1. 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 Lei Chen, Ph.D.1
Richard Whitley, M.S Ted D’Amico, M.D.2
1Bureau of Community Health, Nevada State Health Division
2 Nevada Department of Prisons

2. 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

3. 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 years old, 8th leading cause of death among adults with years old, and 6th leading cause of death among adults with years old in Nevada according to the statistics of year 2000.
2/20/2002
Bureau of Community Health, Nevada State Health Division

4. 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

5. 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 , Volume 4, Number 4
2/20/2002
Bureau of Community Health, Nevada State Health Division

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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