1. Summary Report: Management of Hepatitis C in Prisons
Anne Spaulding MD
CDC/ Division of Viral Hepatitis
January 2003

2. Of All U.S. Patients with Hepatitis C, 39% Were Released From Prison and Jail (1997)
Prevalence of hepatitis C in jails and prisons: %.
Estelle v. Gamble: “deliberate indifference to serious medical needs.”
Source: MMWR 2003 RR-1

3. Issues for Hepatitis C Management in Prisons
Responsibility: most deaths after release.
Cost-Effectiveness: How can we identify the patient
who benefits from treatment?
Capacity: would facilities be overwhelmed?
Consistency: between different providers: protocol driven care

4. Purpose of the Weekend Conference
Translate 2002 NIH Consensus Panel Statement on Hepatitis C and the new MMWR on Corrections and Hepatitis into Practice.
Review controversies and challenges: testing, counseling, and management.
Describe ways to access community resources to improve continuity of care for hepatitis C patients.

5. Treatment Candidates, NIH Consensus Statements
Condition
1997
2002
Normal ALT No
No consensus
Injection Drugs
Alcohol Use
6 month sobriety before treatment
Mild Disease Histologically
Observe,
biopsy every 3-5 years
Individualize decision:
Or treat if patient requests
Compensated Cirrhosis
Unclear if IFN prolongs life, delays HCC
Can be treated, individualize decision
HIV
If stable
Individualize decision
IDU not absolute contraindication
Abstinence before and during treatment

6. Hepatitis C and Injection Drug Use
HCV therapy has been successful even when the patients are on daily methadone or have continued drug use.
Prison is an environment of enforced sobriety, regimented lifestyle--an ideal time to treat?
If you do not treat and complete on inside, will it be available on the outside?

7. Zero Sum for All Resources
“A closed panel HMO with a fixed or declining budget.”
--J. Curran, Dean, Emory School of Public Health

8. Prevention Recommendations
Vaccinate all patients with chronic hepatitis C against hepatitis A.
Vaccinate seronegative persons with risk factors for HBV against hepatitis B.
Make drug and alcohol abuse treatment available to all patients who want and need it.
Teach IDUs harm reduction.
Incorporate both preventive measures and treatment in management of hepatitis C .

9. Prevention Strategies in Prisons
Knowledge of inmate-patient’s status will enable incorporation of preventive measures.
Supports proactive screening in high risk inmates?
Not a legal requirement.
“Good public health.”
Likely to increase demand for treatment.

10. What Do You Need Now?
“I did not even know our state had a hepatitis coordinator until I saw that map of coordinators and my state was highlighted. What we’re doing in prisons for hepatitis doesn’t make sense if we don’t carry it into the community.”
State Department of Corrections Medical Director

11. Thank you

13. Easing the Exclusion Factors: Expands Potential Treatment Pool
All Labs Nml
Alcohol
Drugs
Abnormal ALT
Rehabilitated

14. Easing the Exclusion Factors: Expands Potential Treatment Pool.
Standardized definition of normal ALT: increase number of candidates.
History of alcohol—57%1
History of injection drugs—76%1
Mild disease and compensated cirrhosis
HIV co-infection: 80% HIV infected inmates HCV+2
References:
Allen, Spaulding et al. Annals of Int. Med. 2003
Rich, Chin-Hong. Lancet. 1997

15. Overview of Talk Background Purpose of the weekend conference
For commissioners, medical directors, health administrators.
What were priorities for prisons?
What do attendees now need?

16. Will Liver Damage Progress in Inmates?
Progression worse:
Male
Inmate population 93% male.1
Alcoholic
State inmates: 40% history of binge drinking.2
Compromised immune system.
Prison AIDS prevalence 4x higher than in community.3
References:
Sourcebook of Criminal Justice Statistics, Accessed 1/03
Bureau of Justice Statistics January 1999, NCJ
Bureau of Justice Statistics October 2002, NCJ