinical and public health programs that serve at-risk persons. Because the majority of persons with HCV do not have symptoms of liver disease, their identification requires that testing be conducted on persons with risk factors for infection. CDC has conducted a number of community-based demonstration projects - the Viral Hepatitis Integration Projects, or VHIPs -- which have shown the feasibility and effectiveness of including hepatitis prevention services in a variety of clinical and public health settings. I will now highlight some specific components of the National Hepatitis C Prevention Strategy.

Health Communications: CDC has developed evidence-based guidelines for identification and testing of persons at risk of hepatitis C. In addition, CDC has provided a broad range of materials about hepatitis C for health care professionals and the public. Examples include web-based continuing medical education programs for health care professionals, a Hepatitis C Toolkit for primary care providers and their patients, and health education materials for high school teachers. These materials are available on CDC's web site and can be found at: www.cdc.gov/ncidod/diseases/hepatitis. CDC has also funded 12 viral hepatitis education and training cooperative agreements with academic centers, health departments and non-governmental organizations.

Community-based Prevention Programs: To accelerate the integration of hepatitis C testing, counseling and referral for medical evaluation into community-based programs that provide clinical and public health services, CDC has made funding available for Hepatitis C Coordinators. Currently, there are 53 coordinators in States, large metropolitan areas, and in the Indian Health Service (IHS). One activity that coordinators have been involved in is the development of comprehensive State hepatitis C prevention plans. Currently, 23 States have a plan or are in the process of developing such a plan. In addition, CDC has funded the VHIPs in 21 State and local health departments and in the IHS to provide models and best practices for integration of viral hepatitis prevention services into clinical and public health programs, such as those in STD clinics, drug treatment facilities, HIV/AIDS prevention programs, and correctional settings. Additionally, CDC, in collaboration with the IHS Division of Epidemiology, provides technical assistance to Tribes, IHS facilities, Urban Indian Health Programs, and other American Indian/Alaskan Native groups to implement hepatitis C prevention activities.

Surveillance and Program Evaluation: Since 2003, chronic HCV infection has been a condition that is reportable by States to CDC. In 2003, 19 States submitted case reports. CDC has also developed surveillance guidelines for case investigation and follow-up of persons with chronic HCV infection. CDC will continue to work to develop and maintain enhanced national surveillance systems in order to monitor the effectiveness of hepatitis C prevention efforts. In addition, a study is underway to evaluate the effectiveness of the VHIPs and determine future directions for such demonstration projects.

Research: There continue to remain a number of unanswered questions concerning the epidemiology and natural history of HCV infection that need to be answered to develop interventions to prevent transmission of HCV and to prevent disease progression among persons with chronic infection. Priority areas in which studies are underway or in the planning stages include those that determine: 1) incidence and risk factors for HCV transmission among household contacts of infected persons; 2) risk factors for transmission from mother to infant at birth; 3) risk of infection from intranasal cocaine use, tattooing, and body-piercing; 4) prevalence and incidence of infection in incarcerated populations; 5) risk of infection among steady heterosexual partners of HCV-infected persons; 6) risk factors for infection among persons on chronic hemodialysis; 7) the dynamics of HCV acquisition among injection drug users and the effectiveness of harm reduction strategies in preventing infection; 8) disease burden, including chronic liver disease and liver cancer mortality; and 9) risk factors for health care related transmission.

In conclusion, since 1998, there has been considerable progress made in raising awareness about the prevention of hepatitis C both among healthcare providers and the public. In addition, many States have initiated hepatitis C prevention programs, which are being facilitated by the federally funded Hepatitis C Coordinators.

To help us make further improvements in this area, CDC has established a National Viral Hepatitis Roundtable in conjunction with representatives from national voluntary health organizations, nongovernmental organizations, professional societies, health insurers, industry, and other governmental agencies. The Roundtable is designed to coordinate efforts by CDC and our partners to address hepatitis C and other forms of viral hepatitis. It helps to make sure efforts of CDC and its partners are targeted and not duplicated, so we can all make maximum use of our resources.

Thank you very much for this opportunity to update you on what has happened with hepatitis C prevention since this was last addressed by this Committee. I will be happy to answer any questions you may have.

RIMA KHABBAZ, M.D.
Associate Director for Epidemiologic Science
National Center for Infectious Diseases (NCID)
Centers for Disease Control and Prevention
Department of Health and Human Services

Dr. Khabbaz received her B.S. in 1975 and her M.D. in 1979 from the American University of Beirut (AUB) in Beirut, Lebanon. She first joined CDC as an Epidemic Intelligence Officer in 1980 after 2 years of internal medicine training at the AUB Medical Center in Beirut. She subsequently completed her residency in internal medicine at the Union Memorial Hospital in Baltimore and a fellowship in infectious diseases at the University of Maryland. She is board certified in Internal Medicine. During her CDC career, she has worked primarily in the areas of infection control in healthcare settings, viral infections including non-HIV retroviruses and hantavirus, and blood safety. She is currently Associate Director for Epidemiologic Science in the National Center for Infectious Diseases (NCID), CDC, and before that was Deputy Director of the Division of Viral and Rickettsial Diseases, NCID for 5 years. Her interests include emerging infections, viral diseases, blood safety, food safety, and the transmissible spongiform encephalopathies. She played a leading role in developing CDC's programs related to blood safety and was active in enhancing DVRD's programs under the Food Safety Initiative. She is a fellow of the Infectious Disease Society of America (IDSA), and a member of the American Epidemiologic Society, the American Society for Microbiology, and the American Society of Tropical Medicine and Hygiene. She served on the Blood Product Advisory Committee of the Food and Drug Administration from 1995-1999, and on the IDSA's Annual Meeting Scientific Program Committee from 1999-2002. She is the author of over 100 research and review papers including book chapters. NCID is currently working to address domestic and global challenges posed by emerging infectious diseases and the threat of bioterrorism.

ERIC E. MAST, M.D., M.P.H.
Acting Director, Division of Viral Hepatitis
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Department of Health and Human Services

Dr. Mast is a graduate of the University of Illinois College Of Medicine and the Harvard School of Public Health. He completed a pediatric residency at the University of Wisconsin Hospital and Clinics and is board certified in pediatrics. He joined CDC in 1987 as an Epidemic Intelligence Service Officer assigned to the Wisconsin Department of Health and Human Services. Since 1990, Dr. Mast has been working in the Division of Viral Hepatitis in a variety of positions including Chief of the Hepatitis Surveillance Unit, Medical Officer assigned to the Expanded Programme on Immunization at the World Health Organization, Acting Associate Director for Global Health, and Chief of the Prevention Branch. He is an author of more than 70 scientific manuscripts. His primary area of expertise is prevention and control of viral hepatitis. Dr. Mast is also an officer in the Commissioned Corps of the United States Public Health Service.