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Hepatitis B Transmission in Prisons: sharing needles, sex, mother-to-child, vaccine for prevention
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"...Similarly to HIV transmission, hepatitis B is transmitted easily by exchange of blood and bodily fluids as in with sharing needles, or having sex with hepatitis B-infected individuals. In addition, newborn infants can become infected during childbirth from their infected mothers. Unlike other hepatitis viruses, hepatitis B cannot be spread through air or food, it can only be spread through body fluids.
Hepatitis B infection is particularly serious for women who wish to become pregnant or are pregnant, because the virus is frequently transmitted to their babies, which may cause serious liver disorders and premature death. Thus, all pregnant women should be tested for early detection of hepatitis B infection and consider vaccination for their infants upon birth..."
Hepatitis B transmission high in Rhode Island prisons, study shows
In the first study to gauge the risks of contracting HIV and hepatitis in Rhode Island prisons, Brown University researchers found that a significant number of men get the hepatitis B virus behind bars -- a finding that led the team to call for prison-wide vaccinations. Results are published in the current edition of the American Journal of Public Health.
PROVIDENCE, R.I. — Inmates entering Rhode Island prisons have high rates of HIV and hepatitis, according to new Brown University research, which presents a "significant community health issue." Once in prison, researchers found, male prisoners pass on the hepatitis B virus at alarming rates.
That's why the research team, led by Grace Macalino, assistant professor of community health, is calling for hepatitis B vaccinations for all prisoners. Their findings and recommendations appear in the current issue of the American Journal of Public Health, a leading journal for public health research and policy.
"We have a unique opportunity to access a hidden, high-risk population," Macalino said. "We can do a lot of prevention work to make sure inmates are healthier. Because these men don't stay inside. They come back to the community."
The Brown study is the first of its kind in Rhode Island and one of the few investigations of blood-borne infection rates in prisons in the United States.
To conduct the study, Macalino and her team analyzed blood from mandatory, consensual tests taken when inmates entered the Adult Correctional Institute in Cranston. Researchers gathered test results on 4,269 men sentenced between 1998 and 2000.
Their major finding: high prevalence of life-threatening, contagious infections.
Nearly 2 percent of incoming inmates tested positive for HIV, while HIV can be found in 0.33 percent of the general U.S. population. Twenty percent had hepatitis B and 23 percent had hepatitis C. For comparison, 5 percent of the general public has hepatitis B and 2 percent has hepatitis C.
To see if inmates were spreading disease in prison, researchers retested 446 men who were still serving time at least one year later. This netted some good news: None of the subjects contracted HIV while in prison, and less than 1 percent of inmates contracted hepatitis C.
"Prisons don't appear to be the dangerous incubators we thought they were," Macalino said. "It's not that prisons are doing a good job of prevention. It's just that conditions in lock-down are a lot more prohibitive than they would be out in the community."
Transmission of the hepatitis B virus inside the Cranston prison, however, was alarming. In one years' time, almost 3 percent of inmates contracted the virus -- a rate higher than indicated in previous prison research and exponentially higher than the national average.
Macalino and her colleagues said the spread of hepatitis B -- which is preventable -- is cause for concern. Infants and toddlers are routinely vaccinated to protect them against the disease, which attacks the liver and causes cirrhosis, cancer, even death. Researchers recommend that the Adult Correctional Institute, and all prisons, give inmates the vaccine.
While a recent U.S. prison survey found that only two facilities routinely give hepatitis B shots, Macalino said the investment would be wise. Inmates, on average, serve a two- to three-year sentence. Vaccines would prevent inmates from passing on the virus to the public once they're freed. Teaching prisoners how to steer clear of injection drug use -- a main avenue of transmission -- once they're released would also improve community health, Macalino said.
Macalino's research team from Brown Medical School included Josiah Rich, M.D., associate professor of medicine; staff members Stephanie Sanford-Colby and Christopher Salas; and student Sarju Patel. David Vlavhov from the New York Academy of Medicine and Keith Sabin from the University of Georgia--Athens also assisted in the research and writing.
Funding came from the Centers for Disease Control and Prevention.
Prisoners are willing
Hepatitis B vaccination for inmates would protect health of communities
Ninety-three percent of Rhode Island inmates studied said they would agree to receive the hepatitis B vaccine in prison if it were offered, according to new Brown University research. Although vaccination has been available for two decades, 1.2 million Americans have chronic hepatitis B, and the disease continues to spread. Few prison systems offer the vaccine to inmates.
PROVIDENCE, R.I. — Correctional settings provide a unique opportunity to offer hepatitis B vaccination to a substantial number of high-risk adults who are willing to be vaccinated and who would not otherwise have access to the preventive medicine, according to a new Brown University study of inmates within the Rhode Island Department of Corrections.
Ninety-three percent of inmates studied from June to August 2002 said they would agree to receive the hepatitis B vaccine while incarcerated. Those who said they would not accept vaccination were either undecided or mistrusting of the government and/or prison.
"Implementation of routine hepatitis B vaccination in jails and prisons could substantially decrease hepatitis B transmission by preventing disease in large cohorts of those most at risk," said Snigdha Vallabhaneni, study author and third-year student in the Brown Medical School. Vallabhaneni's paper is in press in the journal Preventive Medicine and available online at www.sciencedirect.com/science/journal/00917435. "Such programs would help protect the health of incarcerated persons and the communities to which they return."
Researchers interviewed 153 male and female inmates selected randomly from the daily roster of the Rhode Island Department of Corrections, which performs 15,000 intakes each year and has an average daily population of 3,000.
Hepatitis B continues to be a substantial problem in this country despite the existence of a safe and effective vaccine for more than two decades, said the researchers. The disease is caused by a virus that attacks the liver and causes lifelong infection, cirrhosis of the liver, liver cancer, liver failure, and death. An estimated 78,000 people were newly infected in 2001 and 1.2 million Americans now have chronic hepatitis B, according to the Centers for Disease Control and Prevention (CDC).
Since 1982, the CDC has recommended hepatitis B vaccination for high-risk adults including healthcare workers, injection drug users, men who have sex with men, and people with multiple sexual partners. Men and women who are incarcerated report a higher prevalence of high-risk behaviors than the general population. In this study, 29 percent of all participants were determined to be at risk for hepatitis B infection based on the list of risk factors.
Outside the prison system, many of the study participants said they do not have access to regular healthcare and therefore may not have the opportunity to take the hepatitis B vaccine series. One-third of those studied used the emergency room as their main source of medical care, said Vallabhaneni.
However the median sentence length is three years in Rhode Island, allowing enough time to complete the hepatitis B vaccination series of three injections while incarcerated, according to Vallabhaneni.
At the time of the study, there was no routine vaccination program for men at the Rhode Island Department of Corrections, although women were routinely offered hepatitis B vaccination. Since that time, routine vaccination has been expanded to the men's division, making the state one of only a few in the nation that offer hepatitis B vaccinations to their inmates.
The study was supported by the National Institutes of Health Center for AIDS Research, the Center for Disease Control, and the Brown Medical School Research Fellowship. Vallabhaneni conducted the research in conjunction with other members of the Brown Medical School, Lifespan Department of Medical Computing, and The Miriam Hospital. They include Grace Macalino, Steven E. Reinert, Beth Scwartzapfel, Francis A. Wolf, and Josiah D. Rich.
Hepatitis A
Hepatitis A disease is caused by the hepatitis A virus (HAV) which causes liver infection. Hepatitis A infection is the seventh most commonly reported infectious disease in the United States. Hepatitis A virus is the cause of 65% of all hepatitis-related cases each year and results in 100 deaths per year. Hepatitis A virus is usually spread by an oral-fecal route where improper hygiene methods are used at eating establishments which contaminate food such as shellfish, or in contaminated drinking water in developing countries. Additionally, very close contact with those persons infected with hepatitis A can lead to transmission. The infection rate is 143,000 cases per year in the United States, but hepatitis A infection is endemic in developing countries. Fortunately, the hepatitis A disease is acute and mild and often asymptomatic, 50% of the time with only flu-like symptoms. However, rarely the illness can be more severe with patients experiencing prolonged anorexia and occasional jaundice and with extr eme infections resulting in liver failure which requires biochemical testing for detection. Until recently, only immunogloblin (IgG) treatments were available to protect at-risk groups from severe infection. This treatment was also offered to alleviate sy mptoms for those who suffered symptoms. Unfortunately, with this treatment symptoms return after a 4-6 month period.
Since 1992, Europe has been using a nearly 100% effective vaccine containing whole inactivated hepatitis A virus to attain immunity. Patients receive two doses (2-4 weeks apart) that provide immunity up to one year. After that, an additional booster can ensure long term protection against hepatitis A. Vaccination or IgG treatment is strongly recommended for asyone planning international travel or vacations.
Introduction
Hepatitis B is common viral infection that can cause severe liver damage. Symptoms of hepatitis B vary but may include flu-like illness, tiredness, fever, body aches, nausea, vomiting, loss of appetite, and occasional diarrhea. Some percentage of people may develop jaundice (a yellowing of skin and whites of eyes) accompanied by the darkening of urine and lightening of stool. However, many people experience no symptoms at all.
Hepatitis B is both easily transmitted and easily prevented. Prevention measures involve avoiding contact with contaminated body fluids. The virus is quite widespread, but still somewhat concentrated in particular high-risk groups, including intravenous drug users and commercial sex workers. If acquired, the condition is treatable with interferon-alpha; in addition, a prophylactic vaccine is available.
Epidemiology
Hepatitis B infection is a concern for everyone. Hepatitis B is the disease caused by the Hepatitis B virus (HBV) that may result in chronic liver disease, cirrhosis (scarring of liver), liver cancer, liver failure, and some cases, death. Currently, e ach year more than 240,000 persons get Hepatitis B in the United States, and more than 300,000,000 persons (close to U.S. population) become infected in the world yearly. There are approximately 1-1.25 million people in the U.S. who have chronic Hepatitis B infection or are carriers. Most times the hepatitis B virus (HBV) is spontaneously cleared after infection (85%), however only about 15% infected with heoatitis C virus clear it spontaneously. Because of large incidence and prevalence of infection, about 5% of all persons in the U.S. will become infected with Hepatitis B virus in their lifetime. In addition, chronic Hepatitis B infection accounts for about 5-10% of all cases of chronic liver disease and liver cirrhosis in the U.S.
The Hepatitis B virus is found in the blood and other body fluids of Hepatitis B infected individuals. Similarly to HIV transmission, Hepatitis B is transmitted by exchange of blood and bodily fluids as in with sharing needles, or having sex with a Hepa titis B infected individual. In addition, newborn infants become infected during childbirth from their infected mothers. Hepatitis B cannot be spread through air or food unlike other hepatitis viruses, but spreads through exchange of body fluids. Becau se there is no cure, it is crucial for all of us to take initiative in our lives to prevent the spread of Hepatitis B virus. Fortunately there is a safe and 90-95% effective vaccine that has been available since 1981. This vaccine can provide lifetime i mmunity to healthy individuals of all ages. The vaccine is usually administered by entramuscular injections with three timely spaced doses.
Hepatitis B infection is very serious for women who wish to become pregnant or who are currently pregnant because the virus frequently infects their babies, which may cause serious liver disorders and premature death. Thus all pregnant women are encoura ged to be tested for early detection of Hepatitis B infection and should consider giving their infants the vaccine upon birth.
Symptoms of Hepatitis B disease vary buy may include flu-like illness, fatigue, fever, body aches, nausea, vomiting, loss of appetite, and occasional diarrhea. Some percentage of people may develop jaundice (a yellowing of skin and eye white), ccompany ed by the darkening of the urine and the lightening of the stool. However many people experience no symptoms at all, therefore if you are in doubt...ask a doctor.
MODE OF INFECTION/TRANSMISSION
Hepatitis B is contracted parenterally through contact with blood, blood products and other bodily fluids. The virus was first contracted through contaminated measles and yellow fever vaccines and was also prevalent among blood transfusion recipients. Re cently, through advancements in blood screening and vaccine technology, contamination and post-transfusion infection have been rapidly reduced. There are still large numbers of infections in homosexual males and intravenous drug users. Hepatitis B can als o be passed from mother to child. The virus has a long incubation period and infection is detected by antibodies in the blood. The early stage of infection is characterized by a long period of flu-like symptoms and fatigue until full manifestation of the disease which results in liver damage.
The liver damage results because of the virus infects liver cells (hepatocytes) and replicates in them. Upon replication, the cells begin to express viral antigens on their cell surfaces, which evokes an immune response against the infected cells. In the case of hepatitis B, cytotoxic T lymphocytes (CTLs) produce an immune response which results in lysis (killing) of the hepatocytes. The virus infects numerous cells which are subsequently lysed by the CTLs, and liver function becomes impaired. Because th e manifestation of the disease, liver damage, is caused by the host immune response, infected persons who are immunosuppressed due to cancer treatment, for example, show less pronounced liver damage.
The hepatitis B virus is found in the blood and other body fluids of infected persons. Similarly to HIV transmission, hepatitis B is transmitted easily by exchange of blood and bodily fluids as in with sharing needles, or having sex with hepatitis B-infected individuals. In addition, newborn infants can become infected during childbirth from their infected mothers. Unlike other hepatitis viruses, hepatitis B cannot be spread through air or food, it can only be spread through body fluids.
Hepatitis B infection is particularly serious for women who wish to become pregnant or are pregnant, because the virus is frequently transmitted to their babies, which may cause serious liver disorders and premature death. Thus, all pregnant women should be tested for early detection of hepatitis B infection and consider vaccination for their infants upon birth.
VACCINES
Numerous vaccines are currently available against hepatitis B. Vaccination is most strongly recommended for children under 20, health-care workers, persons with multiple sexual partners, intravenous drug users, and anyone having intimate contact with tho se people. The common version of the vaccine involves a surface molecule of the hepatitis B virus (HBsAg). In the United States, the recommended regimen consists of three vaccinations; the second one month after the first, and the third six months after t he first (0, 1, and 6 months). This vaccine has been shown to be highly effective at preventing infection. A fourth booster shot will greatly increase chances of successful seroconversion (achieving a state of immunity).
Since the early 1980s, vaccines have existed against hepatitis B. Until today, the most commonly used form of this vaccine makes use of the hepatitis B surface antigen (HBsAg). These particles are either collected from patient serum and inactivated, or m ade in recombinant yeast. A DNA vaccine under development would make use of the same protein. The actual effectiveness of producing an anti-HB response has only very recently been confirmed.
In recent years, researchers have made use of additional proteins to target immune responses, particularly in those patients who do not respond to the HBsAg vaccine. These vaccines make use of the pre-S, pre-S1, pre-S2, and S proteins of the HB genome. W ith one exception (pre-S2) these vaccines are just as effective as the HBsAg vaccine, at least according to preliminary data. Nonetheless, most research has been targeted to the HBsAg vaccine.
The HBsAg vaccine is normally administered three times (at 0, 1, and 6 months) with 10 µg antigen. A fourth booster shot has been shown to decrease nonresponsiveness by 25%. In certain cases, an accelerated schedule (0, 1, and 2 months) has been adopted, which improves program completion rates, but decreases seroconversion rates. In addition, preliminary studies show that intradermal vaccination with 1/10 of the intramuscular dose produces comparable results to the standard vaccine, which is very signifi cant considering the exorbitant cost of the vaccine.
The vaccine has very few side effects besides mild injection-site reactions. However, in rare cases, multiple evanescent white dot syndrome (MEWDS), a rare eye disorder, and lichen planus, normally associated with liver disease, have been reported. In ad dition, low response rates to the vaccine have been reported in patients with renal insufficiency, in children receiving chemotherapy, in substance abusers, persons with malnutrition, and in immune-suppressed patients. Response to the vaccine is also know n to be HLA-dependent, with genotypes HLA-B8 and HLA-DR3 being nonresponders.
The last few years have produced a consensus among the health care policy (WHO) community that implementation of the vaccine should be universal. However, a recent study shows that at least 1/3 of general practitioners and family doctors do not believe t hat this would be the best strategy. Notwithstanding, there are certain groups that are known to be at a higher risk for hepatitis B infection. Nurses and health care workers in general need to be immunized not only for their own protection, but also for the protection of their patients. In addition, while children are most often targeted for immunization programs, the disease occurs much more frequently in adults (100-times as commonly) , warranting increased awareness. In particular, pregnant women must be immunized because of the high risk of transmission to the fetus. Finally, homosexual men have long been known to be a high-risk group for hepatitis B, and the vaccine has been recomme nded for them since 1982.
The last few years have seen a proliferation in vaccine development research. In addition to the vaccines mentioned above, a combined hepatitis A/B vaccine has been developed and shown to be effective. In addition, the existing HBsAg vaccine has been sho wn to treat existing hepatitis B infections, when given in combination with herbal extracts.
BRIEFS ON HEPATITIS C
Hepatitis C is the most common cause of chronic hepatitis in the Western world. Infection with this virus is often symptomless, and only 20-30% of patients develop cirrhosis of the liver. Interferon-alpha is the only proven beneficial therapy and is give n in a 6-12 month course. The current standard of care is pegylated interferon plus ribavirin, which consists of a once weekly subcutaneous injection of the interferon plus ribavirin pills taken daily. The sustained response rate varies from 45% to 90% based on individual variables such as your viral genotype, viral load, weight, and others. A vaccine is currently being researched but it will be difficult to develop one.
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