Viral Hepatitis


Young Persons Who Inject Prescription Opioids and Heroin

The recent explosive increase in the misuse of prescription opioids and heroin in this country has sparked growing public recognition and concern. And deservedly so. The hepatitis B virus (HBV) and hepatitis C virus (HCV) are among the numerous health threats facing people who misuse opioids, particularly those who inject these drugs. These blood-borne viral infections have reached epidemic proportions in most states. Persons who become infected with HBV and HCV are at increased risk for other diseases transmitted through contact with blood, such as HIV.

How Viral Hepatitis is Spread Among Persons Who Inject Drugs

The hepatitis B and hepatitis C viruses are very infectious. People who have direct contact with surfaces, equipment, or objects contaminated with infected blood, even in amounts too small to see, can become infected. Hepatitis B can survive outside of the body for at least 1 week, and hepatitis C can survive on equipment and surfaces for up to 3 weeks.

People who inject drugs can get hepatitis B or hepatitis C from:

  • Sharing needles or reusing needles and syringes
  • Sharing drug preparation equipment such as cookers, cottons, water, ties, and alcohol swabs
  • Reusing personal-care items (e.g., razors, nail clippers, and toothbrushes) from someone infected with HBV or HCV
  • Sexual contact (particularly for HBV infection)

Hepatitis C Among Persons Who Inject Drugs (PWID)

Cases of HCV have been increasing for several years among PWID. The Centers for Disease Control and Prevention (CDC) has investigated and reported outbreaks and alarming increases in disease trends in collaboration with state and local health departments.

  • In 2011, the Massachusetts Department of Health and CDC investigated an epidemic of HCV among adolescents and young adults who were primarily injecting prescription opioids and heroin. In this outbreak, HCV was transmitted through sharing of drug-injection equipment. A report was published in the Morbidity and Mortality Weekly Report (MMWR) describing the HCV epidemic.  The investigation of these cases revealed that HCV was spread from sharing equipment to inject drugs, and that HCV infected persons were mostly injecting prescription opioids or heroin.
  • In 2012, an investigation by the Wisconsin Division of Public Health and CDC attributed rising numbers of HCV infections in the state to increasing use of injected prescription opioid drugs and heroin. CDC found that these infections were caused by different strains of the virus, suggesting the patients were infected through separate, unrelated networks of HCV transmission and that additional cases likely remained undetected.
  • In 2014, the national analysis of HCV surveillance data from 2006-2012 revealed an emerging epidemic of HCV infection, primarily among young persons living in small towns and rural areas. Indeed the number of new HCV infections was found to be rising in at least 30 states, with largest increases in nonurban counties east of the Mississippi River, particularly in Appalachian states.
  • In 2014, a CDC analysis of surveillance data revealed that approximately 30,000 new cases of hepatitis C (referred to as “acute” cases) occurred in 2013, representing a nationwide increase of more than 150% from 2010 to 2013; 28 states reported increases.
  • In 2015, HIV spread quickly among PWID in Scott County, Indiana; almost all persons who became infected with HIV had first been infected with HCV. This outbreak was unique, in that networks of HCV transmission within the community were identified using Global Hepatitis Outbreak and Surveillance Technology (GHOST), technology that enables identification of viruses with similar genetic make-up.
  • In 2015, CDC released a report on the increase in new cases of hepatitis C infection in the Appalachian region associated with injection drug use, often among people who first began drug use with prescription opioids. The article, Increases In Hepatitis C Virus Infection Related To Injection Drug Use Among Persons Aged <30 years, reported an estimated 364% increase in new hepatitis C infections during 2006-2012 among persons aged ≤30 years in four Appalachian states (i.e., Kentucky, Tennessee, Virginia, and West Virginia).

Hepatitis B Among PWID

  • According to CDC estimates, approximately 20,000 new cases of hepatitis B occurred in 2013, representing the first increase in acute cases of hepatitis B since 1990.
  • In 2016, CDC released a report on the increases in new cases of hepatitis B in the Appalachian region.  The report, Increases in Acute Hepatitis B Virus Infections — Kentucky, Tennessee, and West Virginia, 2006–2013, describes a 114% increase in acute hepatitis B from 2006-2013 in three states — Kentucky, Tennessee, and West Virginia; increases primarily occurred after 2009.

Highlights of CDC’s Response to the Epidemic of Viral Hepatitis Associated with Opioid Injection

CDC’s Division of Viral Hepatitis (DVH) is providing the programmatic foundation and leadership for the prevention and control of HBV and HCV infections among PWID. DVH works to improve hepatitis B and hepatitis C prevention by identifying communities at high risk for these infections and increasing testing and linkage to care among persons who inject drugs. Specifically, DVH

  • funds hepatitis coordinators in 48 states and 4 cities who direct local prevention efforts to best meet the needs  of each community;
  • helps communities assess their risks for HBV and HCV transmission, investigate the spread of infection, and prepare a public health response to stop transmission;
  • improves public health surveillance and other sources of critical information to help communities better detect HBV and HCV infected persons and guide delivery of prevention services;
  • studies patterns of HCV transmission, investigates behaviors that increase risk for HCV, and  identifies prevention services (e.g., testing, care, and treatment) that are most effective in stopping disease transmission;
  • trains state/local public health staff in how to guide the delivery of HCV and HBV prevention services in their communities;
  • collaborates with partners to provide technical assistance to prevention programs to identify practices that are most likely to lead to the detection, care, and treatment of viral hepatitis in PWID; and
  • uses a web-based system known as Global Hepatitis Outbreak and Surveillance Technology (GHOST) to improve investigation of HCV infection at the community level.  GHOST allows investigators to determine whether patients are infected with the same strain of HCV, helping uncover patterns and networks of transmission. CDC plans to apply this modern molecular surveillance tool in a growing number of states through a web-based platform that will facilitate effective collaboration and communication across the public health system.

CDC is Committed to Preventing Viral Hepatitis Among PWID

CDC’s DVH recognizes that only through improved prevention (e.g., vaccination, testing, and linkage to viral hepatitis care and treatment) can liver-related morbidity and mortality be prevented in the United States and that PWID are in urgent need for improved access to these services. Although hepatitis B vaccination is over 90% effective in preventing HBV infection, many adults with risks (including PWID) have not been vaccinated. A combination of syringe services programs and drug treatment can reduce transmission of HCV by more than 80% among PWID. The U.S. Department of Health and Human Services (HHS) has released new guidance[PDF – 22 pages] for state, local, tribal, and territorial health departments that will allow them to request to use federal funds to support syringe services programs. CDC models show that the addition of HCV testing and treatment can increase prevention effectiveness even further.

DVH works closely with CDC colleagues in the Division of HIV/AIDS and the Division of Injury Prevention. Partners outside of CDC include the National Institute on Drug Abuse, state and local health departments, and a variety of non-governmental organizations. Partnerships are essential in marshaling the resources to stop transmission of HBV, HCV, and HIV, and the increases in injection drug use.

Additional CDC Resources:

Stay Informed

  • @cdchep  has the latest information on viral hepatitis.
  • Email updates are available from CDC’s Division of Viral Hepatitis.

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