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Prevention and Control of

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

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  1. Prevention and Control of Viral Hepatitis in Correctional Settings An Update on National Recommendations

  2. 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

  3. 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

  4. 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

  5. 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

  6. Hepatitis C Virus Infection Among Incarcerated Adults, United States

  7. Infectious Disease Burden among Released Inmates, United States, 1996 Source: NCCHC, Hammet, Greifinger et.al. unpublished data

  8. Viral Hepatitis in the United States

  9. 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

  10. Outcome HBV HCV HIV Chronic infections ~1.2 (million) ~2.7 (million) ~0.8 (million) New infections /yr ~120,000 ~40,000 ~40,000 Deaths /yr 5,000 8,000 17,000 Disease Burden from Bloodborne Viral Infections, United States, 1999 Source: CDC

  11. Risk Factors for Transmission of Hepatitis Viruses and HIV Proportion of Infections Source: CDC Surveillance data

  12. Viral Hepatitis in the United States Hepatitis B

  13. 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)

  14. 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)

  15. 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

  16. 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

  17. 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

  18. 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

  19. Juvenile Systems with Hepatitis B Immunization Programs Source: NCCHC and CDC, unpublished data

  20. 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

  21. Viral Hepatitis in the United States Hepatitis C

  22. 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

  23. 100 80 60 40 20 0 0 6 12 18 24 30 36 42 48 54 60 66 72 Risk of Bloodborne Virus Infections Among Injection Drug Users, Baltimore 1983–1988 HCV HBV Seroprevalence(%) HIV Duration of Injecting (months) Source: Garfein RS et al Am J Public Health. 1996;86:655.

  24. 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)

  25. 6 Total 5 4 Male 3 Female % Anti-HCV Positive 2 1 0 6-11 12-19 20-29 30-39 40-49 50-59 60-69 70+ Age in Years HCV Infection Prevalence, United States 1988-1994 Source: NEJM 1999;341:556-62

  26. 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)

  27. 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)

  28. Preliminary Recommendations: Prevention and Control of Viral Hepatitis in Correctional Settings

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

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