Tattooing and the risk of acquiring hepatitis C infection

Diseases transmitted by blood transfusion have played a major part in medical practice throughout the past two decades. HIV and hepatitis B dominated the 1980s and were followed by a worldwide pandemic of infection with hepatitis C virus, with up to 2% of adults in the West infected.^{1 2} Risk factors for viruses associated with trans fusion relate predominantly to the direct transfer of infected blood or, to a lesser extent, of bodily fluids, such as semen, between individuals (see box). Patient populations dependent on transfusion products—for example, patients with haemophilia—were often all but destroyed by coinfection with hepatitis C and HIV.¹ The availability and widespread use of vaccines against hepatitis B virus has shifted attention towards hepatitis C and HIV, both of which are largely not curable with current drug therapies, and no suitable vaccines have been developed. Hepatitis C infection is of particular concern as 20-30% of affected patients will develop end stage liver disease within 20 years. Once cirrhosis is established there is a further risk of primary liver cancer (hepatocellular carcinoma) of up to 5% per year.³

Hepatitis C transmission

The rise of hepatitis C (and HIV) is a reflection of changes in society as a whole and the participation of large groups of the population in practices that often put them at high risk. Increased illicit drug use and the sharing of intravenous needles among drug addicts are undoubtedly closely associated with increased rates of infection and remain one of the biggest challenges for public heath systems and services.

Sexual promiscuity is a further major risk factor for hepatitis B and HIV infection, both of which are readily spread during unprotected sexual intercourse, with the recipient partner being most at risk, particularly during sex among men.

Hepatitis C transmission differs, however, markedly from that of HIV and hepatitis B in that sexual intercourse seems to be associated with a very low rate of transmission—partners of infected individuals mostly do not acquire the virus. Studies of groups known to be at high risk—such as prison inmates, in whom the prevalence of hepatitis C infection can be as high as 30%—have, however, identified tattooing as an independent risk factor, with potentially devastating implications for the wider public.⁴

Tattooing and hepatitis C

Tattooing or body art has been practised in various parts of the world for decades (figure. Changes in culture and society have made tattoos more acceptable, and they now appeal to a wide and diverse part of the population. In prison populations where needles are shared between inmates and used for both tattoos and intravenous drug abuse the odds ratio of acquiring hepatitis C infection by means of a tattoo was 3.4 (95% confidence interval 1.6 to 7.5) after correcting for other modes of transmission. Transmission is not restricted to prisons—commercial tattoos carry a risk of up to 3% in the West.⁵ Conversely, it has been suggested that up to 41% of current carriers of hepatitis C virus were infected by obtaining a tattoo. Having multiple tattoos does also increase one’s chances of contracting hepatitis C infection, although size does not seem to matter.⁶ No information has been published relating to the position of the tattoo on the body or its design with regards to hepatitis C infection

Hepatitis C infection is higher for tattoos done by a non-professional friend than by a professional tattooist. The status of the tattooist also plays a part—tattooists who are positive for hepatitis C increase the risk of infection—and probably reflects the fact that many tattooists decorate their own bodies with tattoos.⁶

>Tattoos: you have been warned

Safety, prevention, and the medical perspective of hepatitis C

Hepatitis C infection—like other bloodborne viruses—is fairly easy to avoid and prevent.

Direct inoculation by means of “dirty” needles or sharp objects presents probably the biggest risk of becoming infected. Intravenous drug users should not share needles but exchange them for single use sterile ones that are available free from most drug rehabilitation centres. The same rules are generally applicable to obtaining a tattoo. Always ensure you are dealing with a professional tattooist and that needles are adequately sterilised or, even better, are single use and disposed of after every customer. Another option would be to avoid a tattoo altogether.

All blood products are currently screened for hepatitis C and should be safe. Common sense would however be to avoid all contact with any patients’ blood or other bodily fluids by using adequate barrier methods such as gloves or protective eye wear (even if they are hepatitis C negative). Treat all patients as potentially positive for hepatitis C. Medical staff are especially at risk of acquiring infection with hepatitis C and should observe extreme caution with the handling of sharps and follow guidelines closely in order to avoid needlestick injuries.

A final word: it is worth while noting that doctors are currently not required to be screened for hepatitis C, but that if a doctor is found to be infected, he or she will be prevented from doing certain clinical duties—“exposure prone procedures”—and it might well mean the end of your career. Be careful!

Also in this issue of the studentBMJ see our article on the history of body art and the review of the tattoo exhibition currently on in London

Bertus Eksteen, specialist registrar in gastroenterology, Department of Medicine, Queen Elizabeth Hospital, University of Birmingham, Birmingham B15 2TH

Janusz Jankowski, professor of gastrointestinal research
Email: j.jankowski@bham.ac.uk


studentBMJ 2002;10:171-214 June ISSN 0966-6494

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