Out of Sight: Hepatitis and Corrections On the Front Line

By Elizabeth Desiderio Gondles, Ph.D. Institute for Criminal Justice Healthcare

"Prison hepatitis crisis...a public time bomb" "Prisons draft treatment plans for inmates with hepatitis C," "Jail Quarantine, Hepatitis an Outbreak."

It's true that the issue of hepatitis in our nation's correctional facilities hasn't exactly become household news. However, the problem has become serious enough that headlines like the ones above have begun appearing in newspapers across the country. In fact, an increasing number of individuals who are HBV or HCV positive reside in our country's prisons and jails. Some even argue that HBV and HCV has created one of the most significant challenges for corrections professionals and public health officials since the HIV virus, according to Dr. David Thomas, Assistant Secretary for Health Services for the Florida Department of Correction. The question is, Has hepatitis reached epidemic proportions in U.S. corrections population, and more importantly, What can be done to address this intensifying problem?

The Current State

Monthly, more and more cases of inmates with hepatitis are being reported. Data collected from states like California (1,2), Texas(3) and Rhode Island(13) for instance, clearly indicate a prevalence of hepatitis B and C among the inmate populations in these states' correctional facilities. In certain regions of the United States, we are seeing a high prevalence of hepatitis A(4).

"In part, these high rates can be attributed to inadequate education on the ABC's of hepatitis in our communities for this high risk population, a tendency on the part of some offenders to reject educational efforts on hepatitis, insufficient substance abuse education and lack of drug treatment programs, and too few immunization programs for hepatitis A and B ," said Richard Stalder, Secretary of Public Safety and Correction for the State of Louisiana.

For many offenders, the first interaction with any type of health service occurs only after they have entered the correctional system(5).

Devoid of healthcare, these offenders - many of whom are engaging in high-risk behaviors, such as tattooing, injection drug use, body piercing, and intra-nasal cocaine use - often go without proper treatment and interventions, thereby further escalating the severity of their illness. Since most correctional institutions do not screen-out incoming offenders who happen to carry hepatitis, new inmates with the disease enter correctional systems every day. In some cases, correctional institutions actually could serve as a breeding ground for hepatitis B and C. Considering inmates giving each other tattoos, the close quarters, sexual activity, frequent fighting (and thus contact with blood), and sharing of razors and toothbrushes, transmission of hepatitis from infected to non-infected inmates can occur.(10) A recent study conducted by the Centers for Disease Control in a state corrections facility confirms what we already assumed: HBV transmission can occur behind prison walls.(12)

The Explanation

In spite of what the research has uncovered, few steps in the areas of education and prevention have been taken.(6,10)

"Part of the reason for this is the fact that hepatitis in the correctional community has been largely overshadowed by HIV. As a result, greater attention has been paid to HIV/AIDS, pushing hepatitis to the sidelines. But, over the last year, there is a growing awareness about hepatitis in the correctional population and the correctional leadership in the United States is now starting to address hepatitis issues in their correctional systems," said Stalder.

The incidence of hepatitis B and C in the general U.S. population has begun falling. While the frequency of hepatitis is believed to be declining in the U.S. population, corrections is actually seeing an increase in dramatic proportions in our nation's prisons and jails population. In fact, several sero-prevalence studies on Hepatitis B and C (1, 2, 3 12) have clearly shown a high prevalence of HBV and HCV in the corrections population.

In spite of the results of these and other studies, very few states and counties offer any type of education on hepatitis, and even fewer have offered HBV vaccinations for inmates. (Currently, Texas, Hawaii, Michigan, and Hampton County, Mass. offer the HBV vaccination to inmates). Pennsylvania is the only state offering immunization for Hepatitis A and B for all of their offenders at intake.

In reality, the present set-up in many systems is actually working against prevention(10). As a result, as individuals pass in and out of our nation's jails and prisons, so does hepatitis B and C. It's quite simple: inmates infected with the illness who are released into society carry the illness into the community, and incoming inmates who have the illness carry it with them into the facilities. The spread of this serious disease will continue to move through this revolving door unless preventative steps are taken by public health and correctional authorities.

According to Dr. Jeffrey Beard, Secretary, Pennsylvania Department of Corrections, "With the prevalence of hepatitis B and C in our prisons across the country reaching 25% and upwards, a public health epidemic is occurring behind the walls of our prisons."

This health problem has placed a tremendous burden on correctional facilities. Not only must [health] workers contend with yet another challenge behind prison walls, but officials of facilities with high rates of hepatitis have been forced to allocate more of their already stretched budgets to provide health services to hepatitis-positive inmates and comply with laws that require them to meet healthcare rights of these inmates."

The Solution

What is the solution? For starters, public health agencies and corrections facilities must join forces to offer public health prevention and intervention strategies, such as timely assessments, diagnostic treatment where appropriate, and prevention strategies including HBV immunizations to inmates and staff. This step will not only protect and improve the health of inmates, but also that of correctional staff and the general public.

A second critical step to curbing the incidence of hepatitis is providing education on this infectious illness. It is important to note, however, that in spite of the breadth of attention paid to HIV and STDs, few correctional facilities provide education on these potentially deadly illnesses. In fact, currently only 10 percent of state and federal prison systems and 5 percent of city and county jail systems offer comprehensive programs on HIV and STDs Issues and Practices 1996-1997 Update: HIV/AIDS, STDs and TB in Correctional Facilities. When it comes to hepatitis, there are virtually no existing educational programs in place in correctional facilities. Clearly, much has to be done in this area.

In 2000, The American Correctional Association (ACA) and the Texas Department of Criminal Justice (TDCJ), with the assistance of The Institute for Criminal Justice Healthcare (ICJH) and guidance from the Centers for Disease Control (CDC), joined forces to produce a peer education video for offenders and a separate one for staff. The documentary-style videos feature interviews with inmates or staff who tell their own stories and struggles living with hepatitis. Copies of these two videos are available at no cost through the ACA. While this project represents a step in the right direction, it must be followed by further educational and prevention programs if real inroads are to be made.

Hepatitis in the U.S. corrections population has created serious health risks in many prisons. It is up to the corrections and public health community to make prevention and education efforts a paramount goal if we are to take control of this health care issue in our prisons and communities.

Correctional Agencies may request free copies of the hepatitis offender and staff videos by contacting ACA at 301-918-1802 or 301-918-1860

REFERENCES:

1. 1. Ruiz JD, Mikanda J. Sero-prevalence of HIV, Hepatitis B, Hepatitis C and Risk Behaviors Among Inmates Entering the California Correctional System. California Department of Health Services: Sacramento, CA, March 1996.
2. Ruiz JD, Molitor F, Sun RK, et al. Prevalence and correlates of hepatitis C virus Infection among inmates entering the California correctional system. West J Med 1999 Mar;170(3):156-60
3. HIV and HCV Sero-prevelance Study, "Incoming Inmates Into The Texas Dept. of Criminal Justice," 1999
4. "Jail Quarantine at the Cameron County Detention Center 2 and the Cameron County Jail, Due to an Hepatitis A Outbreak" Associated Press, Brownville Texas. 2/05/02 Brownville Herald, Brownsville Texas, 02/05/02 San Antonio Express-News, San Antonio Texas, 02/04/02
5. Krane, Parce, and Miles " Intervening Among the Invisible Population, CDC Correctional Health Care," Corrections Today, April 1998
6. Hammett. T., Harmon, P., and Maruschak, L., (1999). 1996-1997 Update: HIV/AIDS, STDs and TB in Correctional Facilities, Washington D. C.: National Institute of Justice.
7. Glaser, Jordon, B. and Robert B. Greifinger, Correctional Health Care: A Public Health Opportunity Perspective 9 American College of Physicians, 1993).
8. " Integrating Public Health and Corrections," Preparing for the New Millennium Conference, Chicago, Illinois, Oct. 3-5, 1999.
9. Licretal. L. Y., " A Look Behind Closed Doors, Injection Drugs and Sexual Risk Behaviors and HIV/AIDS, HBV, and HCV Inside a Canadian Prison," Poster Abstract 23528, Presented at the 12th World AIDS Conference, Geneva, 30 June, 1998.
10. Gondles, E.D. " The Impact Of HCV On Correctional Systems In the United States," 2000
11. Lyerla, R., Mast E., Moyer L., and Hodguson, W., " Correctional facilities Offer Opportunity to Vaccinate At-Risk Juveniles and Adults," Preventing the Spread of Hepatitis B, Corrections Today ( April 1998)
12. Khan, Amy J. Hepatitis Branch, CDC, "HBV Infection in Incarcerated Adults: Prevalence, Incidence, and Risk Behaviors" CDC, Consultants Meeting, March 6, 2001.
13. Macalino, G.E. Brown University Medical School & Collaborators: Salas, C., Spaulding, A., Vlahov, D., Sabin, K., & Boredelon, K., "Intake Prevalence and Incidence of Hepatitis B Among Prisoners in Rhode Island." Presented CDC Consultants Meeting, March 6, 2001
14. Spalding, A.(1999, July). HCV and HIV in the correctional setting. HEPP News, 2(7), 1-5.
15. Correctional systems grapple with dual epidemic: HIV and HCV.(2000). Positive Population, 2, (2), 1-12.
16. Hepatitis C & Incarcerated Population, The Next Wave for Correctional Health Initiatives. Association of State and Territorial Health Officials, November 2000.

Dr. Gondles serves as the President of the Institute for Criminal Justice Healthcare. She is the healthcare advisor to the President of the American Correctional Association, and serves as a member of the ACA's Healthcare Committee, Substance Abuse Committee, Mental Health Committee and the International Committee. She also is a member of the American Correctional Association Task Force for the development of performance based standards in correctional healthcare. Dr. Gondles is active internationally as the representative for the International Prisoners Aid Association for Non-Government Organizations at the United Nations.