Seroprevalence of Hepatitis B and C Markers among Inmates Entering the Nevada State Correctional System National Hepatitis Coordinators’ Conference, San Antonio, Texas January 27, 2003 Robert Salcido, M.P.H.1 Lei Chen, Ph.D.1 Richard Whitley, M.S.1 Ted D’Amico, M.D.2 1Bureau of Community Health, Nevada State Health Division 2 Nevada Department of Prisons

Bureau of Community Health, Nevada State Health Division Overview of this presentation Statement of problem Background Objective Benefits Methodology Sample size Questionnaire Hepatitis marker testing algorithm Data collection and analyses Results Recommendations 2/20/2002 Bureau of Community Health, Nevada State Health Division

Statement of the problem Background 1.8 % of Americans (3.9 million) infected with HCV (NHANES III) 40-60% chronic liver diseases were associated with HCV infection Chronic liver disease is the 10th leading cause of death among US adults Hepatitis C prevention and control programs in the state or local health departments (CDC, 2001) 87% - HIV/AIDS 77% - HIV testing <50% - Hepatitis C counseling 23% - HCV testing High-risk population for HCV infection Injection drug users (IDU) Patients who have received blood transfusions, clotting factor concentrates Individuals who have engaged in tattooing, and/or body piercing; Mentally ill patients Prison inmates People with STDs Chronic liver disease is the 9th leading cause of death among adults with age 15-24 years old, 8th leading cause of death among adults with 25-44 years old, and 6th leading cause of death among adults with 45-65 years old in Nevada according to the statistics of year 2000. 2/20/2002 Bureau of Community Health, Nevada State Health Division

Statement of the problem Hepatitis C in other state prisons A few states have begun to measure the prevalence of HCV infection among their inmate populations. Estimation: 17% of all US prison inmates are infected with HCV (Dr. Ted Hammett, Massachusetts) California: 40% (men), 54% (women) Maryland: 38% (admissions) Texas: 29% Others: 30-40% 12%-39% of chronic hepatitis B and C in persons released from correctional settings the previous year (MMWR, Jan 2003). Few US prison health directors know the prevalence of HCV infection among their inmates. Seroprevalence studies are difficult and expensive, and even if they are done well, their validity can be quickly eroded by high inmate turnover. However, a few states have begun to measure the prevalence of HCV infection in their inmate population. Others include many foreign countries such as Australia, Ireland, Brazil, Greek, According to National hepatitis C prevention strategy published by CDC 2001, there are 10 priority areas for hep C epidemiologic and laboratory investigation. Incidence and risk factors for HCV transmission among household contacts of infected persons; Risk factors for transmission from mother to infant at birth; Risk of infection from intranasal cocaine use, tattooing, and body-piercing; Prevalence and incidence of infection in incarcerate population Risk of infection among steady heterosexual partners of HCV-infected persons Risk factors for infection among persons on chronic hemodialysis Risk for infection among persons with occupational exposure to HCV and effectiveness of therapy during acute infection The dynamics of HCV acquisition among injection drug users and the effectiveness of hard reduction strategies in preventing infection The frequency and consequences of infection with multiple HCV strains among injection drug users Development and performance of rapid screening tests for HCV infection 2/20/2002 Bureau of Community Health, Nevada State Health Division

Statement of the problem Objectives To examine the seroprevalence of hepatitis markers among inmates who were entering the Nevada correctional system; To identify and quantitatively assess risk factors associated with hepatitis C and B infection; To assess the needs for hepatitis testing and vaccination for individuals at high-risk Benefits of this project Inmates who participated in this assessment were given their hepatitis status at NO cost and could receive vaccination. Provide health care workers with valuable information for a better hepatitis B and C prevention planning strategy. One good way to help inmates with chronic hepatitis C is to vaccinate them for hepatitis B. If we can get them immunized for hepatitis B, we can really help their long-term survival and reduce the potential morbidity from hep C by vaccinating hep B (Dr. David, Smith, president of Texas Tech University Health Sciences Center) The NIH statement recommends hepatitis B (and hepatitis A) vaccination for all HCV-seropositive patients (management of hep C, NIH Consensus Statement 1997 , March 24-26; 15(3):1-41 Texas plans to spend $15 million to vaccinate all prison inmates We are targeting high-risk people rather than doing everybody. We think it’s a more strategic approach (Dr. Newton Kendig, medical director of Federal Bureau of Prisons) All above are cited from hepatitis Control Report, Winter 1999-2000, Volume 4, Number 4 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Methodology Assumptions The intake process represents future state prison inmate population No seasonal variations for new inmate admissions Subjects All new inmates tested from 11/5/01 forward were asked to participate in this survey until sample size was met. Participation was voluntary. Only 28 inmates (6%) refused testing. 2/20/2002 Bureau of Community Health, Nevada State Health Division

Methodology – Sample Size The calculation of sample size (N) was based on population survey method Assume prevalence (P)=50%, 95% confidence level, Difference = 5%, Refusing rate = 15%, population = 10,000 N = 435 Other factors should be considered 2/20/2002 Bureau of Community Health, Nevada State Health Division

Methodology – Questionnaire Demographics/Social demographics age, gender, race/ethnicity, county of residence, aboriginality (born in U.S.A), education History of imprisonment Ever been in prison, number of imprisonments, how long Length of current sentence Substance abuse Smoked drug, IDU, frequency, duration, cleaning works, sharing works Other risk behaviors tattooing, body-piercing, blood transfusions, sharing personal items (razors, toothbrush, earrings, etc.) Medical history Mental illness, liver disease, hepatitis vaccination Sexual behaviors History of STDs, condom use, number of sex partners 2/20/2002 Bureau of Community Health, Nevada State Health Division

Methodology – Testing Algorithm All blood specimens were sent to Nevada State Public Health Laboratory Serum EIA Anti-HCV Anti-HBC - - + + No further test No further test Anti-HCV (RIBA) Anti-HAV HBsAg HBsAb Anti-HAV 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Methodology - Data Data collection Database creation Data analysis Descriptive statistics Conditional stepwise logistic regression model SPSS 10.1 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Results TABLE 1 and 2 Overview of hepatitis needs assessment among inmates entering Nevada State Correctional System, 11/5-12/21/01 (Handout) 88% completed questionnaire and lab testing Only 28 or 6% refused to participate in the study 108 or 23.9% HCV Riba positive 7 or 1.6% HBsAg positive 123 or 26.8% Anti-HBc and/or Anti-HBs positive 41 or 9.1 % Anti-HAV positive Only 25 women participated in the study. 6 or 24 % HCV positive. 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Results Hepatitis C Hepatitis B Hepatitis B & C 23.9% 17.3% 9.8% Age 25 years or older County of residence Previous imprisonment Injection drug use Blood transfusions Sharing personal items A history of liver disease Age 35 years or older Tattooing A history of hepatitis B vaccination (significant confounding indicator) Age 45 years or older A history of hepatitis B vaccination (significant confounding indicator) Hepatitis A&B vaccination: 50 inmates Hepatitis B vaccination: 32 inmates Hepatitis A vaccination: 15 inmates Prevalence Risk factors Vaccination 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Recommendations Hepatitis testing to evaluate the risk of HCV/HBV infection in correctional settings is strongly encouraged. Routine hepatitis C and B screening tests should be incorporated with existing blood screening (e.g., HIV) in the medical prison intake procedures. Improved access to medical care while incarcerated can benefit communities by reducing disease transmission and costs of medical treatment (CDC). 2/20/2002 Bureau of Community Health, Nevada State Health Division

Bureau of Community Health, Nevada State Health Division Acknowledgements Miguel Forero, B.S., Nevada Department of Corrections Dr. L. D. Brown, M.D., M.P.H., Medical Director, Nevada State Public Health Laboratory Bob Hartman, Nursing Director, High Desert State Prison John Peery, Nursing Director, Northern Nevada Correctional Center Staff members from High Desert State Prison Staff members from Northern Nevada Correctional Center Staff members from Nevada State Health Laboratory Staff members from Nevada State Health Division’s Bureau of Community Health Logistics Department, Lab Corp. 2/20/2002 Bureau of Community Health, Nevada State Health Division