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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

An Update

on National Recommendations

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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

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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

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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

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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

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Infectious Disease Burden among Released Inmates, United States, 1996

Source: NCCHC, Hammet, Greifinger unpublished data

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Viral Hepatitis States, 1996

in the United States

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The A, B, Cs of Viral Hepatitis States, 1996

  • 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

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Outcome States, 1996




Chronic infections







New infections /yr




Deaths /yr




Disease Burden from Bloodborne Viral Infections, United States, 1999

Source: CDC

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Risk Factors for Transmission of Hepatitis Viruses and HIV States, 1996

Proportion of Infections

Source: CDC Surveillance data

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Viral Hepatitis in the United States States, 1996

Hepatitis B

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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)

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Hepatitis B Immunization Recommendations in the United States

  • “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)

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Risk Factors for Acute Hepatitis B in the United States 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

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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

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Hepatitis B Vaccination Programs in Prisons Virus Infection

  • 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

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Effect of Hepatitis B Vaccination of Juveniles, Virus Infection

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

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Juvenile Systems with Virus Infection Hepatitis B Immunization Programs

Source: NCCHC and CDC, unpublished data

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Hepatitis B Vaccination of Incarcerated Persons Virus Infection

  • 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

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Viral Hepatitis in the United States Virus Infection

Hepatitis C

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Injecting drug use 60% Virus Infection

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

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100 Virus Infection



















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.

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Correctional Populations: Hepatitis C Risk Virus Infection

  • 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)

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6 Virus Infection







% Anti-HCV Positive












Age in Years

HCV Infection Prevalence, United States 1988-1994

Source: NEJM 1999;341:556-62

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Recommendations to Identify Persons with HCV Infection Virus 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)

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Hepatitis C Recommendations Virus Infection

“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)

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Preliminary Recommendations: Virus Infection

Prevention and Control of Viral Hepatitis

in Correctional Settings

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Proposed Recommendations-Hepatitis B Virus Infection

  • 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

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Proposed Recommendations-Hepatitis B Virus Infection

  • 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

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Proposed Recommendations-Hepatitis C Virus Infection

  • All incoming inmates should have an assessment of risk-factors for infection

  • All inmates at risk for infection should be tested for anti-HCV

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Proposed Recommendations-Hepatitis C Virus Infection

  • 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

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Health Education & Post-Release Management Virus Infection

  • 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