resources to provide screening, testing, and vaccination services. Therefore, the committee offers the following recommendation:

Recommendation 5-2. The Centers for Disease Control and Prevention, in conjunction with other federal agencies and state agencies, should provide resources for the expansion of community-based programs that provide hepatitis B screening, testing, and vaccination services that target foreign-born populations.

Illicit-Drug Users

Preventing bloodborne infectious diseases, particularly hepatitis C, in illicit-drug users is an important public-health challenge. Hepatitis C incidence in IDUs has been reported to be 2–40 per 100 person-years (PY) of observation, with most rates in the range of 15–30 per 100 PY (Maher et al., 2006; Mathei et al., 2005; van den Berg et al., 2007b). HCV prevalence in IDUs is typically 35–70%, depending on geographic location and duration of exposure to injection-drug use (Hagan et al., 2008). The early years after onset of drug injection are high-risk periods when HCV seroconversion rates are particularly high (Maher et al., 2006).

Non-injection-drug users (NIDUs) who sniff or snort heroin, cocaine, and other drugs also have a high risk of HCV infection. A meta-analysis of 26 studies showed that HCV prevalence in NIDUs was 2–35%, with a median of 14% (Scheinmann et al., 2007). Whether drug practices, sexual exposures, or both are the sources of HCV transmission is unclear (Scheinmann et al., 2007). Low rates of HCV seroconversion have been reported in NIDUs—0.4–2.7 per 100 PY—rates that are similar to those observed in sex partners of HCV-RNA–positive persons (1.2 per 100 PY) (Fuller et al., 2004; Neaigus et al., 2007; Rooney and Gilson, 1998). Studies have shown that HCV RNA can be detected on the surface of crack pipes, so it is biologically plausible that drug-use practices are a route of transmission in these people (Fischer et al., 2008). Research is needed to explicate the etiology of HCV infection in NIDUs so that effective prevention strategies can be designed.

To understand the development and opportunities for control of this hyperendemic state of HCV infection in IDUs, it is important to consider multiple features of the disease agent, the human host, and the environment that determine the occurrence of infection (Lillienfeld and Lillienfeld, 1980). HCV is efficiently transmitted via bloodborne exposure, and several studies have shown that transmission can occur via the shared use of syringes, drug cookers, and filtration cotton (Hagan et al., 2001; Hahn et al., 2002; Thorpe et al., 2002). It takes only a very small amount of infectious blood on injection equipment to result in infection. Awareness of risk



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