Acute hepatitis C virus infection in an Australian prison inmate: tattooing as a possible transmission route

Clinical record

The patient had never been tattooed before entering prison, but was tattooed on four occasions inside prison (December 1997, September and December 1998, and early April 1999). The two most recent episodes were within the recognised incubation period for hepatitis C virus infection of 3-20 weeks.¹ On both occasions fellow inmates tattooed him with sewing needles. The needle used for the December 1998 episode of tattooing was soaked in a 1% bleach solution for one hour, and then wiped and rinsed with water before use. The patient was unsure if the needle was used to tattoo another prisoner before him. He reported that the needle used in the most recent episode (in April 1999) had not been previously used for tattooing. He was unsure if the same stock of pigment had been used to tattoo another prisoner before him on either occasion.

The patient denied previous tattooing, injecting drug use, blood transfusion, needlestick injury and sharing of razors or toothbrushes and having sex while inside prison. He took no regular medications. In March 1998 he had been in a fight, in which he sustained lacerations to his lips and knuckles. He admitted to using drugs, including cocaine, marijuana and ecstasy, before his imprisonment, but only via non-injecting routes of administration. During imprisonment he admitted to smoking marijuana, and had lost visiting privileges when three random urine tests detected marijuana. His prison medical record had no reference to injecting drug use. Several healthcare workers, including a drug and alcohol counsellor, had interviewed him over a two-year period and all had recorded a similar history of non-injecting drug use only.

Physical examination five months after presentation, in November 1999, showed no stigmata of chronic liver disease, a normal liver span and no splenomegaly. There were three tattoos and no evidence of injection scars in the cubital fossae or elsewhere.

Testing showed seroconversion to HCV in samples collected longitudinally between 1997 and 1999 (see Figure). HCV viraemia was detected by polymerase chain reaction on two occasions in the acute phase of the illness. Serological testing for alternative causes of hepatitis showed no evidence of recent infection with hepatitis A, B or E, human immunodeficiency virus, syphilis or cytomegalovirus. Immunoglobulin G (IgG) antibodies against Epstein-Barr virus, human herpes virus type 6 and Toxoplasma gondii were detected at the first sampling point, indicating prior exposure. To corroborate the inmate's self-report and medical interviews, a 5 cm scalp hair sample was taken and tested for injectable drugs. The sample represented hair growth from July to November 1999, a period after the onset of hepatitis, during which the inmate had been prescribed a combination oral analgesic containing codeine. This sample was tested by gas chromatography and mass spectrometry for cocaine, amphetamines, methadone, codeine, morphine and 6-monoacetyl morphine (a heroin metabolite). The analysis showed the presence of codeine and morphine; a quantitative analysis was not possible.

Discussion

Previous reports have not demonstrated seroconversion, leaving uncertainty as to the association between the tattooing, hepatitis and HCV infection.^8-10 Nor have they attempted to exclude injecting drug use as a confounding risk for HCV acquisition. In this patient, the presence of morphine in the hair may relate to prescribed codeine analgesia or indicate undisclosed drug use in the period after the onset of the illness (the period represented by the hair sample). This was unable to be resolved with further interviews as the inmate was lost to follow-up. Thus, the possibility of undisclosed injecting drug use cannot be completely discounted as the route of transmission. It is very unlikely that the patient acquired HCV through blood-to-blood contact during the reported fight, as the clinical illness occurred more than one year after this event. Although tattooing represents a biologically plausible means for the transmission of HCV, this case illustrates that undisclosed injecting drug use may be a confounder in studies where tattooing is the only acknowledged risk factor for transmission of HCV. Indeed, in one study of recently released New South Wales prison inmates, injecting drug users were more likely to report receiving a tattoo in prison than non-injecting drug users.¹²

Previously reported modes of transmission of HCV in prisons include sharing drug injecting equipment, fights between inmates, barbers shears¹¹ and a blood splash to the eye.¹⁴ Clinically apparent cases are likely to represent a small proportion of new HCV infections in prisons. Clinically apparent hepatitis is uncommon in primary HCV infection,¹ occurring in only one case in every five.

Prison inmates report boredom as a common motivation for tattooing inside prison.¹⁵ As tattooing is likely to continue among prison inmates despite being banned, allowing access to licensed tattooists (or trained prisoners), with effective infection control procedures, may reduce the risk of HCV transmission in prisons.

In conclusion, large, prospective studies with meticulous assessment of confounding risk factors are required to effectively assess the potential association between tattooing and primary HCV infection.

References

1. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes, and cofactors. Epidemiol Rev 1996; 18: 137-148.
2. Balasekaran R, Bulterys M, Jamal MM, et al. A case-control study of risk factors for sporadic hepatitis C virus infection in the southwestern United States. Am J Gastroenterol 1999; 94: 1341-1346.
3. Ko YC, Ho MS, Chiang TA, et al. Tattooing as a risk of hepatitis C virus infection. J Med Virol 1992; 38: 288-291.
4. Holsen DS, Harthug S, Myrmel H. Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. Eur J Clin Micro Infect Dis 1993; 12: 673-676.
5. Kaldor JM, Archer GT, Buring ML, et al. Risk factors for hepatitis C virus infection in blood donors: a case-control study. Med J Aust 1992; 157: 227-230.
6. Neal KR, Jones DA, Killey D, James V. Risk factors for hepatitis C virus infection. A case-control study of blood donors in the Trent Region (UK). Epidemiol Infect 1994; 112: 595-601.
7. Sun CA, Chen HC, Lu CF, et al. Transmission of hepatitis C virus in Taiwan: prevalence and risk factors based on a nationwide survey. J Med Virol 1999; 59: 290-296.
8. Abildgaard N, Peterslund NA. Hepatitis C virus transmitted by tattooing needle. Lancet 1991; 338: 460.
9. Thompson SC, Hernberger F, Wale E, Crofts N. Hepatitis C transmission through tattooing: a case report. Aust N Z J Pub Health 1996; 20: 317-318.
10. Sun DX, Zhang FG, Geng YQ, Xi DS. Hepatitis C transmission by cosmetic tattooing in women [letter]. Lancet 1996; 347: 541.
11. Haber PS, Parsons SJ, Harper SE, et al. Transmission of hepatitis C within Australian prisons. Med J Aust 1999; 171: 31-33.
12. Dolan KA, Wodak AD, Hall WD. A bleach program for inmates in NSW: an HIV prevention strategy. Aust N Z J Pub Health 1998; 22: 838-840.
13. Vlahov D, Nelson KE, Quinn TC, Kendig N. Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. Eur J Epidemiol 1993; 9: 566-569.
14. Rosen HR. Acquisition of hepatitis C by a conjunctival splash. Am J Infect Control 1997; 25: 242-247.
15. Crofts N, Thompson S, Wale E, Hernberger F. Risk behaviours for blood-borne viruses in a Victorian prison. Aust N Z J Criminol 1996; 29: 20-28.

Authors' details

Prince of Wales Hospital, Sydney, NSW.
L Ross Whybin, BSc, MASM, Senior Hospital Scientist, SEALS Area Serology Laboratory;
Ian W J Carter, MSc, Senior Hospital Scientist, Virology Diagnostic Laboratory, Microbiology Department.

Drug and Alcohol Department, Royal Prince Alfred Hospital, Sydney, NSW.
Paul S Haber, MD, FRACP, Staff Specialist.

Reprints will not be available from the authors.
Correspondence: Dr J J Post, Inflammation Research Unit, School of Pathology, University of NSW, Sydney, NSW, 2052.
j.postATunsw.edu.au