Seroepidemiology and risk factors of Hepatitis B and C virus infections among drug users in Jakarta, Indonesia
48
Gani et al
Med J Indones
Seroepidemiology and risk factors of Hepatitis B and C virus infections
among drug users in Jakarta, Indonesia
Rino A Gani, Unggul Budihusodo, Agus Waspodo, L.A. Lesmana, ksan Hasan, Nurul Akbar, H.M Sjaifoellah Noer
Abstrak
Pasien pengguna obat-obatan sangat meningkat beberapa tahun terakhir ini. Telah dilakukan peneLitian untuk mendapatkan
gambaran seroepidemiologi infeksi virus hepatitis B dan C pada pelaku penyalahgunaan obat di Jakarta. Data diambil secara
konsekutif di RSUPN Cipto Mangunkusumo dan RS Mitra Menteng Abadi, lakttrta, dari semua pasien yang menggunakan narkotika.
Sampel serum diperiksa untuk mendeteksi HBsAg (RPHA, Laboratorium Hepatika, Mataram, Indonesia) dan anti-HCV (dipstik,
Laboratorium Hepatika, Mataram, Indonesia). Dalam 5 bulan (Maret - Agustus 1999) terdapat 203 kasus pengguna narkotika.
Kebanyakan (185/203 kasus, 9l,I Vo) adalah laki-laki dengan rerdta umur 21,2 + 4,3 tahun. Rerata umur mulai menggunakan
narkotikn adalah 18,8 t 4,0 tahun. Prevalensi Anti-HCV dan HBsAg positif masing-masing adalah 74,9 Vo ( I51 kasus) dan 9,9 % (I9
knsus) dari seluruh sampel. Pada 168 kasus (84Vo), narkotika digunakan dengan cara suntik. Hubungan seksual di luar pernikahan
diakui oleh 62 kasus (30,5 Eù, narnun hanya 16 kasus (8 Vo) yang berganti-ganti pasan7an. Tato terdapat pada 32 kasus (15,8 7a).
Analisis muhivaiat menunjukkan bahwa penggunaan suntikan dan tato merupakan faktor risiko yang berkaitan dengan anTi-HCV positif,
dengan OR masing-masing 9,15 (95Vo CI 3,28 - 5,53) dan 13,24 (96Vo CI 1,6 - 109,55). Tidak ada satupunfaktor risiko medikyang
diteliti mempunyai hubungan secara bermal 2 years
Frequency
First time
Not everyday
Everyday
HBsAg
:
hepatitis B surface antigen
I
0
10.5
89.5
0
0
I
l8
5.3
94.7
'l
176
47
43
94
= 184
0.5
3.8
95.7
positiven =
0
J
148
5l.l
38
36
77
25.5
23.4
151
0
negativen= 52
6
45
86.5
25.2
l9
36.5
23.8
9
17.3
51.0
24
2
6
l.l
2
1.3
0
3.3
5
2.3
2
176
95.7
95.4
50
Anti-HCV
IM
: antibody to hepatitis C virus
1.9
1
20
980
l
1.5
0
3.8
96.2
Vol 1 1, No I, January,
- March 2002
Riskfactors of hepatitis B and C
virus 5l
Opiate was abused in a total of 193 cases (94.8 7o).
Type of drug was significantly associated with antiHCV positivity, where opiate was used by 148 of l5l
patients (98ok) withAnti-HCVpositivecomparedto
45 of 52 patients (86.5 Vo) with anti-HCV negative.
Most patients with HBsAg posrtrve (89.5 Vo) also used
opiate, but there was no significant difïerence in type
Univariate analysis of the medical risk factors for
transmission of hepatitis B and C virus were shown in
table 3 and 4. Extramarital sex were practiced by 62
cases (30.5 Vo),but only in 16 cases (8 7o) with more
than one partner. Furthermore, prevention had been
taken for save sex. Tattoos were found in 32 cases
(15.8 Vo of all patients), but HBsAg was positive in
only 2 cases (6.2 7o), while Anti-HCV positive was in
between HBsAg positive and negative
31 cases (96.9 Vo).
of
drug, duration and frequency
of drug usage
cases.
Table 3. Some medical risk fàctors tbr HBsAg positivity in drug users (n = 203)
HBsAg
posirive
nVonVo
Negarive
sex no
yes
15
4
'78.9
2l.l
126
58
68.5
31.5
no
yes
17
2
89.5
10.5
154
30
83.7
I 6.3
no
ycs
l8
I
94.7
5.3
167
17
90.8
9.2
piercing no
ycs
12
7
63.2
36.8
I
14
70
62.0
38.0
Tr:Lnslirsiorr no
yes
19
0
100
0
l8l
3
98.4
l9
0
100
0
l'13
ll
94.0
l8
I
3
16
94.7
5.3
15.8
84.2
164
20
'24
160
89.1
10.9
13.0
87.0
4
l5
21.I
'78.9
31
153
16.8
83.2
Extlirmirrital
Tattoo
Surgery
Body
Family history
jaundice
Drink
of no
yes
alcohol no
yes
Circurncision no
yes
Mcthod of drug usage
non-injection
injection
HBsAg
NA
: hepatitis B surfàce antigen
: not applicable
1.6
6.0
t;'f"
95olo
confidence
Ref.
1.50
0.61 - 3.67
Ref.
I
55
0.40 - 5.98
Ref.
1.76
0.25
-
0.56
-
Rel.
L03
12.47
1.9
NA
NA
NA
NA
I
Ref.
2.07
0.29
-
14.55
0.85
-
I .13
0.83
-
1.34
Rei.
0.98
Ref.
1.05
52
Gani et al
Metl J lndones
Table 4. Some medical risk fàctors fbr
Anti-HCV positivity in drug users (n = 203)
Anti-HCV
Extramarital sex
Tattoo
no
113
748
yes
38
25.2
79.5
20.5
no
120
yes
3l
no
138
yes
13
9t.4
86
no
86
65
yes
Family history of
jaundice
Drink alcohol
Surgery
Body piercing
Circumcision
28
24
538
462
5t
98 I
19
I
OR
Ref.
Ref.
570
430
40
76.9
Ref.
12
23.1
r.35
150
1
99.3
0.7
50
2
96.2
3.8
Ref.
no
141
98.
Ref.
t0
93.4
6.6
51
yes
no
t34
yes
t7
88.7
I t.3
no
21
130
86
139
I
46
ti8
6.0
94.0
26
26
50.0
50.0
yes
Method of drug usage
non-inject'ion
i njection
9
142
r
l.l3 - 1.35
1.23
0.99
no
0.55 - 0.94
Ref.
90.4
9.6
4'7
95 % Confidence
Interval
0.12
5
yes
Transfusi on
Crude
Negative
Positive
0.89 - 1.09
l.r0-
o97
I.66
0.92
- t.02
- l.l
I
1.9
r.05
0.99
48
92.3
7.7
Ref.
1.04
0.94- I.t5
ll5
Ref.
0.8s
0.40
4
6
5
Rel'.
8.40
-
I
r.80
4.2 - 16'72
Anti-HCV : antibody to hepatitis C virus
IDU were identified in 168 cases (82.8
Vo) and 127
cases (75.6 Vo) among them had ever shared needle.
In IDIJ, 142 were positive for Anti-HCY
(84.5
model of the relationship of these factors were shown
in table 5.
Vo),
and I5 were HbsAg positive (8.9Vo).
Table 5. Model for Anti-HCV positivity
Our data showed that there were no medical risk
f'actors (extramarital sex, tattooing, ever had surgery,
body prercing, history of transfusion. {amily history of
jaundice, alcohol drinking) that were associated with
FIbsAg positivity.
i"lrrlijvariate analysis of the above mentioned risk
iijù1,) s revealed that only tattoo (yes/no) and method
oi JiLigr usage (injection/non-injection) were risk
factors associated with anti-HCV positivity. The
OR
Method of drug usage
:
Non-injection
Injection
Tattoo:
No
Yes
95 % Contldence
Intervnl
Ref.
9.1 5
3.28
Ref.
13.24
1.6
Anti-HCV : antibody to hepatitis C virus
-
-
r
25.53
09.55
Vol I l, No
l, Januar\,- March 2002
Riskfactors of hepatiris B and C virus
DISCUSSION
53
HBsAg positivity.l In
This study was done in hospitals where only specific
cases were admitted which make it difïicult to
compare the result to the condition in general population.
However, the two hospitals have a ditferent patient
characteristics. Most patients admitted to Cipto
Mangunkusumo hosprtal appeared to have medical
complications and came ïiom the lower socioeconomic
level. On the contrary, those admitted to Mitra Menteng
Abadi Hospital were fiee fiorn complications and came
Iiom higher socioeconomic level. Nevertheless, no
detailed data about socioeconomic level. and the use
of house hold Lrtensils contributrng in the transmission
of hepatitis viruses could be obtained.
Male patients were predominant in this study and
most of them were IDU who used opiate. These
characteristics were difTerent from a hospital based
stLrdy in other country where most of them were non
IDU. I The use of injection in Indonesian drug users
may just recently arise and is increasing very f'ast.
They were relatively young (adolescence perrod) and
had started to use the drug in high school. The
yoLlngest case of this study was a l2-year-old male who
already used opiate by injection with a shared needle.
Adolescence is recognized as a period of time where
someone has a strong bond to their group of fiiends and
also needs to explore anything including drugs.
In
general population, HBsAg positive prevalence
was 4 %,.4 while rn the present study, it is 9.9 7o
which is 2.5 times greater. This study showed that
dru-{ users were on high-risk fbr HBV infèction. The
prevalence of HBsAg positivity among the drug users
rn this str,rdy is higher compared to the western
coLrntry, but it rs about the same compared to the other
Asian countries.T's o Th" ,"oron fbr this discrepancy is
not clear, but it may be associated with the prevalence
of HBsAg positivity in the general popularion.
HBV and HCV may share the same pathway of
transmission such as via body fluld or biood, hence
the risk tàctor for viral transmission may be the same
tbr both viruses. However, some pathway may
a general population study, only
socioeconomic, ethnicity (Chinese) and number of
family members were the risk fàctors fbr HBsAg
positivity, while medical risk factors such as: bloocl
transfïsion, history of jaundice, family history of
jaundice and ever had operation were not relateci to
HbsAg positivity.a However, no drug users was
included in that study. Risk factors for hepatitis B
transmission in drug users has yet to be determined,
but horizontal transmission may play a bigger role,
because age-specific prevalence in this study showed
bigger percentages of HBsAg posrtivity in the age
range of 16 - 25 compared to the younger age group.
Since inter-relation within drug users in daily lit-e is
very close, this can be the reason for the transmission
of hepatitis B virus among them. Therefore, a more
detailed study in the behavior of drug users is needed.
In this study, extramarital sex was practiced by one
third of the drug users. Having sex with IDU is
reported as a risk factor for HBV and HCV
transmission,T although this study could not confirmed
it. This may be due to cases, who confessed to have
sexual intercourse, and gave the data about the
number of intercourse done, or the number of sexual
partner, that was not suficient to uncover the
relationship between those variables with HBsAg or
Anti-HCV positivity. Nevertheless, this
srudy
revealed that some drug users practiced unsat-e sexual
relatronship, whrch together with IDU were also risk
factors fbr other diseases such as HIV.e
The prevalence of Anti-HCV positivity among IDU in
this study was lower compared to the study on IDU in
Kuala Lumpur, Malaysia where 92.5 7o of the cases
were positive fbr anti-HCV. r0 The just recently
marked increase of drug users in Indonesia may
explain the lower number of HCV prevalence compared
to the prevalence in Malaysia. However, the prevalence
of Anti-HCV positivity in this study was higher
compared to other countries where anti-HCV prevalence
in IDU was 50 - J5 7n.r'8J '-'o This is due to the lack of
specific and major public programs to prevent viral
transmission among IDU in Indonesia, whrle in the
of IDU has already been
be
country where the problem
of
recognized as a major public problem, several programs
have been introduced, such as syringe exchange program
or methadone clinic.
population was not related to the several medical risk
factors mentioned above. Another study also fbund no
relationship between the use of syringe or needle and
In the same age group of the general population in
Jakarta (12-30 years), the prevalence of anti-HCV is
etIèctive fbr HBV, but not fbr HCV, and vice versa.
Hepatitis
B virus
transmission
in this group
54
Med J Indones
Gani et al
only 0.4 Vn.t5 Our data showed that the prevalence of
anti-HCV positivity in drug users was 150 - 200 fold
higher than in general population. Hepatitis C virus
inf'ection is rarely symptomatic. Most HCV infection
occurs as chronic hepatitis which leads to liver
cirrhosis in about 20 years.l6 This can be a substantial
problem in the future long after the addiction problem
HCV in general population will increase rapidly. It
in drug users have been eliminated.
can be expected that in young people (< 30 years old)
the prevalence of hepatitis B and C virus infection will be
increased. Furthermore, the double infection of HBV and
HCV was also high, and this would be a bad prognosis
for the progression to chronic liver disease. [n the future,
the number of people with chronic liver disease in this
area may be increased due to this reason.
This study also showed that the prevalence of double
Experience in another country showed that drug users,
infèction
of hepatitis B and C was also higher
compared to in general population where only 0.2 Vo.
.or", *"r" positive fbr both anti-HCV and HBsAg.a
Double intèction of HBV and HCV is one of the
factors that may lead to the development of chronic
liver disease. Liver disease is usually more severe in
clor.rble inf'ection cases, and the risk of developrng
hepatocellular carcinoma (HCC) are much higher than
paiients inf-ected by either single virus alone.'7''t
The risk factors fbr anti-HCV positivity among drug
users in this study were injection drug usage and
having tattoo. Injection drug usage was also reported
as one of the risk factors for hepatitis C
virus
particularly IDU, who began in the recent past got a
higher risk to suffèr from chronic hepatitis, Ïver
cirrhosis and liver
"ancer.'u''o
A large population
based study should be conducted to clarify this issue.
Preventions
for HBV and HCV
transmission in
Indonesia have been already implemented including
vaccination and screening of blood donors.
Hopefully such measures can minimize both viral
transmission through vertical route for HBV and
horizontal route fbr HCV. However, viral transmission
fiom drug user route may potentially be more imporlant
HBV
in the future and also need prompt management.
transmission among drug users in other study.le'20 Our
No vaccine has yet been available fbr the prevention
of HCV inf-ection, but studies in this field are still
progressing. One candidate is the DNA vaccination
which is promising in animal models and shortly can
be expected to be studied in human.
relatively narrower range of patients' age in this study
cornpared to the study in general population.
In conclusion, this study revealed that in drug users the
prevalence of HCV, HBV and double inf'ection of these
two viruses are high and much higher compared to the
finclings is not in agreement with the study in the
general population, where the risk tàctors fbr antiHCV positivity were age and blood transfusion.a The
reasons for the ditlèrence might be the small number
of cases who ever had blood transfusion, and the
Tattoo
in the general population study was not
associated with
anti-HCV positivrty.5 This might be due
to the relatively smaller number of people who
infècrions in general population. Injected drug usage and
tattoo are risk factors fbr HCV transmission.
had
tattoo in that study compared to our data. Tattooing is
Acknowledgment
enough knowledge of sterility to prevent the transmission
of microorganism. Tattoo had also been reported as one
We highly appreciate Prof. Dr. Mulyanto and his statf
at Laboratorium Hepatrka, Mataram for their help in
training of our stafï and the generosity in supplying
often applied by the drug users' companion, who in
most circumstances were'also a diug user, without
population of non injection drug users, having a tattoo
was associated with anti-HCV positivity.re
the reagent for HbsAg RPHA and anti-HCV dipstick'
Also to Prof. Dr. Dadang Hawari, Dr. Ratna MS. and
Dr. Herdiman who were willing to give permission to
let their patients participate in this study.
Several studies in general population conducted 4 - 5
years ago could identify only a very small number of
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Gani et al
Med J Indones
Seroepidemiology and risk factors of Hepatitis B and C virus infections
among drug users in Jakarta, Indonesia
Rino A Gani, Unggul Budihusodo, Agus Waspodo, L.A. Lesmana, ksan Hasan, Nurul Akbar, H.M Sjaifoellah Noer
Abstrak
Pasien pengguna obat-obatan sangat meningkat beberapa tahun terakhir ini. Telah dilakukan peneLitian untuk mendapatkan
gambaran seroepidemiologi infeksi virus hepatitis B dan C pada pelaku penyalahgunaan obat di Jakarta. Data diambil secara
konsekutif di RSUPN Cipto Mangunkusumo dan RS Mitra Menteng Abadi, lakttrta, dari semua pasien yang menggunakan narkotika.
Sampel serum diperiksa untuk mendeteksi HBsAg (RPHA, Laboratorium Hepatika, Mataram, Indonesia) dan anti-HCV (dipstik,
Laboratorium Hepatika, Mataram, Indonesia). Dalam 5 bulan (Maret - Agustus 1999) terdapat 203 kasus pengguna narkotika.
Kebanyakan (185/203 kasus, 9l,I Vo) adalah laki-laki dengan rerdta umur 21,2 + 4,3 tahun. Rerata umur mulai menggunakan
narkotikn adalah 18,8 t 4,0 tahun. Prevalensi Anti-HCV dan HBsAg positif masing-masing adalah 74,9 Vo ( I51 kasus) dan 9,9 % (I9
knsus) dari seluruh sampel. Pada 168 kasus (84Vo), narkotika digunakan dengan cara suntik. Hubungan seksual di luar pernikahan
diakui oleh 62 kasus (30,5 Eù, narnun hanya 16 kasus (8 Vo) yang berganti-ganti pasan7an. Tato terdapat pada 32 kasus (15,8 7a).
Analisis muhivaiat menunjukkan bahwa penggunaan suntikan dan tato merupakan faktor risiko yang berkaitan dengan anTi-HCV positif,
dengan OR masing-masing 9,15 (95Vo CI 3,28 - 5,53) dan 13,24 (96Vo CI 1,6 - 109,55). Tidak ada satupunfaktor risiko medikyang
diteliti mempunyai hubungan secara bermal 2 years
Frequency
First time
Not everyday
Everyday
HBsAg
:
hepatitis B surface antigen
I
0
10.5
89.5
0
0
I
l8
5.3
94.7
'l
176
47
43
94
= 184
0.5
3.8
95.7
positiven =
0
J
148
5l.l
38
36
77
25.5
23.4
151
0
negativen= 52
6
45
86.5
25.2
l9
36.5
23.8
9
17.3
51.0
24
2
6
l.l
2
1.3
0
3.3
5
2.3
2
176
95.7
95.4
50
Anti-HCV
IM
: antibody to hepatitis C virus
1.9
1
20
980
l
1.5
0
3.8
96.2
Vol 1 1, No I, January,
- March 2002
Riskfactors of hepatitis B and C
virus 5l
Opiate was abused in a total of 193 cases (94.8 7o).
Type of drug was significantly associated with antiHCV positivity, where opiate was used by 148 of l5l
patients (98ok) withAnti-HCVpositivecomparedto
45 of 52 patients (86.5 Vo) with anti-HCV negative.
Most patients with HBsAg posrtrve (89.5 Vo) also used
opiate, but there was no significant difïerence in type
Univariate analysis of the medical risk factors for
transmission of hepatitis B and C virus were shown in
table 3 and 4. Extramarital sex were practiced by 62
cases (30.5 Vo),but only in 16 cases (8 7o) with more
than one partner. Furthermore, prevention had been
taken for save sex. Tattoos were found in 32 cases
(15.8 Vo of all patients), but HBsAg was positive in
only 2 cases (6.2 7o), while Anti-HCV positive was in
between HBsAg positive and negative
31 cases (96.9 Vo).
of
drug, duration and frequency
of drug usage
cases.
Table 3. Some medical risk fàctors tbr HBsAg positivity in drug users (n = 203)
HBsAg
posirive
nVonVo
Negarive
sex no
yes
15
4
'78.9
2l.l
126
58
68.5
31.5
no
yes
17
2
89.5
10.5
154
30
83.7
I 6.3
no
ycs
l8
I
94.7
5.3
167
17
90.8
9.2
piercing no
ycs
12
7
63.2
36.8
I
14
70
62.0
38.0
Tr:Lnslirsiorr no
yes
19
0
100
0
l8l
3
98.4
l9
0
100
0
l'13
ll
94.0
l8
I
3
16
94.7
5.3
15.8
84.2
164
20
'24
160
89.1
10.9
13.0
87.0
4
l5
21.I
'78.9
31
153
16.8
83.2
Extlirmirrital
Tattoo
Surgery
Body
Family history
jaundice
Drink
of no
yes
alcohol no
yes
Circurncision no
yes
Mcthod of drug usage
non-injection
injection
HBsAg
NA
: hepatitis B surfàce antigen
: not applicable
1.6
6.0
t;'f"
95olo
confidence
Ref.
1.50
0.61 - 3.67
Ref.
I
55
0.40 - 5.98
Ref.
1.76
0.25
-
0.56
-
Rel.
L03
12.47
1.9
NA
NA
NA
NA
I
Ref.
2.07
0.29
-
14.55
0.85
-
I .13
0.83
-
1.34
Rei.
0.98
Ref.
1.05
52
Gani et al
Metl J lndones
Table 4. Some medical risk fàctors fbr
Anti-HCV positivity in drug users (n = 203)
Anti-HCV
Extramarital sex
Tattoo
no
113
748
yes
38
25.2
79.5
20.5
no
120
yes
3l
no
138
yes
13
9t.4
86
no
86
65
yes
Family history of
jaundice
Drink alcohol
Surgery
Body piercing
Circumcision
28
24
538
462
5t
98 I
19
I
OR
Ref.
Ref.
570
430
40
76.9
Ref.
12
23.1
r.35
150
1
99.3
0.7
50
2
96.2
3.8
Ref.
no
141
98.
Ref.
t0
93.4
6.6
51
yes
no
t34
yes
t7
88.7
I t.3
no
21
130
86
139
I
46
ti8
6.0
94.0
26
26
50.0
50.0
yes
Method of drug usage
non-inject'ion
i njection
9
142
r
l.l3 - 1.35
1.23
0.99
no
0.55 - 0.94
Ref.
90.4
9.6
4'7
95 % Confidence
Interval
0.12
5
yes
Transfusi on
Crude
Negative
Positive
0.89 - 1.09
l.r0-
o97
I.66
0.92
- t.02
- l.l
I
1.9
r.05
0.99
48
92.3
7.7
Ref.
1.04
0.94- I.t5
ll5
Ref.
0.8s
0.40
4
6
5
Rel'.
8.40
-
I
r.80
4.2 - 16'72
Anti-HCV : antibody to hepatitis C virus
IDU were identified in 168 cases (82.8
Vo) and 127
cases (75.6 Vo) among them had ever shared needle.
In IDIJ, 142 were positive for Anti-HCY
(84.5
model of the relationship of these factors were shown
in table 5.
Vo),
and I5 were HbsAg positive (8.9Vo).
Table 5. Model for Anti-HCV positivity
Our data showed that there were no medical risk
f'actors (extramarital sex, tattooing, ever had surgery,
body prercing, history of transfusion. {amily history of
jaundice, alcohol drinking) that were associated with
FIbsAg positivity.
i"lrrlijvariate analysis of the above mentioned risk
iijù1,) s revealed that only tattoo (yes/no) and method
oi JiLigr usage (injection/non-injection) were risk
factors associated with anti-HCV positivity. The
OR
Method of drug usage
:
Non-injection
Injection
Tattoo:
No
Yes
95 % Contldence
Intervnl
Ref.
9.1 5
3.28
Ref.
13.24
1.6
Anti-HCV : antibody to hepatitis C virus
-
-
r
25.53
09.55
Vol I l, No
l, Januar\,- March 2002
Riskfactors of hepatiris B and C virus
DISCUSSION
53
HBsAg positivity.l In
This study was done in hospitals where only specific
cases were admitted which make it difïicult to
compare the result to the condition in general population.
However, the two hospitals have a ditferent patient
characteristics. Most patients admitted to Cipto
Mangunkusumo hosprtal appeared to have medical
complications and came ïiom the lower socioeconomic
level. On the contrary, those admitted to Mitra Menteng
Abadi Hospital were fiee fiorn complications and came
Iiom higher socioeconomic level. Nevertheless, no
detailed data about socioeconomic level. and the use
of house hold Lrtensils contributrng in the transmission
of hepatitis viruses could be obtained.
Male patients were predominant in this study and
most of them were IDU who used opiate. These
characteristics were difTerent from a hospital based
stLrdy in other country where most of them were non
IDU. I The use of injection in Indonesian drug users
may just recently arise and is increasing very f'ast.
They were relatively young (adolescence perrod) and
had started to use the drug in high school. The
yoLlngest case of this study was a l2-year-old male who
already used opiate by injection with a shared needle.
Adolescence is recognized as a period of time where
someone has a strong bond to their group of fiiends and
also needs to explore anything including drugs.
In
general population, HBsAg positive prevalence
was 4 %,.4 while rn the present study, it is 9.9 7o
which is 2.5 times greater. This study showed that
dru-{ users were on high-risk fbr HBV infèction. The
prevalence of HBsAg positivity among the drug users
rn this str,rdy is higher compared to the western
coLrntry, but it rs about the same compared to the other
Asian countries.T's o Th" ,"oron fbr this discrepancy is
not clear, but it may be associated with the prevalence
of HBsAg positivity in the general popularion.
HBV and HCV may share the same pathway of
transmission such as via body fluld or biood, hence
the risk tàctor for viral transmission may be the same
tbr both viruses. However, some pathway may
a general population study, only
socioeconomic, ethnicity (Chinese) and number of
family members were the risk fàctors fbr HBsAg
positivity, while medical risk factors such as: bloocl
transfïsion, history of jaundice, family history of
jaundice and ever had operation were not relateci to
HbsAg positivity.a However, no drug users was
included in that study. Risk factors for hepatitis B
transmission in drug users has yet to be determined,
but horizontal transmission may play a bigger role,
because age-specific prevalence in this study showed
bigger percentages of HBsAg posrtivity in the age
range of 16 - 25 compared to the younger age group.
Since inter-relation within drug users in daily lit-e is
very close, this can be the reason for the transmission
of hepatitis B virus among them. Therefore, a more
detailed study in the behavior of drug users is needed.
In this study, extramarital sex was practiced by one
third of the drug users. Having sex with IDU is
reported as a risk factor for HBV and HCV
transmission,T although this study could not confirmed
it. This may be due to cases, who confessed to have
sexual intercourse, and gave the data about the
number of intercourse done, or the number of sexual
partner, that was not suficient to uncover the
relationship between those variables with HBsAg or
Anti-HCV positivity. Nevertheless, this
srudy
revealed that some drug users practiced unsat-e sexual
relatronship, whrch together with IDU were also risk
factors fbr other diseases such as HIV.e
The prevalence of Anti-HCV positivity among IDU in
this study was lower compared to the study on IDU in
Kuala Lumpur, Malaysia where 92.5 7o of the cases
were positive fbr anti-HCV. r0 The just recently
marked increase of drug users in Indonesia may
explain the lower number of HCV prevalence compared
to the prevalence in Malaysia. However, the prevalence
of Anti-HCV positivity in this study was higher
compared to other countries where anti-HCV prevalence
in IDU was 50 - J5 7n.r'8J '-'o This is due to the lack of
specific and major public programs to prevent viral
transmission among IDU in Indonesia, whrle in the
of IDU has already been
be
country where the problem
of
recognized as a major public problem, several programs
have been introduced, such as syringe exchange program
or methadone clinic.
population was not related to the several medical risk
factors mentioned above. Another study also fbund no
relationship between the use of syringe or needle and
In the same age group of the general population in
Jakarta (12-30 years), the prevalence of anti-HCV is
etIèctive fbr HBV, but not fbr HCV, and vice versa.
Hepatitis
B virus
transmission
in this group
54
Med J Indones
Gani et al
only 0.4 Vn.t5 Our data showed that the prevalence of
anti-HCV positivity in drug users was 150 - 200 fold
higher than in general population. Hepatitis C virus
inf'ection is rarely symptomatic. Most HCV infection
occurs as chronic hepatitis which leads to liver
cirrhosis in about 20 years.l6 This can be a substantial
problem in the future long after the addiction problem
HCV in general population will increase rapidly. It
in drug users have been eliminated.
can be expected that in young people (< 30 years old)
the prevalence of hepatitis B and C virus infection will be
increased. Furthermore, the double infection of HBV and
HCV was also high, and this would be a bad prognosis
for the progression to chronic liver disease. [n the future,
the number of people with chronic liver disease in this
area may be increased due to this reason.
This study also showed that the prevalence of double
Experience in another country showed that drug users,
infèction
of hepatitis B and C was also higher
compared to in general population where only 0.2 Vo.
.or", *"r" positive fbr both anti-HCV and HBsAg.a
Double intèction of HBV and HCV is one of the
factors that may lead to the development of chronic
liver disease. Liver disease is usually more severe in
clor.rble inf'ection cases, and the risk of developrng
hepatocellular carcinoma (HCC) are much higher than
paiients inf-ected by either single virus alone.'7''t
The risk factors fbr anti-HCV positivity among drug
users in this study were injection drug usage and
having tattoo. Injection drug usage was also reported
as one of the risk factors for hepatitis C
virus
particularly IDU, who began in the recent past got a
higher risk to suffèr from chronic hepatitis, Ïver
cirrhosis and liver
"ancer.'u''o
A large population
based study should be conducted to clarify this issue.
Preventions
for HBV and HCV
transmission in
Indonesia have been already implemented including
vaccination and screening of blood donors.
Hopefully such measures can minimize both viral
transmission through vertical route for HBV and
horizontal route fbr HCV. However, viral transmission
fiom drug user route may potentially be more imporlant
HBV
in the future and also need prompt management.
transmission among drug users in other study.le'20 Our
No vaccine has yet been available fbr the prevention
of HCV inf-ection, but studies in this field are still
progressing. One candidate is the DNA vaccination
which is promising in animal models and shortly can
be expected to be studied in human.
relatively narrower range of patients' age in this study
cornpared to the study in general population.
In conclusion, this study revealed that in drug users the
prevalence of HCV, HBV and double inf'ection of these
two viruses are high and much higher compared to the
finclings is not in agreement with the study in the
general population, where the risk tàctors fbr antiHCV positivity were age and blood transfusion.a The
reasons for the ditlèrence might be the small number
of cases who ever had blood transfusion, and the
Tattoo
in the general population study was not
associated with
anti-HCV positivrty.5 This might be due
to the relatively smaller number of people who
infècrions in general population. Injected drug usage and
tattoo are risk factors fbr HCV transmission.
had
tattoo in that study compared to our data. Tattooing is
Acknowledgment
enough knowledge of sterility to prevent the transmission
of microorganism. Tattoo had also been reported as one
We highly appreciate Prof. Dr. Mulyanto and his statf
at Laboratorium Hepatrka, Mataram for their help in
training of our stafï and the generosity in supplying
often applied by the drug users' companion, who in
most circumstances were'also a diug user, without
population of non injection drug users, having a tattoo
was associated with anti-HCV positivity.re
the reagent for HbsAg RPHA and anti-HCV dipstick'
Also to Prof. Dr. Dadang Hawari, Dr. Ratna MS. and
Dr. Herdiman who were willing to give permission to
let their patients participate in this study.
Several studies in general population conducted 4 - 5
years ago could identify only a very small number of
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