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Implementing routine hepatitis B vaccination at the Rhode Island Department of Corrections (RIDOC) Women’s Division

Implementing routine hepatitis B vaccination at the Rhode Island Department of Corrections (RIDOC) Women’s Division. Beth Schwartzapfel Jennifer Clarke MD, Susan Shepardson MA, Stephanie Sanford-Colby MPH, Jennifer Pomposelli RN, Gerald Dornhecker RN, Josiah D. Rich MD MPH The Miriam Hospital/

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Implementing routine hepatitis B vaccination at the Rhode Island Department of Corrections (RIDOC) Women’s Division

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  1. Implementing routine hepatitis B vaccination at the Rhode Island Department of Corrections (RIDOC) Women’s Division Beth Schwartzapfel Jennifer Clarke MD, Susan Shepardson MA, Stephanie Sanford-Colby MPH, Jennifer Pomposelli RN, Gerald Dornhecker RN, Josiah D. Rich MD MPH The Miriam Hospital/ Brown Medical School Providence RI BSchwartzapfel@lifespan.org

  2. Prisons in the United States • The incarcerated population in the U.S. has skyrocketed in the past two decades • Reached 2 million for the first time in 2002 • Incarcerations from drug offenses have pushed this growth • Since 1980 the number of people incarcerated for drug offenses has grown from 40,000 to 450,000. Bureau of Justice Statistics 2003;NCJ 198877 www.cdc.gov.idu/facts/druguse.htm

  3. Incarcerated persons comprise 0.7% of the US population

  4. The incarcerated setting: a public health opportunity • TURNOVER • 528,848 individuals released from prison each year • 10 million jail releases = ~7.2 individuals released from jail each year • Missed opportunities for HBV vaccination • Incidence study in sentinel counties, 1982-1998 • 29% of acute HBV patients reported incarceration prior to becoming infected Hammett et al. Am J Pub Health 2002;92:1789. Goldstein et al. J Infect Dis 2002;185:713.

  5. The incarcerated setting: a public health opportunity • Routine HIV screening implemented at the RIDOC in 1989 • Prevalence = 2% - 8x higher than RI population • 31% of HIV cases in RI identified at RIDOC • 43% of IDU-associated cases and 43% of MSM&IDU cases in RI identified at RIDOC Desai et al. AIDS Education and Prev 2002;14(Supp B):45.

  6. Hepatitis B in prisons and jails • Evidence of past infection among inmates ranges from 30-43% • General population (NHANES), 1988-1994: ~5% • Prevalence higher among women than men • 12-15% of all Americans with HBV (155,000 people) were releasees from prison or jail the previous year J Infect Dis 1984;150:529 / Am J Public Health 1985;75:1213 Clin Ther 1987;9:622. / Am J Public Health 1990;80:471. MMWR 2003;52(RR-1): 2.

  7. Public safety vs. public health • Estelle vs. Gamble, 1978: Prisons constitutionally mandated to provide health care • Conflicting priorities? • Proactive vs. Reactive health care • Public safety = public health

  8. Why NOT vaccinate in prisons and jails? • Inmates often not incarcerated long enough to complete series • High refusal rates • $$$$$$$$$$$$$$$$$ Charuvastra et al. Public Health Reports 2001;116:1-12.

  9. Hepatitis B in Rhode Island prisons and jails • Epidemiologic study in female prisoners (1996-7) • Prevalence among incoming women 36% • Community incidence among re-incarcerated women was 12.2 per 100 person-years • Epidemiologic study in male prisoners (1998-2000) • Prevalence among incoming men was 20% • Incidence among incarcerated men 2.7 per 100 p-y Macalino et al. 6th Conference on Retroviruses and Opportunistic Infections, 1999. Macalino et al. Am J Pub Health 2004. In press.

  10. RI Department of Corrections • Single state correctional facility • Jail and prison • Average daily population • Total: 3,426 • Women’s: 217 • Average length of stay: • Non-sentenced: 2 weeks • Sentenced: 10 months • Women’s: 24 hours

  11. RI Department of Corrections • Intakes/year • Total: 16,000 • Women’s: 2,000 • At intake: • HIV testing • Syphillis testing • PPD • Preliminary medical history

  12. History of our program • Medical director put $$ for HBV vaccine in budget every year • Every year this $$ was cut • Vaccinations were offered non-systematically to inmates with risk factors at medical visits • 2000: 200 soon-to-expire doses of vaccine donated to Women’s Division by DOH • 93% of eligible inmates were vaccinated • 73% received 2 doses • 40% completed series Clarke et al. Journal of Health Care for the Poor and Underserved 2003;14:318-323.

  13. History of our program • VHIPS, 1999-2003 • Meetings with wardens, medical staff, director of RI DOC, MIS • Agreed that nurses in Women’s Division would administer HBV vaccine at intake • Compromise: computerize • Trainings with nursing staff • Hepatitis B • Benefits of vaccination • Use of computer/database

  14. History of our program • Initiated vaccination of all incoming women in 3/2002 • Initiated vaccination of sentenced men in 3/2003 • Goals for future: expand vaccination to all incoming men

  15. Acceptance rates(as of 10/03) • Women’s = 59% • 1 dose: 65% • 2 doses: 21% • 3 doses: 14% • Men’s = 95%

  16. Cost • Vaccine paid for by Federal 317 $$ under state perinatal HBV prevention program • Once vaccine was paid for, little additional $$ was spent • Some additional staff hours • Infrastructure already exists • HBV vaccination in prison is cost saving to the health care system even when only 1 dose is administered Pisu et al. Vaccine 2002;21:312.

  17. Why not vaccinate in prisons and jails? • Inmates often not incarcerated long enough to complete series • Even 1 or 2 doses can confer 50-80% immunity • Incomplete series does not need to be restarted • Inmates who are released and reincarcerated can pick up where they left off • Alternative vaccination sites in the community • Needle exchange/methadone clinics/drug treatment centers • STD clinics (San Diego!) • Homeless shelters/soup kitchens

  18. Why not vaccinate in prisons and jails? • High acceptance rates • Our #s are comparable to acceptance rates in other high-risk settings • Success in Men’s suggests that rates are improved when: • Staff is enthusiastic • Inmates are not offered vaccine just hours after being arrested

  19. Why vaccinate in prisons and jails? • $$$$$$$$$$$$$$$$ • Be creative!! • Be flexible!! • Soon-to-expire doses • Work with state vaccine coordinator

  20. Conclusions • Given cost of vaccine, routine HBV vaccination can be implemented in the correctional setting with little additional effort or funds • Requires communication and education among all players • Future directions • Wraparound viral hepatitis program • Peer education

  21. Acknowledgements • Centers for Disease Control and Prevention, Viral Hepatitis Integration Program • Cooperative agreement #U50/CCU119078 • RI Department of Health • RI Department of Corrections • A.T. Wall, Director • Scott Allen, MD, medical director

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