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Hepatitis C transmission through tattooing: a case report

Hepatitis C transmission through tattooing: a case report Mugarlane Burnet Centrefor Medical Reseurch, Melbourne Elizabeth Wale Her Majesty s Prison, Pentridge, Melbourne ' Nick Crofts Macfarlane Burnet Centre for Medical Research, Melbourne Abstract: Wt? rgbort the case of a prisoner for whom tattoe source of hepatitis C virus (HCV) infecing was the tion. Many of the tattoos were carried out within prison using equi@mt that was multiply shared with other pzso m s with limited access to means of disinfecttion. This case supports previous reports that pason is a risk factor for HCV infection and that HCV can be transmit& through tattooing. Use of unstailised equipment for tattooing urithin p.iSon must be a high-risk activity, given the high f prevalence o' HCV infection among those incarcerated. Harm reduction approaches are required to diminish risk in this environment. (Aust N ZJPublic Health 1996; 20: 317-18) he association of tattooing and infection has been recognised for many years.' Transmission of hepatitis B virus (HBV) through percutaneous procedures is well do~umented.*-~ Epidemiological evidence supports transmission of hepatitis C virus (HCV) through tattooing,@but few cases have been definitively documented,' owing to long incubation periods, low rates ofjaundice in acute infection, and lack of HCV testing when other risk factors are absent. Scepticism about honest disclosure of past illicit injecting drug use confounds interpretation of epidemiological dam5 Case history W report here the case of a 39-year-old long-term e prisoner, for whom tattooing was considered the risk for HCV infection. A heavily tattooed prisoner was interviewed about participation in a study of risk of blood-borne virus transmission from injecting drug use in prison. He was ineligible for that study because he denied ever injecting drugs, but he agreed to complete an interview about his tattooing experiences. 'This was of particular interest because he had tattooed many other prisoners. He was interviewed by a trained ethnographic worker who used a questionnaire that covered skin penetration procedures and tattooing in both registered and unregis tered premise's. After pretest counselling, blood was collected for testing for HBV, HCV and human Correspondence to Dr Sandra Thompson, Deputy Head, Epidemiology arid Social Research Unit, Macfarlane Burnet Centre for Medic.al Research, PO Box 254,Fairfield, Vic 3078.Fax (03)9482 3123. immunodeficiency virus (HIV), and post-test counselling from the same worker accompanied the return of test results. He had received an autologous skin graft in 1985, but had no history of transfusion, had never been a health care worker, denied male sexual contacts and had no history of clinical hepatitis or icteric illness. His estimated lifetime number of sexual partners was more than 80, of whom none was to his knowledge an injecting drug user or HCV-infected. His first tattoo was in prison in 1978. He worked as a backyard tattooist before working within registered tattooing premises from 1985 to 1989, and reported clearing $2000 every second weekend by tattooing navy recruits in a seaside town. He was aware that HBV could be transmitted through tattooing, and thought HIV could be transmitted, although he had been told there was no recorded case. He had heard of HCV only recently, despite earlier contact with the Professional Tattooing Association. The man reported having 'exactly 743 tattoos', with approximately 400 performed in professional shops, around 200 in prison and about 150 by himself or friends outside prison. He had been tattooed on over 1000 occasions, including alterations and name changes. He reported about 400 occasions of being tattooed in prison, and 300 nonprofessional occasions of tattooing outside. He had also had skin piercing on six to eight occasions, most within prison and none at professional premises. As a tattooist with professional experience he regularly tattooed and taught other prisoners, asserting he could not put his knowledge of sterilisation and disinfection into practice in prison because of the lack of material such as alcohol. When possible, equipment was dipped in liquid laundry bleach but this was delivered to stores only once per month and ran out after the first week. His own last tattoo had been performed on three occasions over a month, during which time seven or eight other prisoners were also being tattooed with the same handpiece, derived from a cassette motor. He believed that tattooing should be legalised within prison 'so that it could conform to the standards of the Skin Penetration Act'. At interview, he reported that he was not infected with HBV, HCV or HIV. Serologically he was HCV antibody-positive,positive for HCV RNA on the polymerase chain reaction test, HBV core antibody317 AUSTRALIAN AND N W ZEALAND JOURNAL O WBUC HEALTH 15'96 m. 2 NO. 3 E F 0 THOMPSON ET AL. negative and surface antigen-negative, and HIVnegative. Discussion Circumstantially, it would appear that this man was infected with HCV through unsterile skin penetration (most likely tattooing) given his multiple potential exposures. Many occasions had been in prison where, because tattooing is prohibited, tattooing equipment is shared and access to means of disinfection are limited. He had no reason to conceal past injecting drug use and believed himself not to be infected with HCV. Although multiple sexual partners have been reported as a risk for HCV in some but not all studies,5s6 there is increasing recognition that HCV is transmitted sexually with low effic i e n ~ y . ~ , ~ unsterilised equipment for tattooing Use of within prison must be a high-risk activity, given the high prevalence of HCV infection among those incarcerated. l o Despite sharing tattooing equipment within prison, he had failed to appreciate the significance of poor disinfection there, both in terms of his own risk and the risk that tattooists might pose to their clients, even though he had been a professional tattooist (with a high case-load) at registered premises for several years. This suggests a need for more education and training of registered tattooists in disinfection and infection control. Although injecting drug use is the major risk for infection with HCV, some studies have found tattooing to be an independent risk f a ~ t o r . ~ a ,One study ~*" found a higher risk from multiple tattoos compared with a single site, and from tattooing performed by nonprofessional tattooists compared with professional tattooi~ts,~ otherwise little detailed assessbut ment of risk from tattooing exposure has been reported. The potential for blood-borne virus transmission within prisons has been re~ognised.~*'*-~~ Transmission of HIV through tattooing has been documented only in the context of prison.16 Prisoners undoubtedly form a core group, which should be included in prevention efforts. This was acknowledged in a recent review of the Victorian Prisons Drug Strategy." Much of the discussion about infection control in prisons has centred on access to condoms and clean injecting equipment. However, as this case illustrates, attention also needs to be given to clean, sterilised equipment for tattooing, since tattooing has the potential to serve as a means for transmission of viruses to other prisoners who do not have risk factors such as injecting drug use or homosexual contact. Tattooing and skin penetration in Australia are restricted by registration of premises. Tattooing within prison is prohibited on the basis that it may allow prisoners to feign a change of identity, but it is common. Given the difficulties which prison authorities have in stopping skin-penetration practices, it may be wiser to adopt a harm-reduction approach and give prisoners access to professional tattooing and skin piercing so that hygiene standards be observed. Acknowledgements We are grateful for the assistance of Dr Peter Hearne, Governor Brian Greaves, Les Setterfield and other staff at Pentridge Prison involved in this study. Serological testing was performed by the Victorian Infectious Diseases Reference Laboratory. The prisoner was interviewed with permission from the Correctional Services Division of the Victorian Department of Justice, but the views represented herein are those of the authors and do not in any way represent policy of the Division or the Department. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Hepatitis C transmission through tattooing: a case report

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Publisher
Wiley
Copyright
Copyright © 1996 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1996.tb01035.x
Publisher site
See Article on Publisher Site

Abstract

Mugarlane Burnet Centrefor Medical Reseurch, Melbourne Elizabeth Wale Her Majesty s Prison, Pentridge, Melbourne ' Nick Crofts Macfarlane Burnet Centre for Medical Research, Melbourne Abstract: Wt? rgbort the case of a prisoner for whom tattoe source of hepatitis C virus (HCV) infecing was the tion. Many of the tattoos were carried out within prison using equi@mt that was multiply shared with other pzso m s with limited access to means of disinfecttion. This case supports previous reports that pason is a risk factor for HCV infection and that HCV can be transmit& through tattooing. Use of unstailised equipment for tattooing urithin p.iSon must be a high-risk activity, given the high f prevalence o' HCV infection among those incarcerated. Harm reduction approaches are required to diminish risk in this environment. (Aust N ZJPublic Health 1996; 20: 317-18) he association of tattooing and infection has been recognised for many years.' Transmission of hepatitis B virus (HBV) through percutaneous procedures is well do~umented.*-~ Epidemiological evidence supports transmission of hepatitis C virus (HCV) through tattooing,@but few cases have been definitively documented,' owing to long incubation periods, low rates ofjaundice in acute infection, and lack of HCV testing when other risk factors are absent. Scepticism about honest disclosure of past illicit injecting drug use confounds interpretation of epidemiological dam5 Case history W report here the case of a 39-year-old long-term e prisoner, for whom tattooing was considered the risk for HCV infection. A heavily tattooed prisoner was interviewed about participation in a study of risk of blood-borne virus transmission from injecting drug use in prison. He was ineligible for that study because he denied ever injecting drugs, but he agreed to complete an interview about his tattooing experiences. 'This was of particular interest because he had tattooed many other prisoners. He was interviewed by a trained ethnographic worker who used a questionnaire that covered skin penetration procedures and tattooing in both registered and unregis tered premise's. After pretest counselling, blood was collected for testing for HBV, HCV and human Correspondence to Dr Sandra Thompson, Deputy Head, Epidemiology arid Social Research Unit, Macfarlane Burnet Centre for Medic.al Research, PO Box 254,Fairfield, Vic 3078.Fax (03)9482 3123. immunodeficiency virus (HIV), and post-test counselling from the same worker accompanied the return of test results. He had received an autologous skin graft in 1985, but had no history of transfusion, had never been a health care worker, denied male sexual contacts and had no history of clinical hepatitis or icteric illness. His estimated lifetime number of sexual partners was more than 80, of whom none was to his knowledge an injecting drug user or HCV-infected. His first tattoo was in prison in 1978. He worked as a backyard tattooist before working within registered tattooing premises from 1985 to 1989, and reported clearing $2000 every second weekend by tattooing navy recruits in a seaside town. He was aware that HBV could be transmitted through tattooing, and thought HIV could be transmitted, although he had been told there was no recorded case. He had heard of HCV only recently, despite earlier contact with the Professional Tattooing Association. The man reported having 'exactly 743 tattoos', with approximately 400 performed in professional shops, around 200 in prison and about 150 by himself or friends outside prison. He had been tattooed on over 1000 occasions, including alterations and name changes. He reported about 400 occasions of being tattooed in prison, and 300 nonprofessional occasions of tattooing outside. He had also had skin piercing on six to eight occasions, most within prison and none at professional premises. As a tattooist with professional experience he regularly tattooed and taught other prisoners, asserting he could not put his knowledge of sterilisation and disinfection into practice in prison because of the lack of material such as alcohol. When possible, equipment was dipped in liquid laundry bleach but this was delivered to stores only once per month and ran out after the first week. His own last tattoo had been performed on three occasions over a month, during which time seven or eight other prisoners were also being tattooed with the same handpiece, derived from a cassette motor. He believed that tattooing should be legalised within prison 'so that it could conform to the standards of the Skin Penetration Act'. At interview, he reported that he was not infected with HBV, HCV or HIV. Serologically he was HCV antibody-positive,positive for HCV RNA on the polymerase chain reaction test, HBV core antibody317 AUSTRALIAN AND N W ZEALAND JOURNAL O WBUC HEALTH 15'96 m. 2 NO. 3 E F 0 THOMPSON ET AL. negative and surface antigen-negative, and HIVnegative. Discussion Circumstantially, it would appear that this man was infected with HCV through unsterile skin penetration (most likely tattooing) given his multiple potential exposures. Many occasions had been in prison where, because tattooing is prohibited, tattooing equipment is shared and access to means of disinfection are limited. He had no reason to conceal past injecting drug use and believed himself not to be infected with HCV. Although multiple sexual partners have been reported as a risk for HCV in some but not all studies,5s6 there is increasing recognition that HCV is transmitted sexually with low effic i e n ~ y . ~ , ~ unsterilised equipment for tattooing Use of within prison must be a high-risk activity, given the high prevalence of HCV infection among those incarcerated. l o Despite sharing tattooing equipment within prison, he had failed to appreciate the significance of poor disinfection there, both in terms of his own risk and the risk that tattooists might pose to their clients, even though he had been a professional tattooist (with a high case-load) at registered premises for several years. This suggests a need for more education and training of registered tattooists in disinfection and infection control. Although injecting drug use is the major risk for infection with HCV, some studies have found tattooing to be an independent risk f a ~ t o r . ~ a ,One study ~*" found a higher risk from multiple tattoos compared with a single site, and from tattooing performed by nonprofessional tattooists compared with professional tattooi~ts,~ otherwise little detailed assessbut ment of risk from tattooing exposure has been reported. The potential for blood-borne virus transmission within prisons has been re~ognised.~*'*-~~ Transmission of HIV through tattooing has been documented only in the context of prison.16 Prisoners undoubtedly form a core group, which should be included in prevention efforts. This was acknowledged in a recent review of the Victorian Prisons Drug Strategy." Much of the discussion about infection control in prisons has centred on access to condoms and clean injecting equipment. However, as this case illustrates, attention also needs to be given to clean, sterilised equipment for tattooing, since tattooing has the potential to serve as a means for transmission of viruses to other prisoners who do not have risk factors such as injecting drug use or homosexual contact. Tattooing and skin penetration in Australia are restricted by registration of premises. Tattooing within prison is prohibited on the basis that it may allow prisoners to feign a change of identity, but it is common. Given the difficulties which prison authorities have in stopping skin-penetration practices, it may be wiser to adopt a harm-reduction approach and give prisoners access to professional tattooing and skin piercing so that hygiene standards be observed. Acknowledgements We are grateful for the assistance of Dr Peter Hearne, Governor Brian Greaves, Les Setterfield and other staff at Pentridge Prison involved in this study. Serological testing was performed by the Victorian Infectious Diseases Reference Laboratory. The prisoner was interviewed with permission from the Correctional Services Division of the Victorian Department of Justice, but the views represented herein are those of the authors and do not in any way represent policy of the Division or the Department.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Jun 1, 1996

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