The most common chronic bloodborne infection in the United States is hepatitis C virus (HCV).1 Appalachia has a very high prevalence of HCV infections and it is epidemic in drug-using persons.2 There was a 364% increase in HCV infections from 2006 to 2012; because of this, HCV testing has become part of routine prenatal screening in our obstetric care center.1 When pregnant patients are informed that they are HCV-infected, many deny intravenous (IV) drug use or sharing of needles, stating that they purposely wanted to avoid becoming infected with human immunodeficiency virus (HIV) and other infections including hepatitis. However, in questioning these patients further, they often would state that they snorted opiates and that they frequently shared the snorting straws or utensils.
There is growing evidence that straws used in snorting drugs may transmit HCV. Conry-Cantilena et al3 studied 248 HCV-infected blood donors and found through logistic regression analysis that among other risk factors, intranasal cocaine use was a risk factor for HCV infection. Investigators studying sexual transmission of HCV in HIV-infected gay men found sharing drugs by a nasal route was a significant risk factor for infection.4 In terms of laboratory investigation, of nasal secretions from five HCV-infected drug users, one sample tested HCV-positive.5 In addition, Aaron et al6 found that 28 (74%) of the nasal secretions of 38 HCV-infected individuals were positive for blood, and five (13%) tested positive for the presence of HCV RNA. In that study, the 38 participants were also asked to insert a sterile straw intranasally and “snort air” to mimic the process of snorting drugs, and of these straws, three (8%) were positive for blood and two (5%) were positive for HCV RNA.
The study purpose was to evaluate possible modes of HCV acquisition through known common routes as well as possible straw transmission in HCV-infected pregnant patients in eastern Tennessee.
MATERIALS AND METHODS
This was a prospective cohort study involving the distribution of an anonymous survey to HCV-infected pregnant women in our institutional obstetric high-risk clinic who tested positive for HCV RNA. The questionnaire was printed on a single page and contained 21 questions with six subquestions depending on individual responses. Areas evaluated included IV drug use, blood transfusion, organ transplant, sexual contact, tattoos, and snorting drugs with a straw or some other utensil. Several questions were in the questionnaire that the authors knew would be negative or not relevant to our study objective but were placed to not draw attention to the primary focus of the study. Each pregnant woman who participated was told that their responses would be beneficial to other women who might become pregnant in the future to potentially avoid HCV and other infections. There were no questions of any kind that would identify the participant who completed the survey and no monetary or other incentives were used.
Demographic data were collected on the group as a whole but this information was not specifically attached to the survey material to keep the process completely anonymous. Pregnant women were chosen because we perform routine screening for HCV in all pregnancies in our high-risk obstetric clinic. The study duration was 16 months, from March 2014 through June 2015.
The primary questions of interest involved IV drug use and the sharing of needles and the snorting of drugs and the sharing of straws. Statistical analysis involved simple percentages with Poisson binomial 95% confidence intervals and χ2 comparisons where appropriate and a P value <.05 was considered significant. All tests were considered against a two-sided alternative hypothesis where appropriate.
To study the biological plausibility of blood being found on snorting utensils in eastern Tennessee, straws confiscated by local law enforcement authorities from a different population than the pregnant study group were tested for the presence of human blood. The Hexagon OBTI Immunochromatographic Test for Confirming the Presence of Human Blood Traces forensic test, which is used by law enforcement agencies to test for the presence of human blood, was used in testing the confiscated utensils. The detection limit is 0.05 micrograms hemoglobin per milliliter. The test is more than 95% accurate up to 6 months from the time of blood staining to the time of testing. This study was approved by the institutional review board of the University of Tennessee Medical Center, Knoxville.
A total of 189 HCV-infected pregnant patients were consented to participate and completed the survey; no approached patients declined. These women were generally young (mean age 26.5 years) and white nonminority (84%). All study patients had a positive HCV RNA viral load with a range of 250 copies per milliliter up to 34.5 million copies per milliliter. None (0%) of the 189 women had received a blood transfusion, clotting factor, or organ transplant before 1992 (when screening for HCV was adopted nationally); none were on hemodialysis; and none had an HIV coinfection.
Of the 189 study patients, 136 (72%, 95% confidence interval [CI] 65–78%) admitted to IV drug use and 89 of these (65%, 95% CI 57–73%) said they had shared needles. These 89 patients constitute only 47% of the study population. However, even more of them, 178 (94%, 95% CI 90–97%), admitted to snorting drugs and 164 (92%, 95% CI 87–96%) of these shared the snorting straws or utensils. These 164 patients constitute 87% of the study group. The greater frequency of sharing snorting utensils when compared with sharing needles was significant (P<.001; Table 1). Additional responses to questions related to risks for HCV transmission are found in Table 1.
Overall, 29 (15%, 95% CI 11–21%) HCV-infected pregnant women snorted drugs and shared straws but denied any history of IV drug use or any other major risk factor. There were 80 patients (42% of the study population) who reported the sharing of snorting utensils but denied the sharing of needles. Of interest, 133 participants (70%, 95% CI 63–77%) did not have any idea when they had become infected, and 127 (67%, 95% CI 60–74%) were first told they had HCV after the prenatal laboratory work that was obtained during routine prenatal care.
We obtained 54 straws and other snorting utensils from local law enforcement agencies that were confiscated through arrests related to illicit drug use from individuals not part of the study population. The time from confiscation to testing ranged from 3 weeks up to 8 weeks. We forensically tested these in our department for the presence of human blood and 13 (24%, 95% CI 13–38%) were found to be positive.
Many risk factors exist for becoming infected with HCV; however, the sharing of straws in the process of snorting opiates (or any other drug) is probably an additional risk factor. The snorting of drugs with straws and other utensils does result in blood contamination, as shown by this study and Aaron et al,6 and, if shared by another individual, can expose the mucous membrane of the nasal cavity to blood that might contain the HCV or any other bloodborne virus, leading to possible infection.
The May 2015 Morbidity and Mortality Weekly Report publication that reported a 364% increase in HCV infections from 2006 to 2012 in the central Appalachian region discusses a concern that, if HIV were to enter the blood pool of this population, an increase in this serious infection might also develop.1 A large number of HIV infections were reported in 2015 in a southeastern rural county of Indiana.7 A warning sign for this event was a cluster of HCV infections that occurred in the same region in 2011.8 Human immunodeficiency virus would be another viral illness that could potentially be passed through infected blood exposure to mucous membranes.
Some could argue that sexual transmission is potentially a major route, especially because all of our participants were pregnant. The survey results actually show that 82% reported more than five sexual partners. However, the rate of becoming HCV-infected through sexual transmission is considered low with many studies reporting risks at less than 10%.9–12 Therefore, this particular risk factor is unlikely to explain all of the infections seen in this study unrelated to IV drug use and the sharing of needles.
Although not part of the survey, nearly all of the participants reported that opiates were the primary drug that was snorted. In addition, the opiates used intravenously and snorted in our region are crushed prescription analgesics. Heroin use in our study population is currently less than 5%. Neonatal abstinence syndrome is also epidemic in Tennessee and a recent study performed in the same region that analyzed fetal and newborn growth only found heroin use in three of 332 cases or 1%.13
This study is subject to several limitations. First, to make the participants comfortable about answering candidly and honestly, no identification of any kind was placed on the survey as shown. Therefore, there is no way to correlate demographic material to the individual responses. Furthermore, we are limited to the questions on the survey and going back to acquire further information on the patients or to assess other questions is not possible.
Second, individuals can always be untruthful when filling out a survey and, therefore, the exact values for each inquiry can be questioned. However, we specifically chose the pregnant population because pregnancy provides a populace that often is more motivated for health care as a result of potential effects on an unborn child.14,15 However, our results are similar to those in a recent Centers for Disease Control and Prevention national surveillance study of 635 interviews from five states and one city.2 The response rate of “ever injecting drugs” was 77% (367/477) compared with our study of 72% (136/189). Likewise, the response rate of sharing needles was 57% (76/133) compared with our study of 65% (89/136).
Third, none of the snorting straws or utensils used by the participants in the study were tested for the presence of human blood; however, 24% of tested straws confiscated from other drug users were positive for human blood, which supports the biologic plausibility of snorting straw transmission. Again, IV drug abuse and the sharing of needles are well established as a mode for transmission of bloodborne viral infections including HCV and HIV. However, none of these studies ever show that 100% of the infected group had IV drug use as a risk factor. The rate of IV drug abuse in our study was 72%, which is no different than two other Centers for Disease Control and Prevention studies of 73% and 77%.1,2 This means that approximately 25% have some other potential mode of transmission. A National Institutes of Health systematic review of 28 studies that evaluated HCV infection and noninjection drug use determined that HCV infection in the non-IV drug abuse population exists but the route of transmission is unclear.16
In conclusion, the sharing of snorting utensils in the process of snorting opiates (or any other drug) may be an additional risk factor for becoming infected with HCV and other bloodborne infections and this risk needs to be communicated to the public and the health care community.
1. Zibbell JE, Iqbal K, Patel RC, Suryaprasad A, Sanders KJ, Moore-Moravian L, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep 2015;64:453–8.
2. Suryaprasad AG, White JZ, Xu F, Eichler BA, Hamilton J, Patel A, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006–2012. Clin Infect Dis 2014;59:1411–9.
3. Conry-Cantilena C, VanRaden M, Gibble J, Melpolder J, Shakil AO, Viladomiu L, et al. Routes of infection, viremia, and liver disease in blood donors found to have hepatitis C virus infection. N Engl J Med 1996;334:1691–6.
4. Danta M, Brown D, Bhagani S, Pybus OG, Sabin CA, Nelson M, et al. Recent epidemic of acute hepatitis C virus in HIV-positive men who have sex with men linked to high-risk sexual behaviours. AIDS 2007;21:983–91.
5. McMahon JM, Simm M, Milano D, Clatts M. Detection of hepatitis C virus in the nasal secretions of an intranasal drug-user. Ann Clin Microbiol Antimicrob 2004;3:6.
6. Aaron S, McMahon JM, Milano D, Torres L, Clatts M, Tortu S, et al. Intranasal transmission of hepatitis C virus: virological and clinical evidence. Clin Infect Dis 2004;47:931–4.
7. Conrad C, Bradley HM, Broz D, Buddha S, Chapman EL, Galang RR, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep 2015;64:443–4.
8. Strathdee SA, Beyrer C. Threading the needle—how to stop the HIV outbreak in rural Indiana. N Engl J Med 2015;373:397–9.
9. Feldman JG, Minkoff H, Landesman S, Dehovitz J. Heterosexual transmission of hepatitis C, hepatitis B, and HIV-1 in a sample of inner-city women. Sex Transm Dis 2000;27:338–42.
10. Marincovich B, Castilla J, del Romero J, García S, Hernando V, Raposo M, et al. Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples. Sex Transm Infect 2003;79:160–2.
11. Roy KM, Goldberg DJ, Hutchinson S, Cameron SO, Wilson K, MacDonald L. Hepatitis C virus among self declared non-injecting sexual partners of injecting drug users. J Med Virol 2004;74:62–6.
12. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis C virus transmission? Hepatology 2010;52:1497–505.
13. Visconti KC, Hennessy KC, Towers CV, Howard BC. Chronic opiate use in pregnancy and newborn head circumference. Am J Perinatol 2015;32:27–32.
14. Smoking cessation during pregnancy. Committee Opinion No. 471. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:1241–4.
15. Crozier SR, Robinson SM, Borland SE, Godfrey KM, Cooper C, Inskip HM, et al. Do women change their health behaviors in pregnancy? Findings from the Southampton Women's Survey. Paediatr Perinat Epidemiol 2009;23:446–53.
16. Scheinmann R, Hagan H, Lelutiu-Weinberger C, Stern R, Des Jarlais DC, Flom PL, et al. Non-injection drug use and hepatitis C virus: a systematic review. Drug Alcohol Depend 2007;89:1–12.