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Hepatitis B Virus (HBV) Infection. Incarcerated Adults, United States ... Missed Opportunities for Immunization Against Hepatitis B Virus Infection ...

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prevention and control of viral hepatitis in correctional settings

Prevention and Control of Viral Hepatitis in Correctional Settings

An Update

on National Recommendations


Why Intervene in Correctional Settings?

Its where the disease is!

  • Thousands of former inmates return to the community each month
    • Correctional health programs provide the opportunity to make prevention and health care services available to a segment of the community with disparities in health outcomes
adult correctional population united states
Adult Correctional Population United States
  • Annually, about 6.5 million adults are in prison, jail, probation and parole
  • Represents about 3.1% of the adult US population -- 1 in every 32 adults
  • About 30% of persons in the correctional system are incarcerated (~1.9 million)

Source: Bureau of Justice Statistics, Probation & Parole 1n 2000

(8/2001) NCJ 188208

juvenile correctional population united states
Juvenile Correctional PopulationUnited States
  • 2.5 million arrested per year
    • 1.8 million to court
    • 327,000 detained
    • 126,000 currently incarcerated

Source: Office of Juvenile Justice and Delinquency Programs, 2001

hepatitis b virus hbv infection incarcerated adults united states
Hepatitis B Virus (HBV) Infection Incarcerated Adults, United States
  • 20% - 30% of inmates have been infected with HBV
  • About 2% of inmates are chronically infected
  • Each year, 1%-3% of inmates are infected while in prison
infectious disease burden among released inmates united states 1996
Infectious Disease Burden among Released Inmates, United States, 1996

Source: NCCHC, Hammet, Greifinger unpublished data


Viral Hepatitis

in the United States


The A, B, Cs of Viral Hepatitis

  • Hepatitis A
    • fecal-oral, spread: person-to-person, drug use, men having sex with men, travelers, day care, food
    • vaccine-preventable
  • Hepatitis B
    • blood and body fluids: sex, drugs, perinatal, occupational, nosocomial
    • vaccine-preventable
  • Hepatitis C
    • blood: drugs, sex, perinatal, nosocomial, occupational
    • NOT vaccine-preventable





Chronic infections







New infections /yr




Deaths /yr




Disease Burden from Bloodborne Viral Infections, United States, 1999

Source: CDC


Risk Factors for Transmission of Hepatitis Viruses and HIV

Proportion of Infections

Source: CDC Surveillance data

immunization recommendations to eliminate hbv transmission in the united states
Immunization Recommendations to Eliminate HBV Transmission in the United States
  • Maternal screening to prevent perinatal infection
  • Universal vaccination of infants
  • Catch-up vaccination of adolescents
    • previously unvaccinated at 11-12 years of age
    • high risk
  • Adults at high risk of infection

Source: Advisory Committee on Immunization Practices. MMWR 1991; 40: (RR-13)

hepatitis b immunization recommendations
Hepatitis B Immunization Recommendations
  • “High-risk groups for whom vaccination is recommended include:

Inmates of long-term correctional facilities. Prison officials should consider undertaking screening and vaccination programs directed at inmates with histories of high-risk behaviors.”

Source: MMWR 1991;40 (No. RR-13)

risk factors for acute hepatitis b 1990 1999
Risk Factors for Acute Hepatitis B 1990-1999

Heterosexual activity (38%)

No current

risk factor (31%)

MSM (12%)

IDU (14%)

Other (5%)

Other: occupational exposure, transfusion recipient, hemodialysis, household contact, employee or resident of institution for developmentally disabled

   Source: Goldstein et al. J Infect Dis 2002; 185: 713-719


Missed Opportunities for Immunization Against Hepatitis B Virus Infection

  • 39% have been previously incarcerated
  • 2% were incarcerated during their incubation period
  • 70% of IDUs were previously incarcerated

Of reported cases of acute hepatitis B:

 Source: Goldstein et al. J Infect Dis 2002; 185: 713-719

and CDC unpublished

hepatitis b vaccination programs in prisons
Hepatitis B Vaccination Programs in Prisons
  • National Survey – 50 States and FBOP
    • 35 respondents, 77% of incarcerated adults
  • Results
    • 2 states offer vaccine to all incoming prisoners
    • 25 states and FBOP offer vaccine to some
    • 9 states offer no vaccine
  • Barriers
    • Cost of vaccine
    • 25 states would offer routine vaccination if funds available

Source: Charuvastra, et al. Pub Hlth Rep May 2001


Effect of Hepatitis B Vaccination of Juveniles,

Hampden County, MA

  • Massachusetts began vaccinating juvenile detainees in 1996
    • 1% refuse, 43% completed 3 doses
  • Of entering jail inmates in 2000
    • Vaccine immunity
      • 20 year olds = 40%
      • 40-49 year old = <5%
    • HBV infection
      • 20 year olds = 7%
      • 40-49 year olds = 35%

Source: Lincoln T, DePietro S, Keough K et al., unpublished data

juvenile systems with hepatitis b immunization programs
Juvenile Systems with Hepatitis B Immunization Programs

Source: NCCHC and CDC, unpublished data


Hepatitis B Vaccination of Incarcerated Persons

  • Recommended since 1982
  • Prevents infection outside and inside of facilities
  • Feasible
  • Cost-effective
  • Anticipated impact on the entire community
  • A number of challenges to implementation
    • Juveniles = covered under Vaccines for Children (VFC) program
    • Adults = no national programs
sources of infection for persons with hepatitis c

Injecting drug use 60%

Sexual 15%

Transfusion 10%

(before screening)

Other* 5%

Unknown 10%

*Nosocomial; Health-care work; Perinatal

Sources of Infection forPersons with Hepatitis C

Source: Sentinel Counties Study of Viral Hepatitis, CDC

risk of bloodborne virus infections among injection drug users baltimore 1983 1988




















Risk of Bloodborne Virus Infections Among Injection Drug Users, Baltimore 1983–1988





Duration of Injecting (months)

Source: Garfein RS et al Am J Public Health. 1996;86:655.

correctional populations hepatitis c risk
Correctional Populations: Hepatitis C Risk
  • 3%-6% of juvenile offenders inject drugs
  • 18% of jail inmates report IDU
  • Drug offenders account for 84% of the total adult inmate population (16% in 1970)








% Anti-HCV Positive












Age in Years

HCV Infection Prevalence, United States 1988-1994

Source: NEJM 1999;341:556-62


Recommendations to Identify Persons with HCV Infection

  • Identify persons at risk for HCV and test to determine infection status
    • Identify at-risk persons through history, record review
  • Provide HCV-positive persons
    • Medical evaluation and management
    • Counseling
      • Prevent further harm to liver
      • Prevent transmission to others

Source: MMWR 1998;47 (No. RR-19)

hepatitis c recommendations
Hepatitis C Recommendations

“Testing persons in settings with potentially high proportions of IDUs (e.g., correctional institutions…) might be particularly efficient for identifying HCV-positive persons”

Source: MMWR 1998;47 (No. RR-19)


Preliminary Recommendations:

Prevention and Control of Viral Hepatitis

in Correctional Settings

proposed recommendations hepatitis b
Proposed Recommendations-Hepatitis B
  • Test pregnant inmates for HBsAg
    • Immunize women not previously vaccinated
  • Vaccinate ALL incarcerated persons
    • Regardless of length of incarceration
    • Initiate upon entry for all who receive medical evaluation
  • Pre-vaccination screening
    • Consider if cost effective
proposed recommendations hepatitis b30
Proposed Recommendations-Hepatitis B
  • Initiate complete series for ALL incarcerated persons - regardless of ability to ensure completion
    • First dose protects ~40% of people
    • Second dose protects ~75%
  • Develop mechanisms to complete vaccination series
    • Tracking within the facility/system
    • Referrals into community health care
proposed recommendations hepatitis c
Proposed Recommendations-Hepatitis C
  • All incoming inmates should have an assessment of risk-factors for infection
  • All inmates at risk for infection should be tested for anti-HCV
proposed recommendations hepatitis c32
Proposed Recommendations-Hepatitis C
  • Inmates with chronic HCV infection should be evaluated for liver disease
  • Treatment should be offered to persons who meet criteria of current NIH Consensus Guidelines and be conducted in consultation with a specialist
  • HCV infected persons who abuse substances should be offered substance abuse treatment
health education post release management
Health Education & Post-Release Management
  • Viral hepatitis should become part of comprehensive health education and risk reduction program
  • Consider offering as part of HIV curriculum
  • Necessary Components:
    • How to prevent acquiring infection
    • Where to go for vaccine series completion
    • For infected persons
      • How to prevent infecting others
      • How to prevent further liver damage