Position Statements

The Management of Hepatitis C in Correctional Institutions

Introduction
The National Commission on Correctional Health Care and the Society of Correctional Physicians are not-for-profit organizations that work toward the improvement of health services in the nation's jails, prisons, and juvenile confinement facilities. The Commission publishes health services standards and operates a voluntary accreditation program for institutions that meet these standards. The Society is an organization of physicians specializing in correctional medicine.

The issue of Hepatitis C is of great concern to the Commission and Society since it is a threat to the quality of health care provided in prisons and jails. The Commission and Society have adopted the following position statement that, along with the published standards, may assist policy makers and health professionals in designing their own policies and procedures on this matter.

Background
Chronic liver disease is the 10th leading cause of death among adults in the United States. The Centers for Disease Control and Prevention (CDC) estimates that approximately 25,000 deaths occur annually from chronic liver disease, and that hepatitis C virus (HCV) is responsible for 40 percent of that death toll (CDC, 1998).

The HCV is a bloodborne pathogen and is transmitted primarily through large or repeated direct percutaneous exposures to blood (Alter, 1997).  In the United States, the relative importance of the two most common exposures associated with transmission of HCV, blood transfusion and injection drug use, has changed over time. Blood transfusion, which accounted for a substantial proportion of HCV infections acquired >10 years ago, rarely accounts for recently acquired infections. In contrast, drug use consistently has accounted for a substantial proportion of HCV infection and currently accounts for the majority of HCV transmission in the United States. Health-care professionals who are exposed to needlestick injuries in an occupational setting and hemodialysis patients are also at risk from exposure to infectious blood, as are infants born to infected women.  In addition, HCV may be transmitted by sexual or household exposure to an infected contact; however, the efficiency of transmission in these settings appears to be low.  Although any percutaneous exposure has the potential for transmitting bloodborne pathogens, including HCV, no data exist in the United States indicating that persons with exposures to tattooing and body piercing alone are at increased risk for HCV infection. Further studies are needed to determine if these types of exposures and settings in which they occur (e.g. correctional institutions, unregulated commercial establishments) are risk factors for HCV infection in the United States.

An estimated 3.9 million persons in the civilian, non-institutionalized population are infected with HCV. This estimate is based on the Third National Health and Nutrition Examination Survey (NHANES III) data; however, it does not include the incarcerated, institutionalized, or homeless populations. Still, in the general population, HCV is more prevalent than human immunodeficiency virus and tuberculosis infections in the United States.

The prevalence of hepatitis C virus infection among the prison population has not been sufficiently studied. However, because many inmates have a history of drug use, it stands to reason that correctional systems will experience high HCV prevalence rates. The California Department of Corrections and the California Office of AIDS conducted a 1994 blinded study supporting this concern. The study found 41 percent of entering inmates testing positive for antibody to HCV (Nieto, 1998).

In spite of the morbidity of hepatitis C and the likely high prevalence of HCV infection in the prisoner population, there is no national policy on the screening or treatment for HCV infection in federal or state correctional systems. The following position statement provides guidance to correctional administrators in the management and treatment of hepatitis C.

Discussion
The diagnosis of hepatitis C should be considered in patients with risk factors, such as injection or inhalation drug use, symptoms such as fatigue, or a history of jaundice or hepatitis. Prior to testing, inmates should be given information about the transmission of HCV, the nature of hepatitis C and chronic liver disease, potential health consequences, the test procedure and meaning of the test results, and the benefits and side effects of treatment.

The standard initial laboratory test for anti-HCV is by enzyme immunoassay (EIA). Several factors may determine how extensive further evaluation should go. Correctional health care workers need to contemplate whether an inmate patient is a candidate for treatment before proceeding much beyond antibody testing (Spaulding, 1999). Patients with persistently normal serum transaminases probably do not benefit from treatment (NIH, 1997). Because of interferon's propensity to induce depression, inmates need to be mentally stable before treatment. Other medical problems also should be under control. The expected benefit of prolonging life with HCV treatment may only be realized decades after treatment.  Inmates should have a remaining life expectancy of at least one or two decades. Because HCV disease may progress rapidly in the setting of HIV, less stringent criteria for life expectancy should apply for patients co-infected with HIV and HCV. Treatment for youths less than 18 years old is at present still controversial.

Long term adult facilities should give standard therapy to appropriate patients, in an attempt to treat and perhaps eradicate the virus. Even after treatment for  HCV,  a patient may reacquire HCV; drug and alcohol rehabilitation should precede HCV treatment (NIH, 1997). Expected remaining duration of incarceration can determine whether a correctional facility ethically bears a responsibility to treat disease (Anno, 1996). Because hepatitis C infection can lead to fatal liver failure and hepatocellular carcinoma, all prisons should develop criteria for appropriate treatment candidates. These criteria should not be so stringent that they exclude all prisoners from a treatment that may be lifesaving.

Prisoners who have a positive EIA test should then be given confirmatory test if treatment is contemplated. There is a high pretest probability that a positive EIA in an inmate with HCV risk factors is a true EIA, the appropriate confirmatory test is one looking for the virus itself, such as a polymerase chain reaction (PCR) test, rather than a recombinant immunoblot assay (RIBA).  Prisoners who test positive on their confirmatory tests should be ruled out for other chronic liver disease such as hemochromatosis, Wilson's disease, autoimmune hepatitis, and alpha-1 antitrypsin deficiency. A liver biopsy, though it may convey some useful information, is not a cost effective part of a work up (Wong, 1998).

All inmates who test positive for HCV should receive counseling to encourage behavioral changes that may be required to prevent future contagion of others, and when appropriate, should receive intensive chemical dependency and substance abuse treatment.

HCV infected inmates should be counseled to avoid drinking alcohol. HCV infected inmates also should be encouraged to voluntarily inform their sexual and intravenous drug using partners to advise them of their potential contact with the HCV.

Correctional health care systems also should study the prevalence of hepatitis C in their inmate population and factors that contribute to disease and its transmission. They should use the results of the study to prepare guidelines for prevention, screening, and treatment aimed at reducing the prevalence of the disease.

Education on hepatitis C infection should be incorporated into prison and jail health education programs. 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 HCV. The target population should be involved in the development and provision of educational programs to encourage acceptance of the disease and changes to life-style and behavior.

Correctional and health staff should receive training on confidentiality as it applies to HCV.  Correctional officers and health staff should also be informed about their potential occupational or personal risk for acquiring hepatitis C. When appropriate, staff should pursue testing and treatment from their personal physicians.

Most HCV infected inmates will return to their community soon. State correctional systems should work with their state public health departments to develop state specific health policy guidelines to coordinate the screening, education, and treatment of hepatitis C.

When developing HCV policies, administrators should refer to the following documents for guidance: NCCHC standards on receiving screening, infection control, health promotion and disease prevention, and health assessment, as well as NCCHC's position statement on managing hepatitis B in prisons. In addition, correctional health administrators should refer to the Centers for Disease Control and Prevention or the American Academy of Family Physicians for their most recent recommendations on the prevention and control of HCV.

Position Statement
Correctional health administrators should develop a system and/or facility policy on the management and treatment of hepatitis C.

Adopted by the National Commission on Correctional Health Care Board of Directors
November 7, 1999

References
Alter, M. J. (1997). Epidemiology of hepatitis C. Hepatology ,26(6):2S-5S.

Anno B. J. et al. (1996). A preliminary model for determining limits for correctional health care services. J Correctional Health Care 1996; 3(1):67-84.

Centers for Disease Control and Prevention (1998). Recommendations for Prevention and Control Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Morbidity Mortality Weekly Report .October 16, 1998, 47 (RR-19)

Department of Health and Human Services, National Center for Health Statistics (NCHS).
 NHANES III (National Health and Nutrition Examination Survey, 1988-1994).

Marcellin P. et al., (1997) Long-term histological improvement and loss of detectable intrahepatic HCV RNA in patients with chronic hepatitis C and sustained response to interferon-alfa therapy. Annals Int Med 1997; 127:875

McHutchison J. G. et al (1998) Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. N Engl J Med 1998; 339:1493-9.

National Institutes of Health (1997). Consensus Development Conference Panel Statement: Management of Hepatitis C. Hepatology, 1997 26(Suppl 1:2S-10S).

Ruiz J. D., Mikanda J. Seroprevalence of HIV, Hepatitis B, Hepatitis C, and risk behaviors among inmates entering the California correctional system. Sacramento, California Department of Health Services, March 1996.

Spaulding A. et al (1999). Hepatitis C in State Correctional Facilities. Preventive Medicine 1999; 28: 92-100.

Wong J. B., Bennett W. G., Koff R. S., Pauker S. G. Pretreatment evaluation of chronic hepatitis C: Risks, benefits and costs. JAMA 1998; 280 (4):2088-93.