Elsevier

Public Health

Volume 122, Issue 10, October 2008, Pages 990-1003
Public Health

Review Paper
Epidemiology of hepatitis C virus infection among injection drug users in China: Systematic review and meta-analysis

https://doi.org/10.1016/j.puhe.2008.01.014Get rights and content

Summary

Objectives

Injection drug use (IDU) is the predominant mode of hepatitis C virus (HCV) transmission in China. This paper aims to provide a comprehensive and reliable tabulation of available data on the epidemiological characteristics and risk factors for HCV infection in injection drug users (IDUs) in China to help inform prevention programmes and guide future research.

Study design

Data from articles and reports according to pre-defined criteria on HCV infection rates among IDUs of different regions, genders, ethnic backgrounds and risk factors (injecting practice, needle sharing, long duration, sex behaviour and co-infection status) were abstracted and pooled by meta-analysis. A systematic review was constructed based on both pooled data and representative viewpoints.

Methods

Ninety-five percent confidence intervals (CI) of infection rates were calculated using the approximate normal distribution model. Odds ratios and 95% CI were calculated by fixed or random effects models. Publication bias was examined using Begg's test and Egger's test. Data manipulation and statistical analyses were undertaken using STATA 7.0 and RevMan 4.2. Epi Info 3.4.3 was used for map construction.

Results

The pooled prevalence of HCV infection among IDUs in China was 61.4% (95% CI 55.7–67.2%), and the epidemic was most severe in Hubei, Yunnan, Guangxi, Hunan and Xinjiang. No significant difference was found in HCV infection rates between male and female IDUs. A significant association was found between HCV infection and ethnic-minority status. IDUs were 9.24 times more likely to be infected with HCV than non-IDUs, while non-IDUs were more likely to be infected with HCV than members of the general population and other risk populations. There was no significant difference in the risk of HCV infection for needle-sharing IDUs and non-needle-sharing IDUs. A longer duration of IDU was associated with increased HCV prevalence. High-risk sexual practices were strongly associated with drug injection behaviours. Co-infection with human immunodeficiency virus (HIV) greatly increased the probability of HCV infection among IDUs, while the probability of hepatitis B virus infection remained similar for HCV-positive and HCV-negative IDUs in China.

Conclusions

IDU continues to fuel the HCV/HIV epidemics spreading throughout China. Many pragmatic strategies are being implemented but need further evaluation.

Introduction

Worldwide, infection with hepatitis C virus (HCV) has become a major cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma.1, 2, 3, 4 The World Health Organization (WHO) has estimated that 170 million persons are chronically infected with HCV worldwide, and 3–4 million persons are newly infected each year.5 According to a multicentre epidemiological study in China between 1991 and 1995 (about 90,000 persons investigated), HCV prevalence averages 2.2% in the general population (range 0.52–3.15%), amounting to approximately 26.4 million infected individuals.6

HCV is spread primarily by direct contact with human blood. High risks for HCV infection include intravenous and percutaneous drug use [referred to as injection drug use (IDU)], transfusion of blood products, haemodialysis and unprotected sex with multiple sex partners.7 IDU has been the predominant mode of HCV transmission since a scrutiny system was established for blood donors throughout China. By the end of 2005, approximately 1,160,000 drug users were documented in China, although the actual number could be much greater, and 78.3% of drug users were addicted to heroin.8 Approximately 53.8% of drug users use injection as the primary route of administration, and it is estimated that 45% of injection drug users (IDUs) share needles and syringes. Bloodborne viruses, such as human immunodeficiency virus (HIV), HCV and hepatitis B virus (HBV), are transmitted efficiently through needles and syringes.9, 10, 11 It has been reported that anti-HCV positive rates among IDUs in China are very high, ranging from 15.6% to 98.7%.12, 13, 14, 15 The HCV incidence rate reported by an IDU cohort in Guangxi Province was 37.6 per 100 person-years [95% confidence interval (CI) 28.4–48.8],16 which is among the highest published for IDU cohorts around the world.17, 18, 19

Considering the enormous number of drug users in China, rapid transmission of HCV among and beyond this population, long duration of clinical progression of the virus, and reduced access of infected addicts to routine treatment, HCV is one of China's major health burdens.

Recent years have seen growing interest in the study of HCV infection and risk behaviours among IDUs in different regions of China. However, many of the studies drew incompatible or even contradictory conclusions, and the generalizability of any single study is limited. This paper reviews the available evidence in an attempt to provide a comprehensive and reliable tabulation of available data on the epidemiological characteristics and risk factors for HCV infection among IDUs in China to help inform policy makers developing prevention strategies, and guide further research.

Section snippets

Literature searching

A number of sources were used to access data for this review. PubMed and Embase were searched for published articles from January 1994 to December 2006 using the search terms: HCV OR hepatitis C* AND drug use OR drug abuse OR drug addict OR substance abuse OR heroin* AND China OR Chinese. A China National Knowledge Infrastructure search from January 1994 to December 2006 was also undertaken for Chinese articles related to HCV and drug use. The reference lists from relevant review articles and

Results

Overall, 357 studies (311 Chinese and 46 English) were identified, of which 204 (190 Chinese and 14 English) were potentially relevant. According to the inclusion criteria, 29 (27 Chinese and two English) studies were not included. This left 175 (163 Chinese and 12 English) studies for more detailed evaluation. One hundred and ten studies (102 Chinese and eight English) were excluded according to the exclusion criteria. Of the 65 (61 Chinese and four English) studies included in the review, 53

Discussion

China has 34 administrative units. Yunnan, located in South-east China and bordering on one of the world's most important opium planting and drug producing bases (the ‘Golden Triangle’, an area near the borders of Laos, Myanmar and Thailand), has been an important transfer station for drug smuggling to other regions of China since the 1980s. The trafficking routes lead out of the Golden Triangle into Yunnan, and then go north to Xinjiang through Sichuan, or go east along the so-called ‘China

Conclusions

It has been reported that drug use was eradicated in China due to the nationwide anti-drug campaign in the early 1950s, but re-emerged since the opening and reform policy in the 1980s.102 IDUs did not receive much attention until the early infected individuals had been through the ‘window phase’ and displayed symptoms. IDU now fuels the HCV/HIV epidemics spreading throughout China. Without adequate treatment options and effective implementation strategies in IDUs, the epidemics will continue to

Limitations

The limitations of this review should be acknowledged. Firstly, because the studies were observational and drug users were not selected at random, selection bias and confounding seems inevitable; as such, only suggestive conclusions can be drawn. Secondly, many of the data were extracted from articles written in Chinese, which makes it difficult for non-Chinese reviewers, editors and readers to recheck the original materials. Thirdly, self-reported data have obvious limitations; information

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