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BMC Infectious Diseases

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Frequency, factors and costs associated with injection site infections: Findings from a national multi-site survey of injecting drug users in England

  • Vivian Hope1, 2Email author,
  • Jo Kimber2, 3, 4,
  • Peter Vickerman2,
  • Matthew Hickman3 and
  • Fortune Ncube1
BMC Infectious Diseases20088:120

https://doi.org/10.1186/1471-2334-8-120

Received: 18 March 2008

Accepted: 18 September 2008

Published: 18 September 2008

Abstract

Background

Injection site infections among injecting drug users (IDUs) have been associated with serious morbidity and health service costs in North America. This study explores the frequency, factors and costs associated with injection site infections among IDUs in England.

Methods

Unlinked-anonymous survey during 2003/05 recruiting IDUs from community settings at seven locations across England. Self-reported injecting practice, symptoms of injection site infections (abscess or open wound) and health service utilisation data were collected using a questionnaire, participants also provided dried blood spot samples (tested for markers blood borne virus infections). Cost estimates were obtained by combining questionnaire data with information from national databases and the scientific literature.

Results

36% of the 1,058 participants reported an injection site infection in the last year. Those reporting an injection site infection were more likely to be female and aged over 24, and to have: injected into legs, groin, and hands in last year; injected on 14 or more days during the last four weeks; cleaned needles/syringes for reuse; injected crack-cocaine; antibodies to hepatitis C; and previously received prescribed substitute drug. Two-thirds of those with an injection site infection reported seeking medical advice; half attended an emergency department and three-quarters of these reported hospital admission. Simple conservative estimates of associated healthcare costs range from £15.5 million per year to as high as £30 million; though if less conservative unit costs assumptions are made the total may be much higher (£47 million). The vast majority of these costs are due to hospital admissions and the uncertainty is due to little data on length of hospital stays.

Conclusion

Symptoms of injection site infections are common among IDUs in England. The potential costs to the health service are substantial, but these costs need more accurate determination. Better-targeted interventions to support safer injection need to be developed and evaluated. The validity of self-reported symptoms, and the relationship between symptoms, infection severity, and health seeking behaviour require further research.

Background

A range of bacteria can infect injecting drug users' (IDUs) injection sites, resulting in illnesses ranging from localised skin and soft tissue infections to systemic and toxin producing infections [1, 2]. These infections can result in serious morbidity requiring inpatient intervention (e.g. intensive intravenous antibiotics, surgical debridement, amputation) and sometimes death [1, 2]. The reported prevalence of recent or current infections such as abscesses, infected ulcers and cellulitus among IDUs ranges from under one in 10 in Australia [3] to between one in five and one in three in North America and Europe [46]. These infections are also the most common presenting diagnoses among IDUs attending emergency departments in North America [7, 8]. Injection site infections are associated with poor hygiene and unsafe injection practices including inadequate cleaning of the hands or the injection site, needle and syringe re-use, multiple injection attempts, use of multiple injection sites, subcutaneous injection, and drawing blood back into the syringe repeatedly [3, 5, 9, 10].

There has been increasing concern in the United Kingdom (UK) about the extent of bacterial infections among IDUs [1113]. Reports of severe group A streptococci infections among IDUs in the UK have increased over ten fold in recent years from less than ten per annum in the mid 1990's to 143 per annum in 2004 [11]. There have also been reports of community acquired Meticillin resistant Staphylococcus aureus infection among IDUs in recent years [14, 15], and outbreaks of tetanus and wound botulism [16, 17].

Little is known about the extent of injection site infections, or the factors associated with them, among IDUs in England. These infections are, however, likely to place a considerable, and possibly increasing burden on health services as observed elsewhere [35, 18]. Using survey data, this paper explores the prevalence and factors associated with self-reported symptoms of injection site infections (abscess or open wound), which are likely to be due to bacterial infection, among IDUs in England, and exploratory cost estimates of their treatment.

Methods

Data on subject-reported symptoms of an injection site bacterial infection, from a community-recruited survey of IDUs undertaken in England was used [19]. Briefly, an unlinked anonymous community-recruited survey was undertaken between autumn 2003 and summer 2005. This involved recruiting drug users who had injected during the proceeding 28 days using established methods at seven broadly representative locations across England. Participants were recruited either directly from a range of low threshold services, including drop-in centres and needle exchanges, or using indigenous fieldworkers to recruit from the community settings[20]. Those who agreed to take part, by providing verbal consent, were taken through a detailed questionnaire on their demographic, behavioural and drug use characteristics by trained interviewers. They also provided dried blood spot samples for testing for anti-bodies to hepatitis C (anti-HCV), hepatitis B core antigen (anti-HBc), and HIV (anti-HIV), and were offered a £10 acknowledgement. The questionnaire collected information on self-reported symptoms of injecting site infections, and use of health services in response to these. The survey, part of the unlinked anonymous programme, had multi-site approval from the London Research Ethics Committee and from the relevant local committees.

Analyses

The symptoms of injection site infections considered were reporting either an 'abscess (pus filled swelling)' or 'open wound/sore' at an injection site, as these symptoms are most likely to be due to a bacterial infection. All analyses were undertaken in SPSS 14. Variables, such as demographic, drug use and behavioural characteristics, that were found to be univariately associated with these symptoms using χ2, were then entered using the forward stepwise procedure in SPSS in to a logistic regression model with inclusion assessed using the likelihood ratio (with the stepwise probability for inclusion of 0.05 and exclusion of 0.1).

Cost estimation

The cost of treatment was estimated for those IDUs reporting having had an injection site infection in the last year who also reported seeking medical advice. However, specific costs were not collected, and so the cost estimation used standard UK costs from the National Health Service (NHS) reference cost database for 2005–2006 [21] and the 2006 review of 'Unit costs of Health and Social Care' [22]. Also, only limited survey data were collected on healthcare usage. Thus cost estimates were produced that used lower and upper bound estimates for each unit cost and assumed each IDU only had one injection site infection per year.

For those IDUs reporting that they attended an emergency department, the lower and upper quartile costs of an 'Accident and Emergency lower cost investigation' (£67 or £86) was applied [22]. For those who were then admitted to hospital the survey did not collect data on the average duration of hospital stay. Because of this, and because there is little suitable published data on their likely length of stay, two methods were used to produce estimates for the costs of hospital care. The first method simply assigned a low and high cost to each IDU's hospital stay from the range in average unit costs for non-elective hospital based acute care of skin infections (£944–1,556 per patient) [21]. Alternatively, cost projections were produced using the average daily NHS cost for hospital based adult acute care for skin infections (£247–370 per day) [21], and assuming a low and high estimate for the average number of days they stay in hospital (2 or 4 days) [4, 8, 23]. However, because the cost per day is higher for shorter hospital stays in the NHS cost database, the higher daily cost was applied to the shorter length of stay and vice versa for the longer length of stay. The estimates for an IDU's length of stay were obtained from one Scottish study and two US studies that looked at hospital admissions of IDUs with soft tissue infections [4] or skin infections, abscesses and other health problems [8, 23].

For those that sought medical advice but did not attend an emergency department, it was assumed that they consulted their general practitioner (GP). A low and high cost was applied to this by using the upper and lower bound cost for a GP surgery consultation (£18–25 per consultation) from Unit Costs of Health and Social Care [22].

The cost estimates for each care option were combined to produce different cost estimates for the treatment of the IDUs in the study. By multiplying the reported prevalence of injection site infections in the last year with estimates for the number of IDUs in England, 140,000 (only injectors of opiates or crack-cocaine, low estimate) [24] or 215,000 (all IDUs, high estimate) [25], these treatment costs were then scaled up to produce a range of estimates for the yearly cost of treating IDUs with injection site infections.

Results

This survey recruited 1,058 injectors from seven locations in England: 77% (810/1,054) were male, 18% (193/1,058) aged under 25 years (median age 30 years, range 16 to 72 years), 21% (221/1,056) had been injecting for less than five years (median number of years injecting 9, range < 1 to 41 years), and the prevalence of anti-HCV was 53% (566/1,058), anti-HBc was 32% (332/1,049), and anti-HIV was 0.8% (8/1,058). Almost all had injected an opiate in the previous four weeks (999/1,058), whilst 40% (424/1,058) had injected crack-cocaine and 13% (136/1,058) an amphetamine. The majority (86%, 904/1,056) had ever been homeless (having lived in a hostel, being of no fixed abode, or living on the streets) and over half (59%, 622/1,056) had last been homeless during the proceeding 12 months.

Of the 1,058 participants, 385 (36%) reported having had a symptom of an injection site infection (either an abscess or open wound) in the previous year.

Factors associated with symptoms injection site infections

Reporting injection site infection in the previous year was associated univariately with a range of factors (Table 1). In the multivariate analysis (Table 1), a number of factors remained associated with reporting an injection site infection: female gender; being aged 25 or over; having injected into legs, groin, and hands in last year; injecting on 14 or more days during the last 4 weeks, cleaning needles/syringes for reuse; injecting crack-cocaine; being anti-HCV positive; and having previously received prescribed substitute drug (i.e. not currently on prescribed opioid substitute drug).
Table 1

Factors associated with an injection site infection in last year among injecting drug users: England 2003/05.

  

Yes

N

(Total = 990)

Univariate Odds

Ratio with 95%

confidence interval

Mulitvariate Adjusted

Odds Ratio with 95%

confidence interval

Gender

Male

263

755

35%

1.0

 

1.0

 
 

Female

102

235

43%

1.4

1.1 – 1.9

1.7

1.2 – 2.4

Received prescribed substitute drug

Currently

178

511

35%

1.0

 

1.0

 
 

Previously

150

322

47%

1.6

1.2 – 2.2

1.7

1.3 – 2.4

 

Never

37

157

24%

0.6

0.4 – 0.9

0.9

0.5 – 1.3

Age in Years

<= 24

47

186

25%

1.0

 

1.0

 
 

25 – 29

103

273

38%

1.8

1.2 – 2.7

1.6

1.0 – 2.6

 

30 – 34

107

258

41%

2.1

1.4 – 3.2

2.0

1.3 – 3.2

 

35+

108

273

40%

1.9

1.3 – 2.9

1.9

1.2 – 3.0

Inject into leg last 4 weeks

No

212

701

30%

1.0

 

1.0

 
 

Yes

153

289

53%

2.6

2.0 – 3.4

2.2

1.6 – 3.1

Inject into groin last 4 weeks

No

176

543

32%

1.0

 

1.0

 
 

Yes

189

447

42%

1.5

1.2 – 2.0

1.4

1.1 – 1.9

Inject into hand last 4 weeks

No

245

759

32%

1.0

 

1.0

 
 

Yes

120

231

52%

2.3

1.7 – 3.1

1.9

1.3 – 2.6

Clean Needle/Syringe for reuse

No

77

259

30%

1.0

 

1.0

 
 

Yes

288

731

39%

1.5

1.1 – 2.1

1.5

1.1 – 2.1

Inject crack last 4 weeks

No

188

588

32%

1.0

 

1.0

 
 

Yes

177

402

44%

1.7

1.3 – 2.2

1.5

1.1 – 2.0

Days injected last 4 weeks

<= 13 days

46

181

25%

1.0

 

1.0

 
 

14 – 27 days

84

208

40%

2.0

1.3 – 3.1

1.8

1.2 – 2.9

 

28 days

235

601

39%

1.9

1.3 – 2.7

1.5

1.0 – 2.3

Anti-HCV Positive

No

135

454

30%

1.0

 

1.0

 
 

Yes

230

536

43%

1.8

1.4 – 2.3

1.5

1.1 – 2.0

Homeless

Never

36

140

26%

1.0

 

 
 

Over a year ago

98

266

37%

1.7

1.1 – 2.7

  
 

In last year

231

584

40%

1.9

1.2 – 2.9

  

Number of years injecting

<= 4

53

210

25%

1.0

 

 
 

5 – 9

120

300

40%

2.0

1.3 – 2.9

  
 

10 – 14

87

227

38%

1.8

1.2 – 2.8

  
 

15 +

105

253

42%

2.1

1.4 – 3.1

  

Inject into neck last 4 weeks

No

288

841

34%

1.0

 

 
 

Yes

77

149

52%

2.1

1.4 – 2.9

  

Prepare drug using citric acid

No

12

59

20%

1.0

 

 
 

Yes

353

931

38%

2.4

1.3 – 4.6

  

Times injected last full day

Once

53

168

32%

1.0

 

 
 

Twice

77

266

29%

0.9

0.6 – 1.3

  
 

Thee times

81

203

40%

1.4

0.9 – 2.2

  
 

4+ times

154

353

44%

1.7

1.1 – 2.5

  

Clean injecting site last 4 weeks

Never

185

444

42%

1.0

 

 
 

Sometimes

83

224

37%

0.8

0.6 – 1.1

  
 

Always

97

322

30%

0.6

0.4 – 0.8

  

Times injected with last needle

Once

186

549

34%

1.0

 

 
 

Twice

68

189

36%

1.1

0.8 – 1.5

  
 

Three times

39

100

39%

1.2

0.8 – 1.9

  
 

4+ times

72

152

47%

1.8

1.2 – 2.5

  

Ever had voluntary confidential test for hepatitis C

Yes

257

652

39%

1.4

1.0 – 1.8

 
 

No

108

338

32%

1.0

   

Anti-HBc positive

No

239

680

35%

1.0

 

 
 

Yes

126

310

41%

1.3

1.0 – 1.7

  

† Variable not in final model.

Note: Reporting an injection site infection in previous year was not associated with: having been imprisoned; having had an overdose; injecting amphetamines; washing hands before injection; injecting into arms; using vitamin c/ascorbic acid, lemon juice or vinegar to dissolve drugs; ever having had voluntary-confidential test for HIV; and uptake of hepatitis B vaccine.

Factors associated with seeking health care for an injection site infection

Two thirds of those reporting an injection site infection reported seeking health care (68%, 260/382). Seeking health care among those having had injection site infection was associated univariately with the factors shown in Table 2. In multivariate analyses (table 2), seeking health care remained associated with two markers of healthcare utilisation (currently being prescribed substitute drug, and ever having had voluntary-confidential test for hepatitis C); a risk factor for infection (injecting into the groin); and a marker of good hygiene practice (always swabbing injection sites).
Table 2

Factors associated with healthcare seeking among injecting drug users reporting an injection site infection in past year: England 2003/05.

  

Yes

N

(Total = 365)

Univariate Odds

Ratio with 95%

confidence interval

Mulitvariate Adjusted

Odds Ratio with 95%

confidence interval

Received prescribed substitute drug

Currently

138

182

76%

1.0

 

1.0

 
 

Previously

94

147

64%

0.6

0.4 – 0.9

0.5

0.3 – 0.9

 

Never

15

36

42%

0.2

0.1 – 0.5

0.3

0.1 – 0.7

Inject into groin last 4 weeks

No

100

174

57%

1.0

 

1.0

 
 

Yes

147

191

77%

2.5

1.6 – 3.9

2.1

1.3 – 3.4

Clean injecting site last 4 weeks

Never

113

184

61%

1.0

 

1.0

 
 

Sometimes

58

85

68%

1.3

0.8 – 2.3

1.4

0.8 – 2.6

 

Always

76

96

79%

2.4

1.3 – 4.2

2.5

1.4 – 4.6

Ever had voluntary confidential test for hepatitis C

Yes

195

257

76%

3.4

2.1 – 5.4

3.5

2.1 – 5.8

 

No

52

108

48%

1.0

 

1.0

 

Number of years injecting

<= 4

25

53

47%

1.0

 

 
 

5 – 9

80

120

67%

2.2

1.2 – 4.3

  
 

10 – 14

64

84

76%

3.6

1.7 – 7.5

  
 

15 +

78

108

72%

2.9

1.5 – 5.8

  

Inject into arm last 4 weeks

No

72

94

77%

1.0

 

 
 

Yes

175

271

65%

0.6

0.3 – 1.0

  

Ever had voluntary confidential test for HIV

No

71

132

54%

1.0

 

 
 

Yes

176

233

76%

2.7

1.7 – 4.2

  

Anti-HCV Positive

No

80

134

60%

1.0

 

 
 

Yes

167

231

72%

1.8

1.1 – 2.8

  

† Variable not in final model.

Note: Seeking health care an injection site infection was found not to be associated with: gender; age; homelessness; having been imprisoned; having had an overdose; cleaning needles and syringes before reuse; injecting crack-cocaine; injecting amphetamines; number of days injecting per month; number times inject per day; using citric acid, vitamin c/ascorbic acid, lemon juice, or vinegar to dissolve drugs; injecting into legs, neck or hands; number times used last needle; washing hands before injection; and uptake of hepatitis B vaccine.

Heath services use and costs

Almost half of those seeking advice for an injection site infection reported attending an emergency department (47%, 180/381), with over three-quarters of those attending an emergency department reporting admission to hospital (78%, 140/180). Estimates of the numbers of IDUs accessing health services in England in relation to a concern about an injection site infection are given in table 3. These estimates indicate that over 30,000 IDUs are likely to seek health care for injection site infections each year, with at least 18,500 of them being admitted to hospital. Assuming only a single episode per IDU each year, and using conservative unit costs, the annual healthcare costs associated with injection site infections among IDUs in England are estimated to be at least £19.2 million for the lower bound cost per hospital stay, and at least £30.5 million for the upper bound cost per hospital stay (see table 4 for these estimates, both assuming an IDU population of 140,000). This compares with a lower bound estimated cost of at least £15.5 million when daily costs are used and IDUs are assumed to stay in hospital for on average 2 days, and an upper bound cost of at least £20.6 million when IDUs are assumed to stay on average 4 days (both assuming an IDU population of 140,000). Irrespective of the method used, the vast majority of these costs are due to the periods of hospital admission, which makes up over 88% of the total cost estimate.
Table 3

Estimated annual numbers of injecting drug users in England seeking healthcare for injection site infections.

 

Proportion of survey respondents

Estimated number of IDUs in England: 140,000 *

Estimated number of IDUs in England: 215,000 **

IDUs reporting abscess/open wound in last year

36%

50,400

77,400

Those IDUs reporting abscess/open wound in last year seeking care:

24%

34,272

52,632

Of these, those that sought care:

   

   other than at an Emergency Department

8%

10,584

16,254

at an Emergency Department, not admitted

to hospital

4%

5,211

8,003

at an Emergency Department, & admitted

to hospital

13%

18,477

28,375

* Estimated number of injectors of heroin or crack-cocaine only, form a study aiming to estimate the total number of heroin and crack-cocaine users [24].

** Estimated number of injecting drug users (all drugs) obtained from a study using an evidence synthesis method to estimate number of injecting drug users [25].

Table 4

Estimated annual costs for injecting drug users (IDUs) in England seeking healthcare for injection site infections.

 

Estimated costs in 1,000 pounds sterling (£)

 

Low unit costs†

High unit costs†

Estimated number of IDUs in England

140,000*

215,000**

140,000*

215,000**

Estimated cost of GP consultations

191

293

265

406

Estimated cost of A&E visits

1,587

2,437

2,037

3,129

Estimated cost of hospital bed days

17,442

26,786

28,750

44,151

Total

19,220

29,516

30,527

46,881

* Low estimate of number of IDUs is the number of heroin or crack-cocaine injectors, form a study aiming to estimate the total number of heroin and crack-cocaine users [24].

** High estimate of number of IDUs is the estimated number of IDUs (all drugs) obtained from a study using an evidence synthesis method to estimate number of injecting drug users [25].

† Low and High Unit costs based on Unit Costs of Health and Social Care 2006 [22] and NHS cost database [21]. Unit cost GP consultation: Low £18 & High £25 [22]. Average Unit cost for a lower cost investigation at Accident and Emergency (Emergency Department): Low £67, & High £86 [22, 21]. Average Unit costs per hospital stay were based on the low and high average cost for non-elective adult acute care in a hospital for a skin infection from NHS cost database [21], Alternative estimates are produced using daily unit costs and assuming they stay in hospital for 2 or 4 days [4, 8, 23]

Discussion

Symptoms of injection site infections appear to be common amongst IDUs in England. These infections are associated with reuse of syringes, particular injection sites, crack injecting, having hepatitis C infection and being female; with one in seven of the IDUs reporting hospital admission annually. These infections are preventable, yet based on conservative exploratory estimates they may cost the health service in England at least £15.5–19.2 million per annum.

The high prevalence of self-reported injection site infections found in this study, as found elsewhere [4, 5], are of concern and highlight the need for interventions which facilitate good injection related hygiene and practice. Firstly, this study found that the injection sites used and the reuse of injecting equipment were associated with injection site infections. Previous studies have found similar associations [9, 10]; and also associations with inadequate washing of hands or cleaning of the injection site [5, 9, 10]; multiple injection attempts before locating a vein, and the use of multiple injection sites [9, 10]. The association with femoral ('groin') injection is of particular concern as this has become more common in recent years [26], with indications of increased hospital admissions related to femoral injection among IDUs [13].

Participants injecting crack-cocaine also reported higher levels of injection site infections, as has been observed elsewhere with the injection of cocaine [6, 8, 36], and heroin and cocaine combinations [10, 27]. There is also evidence to suggest crack-cocaine use, which is associated with risky behaviours [26, 28], has become more common in the UK [29]. As in other studies, women were more likely to report an injection site infection [6, 10, 27]. This may reflect a higher awareness of infections, and/or a greater vulnerability to injection site infections among female injectors[30]. The positive association with previously receiving a prescribed substitute drug suggests that those factors leading to people not successfully completing treatment for their drug use may also put them at elevated risk of infection, though this needs further examination.

In this study homelessness – a possible marker for injection in public places – was not associated with injection site infections in the final analyses. This may reflect the relatively broad definition used. In previous studies public or semi-public injecting environments have been related to poor injection hygiene and infections [9, 10, 31]. In the UK there is increasing concern about public injection and its impact on injecting hygiene [26, 28]. Preventive interventions should thus focus on the reuse of injecting equipment, and target those injecting into groins, legs or hand, using crack-cocaine, and female injectors; they may also need to consider the role of the injecting environment [32].

The conservative cost estimate from this study – at least £15.5–19.5 million per annum – indicates that injecting site infections could place a considerable cost burden on the health care system in England. Previous work looking at the costs of problematic drug use, both injecting and non-injecting, in England indicated considerable health care costs of around £500 million per annum [33]. Whilst £25 million of this was estimated to be due to blood borne viruses (HIV, hepatitis B and C) among IDUs, the authors did not separate the costs related to injecting users. They were also not able to separate out the costs related to injecting site infections, and these may not have been fully accounted for in their estimate.

Most of the participants reporting an injection site infection sought medical advice and one third of those with an infection reported being admitted to hospital, many via an emergency department. This is consistent with other studies which suggest that IDUs tend not to seek timely medical care for their injecting-related health problems, often resulting in emergency treatment at considerable cost [8, 18, 34, 35]. The failure to seek earlier treatment probably reflects competing priorities, such as, obtaining money, purchasing and using drugs, barriers to accessing care, and poor compliance with oral antibiotic regimes and follow-up care [8, 18, 35, 36]. Emergency room use (8% of total cost) and hospital admission (> 90% of total cost) account for much of the estimated costs. These costs could be reduced substantially, past studies have shown that earlier health care seeking and targeted prevention can reduce emergency department visits, hospital bed days, and surgical procedures by more than a third [37, 38]. Whilst further work needs to identify, develop, and evaluate suitable interventions, our findings suggest a need to focus on improving injection hygiene, the better management of the body sites used for injection, and that IDUs are possibly more likely to seek care if in contact with other services.

It is important to consider the limitations and generalisability of these findings. Self-reported symptoms of injecting site infections were used in this study; however, studies have shown good concordance between self-reported symptoms and clinical diagnosis [18]. The comparative rarity, marginalisation and illegal nature of injecting drug use impedes the recruitment of a representative sample of injectors. This study aimed to minimise sampling biases and maximise representativeness by using an established community sampling strategy [20]. However, in particular, bias might arise from high-risk individuals being more likely to be captured in the survey as a result of them making greater use of the needle exchanges, and other settings, where sampling occurred. As a consequence the cost estimates could be over estimates. The cost estimates were however calculated conservatively. Firstly, they assume that IDUs seeking care only did so once each year – yet some will have more than one such episode of care per annum and a Canadian study found that half of IDUs admitted to hospital for soft-tissue and systemic infections had multiple admissions [8]. If this was the case then the estimated costs of injection site infections in England could be more than 50% greater, or at least £23 million per annum. Four days for a long hospital stay may also be conservative, as those with a serious systemic infection could stay much longer, as has found in hospitals in the USA (3 to 13 days) [4, 34, 39]. However, the available data on length of IDU hospital stays is limited, with the only UK data being 20 years old and no clinical data were collected as part of this study. The cost estimates also excluded any periods of care in high dependency units, or other high cost services, which may be required for treatment of the more severe infections. Even so, the costing, and other findings, presented here are tentative, and a more rigorous economic evaluation is required that includes UK specific data on the average hospital stay for IDUs with infection site infections and the costs of these.

Conclusion

Taken together these findings suggest injection site infections are common experiences among IDUs in England, and that the resultant health care costs are likely to be substantial. However, the size of these costs needs to be more fully determined. Further research is also needed to explore issues around the validity of self-reports and the relationship between these reported symptoms of infection, the severity of the infection, and health seeking behaviour.

Abbreviations

anti-HBc: 

antibodies to hepatitis B core antigen

anti-HCV: 

antibodies to hepatitis C

anti-HIV: 

antibodies to HIV

IDUs: 

Injecting Drug Users, NHS: National Health services

GP: 

General Practitioner

UK: 

United Kingdom

USA: 

United States of America.

Declarations

Acknowledgements

We are grateful to all of the injecting drug users who took part in the survey, and to the various services and fieldworkers who assisted with their recruitment. We would like to thank those who undertook the blood borne viruses testing on the samples collected which was undertaken by the Health Protection Agency and supervised by John Parry. The survey was funded by the Department of Health and the National Treatment Agency. Centre for Research on Drugs & Health Behaviour receives programme funding from the National Coordinating Centre for Research Capacity and Development (NCCRCD). Jo Kimber is supported by an Australian National Health and Medical Research (NHMRC) Post-Doctoral Training Fellowship. The National Centre in HIV Epidemiology and Clinical Research is core-funded by the Australian Government Department of Health and Ageing.

Authors’ Affiliations

(1)
Centre for Infections, Health Protections Agency
(2)
Centre for Research on Drugs & Health Behaviour, London School of Hygiene & Tropical Medicine
(3)
Department of Social Medicine, University of Bristol
(4)
National Centre in HIV Epidemiology and Clinical Research, University of New South Wales

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  40. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/8/120/prepub

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© Hope et al; licensee BioMed Central Ltd. 2008

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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