Position Statements

Management of Hepatitis B Virus in Correctional Facilities

Background
Hepatitis B virus (HBV) is a bloodborne pathogen (the infectious component is hepatitis B surface antigen or HBsAg) whose highest concentrations are found in blood and serous fluids, but are also found in saliva and semen. Its most common transmission is through sexual contact, but it can also be transmitted by percutaneous exposure (intravenous drug use, skin popping, tattooing,  body piercing, and acupuncture) or through bites. In 1995, there were 10,805 cases reported to the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention [CDC], 1995). Acute infection may be asymptomatic, however, and many new cases do not get reported.  It is estimated that 1.5 million people in the United States are infected with the hepatitis B virus, and 5,000 deaths annually are attributed to the infection (“Current Concepts,” 1996). Chronic viral hepatitis is often a progressive disease. Approximately 10% of cases of acute HBV infection progress to chronic infection. Persons with chronic infection are often asymptomatic and may not be aware that they are infected, but still have the capacity to infect others. Persons with chronic infection have an increased risk for developing cirrhosis and liver failure, and are at 12 to 300 times higher risk of developing hepatocellular carcinoma than non-carriers. An estimated 1,000 to 1,500 persons die each year in the United States of hepatitis B related liver cancer.

It is estimated that treating one episode of acute HBV infection costs about $6,000. The province of British Columbia in Canada estimated that in 1990 management of HBV cost the province $5.6 million (Province of British Columbia, personal communication, 1993).

Data from areas of intensive clinical and serologic surveillance for hepatitis indicate that as many as 200,000 to 300,000 persons in the United States become infected with HBV each year (CDC, 1993). A survey conducted by the California Department of Corrections found that half of their incoming female inmates and one third of their incoming male inmates tested positive for HBV (“California Study,” 1995). National figures of HBV in the correctional environment are not as high as the numbers from the California Department of Corrections, though they do indicate growth, and there is evidence of transmission of HBV within confinement (Bader, 1986; Glaser & Greifinger, 1993).

The reasons for the high rate of HBV infection in prisons and jails is that the population generally represents the persons at highest risk for HBV. The correctional population is generally derived from medically under-served communities who are sexually active individuals, injection drug users, have tattoos, or are immigrants and refugees from areas of high HBV endemicity (CDC, 1993).

Unlike other infectious diseases common in the correctional environment, such as HIV and tuberculosis, whose containment depends upon detection for prevention, HBV can be prevented with vaccine. With the advent of hepatitis B vaccination programs for children and high-risk adults, the incidence of chronic hepatitis B is likely to lessen over time. The annual incidence of HBV has actually declined by 62% since 1986 (CDC, 1993). HBV is a lethal, infectious disease common in the correctional environment. Given the high cost of foregoing treatment and the devastating nature of the disease, it is essential that correctional facilities prevent, detect and treat HBV to control and contain its spread, both within and outside the facility.

Neither bed rest, corticosteroids, nor azathioprine work for treatment of hepatitis B. The only agent currently known to be even modestly effective in treating chronic hepatitis B is Interferon alfa-2b. Treatment with interferon is expensive, but some patients get good benefit. A course of 4-6 months duration induces a long-term remission in 25%-40% of patients.  HIV antibody negative patients are more likely to respond to treatment.

Hepatitis B Vaccine
The vaccine currently available for HBV is produced using recombinant DNA technology. The vaccine cannot result in HBV infection because it does not contain potentially infectious viral DNA or complete viral particles. Consequently, it is safe to administer to immuno-compromised persons, though its efficacy may not be as great. Moreover, the vaccine is safe to administer to persons who have already been exposed to HBV, although it will not benefit them. Research on pregnant women who are carriers of HBV indicates that most transmission of HBV occurs between mother and child during or shortly after birth. Therefore, current CDC guidelines recommend that infants begin a vaccination course shortly after birth (CDC, 1990).

The vaccine is administered through three intramuscular doses with the second and third doses occurring 1 and 6 months after the first, respectively. After three intramuscular doses, at least 90% of adults will be immune to hepatitis B. Two shots confer long-term immunity in 60-80% of the cases in which they are administered (CDC, 1993; Province of British Columbia, personal communication, 1993). A single shot confers partial immunity in 40-60% of individuals, though it is not known how much immunity it confers, or the duration of that immunity.

Position Statement
Treatment and prevention programs should be developed to detect and prevent the spread of the hepatitis B virus (HBV). This responsibility can be met in large part by compliance with the National Commission on Correctional Health Care's Standards For Health Services that have been developed for prisons, jails, and juvenile detention and confinement facilities. Compliance with these standards, with particular attention being given the standards for Infection Control Program, Continuing Education for Qualified Health Services Personnel, Orientation Training for Health Services Staff, Initial Health Screening, Health Assessment, Appraisal, Health Promotion and Disease Prevention, and Continuity of Care will provide the necessary groundwork for the control, treatment, and prevention of HBV in the correctional setting.

1. HBV Testing for the Incarcerated
   All inmates should be screened for HBV in accordance with the National Commission on Correctional Health Care’s standards for receiving screening. Inmates with symptoms of HBV and with a history of injection drug use, previous jaundice, or hepatitis should be considered high-risk and tested for hepatitis (CDC, 1993).
2. Treatment Interventions
   Infection with HBV is usually a self-limited illness. Chronic infection develops in a small percentage of infected individuals and may result in death from cirrhosis and hepatic carcinoma. More importantly, untreated carriers pose a risk to others. Inmates with identified hepatitis should undergo diagnostic studies, including referral to specialists when necessary. When indicated, treatment with appropriate agents should be initiated and maintained.
3. Education/Counseling
   HBV education should be provided to all staff and inmates in jails, prisons, and juvenile confinement facilities.
   1. This education should include information on modes of transmission, prevention, treatment, and disease progression. Educational programs should include culturally sensitive and scientifically accurate health information providing clear and easily understandable explanations of practices which reduce the risk of becoming infected or transmitting HBV. It is highly recommended that information on the availability of a vaccine to prevent disease spread be included as well. NCCHC recommends involvement of the target population in the development and provision of educational programs to encourage acceptance of the material. Staff should also receive training on confidentiality as it applies to HBV.
   2. All inmates who are infected with HBV should receive counseling to encourage treatment and to alert them to behavioral changes which may be required to prevent future contagion of others. Additionally, such inmates should be encouraged to voluntarily contact sexual or drug-use partners and advise them of their condition.
   3. Pregnant women who are HBsAg positive or who are at risk of HBV should be educated on the risk of transmission to their newborn children, and should be counseled to have their infants vaccinated against the disease.
   4. Inmates who have tested negative for HBV antibody should be counseled to receive the vaccination.
   5. The NCCHC supports and recommends strict compliance with the statement on  Universal Precautions in all settings within corrections. All Health Care Professionals should adhere to universal precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Health Care Professionals who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves. Health Care Professionals should also comply with current guidelines for disinfection and sterilization of reusable devices used in invasive procedures. (CDC, 1991)
4. Vaccination
   Facilities should consider a vaccination program for all inmates against HBV. At the least, facilities should offer vaccine to high-risk inmates, coordinated with the local health department whenever possible. Facilities should evaluate their inmate populations and the risk of developing HBV in those populations. Given the growing number of cases of HBV in the correctional environment, the recidivism rate in corrections, and the high cost of HBV— both financial and to the public health—vaccination is advisable.
5. HBV Vaccine for Health Care Professionals
   All health care professionals in jails, prisons and juvenile confinement centers should be offered hepatitis B vaccinations. In addition, Occupational Safety and Health Administration (OSHA) guidelines require that employers provide all employees who may be exposed to blood or other potentially infectious materials, as part of their jobs, with the 3-part hepatitis B vaccine (“Occupational Exposure,” 1991).
6. Discharge Planning
   All inmates' HBV vaccination data should accompany them when transferred to another institution or discharged. Because the vaccine needs to be administered over an extended time period, it is essential that facilities establish linkages with their community and public health facilities. These linkages should include a plan to complete the administration of the HBV vaccine, when necessary. Referral and linkage to an aftercare provider should be made for patients with active disease.

Adopted by the National Commission on Correctional Health Care Board of Directors
March 31, 1996
Last Amended:  April 13, 1997

References
Bader, T. F.  (1986). Hepatitis B in prison. Biomedicine and Pharmacotherapy, 40, 248-251.

California study examines TB, HIV, and hepatitis. (1995, December). CorrectCare, p. 3.

Centers for Disease Control and Prevention. (1990, 9 February). Protection against viral hepatitis.  Morbidity and Mortality Weekly Report, 39(RR-2).

Centers for Disease Control and Prevention (1991, 12 July). Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure prone invasive procedures. Morbidity and Mortality Weekly Report, 44(RR-8).

Centers for Disease Control and Prevention. (1993). Epidemiology, prevention, and control of vaccine-preventable diseases. Atlanta, GA: Author.

Centers for Disease Control and Prevention. (1996). Summary of notifiable diseases, United States 1995. Morbidity and Mortality Weekly Report, 44(53), 10-11.

Current concepts in the diagnosis and management of chronic viral hepatitis. (1996). Clinical Courier, 14(16), 1-7.

Glaser, J. B., & Greifinger, R. B. (1993, 15 January). Correctional health care: A public health opportunity. Annals of Internal Medicine, 188(2): 139?144.

Hoofnagle, Jay H., & Di Bisceglie, Adrian M. (1997). The treatment of chronic viral hepatitis. The New England Journal of Medicine, 336(5): 347-355.

Lemon, Stanley M., &  Thomas, David L. (1997). Vaccines to prevent viral hepatitis. The New England Journal of Medicine, 336(5): 347-355.

Occupational exposure to bloodborne pathogens; final rule (29 CFR Part 1910.1030). Federal Register. December 6, 1991; 64175.