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We read with great interest the letter by Saxena et al (Gut 2003;52:1656–7). We would however take issue with their hypothesis, as we indeed believe in the remarkable differences in the mode of hepatitis C virus (HCV) transmission in these two high risk groups. Studies have reported a value of 70–90% for the prevalence rate of HCV infection among intravenous drug abusers (IVDAs).1 The main source of HCV infection in this population is sharing contaminated needles. The incidence of rapid acquisition of HCV infection following initial intravenous drug use within the first year has been reported to be as high as 80%.2 Moreover, syringe exchange programmes have been shown in some studies to reduce the risk of infection.3 In the study in India,4 as also mentioned by Saxena et al, although the syringe exchange programme was not effective in the prevention of HCV infection, it was effective in controlling hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infection. Moreover, in these types of studies and programmes, consideration should be given to the fact that IVDAs are a special population with particular behaviour patterns. As they often have no strong motivation to be educated, they may deny their high risk behaviour, even within an instructive programme.
On the other hand, the main route of HCV transmission in haemodialysis (HD) patients seems to be transfusion, as the HCV infection incidence in haemodialysis units has been declining following implementation of blood product screening in developed countries.5 The Centers for Disease Control and Prevention (CDC, Atlanta, Georgia, USA) reported a nationwide prevalence of HCV infection in HD patients of 8.9% in a recent update.5 Thus the prevalence and incidence of HCV infection in HD patients appear not to be as high as that for IVDAs. However, we are in agreement with Saxena et al that nosocomial transmission should not be neglected in HD sites. The study by Okuda et al showed that education of staff members and application of adhesive pads at the time of needle withdrawal in HD sites resulted in a decrease in the incidence of HCV infection to zero, and no new HCV infected cases were reported for over a year in 730 patients on maintenance HD.6
The other point to note is the fact that coinfection with HCV and HBV is common in IVDAs7 but less prevalent in HD patients. This interesting point may highlight evidence of another difference in the main transmission route of infection in these two populations.