A new report in the October issue of Hepatology underlines the importance of vaccinating injection drug users (IDUs) for hepatitis B. Health officials from the Centers for Disease Control and health departments in Montana and New Mexico report on a series of acute hepatitis B infections in IDUs that resulted in fatal fulminant hepatitis.
Fulminant means sudden and severe; fulminant hepatitis is characterized by massive and rapid killing of liver cells. Fulminant hepatitis is rare, but generally fatal in adults. About 1% of new hepatitis B infections result in fulminant hepatitis and death. Fulminant hepatitis has also been reported in a small number of people chronically infected with hepatitis C who become infected with hepatitis A. Drugs and medications have also been linked to fulminant hepatitis.
The Hepatology paper identified 10 cases of fulminant hepatitis B among IDUs, all of whom died from liver failure. Comparison with people with acute hepatitis B infections that did not result in fulminant hepatitis suggests that use of alcohol, methamphetamine, and acetaminophen (an ingredient in Tylenol and some other pain relievers) may have contributed to the incidence of fulminant hepatitis.
The authors conclude that "[i]mproved vaccination coverage among IDUs has the potential to prevent similar outbreaks in the future."
Full abstract follows:
Factors associated with fulminant liver failure during an outbreak among injection drug users with acute hepatitis B
Richard S. Garfein1, William A. Bower1*, Cherry M. Loney2, Yvan J. F. Hutin1, Guo-liang Xia1, Jaspaul Jawanda1, Amy V. Groom3, Omana V. Nainan1, James S. Murphy4, Beth P. Bell1
1 Centers for Disease Control and Prevention, Atlanta, GA
2 Cascade City-County Health Department, Great Falls, MT
3 Indian Health Service, Headquarters West, Albuquerque, NM
4 Montana Department of Public Health and Human Services, Helena, MT
email: William A. Bower (firstname.lastname@example.org)
*Correspondence to William A. Bower, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G37, Atlanta, GA 30017. Fax: 404-639-6127
Death related to acute hepatitis B occurs in approximately 1% of patients. We investigated an outbreak of hepatitis B virus (HBV) infections among injection drug users (IDUs) resulting in several deaths. We conducted a case-control study of fulminant (case patients) and nonfulminant (control patients) HBV infections. We directly sequenced the entire HBV genome from fulminant and nonfulminant cases. From October 1998 to July 2000, 21 acute HBV infections, including 10 fulminant hepatitis B cases, were identified. The median age was 30 (range, 18-49) years, 12 (57%) were female, 20 (95%) were American Indians, and 20 (95%) reported injecting illicit drugs. All patients with fulminant hepatitis B died (case-fatality rate = 47.6%). Case patients (n = 5) and control patients (n = 9) were similar with respect to age, sex, race, and hepatitis C virus serostatus. All case patients used acetaminophen during their illness compared with 44% of control patients (P = .08). Compared with control patients, case patients lost more weight in the 6 months before illness (P = .04); during their illness, they used more alcohol (P = .03) and methamphetamine (P = .04). All 9 isolates sequenced were genotype D, shared 99.7% homology, and included mutations previously described in association with fulminant hepatitis B. In conclusion, a high prevalence of exposure to factors potentiating hepatic damage with acute hepatitis B contributed to the outbreak's high mortality rate; mutations present in the outbreak strain might also have been a factor. Improved vaccination coverage among IDUs has the potential to prevent similar outbreaks in the future.