Hepatitis B Virus Infection Among Street Youths in Montreal

Hepatitis B virus is a major cause of chronic liver disease and primary hepatocellular carcinoma in North America. Among adolescents and young adults it is transmitted mainly through unprotected sexual intercourse. The sharing of injection material among drug users is another major risk factor. Tattooing and body piercing may also play a role, but the magnitude of this risk in not well known.

Note: Although Hep. B can be transmitted by tattooing and body piercing; we now have the technology to sterilize needles and other equipment to prevent such occurrences.

In a recent seroprevalence study in northern Ontario involving people 14-30 years of age, HBsAg seroprevalence rates were estimated between 0.24% and 0.47% and anti-HBs seroprevalence rates between 0.40% and 0.78%. Among young adults presenting to an urban STD clinic in Ontario, 2.7% were found to be HBsAg positive.

Few studies have been published on the prevalence of HBV infection among street people. In a New York study 12% of men living in a shelter were found to be positive for HBsAg and 43% had HBV antibodies. Among 87 street youths in Toronto (mean age 16 years), 8 were found to be anti-HBs positive. In a more recent New York study 21% of homeless adolescents recruited in an urban drop-in center had evidence of prior HBV infection.

The study was conducted from December 1995 to September 1996. Subjects were recruited from among those participating in the Montreal Street Youth Cohort (MSYC) study, which began in January 1995 and followed youth over time for changes in sexual and drug use behaviors and HIV infection. Subjects were eligible if they were between 14 and 25 years of age, spoke French or English, intended to stay in Montreal during the following year and were “street active”. (Had either been without a place to sleep more than once or had regularly used the services of Montreal Street Youth agencies during the previous year).

Participants were also tested for Hepatitis C; because of the public health Implications and the risk factors associated with Hepatitis C are somewhat different, the results concerning Hepatitis C in this population will presented in a future paper.


A total of 437 street youths participated in the study, 372 of whom were recruited from among the MSYC study participants. The cohort and non-cohort subgroups were similar with respect to socio-demographic variables and risk behaviors such as prostitution, injection drug use and homosexual relations. The mean age was 19.5 years, and 69.3% (303/437 were males. Most (94.3%) were born in Canada, and most had Canadian–born parents (85.3% had a Canadian-born father and 91.2% a Canadian-born mother).

In terms of medical history, 4.1% (18/436 of the subjects reported a history of HBV infection. At least one dose of hepatitis B vaccine had been given to 38.5% (168/436); only 11.8% (51/434) of the participants had received 3 doses. Twenty-one (4.8%) reported that they had received blood or blood products for medical reasons. A small proportion (1.1%) said that they injected steroids.

Over Half (56.5% {247/437}) of the participants said that they had one or more tattoos (range 1-30). Of these, 162 (65.6%) had at least one tattoo done by a non- professional. As for body piercing, 40.3% (176/437) had a body part other than ears pierced; of these 101 (57.4%) had at least one piercing done by a nonprofessional.

Note: While some nonprofessional tattoo artists, and body piercers, use new needles every time they do a tattoo or piercing, others use more conventional methods such as bleach. I recommend to go to a professional if you are going to get a tattoo or piercing.

Most of the street youths were sexually active; 99.3% (434/437) reported heterosexual relations, and 18.3% (80/437) said they had had at least one homosexual partner in their lifetime. Proportionately more girls than boys reported homosexual activities (24.6% v. 15.5%) More than half (55.7%) of the participants reporting heterosexual relations and 21.3% of those reporting homosexual relations had had more than 10 partners in their lifetime. One quarter of the participants (24.5% {107/436}; 40.3% of the girls and 17.5% of the boys) reported having ever had sex in exchange for such items as money, gifts, drugs or a place to sleep.

In all, 45.8% (200/437) of the participants reported having ever injected drugs, 47.8% of the girls, 44.9% of the boys). Age at first injection ranged from 10 to 24 years (mean 16.8 years overall, 16.1 for girls, 17.1 for boys). During the month before the interview, 10.6% of the 200 injected daily 16.6% injected several times a week, 21.1% injected sporadically, and 50.8% obstained.

Just over half (51.8% {103/199}) of the youths who reported having injected drugs said they had borrowed a used needle at least once. Other injection materials were borrowed as followed: cotton (38.2%), spoon (56.8%) and water or other substances to clean needles and syringes (43.2%)

Of the 434 participants who completed the laboratory tests, 40 were found to be positive for one or both HBV markers, for a rate of 9.2% (95% confidence interval (CI) 6.7%-12.3%); 1.6% were HBsAg positive.

Being over 18 years of age, having injected drugs and having had a sexual partner with a history of unspecified hepatitis were all independently associated with HBV infection. Having had at least one tattoo and having had body piercing were not found to be a significant factors; nevertheless, they contributed as adjustment variables, and their odds ratios suggest that they may be associated with HBV infection.


Physicians will need to continue to verify vaccination status and offer vaccination to adolescents when they come in for other medical consultations. Innovative programs will be needed to educate street youths about the prevention of blood borne infections and to provide them with comprehensive health care that will include HBV vaccination. Sexual risk behaviors and injection drug use put these youths at high risk for hepatitis B and many other preventable diseases. Youth-friendly, accessible medical and social services, including substance abuse treatment programs, are urgently needed for this population.

Reproduced from Monthly News in Adolescence, October 1999.
Original research: CMAJ 167 (6), 1999.
Authors: Roy E., Haley N., Leclerc P. et al.