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The Tattooing Paradox
Are Studies of Acute
Hepatitis Adequate to Identify Routes of Transmission of
Subclinical Hepatitis C Infection?
Robert W. Haley, MD; R. Paul
Fischer, MD
Arch Intern Med. 2003;163:1095-1098.
Background The Hepatitis Branch of the
Centers for Disease Control and Prevention
does not recommend routine regulation and
inspection of tattoo parlors because surveillance of
hepatitis C virus (HCV)-positive acute
hepatitis cases rarely identifies tattooing
in the incubation period. However, the majority of
seroepidemiological studies agree that tattooing
is a strong, independent risk factor for
subclinical HCV seropositivity. We postulated
that this paradox might be explained if transmission
of HCV by tattooing generally caused subclinical
HCV seropositivity without the acute
hepatitis syndrome.
Methods We reanalyzed data from a prior
seroepidemiological study of 626 consecutive
patients who were unaware of their HCV
serologic status and whose risk factors were ascertained
by interview of an internist. Separate multiple
logistic regression models were developed to
predict a history of the acute hepatitis
syndrome and HCV seropositivity.
Results A history of injection-drug use was
strongly associated with both HCV
seropositivity (adjusted odds ratio [AOR], 7.2;
95% confidence interval [CI], 3.1-16.5) and a
history of acute hepatitis (AOR, 5.9; 95% CI,
2.5-13.8), whereas having a commercially
applied tattoo was strongly associated with HCV
seropositivity (AOR, 6.5; 95% CI, 2.9-14.4)
but not with a history of acute hepatitis
(AOR, 1.2; 95% CI, 0.5-3.3).
Conclusions Intravenous injection of
relatively large quantities of innocula of
HCV may be more likely to result in the
relatively rare acute HCV hepatitis syndrome, whereas
intradermal exposure to small quantities of
innocula may cause only subclinical HCV
infections. If so, public policy on regulation and
inspection of tattoo parlors should be
determined by seroepidemiological studies
rather than by the Sentinel Counties Study of acute
hepatitis cases.
From the Epidemiology Division, Department of
Internal Medicine, University of Texas Southwestern
Medical Center (Dr Haley), and the Department of
Internal Medicine, Presbyterian Hospitals of Dallas (Dr
Fischer), Dallas, Tex. The authors have no relevant
financial interest in this article.
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