Healthcare Infection Prevention: Prison testing could catch HCV before inmates released

CDC recommends targeted, not universal screening

Prison systems are a prime intervention point to stop the "silent epidemic" of hepatitis C virus (HCV), as millions of people infected with HCV in the United States are in jail or have a history of incarceration.

With constant inmate turnover, at any given time in the United States, more than a third of the roughly 3 million people with chronic HCV in the United States were released from a jail or prison in the previous year. (See table, below.)

To target this population, the Centers for Disease Control and Prevention (CDC) recommends that all inmates be questioned about risk factors for HCV infection (e.g., injecting drug use) during their entry medical evaluations. (See box, below.)

Hepatitis C Virus (HCV) Testing Recommendations
On the basis of risk for infection, people who:
  • ever injected illegal drugs;
  • received clotting-factor concentrate produced before 1987;
  • ever were on long-term hemodialysis;
  • have evidenced of chronic liver disease including persistently abnormal levels of 
    alanine aminotransferase (ALT);
  • received a transfusion of blood or blood components or an organ transplant before July 1992.

On the basis of a recognized exposure:

  • health care, emergency medical, public safety, and correctional workers after needlesticks, sharps, or mucosal exposure to HCV-positive blood;
  • children born to HCV-positive women.

Note: Screening testing for antibody to HCV (anti-HCV) followed by appropriate confirmatory testing for people found to be screening test-positive.
Source: Centers for Disease Control and Prevention. Prevention and control of hepatitis C virus (HCV) and HCV-related chronic disease. MMWR 1998; 47(RR-19):1-39.

Those reporting risk factors for HCV infection should be tested for anti-HCV.

The recommendations are part of comprehensive new CDC guidelines for prevention and control of infections with hepatitis A, B, and C in prison inmates and correctional officers.1

"People who spend time in jails, prisons, and juvenile institutions have an increased risk of infectious diseases, including rates of infections with hepatitis B and hepatitis C viruses," says Cindy Weinbaum, MD, a medical epidemiologist in the CDC division of viral hepatitis.

"These recommendations look at the incarceration period as a time for potential interventions, basically as an extension of the public health system. Medical prevention measures can be delivered effectively in prisons," she says.

The guidelines synthesize and expand previous hepatitis guidelines and clarify that targeted — not universal — testing is recommended to identify HCV in prison.

"We clarified that [testing] should be, in most settings, based on reported risk behaviors by inmates," she says.

"At the consultant’s meeting that was convened when these recommendations were put together, we [reviewed] data from a couple of different correctional systems where they had looked at risk factors among their inmates who had been tested for hepatitis C," Weinbaum explains.

"They found that self-reported risk factors were very predictive of hepatitis C virus positivity. A large proportion of people with hepatitis C in this country might be identified through testing in correctional settings," she adds.

Since HCV is not transmitted efficiently via sexual contact, the primary risk factor to identify in the prison population is a history of injecting illegal drugs, she notes.

"Since the main issue with hepatitis C infection is injection drug use, it seemed that people would be willing to admit to their injection drug use, [while] they might not be willing to admit to, say, sex in a prison," Weinbaum says.

Still, it is an open question how many prisons would want to bear the cost of such testing and how many HCV-positive inmates would ultimately receive treatment.

"A couple of studies have tried to determine how many [inmates] would actually be treated for hepatitis C if so many people were being tested," she says. "They have found that only about 5% to 7% of people who get tested would end up even entering a treatment protocol."

Those identified would know their status, might pursue later treatment, and could be educated about preserving their health and preventing further transmission of the virus.

"Counseling, testing, and education are also things that haven’t specifically been recommended for the correctional setting [before]," she adds.

People at risk for HCV infection or those chronically infected with HCV can benefit from health education on topics including, substance-abuse treatment, clean needle and syringe use, risks of sharing drug paraphernalia, and condom use.

Prison counseling and educational materials should include information concerning reducing further liver damage, as well as treatment options for those with chronic liver disease.

Release planning should include substance-abuse-treatment referrals for injecting drug users and medical referrals to specialists for future medical management and treatment.

Health education directed toward prevention of viral hepatitis includes information related to the disease, routes of transmission, risk factors for infection, methods of prevention, disease outcomes, and treatment options.

During incarceration, numerous educational opportunities exist. Education can take different forms, including videos, brochures, and formal classroom presentations. However, repeated face-to-face sessions have been determined to be the most effective means with the highest retention.

Model programs use peer health educators in workshops for incoming inmates, and community educators to discuss risk assessment, risk reduction, and referrals for soon-to-be released inmates, the CDC notes.

Because no vaccine exists to prevent HCV infection, prevention must focus on risk reduction through counseling of people who have admitted to or are at risk for illicit drug use or other factors. Of the estimated 25,000 to 40,000 people newly infected with HCV annually during the past five years, approximately 60% acquired their infection through injection-drug use, the CDC reports.

To be effective, risk reduction among this population often requires a multidisciplinary approach to address drug use as well as other medical, psychological, social, vocational, and legal problems.

Those already HCV-positive require further evaluation for chronic HCV infection and liver disease, and people with chronic hepatitis C require evaluation for possible antiviral therapy and the need for further medical management.

People with chronic hepatitis C are at risk for increased morbidity from additional liver problems. Fulminant hepatitis caused by hepatitis A can be prevented by vaccination.

HCV-infected people often have risk factors for HBV infection so HBV vaccination also is recommended. People with HCV are advised not to use alcohol, because its use (>10g/day for women and >20g/day for men) has been associated with more rapid progression to cirrhosis.

Transmission within prison rare

Though there is clearly a high prevalence of HCV in the prison population, the risk of acquiring the virus while incarcerated is not well established. The only published study to examine the incidence of HCV infection among prison inmates reported a rate of 1.1 infections/100 person-years of incarceration among males.2

No published studies have reported the prevalence of HCV infection among correctional staff.

The CDC cites one unpublished study, among correctional health care workers, the prevalence of HCV infection was 2% — no higher than in the general population. The finding is similar to that of studies among other occupational groups, including hospital-based health care workers, surgeons, and public safety workers

"Basically, our recommendations for correctional staff are that individuals who come into frequent contact with blood should be vaccinated against hepatitis B," Weinbaum says.

"Anybody who has an exposure that’s potentially infectious should be tested, the source should be tested, if possible, and post-exposure prophylaxis should be given for hepatitis [B]," she adds.

Integrate prevention methods

Measures to prevent occupational exposure to HBV and HCV among correctional workers should be integrated into each facility’s bloodborne pathogen and infection control plan according to the requirements of the Occupational Safety and Health Administration (OSHA).

The plan should cover all employees (including inmates who are assigned work duties at a correctional facility) who could be reasonably anticipated, as the result of job duties, to be exposed to blood, bodily fluids, or other materials that might contain HBV or HCV.

The plan should mandate standard (i.e., universal) precautions for all contact with blood or body fluids.

This should include procedures used to prevent needle sticks, including use of safer needle devices, to minimize splashing and spraying of potentially infectious material, and to ensure appropriate disinfection and decontamination of potentially contaminated surfaces and equipment, and appropriate disinfection and disposal of infectious material and contaminated clothing.

As a part of the plan, correctional facilities should require employees to use appropriate personal protective equipment (e.g., gloves, gowns, masks, mouthpieces, and resuscitation bags) that are provided by the employer.

Plan administrators should consider strategies to overcome the unique barriers to an effective infection control plan in a correctional environment. For example, potential inaccessibility of sharps disposal containers might necessitate using specific safe-needle devices and other strategies to minimize needle-stick injuries in correctional health care settings, according to CDC recommendations.

References

1. Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR 2003; 52(RR-01):1-33.

2. Vlahov D, Nelson KE, Quinn TC, et al. Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. Eur J Epidemiol 1993; 9:566-569.