1. Implementing routine hepatitis B vaccination at the Rhode Island Department of Corrections (RIDOC) Women’s Division Beth Schwartzapfel Jennifer Clarke MD, Susan Shepardson MA, Stephanie Sanford-Colby MPH, Jennifer Pomposelli RN, Gerald Dornhecker RN, Josiah D. Rich MD MPH The Miriam Hospital/ Brown Medical School Providence RI BSchwartzapfel@lifespan.org

2. Prisons in the United States The incarcerated population in the U.S. has skyrocketed in the past two decades Reached 2 million for the first time in 2002 Incarcerations from drug offenses have pushed this growth Since 1980 the number of people incarcerated for drug offenses has grown from 40,000 to 450,000. Bureau of Justice Statistics 2003;NCJ 198877 www.cdc.gov.idu/facts/druguse.htm

3. Incarcerated persons comprise 0.7% of the US population

4. The incarcerated setting: a public health opportunity TURNOVER –528,848 individuals released from prison each year –10 million jail releases = ~7.2 individuals released from jail each year Missed opportunities for HBV vaccination – Incidence study in sentinel counties, 1982-1998 –29% of acute HBV patients reported incarceration prior to becoming infected Hammett et al. Am J Pub Health 2002;92:1789. Goldstein et al. J Infect Dis 2002;185:713.

5. The incarcerated setting: a public health opportunity Routine HIV screening implemented at the RIDOC in 1989 –Prevalence = 2% - 8x higher than RI population –31% of HIV cases in RI identified at RIDOC –43% of IDU-associated cases and 43% of MSM&IDU cases in RI identified at RIDOC Desai et al. AIDS Education and Prev 2002;14(Supp B):45.

6. Hepatitis B in prisons and jails Evidence of past infection among inmates ranges from 30-43% –General population (NHANES), 1988-1994: ~5% Prevalence higher among women than men 12-15% of all Americans with HBV (155,000 people) were releasees from prison or jail the previous year J Infect Dis 1984;150:529 / Am J Public Health 1985;75:1213 Clin Ther 1987;9:622. / Am J Public Health 1990;80:471. MMWR 2003;52(RR-1): 2.

7. Public safety vs. public health Estelle vs. Gamble, 1978: Prisons constitutionally mandated to provide health care Conflicting priorities? –Proactive vs. Reactive health care –Public safety = public health

8. Why NOT vaccinate in prisons and jails? Inmates often not incarcerated long enough to complete series High refusal rates $$$$$$$$$$$$$$$$$ Charuvastra et al. Public Health Reports 2001;116:1-12.

9. Hepatitis B in Rhode Island prisons and jails Epidemiologic study in female prisoners (1996-7) –Prevalence among incoming women 36% –Community incidence among re-incarcerated women was 12.2 per 100 person-years Epidemiologic study in male prisoners (1998- 2000) –Prevalence among incoming men was 20% –Incidence among incarcerated men 2.7 per 100 p-y Macalino et al. 6th Conference on Retroviruses and Opportunistic Infections, 1999. Macalino et al. Am J Pub Health 2004. In press.

10. RI Department of Corrections Single state correctional facility Jail and prison Average daily population –Total: 3,426 –Women’s: 217 Average length of stay: –Non-sentenced: 2 weeks –Sentenced: 10 months –Women’s: 24 hours

11. RI Department of Corrections Intakes/year –Total: 16,000 –Women’s: 2,000 At intake: –HIV testing –Syphillis testing –PPD –Preliminary medical history

12. History of our program Medical director put $$ for HBV vaccine in budget every year –Every year this $$ was cut Vaccinations were offered non-systematically to inmates with risk factors at medical visits 2000: 200 soon-to-expire doses of vaccine donated to Women’s Division by DOH –93% of eligible inmates were vaccinated 73% received 2 doses 40% completed series Clarke et al. Journal of Health Care for the Poor and Underserved 2003;14:318-323.

13. History of our program VHIPS, 1999-2003 Meetings with wardens, medical staff, director of RI DOC, MIS –Agreed that nurses in Women’s Division would administer HBV vaccine at intake –Compromise: computerize Trainings with nursing staff –Hepatitis B –Benefits of vaccination –Use of computer/database

18. History of our program Initiated vaccination of all incoming women in 3/2002 Initiated vaccination of sentenced men in 3/2003 Goals for future: expand vaccination to all incoming men

19. Acceptance rates (as of 10/03) Women’s = 59% 1 dose: 65% 2 doses: 21% 3 doses: 14% Men’s = 95%

20. Cost Vaccine paid for by Federal 317 $$ under state perinatal HBV prevention program Once vaccine was paid for, little additional $$ was spent –Some additional staff hours –Infrastructure already exists HBV vaccination in prison is cost saving to the health care system even when only 1 dose is administered Pisu et al. Vaccine 2002;21:312.

21. Why not vaccinate in prisons and jails? Inmates often not incarcerated long enough to complete series –Even 1 or 2 doses can confer 50-80% immunity –Incomplete series does not need to be restarted Inmates who are released and reincarcerated can pick up where they left off Alternative vaccination sites in the community –Needle exchange/methadone clinics/drug treatment centers –STD clinics (San Diego!) –Homeless shelters/soup kitchens

22. Why not vaccinate in prisons and jails? High acceptance rates –Our #s are comparable to acceptance rates in other high-risk settings –Success in Men’s suggests that rates are improved when: Staff is enthusiastic Inmates are not offered vaccine just hours after being arrested

23. Why vaccinate in prisons and jails? $$$$$$$$$$$$$$$$ –Be creative!! –Be flexible!! Soon-to-expire doses –Work with state vaccine coordinator

24. Conclusions Given cost of vaccine, routine HBV vaccination can be implemented in the correctional setting with little additional effort or funds Requires communication and education among all players Future directions –Wraparound viral hepatitis program –Peer education

25. Acknowledgements Centers for Disease Control and Prevention, Viral Hepatitis Integration Program –Cooperative agreement #U50/CCU119078 RI Department of Health RI Department of Corrections –A.T. Wall, Director –Scott Allen, MD, medical director