Modelling the hepatitis B vaccination programme in prisons

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. Over the coming years it is anticipated this vaccination programme will be extended. A model has been developed to assess the potential impact of the programme on the vaccination coverage of prisoners, ex-prisoners, and injecting drug users (IDUs). Under a range of coverage scenarios, the model predicts the change over time in the vaccination status of new entrants to prison, current prisoners and IDUs in the community. The model predicts that at baseline in 2012 57% of the IDU population will be vaccinated with up to 72% being vaccinated depending on the vaccination scenario implemented. These results are sensitive to the size of the IDU population in England and Wales and the average time served by an IDU during each prison visit. IDUs that do not receive HBV vaccine in the community are at increased risk from HBV infection. The HBV vaccination programme in prisons is an effective way of vaccinating this hard-to-reach population although vaccination coverage on prison reception must be increased to achieve this.     

A syringe exchange programme in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany

In two prisons in Berlin, Germany, provision of sterile injection equipment for injecting drug users (IDUs) started in 1998. To assess the programme's impact, the frequency of injecting drug use and syringe sharing, and the incidence of HIV, HBV, and HCV infection were determined in a follow-up study. Of all IDUs (n=174), 75% continued to inject. After the project start the level of syringe sharing declined from 71% during a 4-month period of previous imprisonment to 11% during the first 4 months of follow-up, and to virtually zero thereafter. Baseline seroprevalences for HIV, HBV, and HCV were 18, 53, and 82%. HIV and HCV seroprevalence at baseline was significantly associated with drug injection in prison prior to the project start. No HIV and HBV seroconversions, but four HCV seroconversions occurred. The provision of syringes for IDUs in appropriate prison settings may contribute to a substantial reduction of syringe sharing. However, the prevention of HCV infection requires additional strategies.     

Modelling the impact of prison vaccination on hepatitis B transmission within the injecting drug user population of England and Wales

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. The work here considers the impact of prison vaccination on the incidence and prevalence of hepatitis B virus (HBV) in the injecting drug user (IDU) population of England and Wales. A dynamic model of the transmission of HBV in IDUs is developed with key model assumptions and parameters being subject to sensitivity analyses. The base case model (that assumes that the vaccination coverage on prison reception is 5% in 2002, 10% in 2003 and then increases linearly up to 50% of prison receptions being vaccinated by 2006) predicts that the incidence of HBV in IDUs might be reduced by almost 80% in 12 years, and the HBV prevalence (IDUs ever infected by HBV) may be reduced from approximately 18% in 2002 to 7% in 2015. The model presented here demonstrates that HBV vaccination on prison reception can have a significant impact on the prevalence and incidence of HBV in the IDU population over time.     

Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA.

This study aimed to assess the seroprevalence and risk factors for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV-1 infections among injecting drug users (IDU) in New Mexico. Serological and behavioural surveys were conducted in conjunction with street-based outreach, education and HIV counselling and testing. High rates of antibody positivity for HCV (82.2%) and HBV (61.1%), and a low rate for HIV (0.5%) were found. In multivariate analyses, both HBV and HCV infection were positively associated with increasing age, increasing years of injection and heroin use. Receipt of a tattoo in prison/jail was associated with HBV (odds ratio = 2.3, 95% confidence interval 1.4, 3.8) and HCV (OR = 3.4, 95% CI = 1.6, 7.5) infections. Prevention of bloodborne pathogens among IDUs should focus on young users, early in their drug use experience. Studies examining the relationship between tattooing and HBV and HCV infection are needed as are efforts to promote sterile tattooing, in prisons and elsewhere.     

Blood borne viral infections among Danish Health Care Workers – frequent blood exposure but low prevalence of infection

Denmark is a country with low prevalence and incidence of blood borne viral infections. Among health care workers (HCWs) vaccination for hepatitis B is only offered to high-risk groups. The aims of this cross sectional survey were to determine the prevalence of hepatitis B, -C, and human immunodeficiency virus (HIV) among the staff at a Danish University hospital and to correlate this with risk factors for transmission. Additionally, we wanted to examine the current frequency of blood exposure, reporting habits and hepatitis B vaccination status in the staff. Of 1439 eligible hospital staffs included, 960 (67%) were HCWs. The overall human immunodeficiency virus (HIV)-, hepatitis C Virus (HCV)- and hepatitis B Virus (HBV)-prevalence was 0% (0/1439), 0.14% (2/1439) and 1.6% (23/1439), respectively. Twenty-three percent of HCWs were vaccinated against HBV. Age, blood transfusion and stay in endemic areas were associated independently to HBV infection as opposed to job-category, duration of employment, HBV vaccination status and blood exposure. Based on a 4-week recall period, the incidence of percutaneous blood exposure was 1.5/person-year. In conclusion the HIV and hepatitis prevalence was low despite frequent blood exposure and the principal risk factors were unrelated to work. Danish HCWs do not seem to be at increased risk of hepatitis B even though universal HBV vaccination has not been implemented.     

Prevalence and Correlates of HCV,HVB, and HIV Infection among Prison Inmates and Staff,Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.     

Case-reporting of acute hepatitis B and C among injection drug users

Although public health surveillance system data are widely used to describe the epidemiology of communicable disease, occurrence of hepatitis B and C virus (HBV and HCV, respectively) infections may be misrepresented by under-reporting in injection drug users (IDUs). This study was carried out to examine the relationship between HBV and HCV incidence and case-reporting of hepatitis B and C in Seattle IDUs. Names of participants in a Seattle IDU cohort study who acquired HBV or HCV infection over a 12-month follow-up period were compared to a database of persons with acute bepatitis B and C reported to the bealth department surveillance unit over the same period. Of 2,208 IDUs enrolled in the cohort who completed a follow-up visit, 63/759 acquired HBV infection, 53/317 acquired HCV infection, and 3 subjects acquired both HBV and HCV. Of 113 cohort subjects who acquired HBV or HCV, only 2 (1.5%) cases were reported; both bad acute bepatitis B. The upper 95% confidence limit for case-reporting of bepatitis C in the cohort was 5.7%, and for hepatitis B, it was 7.5%. In this study, reporting of acute bepatitis in IDUs was extremely low, raising questions regarding the use of community surveillance data to estimate underlying incidence in that population group.     

Sudden rise in uptake of hepatitis B vaccination among injecting drug users associated with a universal vaccine programme in prisons

Hitherto, services have failed to deliver the UK Government's 1988 recommendation to vaccinate injecting drug users (IDUs) against hepatitis B virus (HBV). In April 1999, the Scottish Prison Service implemented an initiative to offer HBV vaccination to all inmates; we sought to determine the impact of this initiative on the IDU population. Among community-recruited IDUs (who had injected for < or =5 years) in Glasgow, vaccine uptake was significantly higher among those surveyed in 2001-2002 (52% of 387) than in 1993 (16% of 166), 1994 (19% of 138) or January-March 1999 (15% of 128); of the 2001-2002 vaccinees, 56% had been vaccinated in prison. Our results indicate that the universal offer of vaccination to all prisoners, within two years of the initiative's implementation, has had a dramatic impact on uptake among IDUs.     

Prevalence of hepatitis and HIV infections and vaccination rates in patients entering the heroin-assisted treatment in Switzerland between 1994 and 2002

Background:  Hepatitis C virus (HCV) remains very prevalent in injection drug users (IDUs). In spite of recommended vaccinations against hepatitis A virus (HAV) and hepatitis B virus (HBV), many IDUs remain susceptible to HAV and HBV. Study population and methods:  Patients entering heroin-assisted treatment between 2000 and 2002 (N = 210) were compared for infectious disease status with patients entering this treatment in 1998 (N = 243) and between 1994 and 1996 (N = 1035). Infection status was determined with the aid of questionnaires and blood tests for antibodies against HAV, HBV core antigen, HCV and HIV. Results:  In the cohort 2000–2002 78.3% of the patients were HCV positive, 53.3% were HBV positive, 41.2% were HAV positive and 12.6% were HIV positive. In comparison to the cohorts entering the heroin- assisted treatment at an earlier time, there was a significant reduction of HBV and HAV infections, but not of HCV and HIV infections. 15.6% of the patients entering between 2000 and 2002 were vaccinated against HBV and 10.3% against HAV. 31.1% of patients at entrance were susceptible for HBV and 48.5% for HAV. In comparison to patients entering treatment in 1998 there was no significant increase in patients who were vaccinated against HBV. Conclusions: This data illustrates the need for improving HCV prevention and more consequent vaccination against HBV and HAV in IDUs.     

Sudden rise in uptake of hepatitis B vaccination among injecting drug users associated with a universal vaccine programme in prisons

Hitherto, services have failed to deliver the UK Government’s 1988 recommendation to vaccinate injecting drug users (IDUs) against hepatitis B virus (HBV). In April 1999, the Scottish Prison Service implemented an initiative to offer HBV vaccination to all inmates; we sought to determine the impact of this initiative on the IDU population. Among community-recruited IDUs (who had injected for ≤5 years) in Glasgow, vaccine uptake was significantly higher among those surveyed in 2001–2002 (52% of 387) than in 1993 (16% of 166), 1994 (19% of 138) or January–March 1999 (15% of 128); of the 2001–2002 vaccinees, 56% had been vaccinated in prison. Our results indicate that the universal offer of vaccination to all prisoners, within two years of the initiative’s implementation, has had a dramatic impact on uptake among IDUs.     

Increasing hepatitis B vaccine coverage in prisons in England and Wales

The most frequently reported risk factor for hepatitis B infection in England and Wales is injecting drug use (38%). Since approximately 61% of injecting drug users (IDUs) had been imprisoned and less than 40% had received hepatitis B vaccine, a prison based hepatitis B vaccination programme was set up in 2001. At the 42 establishments participating in this study, all prisoners were offered vaccine at reception. Prisoners over 18 years were vaccinated using the 0, 7 and 21 days schedule and those under 18 years, using the 0, 1 and 2 months schedule. As far as possible a fourth dose was given to all after 12 months. In 2003, 14,163 prisoners received at least one dose of vaccine and altogether 26,265 doses were administered. A further 1111 prisoners reported they had already been vaccinated against hepatitis B. The median vaccine coverage rate was 17% (range 0-94%). Despite low coverage levels, the vaccination programme in prisons can be said to have vaccinated a sizable number of young, male prisoners, a group that have previously been shown to be at high risk of infection. The prisons which achieved vaccine coverage levels over 50% had designated nursing staff who ran the vaccination clinics.     

Coinfections by HIV, hepatitis B and hepatitis C in imprisoned injecting drug users

In order to know the prevalence and risk factors for coinfections by human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among injecting drug users (IDUs), a cross-sectional study was carried out in two prisons of the province of Cantabria, northern Spain. Three hundred and sixty-two IDU inmates were recruited. All inmates were interviewed and their blood tested for HIV, HBV and HCV. Crude and multiple risk factor adjusted for (by polychotomous logistic regression) odds ratios were calculated. Prevalence of HBV-HCV coinfection (42.5%) was higher than HIV-HBV-HCV coinfection (37.3%), whereas monoinfections were very uncommon (overall: 13%). Long-term injectors and reincarceration were the foremost risk factors for both coinfections, showing a trend between the degree of association and the number of viruses infecting a patient. No significant relationship between coinfection status and sexual practices was observed. The results related to coinfections are consistent with previous studies of prevalence and risk factors for HIV, HBV and HCV, in indicating that the high rates of coinfections among IDU inmates emphasise the need to harm-reduction policy across prisons in Spain.     

Major decline of hepatitis C virus incidence rate over two decades in a cohort of drug users

Injecting drug users (DU) are at high risk for hepatitis C virus (HCV) and HIV infections. To examine the prevalence and incidence of these infections over a 20-year period (1985–2005), the authors evaluated 1276 DU from the Amsterdam Cohort Studies who had been tested prospectively for HIV infection and retrospectively for HCV infection. To compare HCV and HIV incidences, a smooth trend was assumed for both curves over calendar time. Risk factors for HCV seroconversion were determined using Poisson regression. Among ever-injecting DU, the prevalence of HCV antibodies was 84.5% at study entry, and 30.9% were co-infected with HIV. Their yearly HCV incidence dropped from 27.5/100 person years (PY) in the 1980s to 2/100 PY in recent years. In multivariate analyses, ever-injecting DU who currently injected and borrowed needles were at increased risk of HCV seroconversion (incidence rate ratio 29.9, 95% CI 12.6, 70.9) compared to ever-injecting DU who did not currently inject. The risk of HCV seroconversion decreased over calendar time. The HCV incidence in ever-injecting DU was on average 4.4 times the HIV incidence, a pattern seen over the entire study period. The simultaneous decline of both HCV and HIV incidence probably results from reduced risk behavior at the population level. Charlotte H.S.B. van den Berg and ColetteSmit contributed equally to this paper     

Epidemiology of hepatitis C virus infection among injecting drug users in Australia.

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.     

Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: Preponderance of parenteral transmission

Between November 1993 and April 1994, our physicians' team interviewed and took blood samples of 631 prisoners randomly drawn from the largest prison of South America, which counted about 4700 inmates at that time. The interview consisted of questions related to risk behaviour for HIV infection, and the subjects were asked to provide blood for serological tests for HIV, hepatitis C and syphilis. Our main purpose was to investigate the relationship between HCV and injecting drug use as related to HIV seropositivity. Participation in the study was voluntary and confidentiality was guaranteed. Overall prevalences found were as follows: HIV: 16% (95% confidence interval (CI): 13–19%); HCV: 34% (95% CI: 30–38%), and syphilis: 18% (95% CI: 15–21%). Acknowledged use of ever injecting drug was 22% and no other parenteral risk was reported. Our results, as compared with other studies in the same prison, suggest that HIV prevalence has been stable in recent years, and that the major risk factor for HIV infection in this population is parenteral exposure by injecting drug use.     

Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey

Prisoners in eight of the 135 prisons in England and Wales were surveyed in 1997 and 1998 to study the prevalence of and risk factors for transmission of bloodborne viruses in prison. Subjects voluntarily completed a risk factor questionnaire and provided oral fluid specimens for unlinked anonymous testing for the presence of antibodies to HIV, hepatitis C virus (HCV), and the core antigen of hepatitis B virus (HBc). Almost 8% (4778) of the total of 60,561 prisoners were eligible and four fifths (3942) of those eligible took part. Among all those tested (3930) 0.4% (14) were positive for anti-HIV, 8% (308) for anti-HBc, and 7% (293) for anti-HCV (the anti-HBc and anti-HCV prevalences were not adjusted for assay sensitivities of 82% and 80%, respectively). Twenty-four per cent (777/3176) of adult prisoners reported ever having injected drugs, 30% of whom (224/747) reported having injected in prison. Three quarters of those who injected in prison (167/224) shared needles or syringes. Among adult injecting drug users, 0.5% (4/775) had anti-HIV, 31% (240/775) anti-HCV, and 20% (158/775) anti-HBc. The presence of anti-HCV and anti-HBc was associated with injecting inside prison and number of previous times in prison. The results suggest that hepatitis viruses are probably being transmitted in prisons through sharing non-sterile injecting equipment and that a risk of HIV transmission exists. Harm minimisation measures for the 6% of prisoners who continue to inject while in prison should be strengthened.     

Prevalence of HIV,syphilis, hepatitis B,and hepatitis C among entrants to Maryland correctional facilities

Although high prevalence of hepatitis C virus (HCV) in correctional institutions has been established, data are sparse regarding the comorbidities of hepatitis B virus (HBV), HCV, and human immunodeficiency virus (HIV), all of which may complicate the management of HCV. This study sought to estimate the prevalence and correlates associated with HCV prevalence among entrants into the Maryland Division of Correction and the Baltimore City Detention Center. Participants included all newly incarcerated entrants between January 28 and March 28, 2002. Excess sera with identifiers removed from samples drawn for routine syphilis testing were assayed for antibodies to HIV and HCV and for HBV surface antigen and surface and total core antibodies. Separately, all HIV-positive specimens were tested using the serological testing algorithm for recent HIV seroconversion. Of the 1,081 immates and 2,833 detainees, reactive syphilis serology was noted in 0.6% of the combined population; HIV seroprevalence was 6.6%; HCV prevalence was 29.7%; and 25.2% of detainees and prisoners had antigen or core or surface antibodies to HBV. A multivariate analysis of predictors of HCV positivity indicated that detainees, women, whites, older age groups, those who were HIV seropositive, and individuals with past or present infection with HBV were significantly more likely to be positive for HCV. These data indicate that hepatitis C remains an important public health concern among entrants to jail and prison and is complicated with coinfections that need to be addressed for effective treatment.     

Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons

OBJECTIVES: We evaluated prevalence and intraprison incidence of HIV, hepatitis B virus, and hepatitis C virus infections among male prison inmates. METHODS: We observed intake prevalence for 4269 sentenced inmates at the Rhode Island Adult Correctional Institute between 1998 and 2000 and incidence among 446 continuously incarcerated inmates (incarcerated for 12 months or more). RESULTS: HIV, hepatitis B virus, and hepatitis C virus prevalences were 1.8%, 20.2%, and 23.1%, respectively. Infections were significantly associated with injection drug use (odds ratio = 10.1, 7.9, and 32.4). Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV. CONCLUSIONS: High infection prevalence among inmates represents a significant community health issue. General disease prevention efforts must include prevention within correctional facilities. The high observed intraprison incidence of HBV underscores the need to vaccinate prison populations.     

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey

OBJECTIVES: To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States. DESIGN: Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected. RESULTS: National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk. CONCLUSIONS: The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.