1. Hepatitis B and C management pathways in prison:
An audit against UK NICE public health guidance.
KE JACK1 SA SMITH1 J LLOYD2 H SMITH2 BJ THOMSON1
1 Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH HMP Nottingham, Nottingham NG5 3AG
Background
Hepatitis B and C (HBV and HCV) are blood borne viral infections and the second most common cause of liver disease in the UK after alcohol. The principal route of acquiring HCV in the UK is injecting drug use.
Between a third and half of new entrants to prison are estimated to be problem drug users; this equates to between 45,000 and 65,000 prisoners in England and Wales1. 69% of those entering prison will have taken drugs within the previous 12 months2 and 60% of injecting drug users will have been imprisoned by the age of 303.
Against this background, the UK National Institute for Health and Clinical Excellence (NICE) in 2012 published public health guidance on promoting awareness and testing of HBV and HCV4. One recommendation in this NICE guidance is for prison healthcare providers to increase HBV vaccination rates and HBV and HCV testing plus referral for treatment.
Objectives
To evaluate HBV immunisation, HBV and HCV prevalence, testing and treatment in a remand prison in the East Midlands.
Methods
A category B remand prison with capacity for 1060 men was the site chosen for this audit. The electronic health records for all new entrants during December 2012 and January 2013 were audited (n= 474).
The evidence searched for was: having had a secondary health screen (when hepatitis testing and vaccination is offered); a documented HBV or HCV risk factor; already known HBV or HCV positive; receiving a new diagnosis in prison; being informed of their diagnosis; referred for HCV treatment and the outcomes; received 3 doses of HBV vaccine (self reported or documented); number of vaccinations given during current episode of imprisonment.
Results
Prevalence of HBV and HCV and frequency of hepatitis testing among new prisoners during December 2012 and January 2013 (n=474)
Results
Frequency of HBV vaccination and refusal among audited prisoners (n=474)
Results
Only 130/474 (27.4%) received a secondary health screen and were offered hepatitis testing and vaccination
118 (24.9%) had a documented risk factor of injecting drug use and no other risk factors were documented
Across all healthcare appointments at the prison during January 2013 the DNA rate was 21%
Three prisoners had a new positive anti-HCV test result and were given this information. There were no new HBV diagnosis
Prisoners receiving antiviral treatment for HCV and transferred to a prison where there is a clear pathway to facilitate continuity (n=5) were able to continue therapy
Prisoners receiving antiviral treatment for HCV and transferred to prisons without a continuing care pathway, or to the community, had a poor completion rate (n=2/10)
Outcomes of prisoners treated for HCV in Prison during 29 months (N=33)
n =
Completed treatment in prison
a. SVR
b. EOT negative
c. Relapsed
d. Lost to follow up 6 1 3
Transferred to another prison on treatment
a. Treatment continued and completed
b. Treatment continued but patient dropped out
c. Currently on treatment
e. SVR achieved 10 2 5
Released into the community on treatment
b. Lost to follow up
c. SVR achieved 4
Currently on treatment in prison 12
Discussion and Conclusions
Our study has demonstrated that healthcare staff require increased access to the prisoner population in order to successfully offer HBV and HCV testing and HBV vaccination. Antiviral therapy can be initiated in this population but without adequate commissioning to provide care pathways on transfer to other prisons or release, continuation of therapy is unlikely.
The commissioning of care for this important cohort of infected individuals, which includes educating all prison staff, utilising alternative blood taking methods and delivering post-prison health-care, requires prioritisation.
References
1. UK Drug Policy Commission (2008) Reducing Drug Use, Reducing Re-offending
2. Patel (2010) Reducing Drug Related Crime and Rehabilitating Offenders
3. Sutton (2006) Estimating the cost-effectiveness of detecting cases of chronic HCV on reception into prison
4. NICE (2012) PH Guidance 43