HEPATITIS A & B VACCINATION PROGRAM FOR INMATES AND STAFF

By Fred R. Maue, M.D., Chief of Clinical Services, Pennsylvania Department of Corrections; Berel B. Arrow, D.O., Assistant Medical Director, Pennsylvania Department of Corrections; and Melanie Strine, RN, CIC, Infection Control Coordinator, Pennsylvania Department of Corrections

Introduction:

The PA Department of Corrections recognizes that the risk of exposure to correctional staff members working with high-risk inmate population groups, the unpredictable exposure environment, work stress, overcrowded conditions and need for physical contact with inmates during critical incidents are unique to the correctional setting.

The Centers for Disease Control (CDC) will be releasing guidelines for prevention of Hepatitis A, B, and C in correctional settings in the near future. These recommendations will include Hepatitis A for high-risk inmates (those with injectable drug use) and for inmates located in geographic areas with high endemic Hepatitis A infections.

CDC reports a prevalence of past Hepatitis B (HBV) infections of 8-43% in inmate populations and estimates incidence of HBV infections of 1% per year. CDC also recommends Hepatitis B vaccines to inmates due to increased risk of infection including men who have sex with men (MSM), injectable drug users (IDU) and heterosexual males with more than one partner. Vaccinations can prevent transmission of HBV in prison, even though many acutely identified cases are asymptomatic and have not been previously detected. Chronically infected inmates may be a source for HBV transmission. Inmates frequently move within the prison system increasing the proportion of inmates who may be susceptible to infection. Although inmates, both before and during incarceration, may engage in behaviors facilitating transmission of HBV, enhanced surveillance for HBV may help to identify outbreaks and vaccines may help to prevent the spread of the disease.

With these factors in mind, the PA Department of Corrections has embarked on a vaccination program for Hepatitis A & B in all of its facilities. The project will begin in the Spring of 2002 and the estimated completion date is in 18-24 months.

The Vaccination Plan:

The PA Department of Corrections' Hepatitis A & B new vaccination program will offer Hepatitis A & B vaccines to all staff and inmates who are candidates to receive the vaccine. All known Hepatitis C (positive) inmates will also be vaccinated for Hepatitis A & B. Our previous vaccination program offered Hepatitis A & B vaccines to Hepatitis C positive patients, and Hepatitis B vaccine to inmates on the blood and body fluid spill clean up team to all staff members.

The decision to expand the vaccination program was one made by DOC Executive Staff in consultation with Bureau of Health Care Services' medical personnel including Infection Control Coordinator, Melanie Strine, RN and Assistant Infection Control Coordinator, Mary Seesholtz, RN. The purpose of the expansion was to ensure staff protection as well as to foster improved health to inmates/patients in the DOC system and community public health system upon the inmate's release.

Special considerations for Hepatitis A vaccination include:

• Staff not being antibody tested prior to vaccination for Hepatitis A.
  
  
• Inmates over the age of 40 will have Hepatitis A antibody (HAV Ab) prior to a decision for vaccination. If positive, the vaccine will not be administered. It is estimated 66% of these people have previous exposure to Hepatitis A.
  
  
• Inmates under the age of 40 will all receive the vaccine and not antibody tested.
  
  
• Hepatitis B vaccination will be given to all staff and inmates unless there is prior documentation that a complete series of prior vaccination was given or has a documented Hepatitis B surface antibody (Anti-HBs).
  
  
• A complete listing of Hepatitis Lab Tests is included for inspection.
  
  
• Medical staff (physicians and institutional infection control RNs will review inmate/patient charts to determine eligibility for vaccines.

Administration:

The Hepatitis A & B vaccines chosen will be supplied in pre-filled syringes. A safety-glide needle will be purchased and used in place of the non-safety needle attached to each pre-filled syringe supplied with vaccine. The pre-filled syringe was chosen for ease of administration, documentation and storage. The vaccine dose chosen for Hepatitis B will be 20 mcg/cc. Vaccines will be administered in the deltoid muscle by nursing staff.

Vaccines will be offered on a voluntary basis to staff and inmates. For purposes of ordering vaccines, an estimate of 25% refusals was used. Employees will be notified of vaccine availability through payroll stuffers. Vaccines will be first demonstrated to staff and inmates on annual TB screening dates (over a course of 12 months.)

Inmates released from DOC prior to completing a course of vaccines will be instructed to obtain the remaining vaccines as part of the Release Planning-Medical Discharge Process.

*Hepatitis B vaccine will be administered initially, at three months and six months.

*Hepatitis A vaccine will be administered initially and at six months.

Education:

Education is a large part of our training process for inmates and staff. The inmates are educated in the prevention of Hepatitis A, B, and C upon intake. If they are Hepatitis C positive, there are four parts of our current Hepatitis C protocol that educate them in prevention. We utilize videos, handouts, brochures, and one to one teaching by nurses and physicians. The staff receives education on bloodborne infections by our Clinical Training coordinator at our training center. Hepatitis B education materials are included for inspection.

Again, education is a large part of prevention, and the Pennsylvania Department of Corrections is striving to enable employees, and inmates to understand Hepatitis A, B, and C, and other infectious diseases.

Budget Considerations and Vaccine Orders:

The following are the steps and rationale used in implementing this program:

Ordering Vaccines:

1. Initial order will be placed by the BHCS to the distributor.
   
   
2. The Vaccine Company will submit invoices for payment to each facility. The facility is responsible to process the invoice for payment.
   
   
3. Subsequent orders will be placed by each facility as their need dictates.
   
   
   • Call distributor - customer service
   • Place order
   • Delivery time - 24 to 48 hours from time order is placed.
     
     
4. CHCA/designee will be responsible to assure the vaccine is stored in the refrigerator immediately upon arrival to the Medical Department.
   
   
5. Orders will be delivered by 3rd party carriers, not U.S. Mail (i.e., FedEx, UPS, Airborne).
   
   

The following are a few common questions and answers about the program:

Question: Has the PA Department of Corrections budgeted monies to be spent by 6/30/02 and 10/31/02 for this project?

Answer: The initial order noted on the 3/15/02 memo for each facility must be received by 6/30/02. The BHCS arrived at a number of doses for each facility from a survey sent out several months ago. However, we recognize that several facilities may not have the refrigeration space to store those doses. The BHCS recommends you assess your needs and purchase a full size refrigerator to accommodate this vaccine if you don't have sufficient space available.

In the past year, we have added more medicine and vaccines that require refrigeration (i.e., HCV protocol). Therefore, additional refrigeration will be money well spent.

The vaccine company will split this initial order into two shipments.

First shipment to be received at the facility - 4/24/02
Second shipment to be received at the facility - 5/28/02

Therefore, if facilities needed to purchase a full size refrigerator, they should have done so no later than 4/19/02.

Question: What is the shelf life for these vaccines?.

Answer: The vaccines are "good for" 18 months. The vaccine company, will provide representatives to maintain the account.

The Vaccine Company representatives will:

1. Rotate inventory,
2. Provide education materials, and
3. Provide staff in-service.

Summary:

The goal of this vaccination project was to vaccinate as many staff and inmates as possible on a voluntary basis. To ensure the success of a project of this magnitude, the full cooperation of DOC BHCS staff, DOC administrative staff and SCI administrative staff and medical staff is required. Priority must be given at the highest levels of DOC Executive Staff to the vaccination project, to ensure funding and cooperation at all levels of the DOC system. PA Department of Corrections remained focused on fostering the public health benefits to citizens working and living within and without the correctional system as its primary goal. Hopefully, PA Department of Corrections' thoughtful planning included in this report will aid other correctional systems in the future.