Seroprevalence of Hepatitis C and factors associated with this in crack users 1

Copyright © 2013 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms. Corresponding Author: Laís Carvalho de Sá Rua Senador Esmaragdo de Freitas, 1116 Bairro: Piçarra CEP: 64017-200, Teresina, PI, Brasil E-mail: laiscarvalhodesa@hotmail.com Laís Carvalho de Sá2 Telma Maria Evangelista de Araújo3 Rosane Harter Griep4 Viriato Campelo5 Claudete Ferreira de Souza Monteiro3


Introduction
The viral hepatites are a serious public health problem. Although hepatitis C is universally distributed, its prevalence differs depending on each region's socioeconomic and cultural characteristics. It is interesting to observe that some at-risk populations have higher prevalences when compared to the population in general.
In this regard, the consumption of crack related to the hepatitis C virus (HCV) has begun to awaken the interest of the world scientific community, as the users present risk behaviors which may make them more susceptible to infection.
In dependent use, the crack user faces problems of organic, psychological, social and legal natures.
In relation to organic problems, the World Health Organization (WHO) stresses particularly those which are infectious, such as Acquired Immunodeficiency Syndrome (AIDS), hepatitis B and C, and the infective endocardites.
Although hepatitis C's natural history has not been well elucidated, the consensus is that the virus is transmitted by parenteral exposure to blood, transfusion, and medical and dental procedures, and that it may also occur through tattooing and body piercing (1) .
The dominant means of transmission of HCV in the developed countries is the use of injectable drugs, with the sharing of needles being the main risk factor.
Nevertheless, infection can also occur as a result of the items used for preparing the drugs. The literature (2)(3)(4)(5) refers to the presence of RNA-HCV in body fluids such as saliva, peripheral lymph nodes and semen. It is worth noting that although the virus is found in low titrations, this form of transmission must be considered.
Corroborating this understanding of the possibility of other means of transmission, the Center for Disease Control and Prevention (CDC) indicated, in an American health report of 2012, that 45% of people with hepatitis C did not report any known exposure risk (6) .
Ratifying this, a study undertaken in Porto Alegre (7) investigated the prevalence of sexually-transmitted diseases (STDs) in female crack users, finding a prevalence of 37% for Human Immunodeficiency Virus and 27.7% for HCV. The authors suggest that specific habits may keep these patients at risk of transmission of, and contagion with, infectious-contagious diseases, given that the use of injections had a low frequency in the sample.
In this regard, there are some questions: Is the prevalence of hepatitis C higher among crack users than in the general population? What are the risk factors for hepatitis C presented by crack users?
In the light of the considerations raised, the disease's seriousness and the scarcity of Brazilian studies associating the use of crack as a risk behavior for acquiring hepatitis C, the present study is considered to be relevant, as it will allow the obtaining of local/ regional epidemiological data on infection among crack users, furthering the understanding of the risk factors, as well as serving as support for the establishing of policies and strategies for prevention.
Based on the above, this study aims to investigate hepatitis C seroprevalence and associated factors among crack users in the CAPS AD in Piauí (PI).

Methodology
This research was undertaken through a seroepidemiological survey and is part of a wider research program entitled "Hepatitis B and C seroprevalence in crack users in the Piauí CAPS AD".
It was carried out in the Brazilian state of Piauí in the Psycho-Social Care Centers -Alcohol and Drugs (CAPS AD) located in four municipalities; Teresina, Parnaíba, Picos and Piripiri. The study's source population was made up of 2,971 crack users registered in the state's four CAPS AD. In the sample calculation, for the total of 353 participants, an acceptable error of 5% was taken into account, with a level of significance of 95%, and through proportional stratification (8) .
The inclusion criteria were to be a crack user registered with the CAPS AD, and to accept to participate in the research. The exclusion criteria were for the user to be unable, at the time of data collection, to respond to the questions of interest to the research, as well as the absence of the express consent of the responsible party, in the case of adolescent crack users. semi-open questions, which had been previously tested so as to improve it, to test the performance of the field researchers, and to promote familiarization.
-Observation of the mouth and nose so as to ascertain the presence of blisters and/or lesions.
-Taking of a blood sample so as to research the crack users' serological situation for hepatitis C.
-Storage, processing and analysis of the samples.

Results
Of the 353 crack users who participated in the study, In the researching of the serological markers for hepatitis C (Table 3), 05 (1.4%) were positive for Anti-HCV and 04 (1.1%) for the RNA-HCV.
In Table 4, there was a statistically-significant association between RNA-HCV and age (p=0.02), living alone (p<0.01) and greater length of crack use (p=0.01).
A statistically-significant association was observed between RNA-HCV and continuity of crack use (p=0.01) and the sharing of the crack pipe (p<0.01). The other variables tested did not present statistical association (Table 5).

Discussion
The socio-demographic characterization of the sample produced a result similar to that ascertained in the first investigation on crack consumption, carried out in São Paulo in 1994 (9) , which confirmed a preponderance of men, younger than 30 years old, unemployed, with little education, and from dysfunctional families.
Regarding the characteristics related to the pattern of crack consumption, the observed was increasingly heavy consumption at progressively shorter intervals, explaining the fact that 37.1% of the crack users used the drug even while being treated in the Piauí CAPS AD.
The tendency for increase in the need for crack was also ascertained in a study (10) undertaken with drug users in the city of Rio de Janeiro in the period 2007-2008.
In order to smoke a rock of crack, the crack users use a type of pipe, and structures improvised from tin cans, plastic or cardboard tubes, aluminum foil, hydraulic parts, and even the wrappers from foodstuffs (11) . In relation to and other, anxiogenic, effects of crack (11) .
When they lack materials for making pipes, the users consume the drug in aluminum cans which they often find in the trash. In Brazil, this form of use has been well documented. In addition to the risk of the presence of infectious agents in these cans found in the gutter or trash, it should be emphasized that the high level of aluminum in brain tissue causes changes in cognitive and neurological function (12) .
It is common for crack users to share pipes between themselves, a behavior verified by the majority of this study's population. In this way, those who smoke crack have possibilities for infectious contamination (1,5) .
In relation to the consumption of injectable drugs, it was observed that this means was abandoned, The non-use of condoms was reported by part of the population studied. A higher frequency was found by researchers in a separate study (14) , in which 49.3% of crack users reported that they rarely used them, in spite of their being available for free in the health services.
Due to the irregular use of condoms, the finding that there was a 31.2% incidence of STDs in the present research is understandable. The use of psycho-active substances can make drug addicts less aware of or concerned about STDs (15) . In one randomized study, the prevalence of HCV antibodies was significantly (p≤0.001) higher in the group of heterosexuals infected with STDs than in the control group (without STDs); 5.3% compared to 0.5% (16) . One possible explanation is that as some sexually-transmissible infections are ulcerative, the presence of ulcers as a gateway may have facilitated the contamination of the organism by HCV.
In relation to the problems which involve the Police or justice system, the study ascertained that a significant majority of crack users have previously had an episode of imprisonment. This data is worrying given that the rates of prevalence of HCV in prisons and other closed institutions are higher than in the community. This occurs due to the limited access to materials, and risk practices that are undertaken, such as tattooing or body piercing without sterilized instruments, homosexual sexual practices, sexual attacks, and the sharing of injectable and non-injectable drug paraphernalia. In one study (17) undertaken in South America, in HCV mono- There are innumerable studies on the presence of RNA-HCV in the saliva (2)(3)(4)(5) but their results vary, reflecting the heterogeneity of the populations studied, and the variety of detection techniques used. Nevertheless, epidemiological studies suggest that the infectious capacity of viral particles of HCV in the saliva is low. There is no evidence that HCV is easily transmitted by kissing, sneezing, coughing or sharing cups and plates (19) .
In spite of the presence of blisters or lesions in the oral and nasal mucosa in a proportion of the sample, the prevalence found was of 1.4% for the Anti-HCV and 1.1% for RNA-HCV. The prevalence of hepatitis C among the crack users was similar to that estimated for Brazil with 1% to 2%, as well as for the chronic cases of hepatitis C which represent 1.5% of the population (20) .
In relation to the Brazilian panorama, it is important to stress that there is a shortage of information on HCV among crack users. The result was below that found among crack users in Bahía, with 2.4% (14) and similar to that among adults in Criciúma, with 1.53% (21) .
Comparing the prevalence rates around the world, prevalences were observed which are higher than that calculated in the population studied. One study (17) estimated the prevalence of HCV in Buenos Aires (Argentina) and Montevideo (Uruguay) at 8.8%. In Mexico, the prevalence of hepatitis C among the users of non-injectable drugs was 4.1% (22) . Nevertheless, it was lower than that found in Canada (0.8%) (23) .
Regarding the association of hepatitis C with age, this finding was in accordance with other investigations of users of illicit drugs (10) . Regarding the continued use of crack, it was evidenced that the fact that the users had not stopped consuming the substance, even when in treatment, suggests a greater association with hepatitis C, due to the risk behaviors described above.
No association was found between the sharing of equipment and HCV seroprevalence among noninjectable drug users, in spite of the literature (25) indicating that sharing crack-smoking equipment is statistically-associated with HCV.