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HEPATITIS B IN CORRECTIONAL FACILITIES: hi prevalence & successful vaccination programs
 
 
  Transmission of Hepatitis B Virus in Correctional Facilities --- Georgia, January 1999--June 2002
 
From CDC MMWR Aug 5, 2004
 
"...HBV is a bloodborne pathogen, transmitted by percutaneous or permucosal exposure to infectious blood or body fluids. The prevalence of chronic infection is higher among prison inmates (1.0%--3.7%) than among the general U.S. population (0.5%) (1), reflecting an overrepresentation of persons entering prison who are at high risk for HBV infection (e.g., injection-drug users and those with reported histories of multiple sex partners)..."
 
The second article below:
"Hepatitis B Vaccination of Inmates in Correctional Facilities ---Texas, 2000—2002"
and summarizes the results of that study, which indicated that rates of vaccine acceptance and vaccine series completion among inmates were high. Establishing hepatitis B vaccination programs in prisons and jails can prevent a substantial proportion of HBV infections among adults in the outside community.
 
TEXT FROM FIRST ARTICLE
 
Incarcerated persons have a disproportionate burden of infectious diseases (1), including hepatitis B virus (HBV) infection. Among U.S. adult prison inmates, the overall prevalence of current or previous HBV infection ranges from 13% to 47%. The prevalence of chronic HBV infection among inmates is approximately 1.0%--3.7%, two to six times the prevalence among adults in the general U.S. population (1). Incarcerated persons can acquire HBV infection in the community or in correctional settings (1). This report summarizes the results of 1) an analysis of hepatitis B cases among Georgia inmates reported to the Georgia Department of Human Resources, Division of Public Health (DPH) during January 1999--June 2002, including a retrospective investigation of cases reported during January 2001--June 2002; and 2) a prevalence survey conducted in prison intake centers during February--March 2003. These efforts identified cases of acute hepatitis B in multiple Georgia prisons and documented evidence of ongoing transmission of HBV in the state correctional system. The findings underscore the need for hepatitis B vaccination programs in correctional facilities.
 
The Georgia correctional system houses approximately 45,000 inmates in 68 correctional facilities; approximately 16,000 new inmates are admitted each year and processed through one of five intake centers. The correctional system does not routinely screen inmates for HBV infection, and diagnostic testing is left to the judgment of individual physicians. In August 2000, in response to two hepatitis B outbreaks at one Georgia correctional facility (2,3), DPH began to monitor reports of acute hepatitis B cases among inmates at all Georgia correctional facilities, as determined by the inmates' addresses on laboratory reports.
 
A case of acute HBV infection was defined as a positive serologic test for IgM antibodies to hepatitis B core antigen (IgM anti-HBc) on at least one occasion and at least one additional supporting finding (e.g., compatible symptoms, liver enzyme elevation, or another positive hepatitis B serologic test), received by DPH during January 1999--June 2002. Cases reported during January 2001--June 2002 were confirmed by retrospective review of the inmate's medical and laboratory records. The date of diagnosis of acute HBV infection was defined as the date that alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels were elevated at least two times greater than the upper limit of normal in conjunction with a positive test for IgM anti-HBc. When ALT or AST levels were not available, the date of the blood draw with a positive IgM anti-HBc result was used as the approximate date of diagnosis.
 
Incarceration histories of inmates with acute HBV infections reported during January 2001--June 2002 were reviewed to identify inmate locations and number of transfers between correctional facilities before illness onset. Persons with asymptomatic and symptomatic cases were considered to have been infected while incarcerated if they were in prison or jail during the 12 months or 6 months, respectively, before illness onset.
 
A prevalence survey to assess the HBV infection status of prisoners on entry was conducted at three Georgia prison intake centers for males and one intake center for females during February--March 2003. Consenting inmates underwent HBV serologic testing; all inmates at intake when the survey was conducted were offered hepatitis B vaccine.
 
During January 1999--June 2002, a total of 92 cases of acute HBV infection were identified, of which 57 (62%) were reported during January 2001--June 2002 and included in the retrospective investigation (Figure). Among the 57 inmates with HBV infection, the median age was 34 years (range: 18--59 years); 52 (91%) were male, and 35 (61%) were non-Hispanic blacks. Ten (18%) had symptoms that included jaundice, abdominal pain, fever, and vomiting. Seven (12%) subsequently were determined to have chronic infections. The chronic infection status of four inmates was not assessed.
 
  
 
   
 
 
 
Among the 57 inmates included in the retrospective investigation, the most frequently reported reason for HBV testing was the presence of symptoms or elevated liver enzymes (21 cases [37%]). Other reasons included reported characteristics and behaviors that might be associated with HBV transmission (e.g., tattoos or unprotected sex contacts) (14 [24%]), serologic testing performed as part of initial medical evaluation (13 [23%]), and being positive for human immunodeficiency virus (five [9%]). Prison staff reported counseling and providing medical follow-up for 52 (91%) of the 57 inmates.
 
The 57 cases were reported from 27 prisons and four probation detention centers in Georgia, with a mean of 1.8 cases per facility and a range of one to three cases for the 30 facilities that were not involved in the previously recognized outbreaks (2,3). The 57 inmates had been incarcerated for a median of 2.2 years (range: 0--23.7 years) before illness onset and had been transferred 1.4 times on average (median: one time; range: one to seven times) during the 12 months before diagnosis. The majority of HBV infections (41 [72%]) were acquired in prison. Of the remaining 16 cases, 13 (81%) occurred in persons who had been in prison or jail for 1--6 months before receiving a diagnosis. The remaining three (19%) inmates were asymptomatic and had been in prison or jail for 10--11 months before receiving a diagnosis.
 
As of August 2002, the seven inmates who had chronic infections had been transferred among prison facilities 13 times during the cumulative 89 months of incarceration that followed their diagnosis, resulting in a mean of 1.8 transfers per person-year of incarceration (median: two transfers; range: zero to five transfers). Three inmates with chronic infection were released from prison.
 
Of 546 inmates surveyed at intake during February--March 2003, a total of 489 (90%) consented to serologic testing, and 428 (78%) consented to hepatitis B vaccination. Of the 489 inmates tested, three (0.6%) had acute HBV infections, four (0.8%) had chronic infections, 64 (13%) had evidence of resolved infections, and 374 (76%) were susceptible to HBV infection. Two of three inmates with acute infection had spent 5.5--11.0 months in jail before intake.
 
Reported by: K Arnold, MD, Georgia Dept of Human Resources, Div of Public Health; M LaMarre, MN, J Taussig, MPH, Georgia Dept of Corrections. BP Bell, MD, L Farrington, MS, Div of Viral Hepatitis, National Center for Infectious Diseases; S Vong, MD, PR Patel, MD, EIS officers, CDC.
 
Editorial Note:
 
HBV is a bloodborne pathogen, transmitted by percutaneous or permucosal exposure to infectious blood or body fluids. The prevalence of chronic infection is higher among prison inmates (1.0%--3.7%) than among the general U.S. population (0.5%) (1), reflecting an overrepresentation of persons entering prison who are at high risk for HBV infection (e.g., injection-drug users and those with reported histories of multiple sex partners). The prevalence of chronic infection among the intake population in this report (0.8%) suggests that high-risk behaviors practiced within the community before incarceration might not account entirely for the burden of HBV infection in correctional facilities. Although studies are limited, transmission of HBV infection within correctional settings has been documented, with incidence ranging from 0.8% to 3.8% per year (2,4--6).
 
The retrospective investigation described in this report identified an increase in HBV infections in Georgia correctional facilities, beginning in January 2001. This increase likely was related to multiple factors, including enhanced surveillance and increased diagnostic testing by correctional medical staff. Changes in diagnostic practices might have occurred because of increased awareness of hepatitis B among medical staff after outbreaks at a Georgia correctional facility in June 2000 and again in June 2001. Nonetheless, the number of reported cases probably underestimates the extent of HBV transmission in the correctional system because the majority of persons with acute HBV infection are asymptomatic and investigations of single cases are not conducted routinely. In the first previous outbreak, one symptomatic patient reported to DPH was associated with a cluster of 11 acute cases, and four chronic HBV infections were identified (2).
 
The majority of inmates with identified acute HBV infections were housed in multiple Georgia correctional facilities and were infected during their incarceration, suggesting widespread ongoing transmission in multiple facilities. Inmates infected with HBV were transferred frequently among facilities. Thus, potential sources of HBV transmission were distributed throughout the prison system.
 
In the Georgia correctional system, approximately one third of inmates are released each year (7). Inmates who become chronically infected and subsequently are released represent potential sources of infection for others in the community. In addition, susceptible inmates who are released continue to be at increased risk for HBV infection (1). The majority of inmates in the intake survey were susceptible to HBV infection and consented to vaccination, suggesting that vaccination efforts in correctional facilities might effectively capture susceptible, high-risk populations.
 
Although data are lacking regarding the overall burden of HBV infection in correctional systems, the ongoing transmission demonstrated in Georgia prisons might be occurring in other states, where similar conditions are likely to exist. All inmates who receive a medical evaluation should be vaccinated to prevent HBV infection (1). However, the majority of state correctional systems in the United States, including the Georgia system, do not have hepatitis B vaccination programs (1). Implementation of such programs in correctional settings nationwide could result in a considerable reduction in the hepatitis B--associated disease burden, not only by eliminating transmission among the incarcerated population, but also by reducing transmission in the community (8).
 
References
 
  1. CDC. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR 2003;52(No. RR-1).
  2. Khan A, Simard E, Wurtzel H, et al. The prevalence, risk factors, and incidence of hepatitis B virus infection among inmates in a state correctional facility [Abstract]. In: Program and abstracts of the 130th Annual Meeting of the American Public Health Association, Philadelphia, Pennsylvania, 2002.
  3. CDC. Hepatitis B outbreak in a state correctional facility, 2000. MMWR 2001;50:529--32.
  4. Decker MD, Vaughn WK, Brodie JS, Hutcheson RH Jr, Schaffner W. Seroepidemiology of hepatitis B in Tennessee prisoners. J Infect Dis 1984;150:450--9.
  5. Hull HF, Lyons LH, Mann JM, Hadler SC, Steece R, Skeels MR. Incidence of hepatitis B in the penitentiary of New Mexico. Am J Public Health 1985;75:1213--4.
  6. Macalino GE, Vlahov D, Sanford-Colby S, et al. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. Am J Public Health 2004;94:1218--23.
  7. Georgia Department of Corrections. Annual report 2001. Available at http://www.dcor.state.ga.us/pdf/fy01workin.pdf.
  8. Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors for acute hepatitis B in the United States, 1982--1998: implications for vaccination programs. J Infect Dis 2002;185:713--9.

 
TEXT FROM SECOND ARTICLE
 
Hepatitis B Vaccination of Inmates in Correctional Facilities ---Texas, 2000--2002
 
In December 2002, approximately 2.2 million persons were incarcerated in the United States (1); an estimated 8 million were released to the community that year (2). In 2001, approximately 22,000 acute hepatitis B cases and 78,000 new hepatitis B virus (HBV) infections occurred in the United States (3); an estimated 29% of these cases were in persons who had been incarcerated previously (4). The majority of HBV infections among incarcerated persons are acquired in the community; however, infection also is transmitted within correctional settings (2). Hepatitis B vaccination of incarcerated persons is recommended to prevent transmission in correctional facilities and in previously incarcerated persons on their return to the community (2). In May 2000, the Texas Department of Criminal Justice (TDCJ), which oversees custody of state jail and prison inmates, implemented a hepatitis B vaccination program. To determine hepatitis B vaccination rates of inmates during 2000--2002, TDCJ reviewed charts of inmates released during a 3-day period for documentation of vaccination. This report summarizes the results of that study, which indicated that rates of vaccine acceptance and vaccine series completion among inmates were high. Establishing hepatitis B vaccination programs in prisons and jails can prevent a substantial proportion of HBV infections among adults in the outside community.
 
During 2000--2002, TDCJ housed approximately 151,000 inmates in 105 adult facilities, including prisons (median sentence of inmates: 9 years; range: 2--99 years) and jails (median sentence of inmates: 1.3 years; range: 3 months--2 years). Approximately 40,000 new offenders enter these facilities annually, and an estimated 1% of inmates are transferred between facilities daily (5,6). In 1999, state funds were appropriated for hepatitis B vaccination of all inmates in jails and prisons.
 
Before implementation of the vaccination program, a cost-effectiveness model was developed that estimated the cost effectiveness of prevaccination testing for immunity to HBV infection among inmates. Stored serum specimens from 889 inmates incarcerated during 1998--1999 were tested for antibodies to hepatitis B core antigen (anti-HBc); HBV prevalence was 18%. The model estimated that at a threshold prevalence of 25%, the cost of a program with prevaccination testing was equivalent to that of vaccination without testing; at lower prevalence, prevaccination testing would not be cost effective (Figure). On the basis of these findings, all of the estimated 40,000 entering inmates were offered vaccine without prevaccination testing.
 
Entering inmates were offered the first hepatitis B vaccine dose at the time of admission. Persons who were already incarcerated were offered the first dose at the time of their annual health evaluation, which occurred on their anniversary month of incarceration. After vaccination of incarcerated persons, only newly admitted inmates were offered vaccine.
 
Vaccine was administered on a 0-, 2-, and 4-month schedule. An electronic pharmacy auto-renewal system was used to send second and third vaccine doses to the appropriate facility for each inmate. Health-care workers also recorded vaccine dose administration in each inmate's medical record, enabling inmates to complete the vaccination series despite frequent transfers within the system.
 
In February 2002, TDCJ evaluated vaccine acceptance and series completion rates. Charts of 232 prison inmates and 211 jail inmates released during a 3-day period were audited for receipt of hepatitis B vaccine; 426 (96%) inmates with no record of previous vaccination or HBV infection were considered to be eligible for vaccination. Lack of documentation of a vaccination encounter was interpreted as a failure to offer vaccine, and only a signed informed refusal form was counted as a vaccination refusal.
 
Hepatitis B vaccine was offered to 319 (75%) of 426 inmates. Prison inmates were more likely to be offered vaccine (185/220 [84%]) than jail inmates (134/206 [65%]) (p<0.001), which might be related to higher inmate turnover and lack of staff contact time in jails. However, acceptance of the first vaccine dose was higher among jail inmates (114/134 [85%]) than among prison inmates (134/185 [72%]) (p = 0.005).
 
Among 125 prison and 99 jail inmates who began vaccination and were incarcerated for >4 months, the 3-dose completion rate was 96% and 54%, respectively. In December 2002, the hepatitis B vaccination program was suspended because of a lack of funds.
 
Reported by: M Kelley, MD, L Linthicum, MD, Texas Dept of Criminal Justice. A Spaulding, MD, K Billah, PhD, C Weinbaum, MD, Div of Viral Hepatitis, National Center for Infectious Diseases; R Small, Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.
 
Editorial Note:
 
Evaluation of the TDCJ hepatitis B vaccination program demonstrated that high vaccine coverage could be achieved for inmates in a state correctional system. Incarceration provides an opportunity to vaccinate persons at high risk typically not served by prevention services in the public or private sectors, and vaccination of incarcerated populations is cost effective (7).
 
The findings in this report illustrate the need to tailor a program to a particular facility. Completion of the vaccine series is a more feasible goal for long-term facilities; short-term facilities should initiate the vaccine series, supply an immunization record and, where feasible, provide information at discharge about facilities offering the remaining vaccine doses. Vaccination also can be completed if the person returns to a correctional institution.
 
Prevaccination testing to detect existing immunity can eliminate the cost of revaccinating persons who were vaccinated previously or infected. TDCJ's decision not to perform prevaccination testing was based on a model that included the costs of testing and vaccination and the series completion rate. The model assumed that all inmates who received the first vaccine dose would return for subsequent doses; if attrition caused by release was included in the model, prevaccination testing would only be cost effective if the prevalence of immunity was higher. Changes in prevalence of immunity to HBV infection or costs (e.g., vaccine, labor, and testing) also would change the cost effectiveness of prevaccination testing. In particular, immunity to HBV infection in young adults is changing rapidly within most communities because of an increase in vaccinated adolescents. If adequate immunization records are not available for inmates, periodic monitoring of the prevalence of immunity to HBV infection using a serologic marker to detect both infection (i.e., anti-HBc) and immunization (i.e., antibodies to hepatitis B surface antigen) will help corrections officials determine when prevaccination testing might reduce costs (2).
 
The findings in this report are subject to at least two limitations. First, inmates with shorter sentences are more likely to be discharged and might be overrepresented by the sampling. Because inmates with short sentences might not have been incarcerated long enough to complete the vaccination series, more inmates might have completed the vaccination series than this study demonstrated. Second, lack of long-term follow-up precludes evaluation of the eventual series completion by jail inmates, who might have accessed additional doses outside the correctional system or during subsequent incarcerations.
 
Hepatitis B vaccination of inmates in state correctional facilities is feasible if resources are available to purchase and administer vaccine. In 2000, a survey of state correctional facility medical directors indicated that the majority of prison systems would vaccinate inmates if resources were available (8). Although hepatitis B vaccination of inmates has been recommended since the vaccine first became available in 1982 (9), only five states (Hawaii, Michigan, New Mexico, Vermont, and Wisconsin) vaccinate inmates routinely (D. Burnett, M.D., Wisconsin Department of Corrections and F. Pullara, M.D., New Mexico Department of Corrections, personal communications, 2004) (8). Collaborations between public health and corrections authorities at the state and local level are essential to overcome barriers to vaccination program implementation.
 
References
 
  1. Harrison PM, Beck AJ. Prisoners in 2002. Washington, DC: U.S. Department of Justice, 2003; bulletin no. 200248. Available at http://www.ojp.usdoj.gov/bjs/pub/pdf/p02.pdf.
  2. CDC. Disease burden from hepatitis A, B, and C in the United States. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2002. Available at http://www.cdc.gov/ncidod/diseases/hepatitis/resource/dz_burden02.htm.
  3. Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors for acute hepatitis B in the United States, 1982--1998: implications for vaccination programs. J Infect Dis 2002;185:713--9.
  4. CDC. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR 2003;52(No. RR-1).
  5. Texas Department of Criminal Justice. Statistical report fiscal year 2002. Available at http://www.tdcj.state.tx.us/publications/executive/statsum-fy02.pdf.
  6. Texas Department of Criminal Justice. Statistical report fiscal year 2000. Available at http://www.tdcj.state.tx.us/stat/publications/fy2000statsum.pdf.
  7. Pisu M, Meltzer MI, Lyerla R. Cost-effectiveness of hepatitis B vaccination of prison inmates. Vaccine 2002;21:312--21.
  8. Charuvastra A, Stein J, Schwartzapfel B, et al. Hepatitis B vaccination practices in state and federal prisons. Public Health Rep 2001;116:203--9.
  9. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination---recommendations of the Immunization Practices Advisory Committee. MMWR 1991;40(No. RR-13).

 
  
 
 
 
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