Hepatitis B and Injecting-Drug Use Among American Indians -- Montana, 1989-1990

From November 1989 through March 1990, five cases of serologically confirmed acute hepatitis B (HB)* among American Indians from two Montana Indian reservations (combined population: 6300) were reported by Indian Health Service (IHS) clinic staff to the Billings IHS Area Office. In comparison, during 1986-1988, an average of six HB cases among American Indians were reported annually among persons residing both on reservations and statewide (1990 population of American Indians in Montana: 47,679). Four of the five persons with acute HB reported histories of injecting-drug use (IDU).

The IHS attempted to identify close contacts (i.e., household, sexual, and needlesharing) of the five persons to provide counseling, HB serologic testing, and HB prophylaxis. Of 149 contacts identified, 84 provided blood for serologic testing. Of the 84, nine (11%) had serologically confirmed acute HB (eight with symptoms); three (for whom IgM antibody to HB core antigen (IgM anti-HBc) test results were not available) had symptoms of acute hepatitis, were HB surface antigen (HBsAg) positive, and were suspected to have acute HB. Two persons who were HBsAg positive but IgM anti-HBc negative were considered to be HB virus (HBV) carriers. Approximately half (70 (47%)) of the contacts interviewed reported IDU.

All of the 17 persons (five index patients and 12 contacts) with serologically confirmed or suspected acute HB were American Indians living on the two reservations. The median age of patients was 28 years (range: 9-45 years); 13 were male. Fifteen (88%) patients reported histories of IDU; of these, 10 reported sharing needles with one of the two asymptomatic HBV carriers. The predominant drugs of use were methamphetamine and cocaine, injected intravenously. One patient was the child of another patient who was an injecting-drug user. Sixteen persons with acute HB consented to be tested for antibody to human immunodeficiency virus (anti-HIV); none had detectable anti-HIV.

Susceptible contacts of HBV-infected patients were offered HB immune globulin (HBIG) and/or HB vaccination. In addition, all contacts were counseled (both in person and with brochures) about prevention of HBV and HIV transmission. Although no cases of acute HB were identified from April through June 1990, in July, acute HB occurred in two additional persons living on the reservation. One had been identified previously as a sexual contact of an earlier patient and had declined HBIG and HB vaccine. The other was also a sexual contact of an earlier patient but had not been identified as a contact during the initial investigation. Reported by: R Harding, MN; SD Helgerson, MD, Billings Area Office, Indian Health Svc. T Damrow, PhD, State Epidemiologist, Montana Dept of Health and Environmental Sciences. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: HBV is transmitted most commonly and efficiently through percutaneous, sexual, and perinatal exposures (1). Transmission also can occur through inapparent percutaneous exposure, such as person-to-person transfer of infectious body fluids from skin lesions. In the Montana outbreak, most patients were injecting-drug users; several may have been infected through sexual contact, and one, a child, apparently acquired the disease through household exposure.

HBV infection is relatively uncommon among American Indians in the contiguous United States; for example, seroprevalence rates of 1%-2% have been reported among the Navajo and Sioux (2,3). In comparison, the crude prevalence rate of HBV infection in the United States is approximately 5%, and up to 70% of Alaskan Eskimos (among whom HBV infection is endemic) in selected villages are infected with HBV (4,5). Although the extent of IDU among American Indians is not well known, among U.S. high school seniors, American Indians have self-reported higher rates of drug use than have other racial/ethnic groups (6).

This HB outbreak among injecting-drug users on reservations in Montana indicates that risk behaviors exist in certain American Indian communities and that these behaviors may facilitate the spread of HB and other bloodborne viruses. Control measures for HB include vaccination and education about methods to reduce the risk for transmission of bloodborne diseases. Vaccination efforts for injecting-drug users often are unsuccessful because of the difficulty of reaching this population and ensuring completion of all doses of vaccine; therefore, the Immunization Practices Advisory Committee has recommended universal infant vaccination with HB vaccine as part of a strategy to eliminate HBV transmission in the United States (7). In addition to vaccination, education efforts on prevention of the transmission of HBV and other bloodborne pathogens, including HIV and hepatitis C virus, should continue.

References

1. Francis DP, Favero MS, Maynard JE. Transmission of hepatitis B virus. Semin Liver Dis 1981;1:27-32.

2. Ahtone J, Kuberski TT. Hepatitis B and its ancestors. Lancet 1982;1:447.

3. Shaw FE, Shapiro CN, Welty TK, Dill W, Reddington J, Hadler SC. Hepatitis transmission among the Sioux Indians of South Dakota. Am J Public Health 1990;80:1091-4.

4. McQuillan GM, Townsend TR, Fields HA, et al. The seroepidemiology of hepatitis B virus in the United States, 1976-1980. Am J Med 1989;87(suppl 3A):5-10.

5. Schreeder MT, Bender TR, McMahon BJ, et al. Prevalence of hepatitis B in selected Alaskan Eskimo villages. Am J Epidemiol 1983;118:543-9.

6. Bachman JG, Wallace JM Jr, O'Malley PM, Johnston LD, Kurth CL, Neighbors HW. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. Am J Public Health 1991;81:372-7.

7. ACIP. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-13).

*Positive for IgM antibody to HB core antigen.

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