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Viral Hepatitis and Injection Drug Users

September 2002

Millions of Americans have viral hepatitis. It is a particularly significant problem among injection drug users (IDUs). Growing awareness of this problem is leading to new initiatives, but efforts to prevent these diseases and reduce their medical, financial, and social costs face challenges.

Viral Hepatitis Is an Important Health Issue for the Nation

Hepatitis, literally an ?inflammation of the liver,? has a number of causes. Viral infection is one of them. The most common types are hepatitis A, hepatitis B, and hepatitis C.

Viral hepatitis affects millions.

Hepatitis C virus (HCV) infection occurs when blood (or to a lesser extent, other body fluids such as semen or vaginal fluid) from an infected person enters the body of an uninfected person. Injection drug use is the major risk factor for HCV infection. About 3.9 million Americans have been infected with HCV and 2.7 million have chronic HCV infection. Hepatitis C disproportionately affects people of color: 3.2% of African Americans and 2.1% of Mexican Americans are infected with HCV, compared to 1.5% of non-Hispanic whites. These numbers underestimate the actual impact because they do not include infections in prisoners or the homeless. In 2000, about 30,000 new infections occurred. Most of these infections occurred among young adults 20-39 years old.

Hepatitis B virus (HBV) infection occurs when blood or body fluids from an infected person enter the body of an uninfected person. High-risk sexual behaviors (unprotected sex with multiple partners) and injection drug use are the major risk factors. About 5% of people in the U.S. have evidence of past infection with HBV and approximately 1.25 million people have chronic HBV infection. Like hepatitis C, hepatitis B disproportionately affects people of color. An estimated 73,000 new HBV infections occurred in 2000. Most infections occurred in young adults, aged 20-39 years. Hepatitis B can be prevented through immunization.

Hepatitis A virus (HAV) is primarily transmitted through the fecal-oral route, when a person puts something in his or her mouth (such as food or a beverage) that has been contaminated with the feces of a person infected with HAV. Outbreaks occur more easily in overcrowded areas where poor sanitary conditions exist. Outbreaks of hepatitis A also have been reported among IDUs. About one-third of Americans have evidence of past infection with HAV. Hepatitis A can be prevented through immunization.

The medical and health care costs of viral hepatitis are high.

Each year, 8,000 to 10,000 people die from the complications of liver disease caused by hepatitis C and about 5,000 die from complications caused by hepatitis B. Chronic liver disease is currently the 10th leading cause of death, and liver failure due to hepatitis C is the leading reason for liver transplants. Annual health care costs and lost wages associated with hepatitis-related liver disease are estimated to be $600 million for hepatitis C and $700 million for hepatitis B. The costs to individuals and society of illness related to hepatitis A are also substantial.

Viral hepatitis can be insidious. Frequently, symptoms of newly acquired (acute) infection are mild or nonexistent, so people may not even be diagnosed as having viral hepatitis. Those who do have symptoms might experience ?flu-like? symptoms, fatigue, nausea, pain in the upper abdomen, and sometimes jaundice.

People who get HAV infection are able to clear the virus from their bodies and recover fully. They develop a lifelong immunity to the virus. The situation is different with hepatitis B and hepatitis C:

Many people with chronic infection -- 60% of those with HBV infection and 70% of those with HCV infection -- develop chronic liver disease, a situation in which the virus damages the liver. The damage may progress to severe disease, including cirrhosis, liver cancer, and liver failure. This progressive liver disease usually develops slowly over 20 to 30 years. Because symptoms are so frequently mild or nonexistent, the majority of people with chronic HBV and HCV infections do not know they are infected and can unknowingly transmit the virus to others. For many, signs and symptoms appear only when liver disease is advanced and treatments are less effective.

Hepatitis C Is a Particular Concern

Viral Hepatitis Is a Very Significant Problem Among IDUs

Because HBV and HCV are transmitted through exposure to infected blood and body fluids, IDUs are at very high risk of acquiring and transmitting both viruses. For example, it is estimated that 60%, or 17,000, of the 30,000 new cases of HCV that occurred in 2000 occurred among IDUs. Is it estimated that 17%, or 13,000 of the 73,000 new cases of hepatitis B that occurred in 2000, occurred among IDUs.

Hepatitis A, B, and C at a Glance
Virus Risk of Transmission Course of Infection Does Protective Immunity Develop? Vaccine Available?
  Injecting Transfusion/ Transplant Sex Fecal-
A low* high high high none acute -> resolved yes yes
B high low high none high unless immune due to hepatitis B immunization or previous infection acute -> chronic in 90% of infants, 30% in children aged 1-5, 2%-6% of older children and adults yes yes
C high low low none low acute ? chronic in 75%-85% of adults no no
* Hepatitis A outbreaks occur among IDUs; mechanisms of transmission are not known with certainty but are related to poor hygiene and sharing drugs, drug solution, syringes, and drug preparation equipment (water, drug solution containers, cotton filters).

HBV and HCV infections are also acquired relatively rapidly among IDUs. Within 5 years of beginning injection drug use, 50%-70% of IDUs become infected with HBV. Between 50%-80% of IDUs become infected with HCV within 5 years of beginning injection drug use; it is usually the first bloodborne virus they acquire. Several factors favor the rapid spread of HCV infection among IDUs:

Other circumstances also contribute to the heavy impact of viral hepatitis on IDUs:

Agencies and Providers Face a Number of Pressing Issues in Their Efforts to Address Viral Hepatitis

In many ways, the current challenges of viral hepatitis, especially hepatitis B and hepatitis C, resemble those of HIV in the late 1980s and early 1990s. Awareness of viral hepatitis as an important public health issue is growing, but agencies, providers, communitybased organizations, and others who work with those at risk must address several key issues:

The National Hepatitis C Prevention Strategy is One Key Response In 2001, in collaboration with other federal, state, and private sector agencies, the Centers for Disease Control and Prevention (CDC) launched the National Hepatitis C Prevention Strategy. This effort is aimed at lowering the incidence of acute HCV infections in the U.S. and reducing the disease burden from chronic hepatitis C. The principal components of this effort are:

For more information about the Strategy, visit: CDC's Hepatitis C Strategy.

To Learn More About This Topic

Visit websites of the Centers for Disease Control and Prevention and the Academy for Educational Development for these and related materials:

Visit these websites for additional information on viral hepatitis:


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