Infectious Diseases Prevention and Control in Canadian Federal Penitentiaries 2000-01

Publications

Infectious Diseases
Prevention and Control
in Canadian Federal
Penitentiaries 2000-01

Discussion

Infectious Diseases Prevention and Control in Canadian Federal Penitentiaries 2000-01 is the first report of its kind in Canada, using routinely collected surveillance data to report on infectious diseases in correctional settings. The impetus for this report is to provide an in-depth examination of inmate health by presenting data relevant to the epidemiological management of infection and disease in federal penitentiaries. Significant time, energy and effort have resulted in the establishment of consistent standards in reporting, assessment and evaluation of surveillance data across the Correctional Service of Canada (CSC) institutions.

One of the strengths of the CSC Infectious Diseases Surveillance System (CSC-IDSS) is its ability to distinguish between infections in new admissions and general population inmates. New admissions may differ from general population inmates in their risk profile as a result of risk experienced outside the correctional setting compared with those experienced within. Infections detected among inmates in the general population can include chronic infections that have not previously been detected at admission and infections that are possibly acquired while incarcerated (either from community or penitentiary contacts). However, to date, there have been no seroincidence studies conducted in CSC institutions to determine if inmates contract bloodborne or sexually transmitted infections while incarcerated.

The findings in this report underscore the importance of surveillance data for monitoring and evaluating trends in inmate health. Data obtained through surveillance contribute to policy decisions that impact strategies and health-care practices aimed at reducing the burden of infectious diseases within federal correctional facilities. Prevention of infection and subsequent disease increases the quality of life of the incarcerated population and reduces the burden on the health-care system by avoiding the high costs of treatment.

Infectious diseases prevention and control

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The high reported rates of infectious diseases in federal penitentiaries raises several concerns relating to 1) the greater demand for appropriate care, treatment and support for infected inmates, 2) the risk to staff and inmates of disease transmission in the event of exposure to blood or body fluids from an infected inmate, and 3) the increased risk to public health upon reintegration of an infected offender into the community. A combination of testing, treatment and education is essential for preventing the transmission of infectious diseases in correctional settings.

CSC's approach to disease prevention and control is multifaceted. It aims to use best practices and knowledge derived from current research and policy to address issues of infectious diseases in federal inmates. CSC endeavours to expand diagnostic and treatment services such that infected inmates are identified much earlier in their course of infection and are more quickly provided with care and treatment. Education of inmates continues to be one of the major components of promoting and protecting the health of incarcerated populations. CSC encourages the delivery of peer education and input from inmates into prevention program development. Identifying and providing inmates with appropriate life skills, coping mechanisms and risk reduction behaviours prior to release are necessary to lessen the public health impact of infectious diseases.

The high prevalence of reported HIV and HCV in Canadian federal correctional facilities represents a major challenge for control efforts of these pathogens. Progress toward infectious diseases control in federal penitentiaries is one crucial component in the control of infectious diseases in the general Canadian population. The wide variation in testing rates across regions calls for increasing screening, especially in those with low rates, to allow for greater comparability of results between regions in the future.

CSC maintains the practice of actively offering voluntary counselling and testing to all inmates. Testing offered to new admissions upon entry into the federal correctional system may be one of the best opportunities for identifying prevalent infections. Because testing is voluntary, not all infected persons are diagnosed and treated, especially those who may be at highest risk.

Reasons for inmate refusal of testing are complex and may include such factors as misconceptions about one's level of risk, fear of the testing procedure, aversion to health care, anxiety of discovering one's infection status and fear of reproof by fellow inmates upon discovery of one's positive infection status.^1-4 Non-invasive, viable alternatives to blood testing, such as saliva and urine testing, may help to increase the uptake of voluntary testing in the future.⁵

Testing offered to new admissions upon entry into the federal correctional system may be one of the best opportunities for screening and identifying prevalent infections among offenders.

Partner notification is a major component of communicable disease follow-up. Inmates who test positive for an infectious disease may sometimes be reluctant to disclose information about contacts or behaviours that may be deemed inappropriate, illegal or stigmatized. Thus, institutional health workers must ensure confidentiality of disclosed information, encourage patient self-referral when appropriate or provide inmates with options for contact follow-up.

Reduction of inmate infection rates requires broad prevention efforts to address the needs of high-risk individuals. It will continue to be important to co-ordinate prevention activities with local public health and other community-based care groups in order to optimize the continuation of care of offenders outside of the correctional setting. The collaboration with community agencies aims to provide services that are culturally and gender sensitive and which, together with programs offered in the correctional setting, encompass an array of prevention strategies for infectious diseases.

Incarceration presents a valuable opportunity to educate inmates about:

1. the transmission of infectious diseases,
2. healthy practices,
3. the range of health services available to them while incarcerated, and
4. the availability of community resources upon release.

Vulnerable populations

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Women and Aboriginal persons have been identified as vulnerable populations for HIV and hepatitis C in Canada.^6,7 The high rates of infection in these groups are reflected in prison populations (e.g., the high rates of HIV and HCV among women offenders). The reduction of STDs, including HBV, should be considered a complementary control strategy for HIV and HCV.

Increasing hiv infection rates among canadian women are reflected in the continuing high rates of hiv among incarcerated women.

Injection drug users (IDUs) are also at increased risk of infection with HIV and HCV. Worldwide, a large proportion of inmates afflicted with bloodborne pathogens in correctional facilities is due to IDU.^1-3 In Canada, CSC's strategy to address substance abuse in federal facilities aims to reduce the accessibility and demand for drugs among offenders as well as to reduce the harm associated with drug use. The harm reduction approach focuses on educating inmates about ways to minimize the negative consequences of their risky behaviours and providing them with numerous options to achieve this goal.

The CSC-IDSS is currently evolving to include expanded information, which will help to better characterize the pattern of infectious diseases incidence and prevalence within vulnerable populations.

Data limitations

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Observed trends in reported cases of HIV, hepatitis B and C, and STDs must be interpreted with caution, since a number of factors may contribute to such trends. For example, confirmatory tests are sometimes performed to validate a diagnosis and are reported by institutions as part of surveillance activities. Because surveillance data reporting is currently non-identifying, multiple tests and/or multiple positive test reports for the same inmate are not differentiated and, consequently, affects the calculation of testing uptake, test positivity, and infection rates. It should also be noted that not all positive test reports represent new diagnoses; inmates clinically tested by CSC may also have been tested in previous years in the community or during a previous prison sentence but may not have declared their infection status to CSC.

Data in this report are inclusive of all reported cases of disease identified among inmates who have come forward for testing or treatment. Self-selection bias may be present if high-risk inmates refuse testing and are, therefore, systematically excluded from surveillance. Reported disease rates may further underestimate actual disease prevalence if inmates have not disclosed their disease status to CSC or are not aware that they are infected because they have not been tested. Clinically, the window period of many infectious agents can hinder their detection through screening. Thus, inmates tested during this period may indicate a negative test result.

Comparisons between regions and between men and women must be approached with caution for several reasons. First, differences in infection rates by region reflect the varying levels of risk to which individuals are exposed in different communities. Infection rates in correctional settings may, in part, reflect the prevalence of infection among individuals with similar risks in the community. The risk of transmission in inmate populations is influenced by the prevalence of infection among those incarcerated as well as the frequency with which such persons engage in risky behaviours prior to and during their incarceration. Second, aggregate rates of infection that combine men and women are more strongly influenced by the proportionally larger population of men offenders.

Many improvements in data quality are expected in future editions of this report. CSC acknowledges the limitations of current available data in permitting accurate interpretations. Several aspects of data quality, such as completeness of reporting, accuracy, and timeliness of surveillance reports, are currently under review by CSC. CSC is working towards modernization and integration of surveillance activities within its institutions and regions. Efforts are being made to increase health-care providers' awareness of their responsibility for routine surveillance data reporting to CSC-NHQ. The future implementation of case-based reporting will permit improved differentiation of duplicate tests and will include information on inmate demographics such as age-specific and gender-specific reporting. Moreover, data on immunization will be incorporated as part of surveillance. Expanded information on testing characteristics will provide a better picture of groups at greatest risk of infection.

Conclusion

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Data from the CSC-IDSS provide useful information that will deepen our understanding of rates of infection in inmates in Canadian federal penitentiaries. Surveillance represents an important component of disease prevention and control.

This report suggests that improveTo achieve sustained declines in infectious diseases and to interrupt the cycle of disease transmission greater efforts are needed to identify seropositive individuals and provide effective risk reduction interventions. An efficient preventive strategy must optimize use of harm reduction initiatives, while providing gender-specific and culturally-specific education programs. The strengthening of links between penitentiaries and public health services in the community can ensure the continuity of care for inmates upon their release.

To achieve sustained declines in infectious diseases and to interrupt the cycle of disease transmission greater efforts are needed to identify seropositive individuals and provide effective risk reduction interventions. An efficient preventive strategy must optimize use of harm reduction initiatives, while providing gender-specific and culturally-specific education programs. The strengthening of links between penitentiaries and public health services in the community can ensure the continuity of care for inmates upon their release.

References

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