Assessment of Hepatitis C Risk Factors and Infection Prevalence in a Jail Population

Objectives. We sought to validate previous reports of HCV prevalence in jails, identify HCV risk factors prevalence, and identify risk factors associated with HCV infection in this population.Methods. Inmates at the Buzz Westfall Justice Center (BWJC) in St. Louis, Missouri, were offered risk factor screening for HCV and anti-HCV antibody testing from December 2012 through May 2013. Demographic and risk factor information were assessed for significant associations with positive HCV antibody results. Risk factors that were significantly associated in univariate analysis were assessed using binary logistic regression to model the relationship between positive HCV results and the risk factors and demographics.Results. Fifty of 304 inmates were positive for HCV, with a prevalence of 16.4%. The risk factors significantly associated with increased risk for positive HCV antibody were age (odds ratio OR] = 1.09; 95% confidence interval CI] = 1.04, 1.15 for each year), injection drug use (OR = 53.87; 95% CI = 17.78, 163.21), sex with HCV-positive partner (OR = 7.35; 95% CI = 1.41, 38.20), and tattoos by a nonlicensed provider (OR = 2.62; 95% CI = 1.09, 6.33). Prevalence for women was 3 times that of men (38% vs 12%).Conclusions. Prevalence of HCV at BWJC was similar to previous jail studies, which is lower than reported prison rates and higher than the general population.HCV infection is one of the most common and deadly blood-borne infectious diseases in the United States.1–3 National Health and Nutrition Examination Survey (NHANES) data estimate that 1.6% of the US population, or about 4.1 million people are infected with HCV.2 This NHANES estimate is likely an underestimation because it did not sample several high prevalence populations; the true prevalence may be conservatively closer to 2% (5.2 million) or potentially as high as 2.8% (7.1 million).4 In 2010, approximately 17 000 new infections occurred with an incidence rate of 0.3 cases per 100 000 persons in the United States.5 Incidence rates have decreased significantly from 1992, but have been holding fairly steady over the past decade.3 Some authors predict the incidence will likely increase slightly with recent increases in injection drug use. The incidence of complications associated with HCV is expected to continue to increase as well.3,6HCV infection is associated with significant morbidity, mortality, and cost. It is the most common chronic liver disease associated with hepatocellular carcinoma, present in close to half of all cases.7,8 It is the leading indication for liver transplantation in the United States, with a rate nearly double that of the second cause.9 HCV infection was listed as an underlying or contributing cause of more than 15 000 deaths in 2007.10 Patients who do not go on to develop cirrhosis or those in the 20- to 30-year window between infection and development of cirrhosis can also suffer social, emotional, and physical complications; experience a decreased quality of life; and require hospitalization.3,11,12 The yearly total health care costs associated with HCV infection were calculated to be $6.5 billion in 2007 and are predicted to peak at $9.1 billion in 2024 based on current trends and excluding the cost of antiviral treatments.6In the general US population, the risk factors most associated with HCV infection are injection drug use (IDU), sexual contact with HCV-positive partners, receipt of blood and blood products prior to 1992, and needle sticks.2,5 According to data from NHANES, men have a higher prevalence of HCV infection than women (2.1% vs 1.1%), and non-Hispanic Blacks have a higher prevalence than non-Hispanic Whites or Mexican Americans (3%, 1.5%, and 1.3% respectively).2 The Centers for Disease Control and Prevention has recently added a recommendation to test all patients born between 1945 and 1965, as this birth cohort has a HCV prevalence rate of 3.25% and accounts for approximately 75% of HCV infections in the general US population.13 One recent analysis found that among those with a history of IDU, any past incarceration was significantly associated with HCV infection with an adjusted odds ratio (OR) of 2.6 (95% confidence interval CI] = 1.2, 6.1).14As prevalent as HCV infection is in the general population, it is nearly 10-fold higher in the incarcerated population. The prevalence of HCV infection in incarcerated individuals is estimated to be 23.1% to 41.2%.4 Individuals who are incarcerated are more likely to participate in high-risk behavior for HCV infection, including IDU, tattoos from nonlicensed providers, and prostitution. In addition to their increased risk prior to incarceration, inmates are also at higher risk for becoming infected during incarceration, mostly from tattoos received in prison and continued use of injection drugs while incarcerated. With increasing rates of IDU in the United States, rates of incarceration and HCV infection are predicted to increase as well.3Although there is a significant amount of literature assessing HCV in the general population and incarcerated populations as a whole, most of the literature assessing incarcerated populations deals specifically with prison populations rather than jail populations. Jails are more dynamic environments than prisons and include people being released from custody in a short period of time as well as those destined to be imprisoned. Studies relating to HCV infection in a jailed population are much more limited. Only 1 previous study has specifically assessed only jailed populations.15 This study assessed the prevalence of HCV infection from a random sample of stored blood samples from 3 city jails and did not include any risk factor assessment directly from inmates, although it did link results to demographic information, previous incarceration status, hepatitis B virus (HBV) infection, and HIV infection status. This evaluation found the weighted prevalence of HCV to be 13% overall with 10% prevalence in San Francisco, California; 14% in Chicago, Illinois; and 15% in Detroit, Michigan. The study was not able to assess whether inmates were previously aware of their HCV infection.15 Another study assessed both jail and prison populations in Maryland.16 This study also assessed HCV rates on stored samples and was linked to demographic information, reasons for incarceration, syphilis infection, HBV infection, and HIV infection. Those enrollees labeled as “detainees,” meaning presentencing, had an HCV prevalence of 31.1%, higher than that in the prison population at 26.4%.As pointed out in a 2012 editorial, jails may represent an ideal location to institute widespread screening programs for HCV.17 Jails may represent a higher-risk group than the general population. Identifying those at high risk for HCV infection in a jail could lead to education on risk reduction to those not already infected and could lead to earlier detection for those infected with HCV who did not previously know of their infection status. This detection could prevent the spread within communities for those jail inmates who are released from custody shortly after incarceration and could decrease the spread of HCV within prisons for those who are sentenced. In addition to slowing or preventing the spread of HCV, the detection of an infection in jails could lead to more frequent and earlier treatment, improving the health of the infected inmate and decreasing the morbidity and costs associated with late-stage HCV infections. This article also correctly points out, however, that the cost savings that may be realized because of early screening and intervention for HCV are unlikely to be realized directly by the same payers as the initial direct screening costs. Finding ways to better target testing expenditures would enable jails to provide a public health benefit without the costs associated with testing all those incarcerated.The current project was undertaken to add to and validate previous reports of HCV prevalence in jailed populations, identify the HCV risk factors present in this population, and identify the risk factors most associated with HCV infection in the population.