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Hepatitis C virus (HCV) is hyperendemic worldwide in people who inject drugs (PWID) [1]. HCV prevalence rates in PWID typically vary between 40% and 90%, and incidences may fall between 20 and 40 infections per 100 person-years [2–6]. In high-income countries, half of PWID are infected with HCV within 5 years following onset of drug injection, and in lowand middle-income countries, half may be infected within 1 year [1]. A recent publication estimated that, globally, 10 million PWID have been infected with HCV [7]. Infectious disease control strategies typically target features of the agent, host, and environment to interrupt transmission; all such features of HCV favor rapid spread in PWID. The agent is highly efficiently transmitted via parenteral exposure to infectious blood, and it is relatively stable in the environment [8, 9]. Illicit drug injection practices may include the shared use of syringes and drug preparation equipment, such as drug cookers, filtration cotton, and rinse water; each of these host behaviors has been shown to be associated with HCV transmission [5, 6, 10]. Substantial declines in syringe sharing have dramatically reduced human immunodeficiency virus (HIV) incidence in PWID in high-income countries, but the shared use of other drug preparation materials persists [11, 12]; thus, HCV transmission continues at extremely high rates. Owing to HCV’s ability to evade the immune system, 70%–80% of infections become chronic [13, 14]. Thus, the environment—the settings in which PWID inject together—is characterized by a high prevalence of infectious carriers and a wide range of materials that may harbor and transmit HCV. In this issue of the Journal, 2 laboratory studies contribute new knowledge to our understanding of the mechanisms by which HCV may be transmitted among PWID via injectionrelated materials. Dörrbecker et al describe their experiments using cell culture–grown HCV (JFH1, derived from a Japanese patient with fulminant hepatitis) to infect hepatoma cells and study infectivity and inactivation of the virus on inanimate surfaces [15]. Using this state-of-the-art method, they revealed that exposure to disinfectants, including those containing alcohol, will effectively inactivate dried HCV on surfaces. Simulating drug injection, containers (spoons or cookers) to prepare drugs for injection were contaminated with HCV in a water solution and heat was applied. Their experiments showed that HCV could survive temperatures up to 65 –70 C, which required between 80 and 95 seconds of heating. In an earlier study in New York and Denver, ethnographers directly observed drug preparation in injection settings and measured heating times and temperatures applied to drug containers [16]. Only 12% of PWID heated drug solutions for .45 seconds, and nearly half heated for ,15 seconds; they replicated these conditions in the laboratory and found that HIV was rapidly inactivated when heated, within 7–10 seconds. Thus, this new study by Dörrbecker and colleagues lends additional support to the hypothesis that drug preparation practices that include heating may reduce the risk of HIV transmission via the shared use of containers, but that HCV may still be transmitted. This would also be consistent with substantial epidemiologic evidence that sharing containers is associated with HCV seroconversion [5, 6, 10]. The article by Thibault et al [17] describes laboratory analyses of injection materials (syringes, drug cookers, filtration cotton, used water vials, and alcohol and cotton swabs) collected from PWID in France. Some materials were collected from PWID who reported that they were HCV positive, and others were collected without regard to the HCV status of the individual. Six hundred twenty items were obtained and sorted according to type, and 62 pooled samples acquired from batches of 10 similar items were prepared. HCV RNA could be detected in approximately 30% of pooled samples of syringes and 80% of pooled samples of alcohol and cotton swabs, and the results Received and accepted 8 September 2011; electronically published 19 October 2011. Correspondence: Holly Hagan, PhD, New York University College of Nursing, 726 Broadway, New York, NY 10003 (hh50@nyu.edu). The Journal of Infectious Diseases 2011;204:1819–21 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com 0022-1899 (print)/1537-6613 (online)/2011/20412-0001$14.00 DOI: 10.1093/infdis/jir654

Agent, Host, and Environment: Hepatitis C Virus in People Who Inject Drugs