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

Publications

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

RESULTS

Hepatitis C

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Hepatitis C is a viral infection that causes an inflammation of the liver and is primarily spread through contact with infected blood or blood products. Persons at risk for infection with hepatitis C virus (HCV) are those who share needles or equipment for injection drug use, or individuals who received blood or blood products prior to the introduction of universal blood screening programs.¹ Percutaneous procedures such as body piercing and tattooing using contaminated equipment, as well as the sharing of straws for inhaling drugs have also been recognized as viable modes of HCV transmission.^2-4

Approximately 60-70% of persons newly infected with HCV are asymptomatic for up to 5 months and, therefore, are often unaware of their infection.5 However, 15-20% of infected persons may completely resolve their infection without any expression of symptoms.⁵ Despite the lack of clinical symptoms, infected persons are, nevertheless, able to pass on their infection to others.

It is estimated that at least 75% of persons newly infected with HCV progress to chronic infection, a condition in which the person becomes a carrier of the virus.⁶ Among persons chronically infected, cirrhosis can develop in 10-20% and liver cancer in 1-5% over a period of 20 to 30 years.⁷ Individuals with chronic infections may often feel completely healthy even though they carry the virus. They are, nonetheless, able to transmit the virus to others who come in contact with their blood.

HCV infection is often found in individuals who are HIV-positive, with the hepatitis C virus being 10 to 15 times more transmissible by blood than HIV.8 Research indicates that people co-infected with HCV and HIV may develop cirrhosis more quickly than those who are HCV-positive only.^6,8,9 Hepatitis C also increases the severity of liver disease when it co-exists with other hepatic conditions, such as hepatitis A or hepatitis B.

IN SUMMARY

Total reported hepatitis C cases:

• The number of inmates with a positive diagnosis for hepatitis C has increased from 2,542 cases (20.1%) in 2000 to 2,993 cases (23.6%) in 2001.
• Hepatitis C infection rates were higher among women offenders (41.2% in 2001, 42.4% in 2000) than among men (23.2% in 2001, 19.7% in 2000).
• Overall, the rate of reported hepatitis C infection was highest in Pacific Region, with 34.8% of inmates reporting HCV infection in 2001 and 27.3% in 2000.
• The rate of reported women hepatitis C infection was highest among inmates in the Prairie Region (57.1% in 2001, 65.6% in 2000).
• The rate of reported hepatitis C infected in women decreased in all Regions except Ontario and Quebec, where an increase was noted.
• The rate of reported men hepatitis C infection was highest among inmates in Pacific Region (33.9% in 2001, 27.3% in 2000).
• Significant increases in infection rates among men were observed in Pacific and Prairie Regions over 2000.

New reported hepatitis C cases (includes acute and chronic infections):

• Reported rates of new hepatitis C cases went from 533 cases reported in 2000 to 562 cases in 2001.
• 65% of all newly identified hepatitis C cases in 2001 and 54% in 2000 were among general population inmates.
• A large proportion of offenders (15.4% in 2000 and 10.2% in 2001) tested positive for HCV upon entry. Among general population inmates, rates of newly identified infection were 13.4% and 14.6% in 2000 and 2001, respectively.
• In 2001, 1,506 HCV-positive inmates were released from CSC, up from 1,156 inmates in 2000.

The estimated prevalence of hepatitis C infection in Canada is 0.8% but has been found to be higher in certain at-risk population groups such as injection drug users (IDUs).^10,11 Nearly 4,000 cases of hepatitis C occur in Canada every year, 63% of which are attributed to the sharing of contaminated equipment used to inject drugs.¹¹ Inmates of correctional facilities in Canada have higher rates of HCV infection than those for the general population.^12,13 IDUs are over-represented in incarcerated populations and injection of drugs appears to be the main behaviour underlying their higher risk of infection.¹⁴

Hepatitis C in CSC facilities

Between 1997 and 2001, new HCV-positive test reports of acute and chronic infection have averaged close to 526 cases per year (Figure 5). These include cases discovered among new admissions as well as in general population inmates.

Hepatitis C testing and infection rates

Total positive HCV test reports

As of year-end 2001, 23.6% (2,993 cases) of inmates were identified as being HCV-positive, representing an increase over the same period in 2000 (20.1%, 2,542 cases). Figure 6 illustrates the distribution of positive HCV test reports across CSC regions. The highest proportion of cases was reported in the Pacific Region in 2000-01.

New positive HCV test reports

New positive HCV test reports rose 5% during this period, from 533 new cases in 2000 to 562 cases in 2001 (Table 6). Nearly 65% of new positive HCV test reports in 2001 and 54% in 2000 were among general population inmates.

Table 6.
Hepatitis C virus (HCV) antibody testing among inmates in Canadian federal penitentiaries, 2000-01.

HCV antibody testing

HCV counselling and testing are intended to allow inmates to access appropriate treatment and support at an early stage.

Overall, testing uptake increased by close to 4% for new admissions - from 22.3% in 2000 to 26.7% in 2001. There was wide variation in testing uptake across regions (Table 6). During the same period, testing uptake increased nearly 3% for general population inmates, from 17.0% in 2000 to 19.7% in 2001.

Table 7.
Hepatitis C virus (HCV) antibody testing among women offenders in Canadian federal penitentiaries, 2000-01.

There was no discernible trend in test positivity rates, as infection rates among new admissions and general population inmates varied widely across regions and by year of reporting.

Hepatitis C cases by gender

At year-end 2001, 41.2% of incarcerated women and 23.2% of men offenders were reported as having hepatitis C infection. Compared with rates of infection from the previous year, the rate was slightly lower for women (42.4% in 2000) but was higher for men (19.7% in 2000).

The comparatively higher rate of HCV infection among women offenders was consistently reported across all Correctional Service of Canada (CSC) regions (Figure 7). Prairie Region housed the largest proportion of HCV-positive women offenders, followed by Ontario and Atlantic Regions. In contrast, the rate of reported HCV infection among men offenders was highest in Pacific Region.

With the exception of Ontario and Quebec Regions, the proportion of positive HCV test reports for women decreased in all regions in 2001. The opposite trend was observed among men offenders, the group in which rates of HCV infection showed variable increases between 2000 and 2001 for all regions.

A higher proportion of women than men undertook testing for hepatitis C in 2000-01. Testing uptake and test positivity showed higher rates of case-finding for women offenders than for men. The difference in testing rates between men and women was greatest at admission to CSC, where 45% of women (Table 7), compared to 26% of men (Table 8) undertook voluntary testing for HCV in 2001. Health-care visits for routine gynecological examinations may provide additional opportunities for offering HCV testing to women offenders.

Hepatitis C-positive offender intake and community releases

Close to 18.5% (858 inmates) of all new admissions entered CSC in 2001 with a previously documented positive diagnosis for HCV, compared to 16.2% (747 inmates) in 2000. During the same period, the number of HCV-positive inmates released to the community increased from 1,156 offenders (9.1% of all inmates at year-end) in 2000 to 1,506 releases (11.8%) in 2001.

Hepatitis C treatment

The current recommended therapy for hepatitis C is clinically effective in 30-65% of patients.15 The lengthy treatment (24 to 48 weeks) and side effects associated with HCV treatment makes it a difficult course of therapy for patients to maintain. HCV therapy may be precluded for numerous other reasons, including contraindications to HCV treatment, availability of specialists in the community and severity of clinical effects from co-morbid conditions. Co-infected individuals are of particular concern as the presence of multiple pathogens often impacts the clinical course of infection and the responsiveness to treatment. As a result, rates of treatment uptake among CSC inmates can vary widely by region and from year to year.

Inmates diagnosed by CSC with HCV infection are assessed for treatment, including those offenders who enter the federal correctional system with a documented infection. During 2001, 123 inmates were newly initiated on HCV treatment, in comparison to 91 inmates in 2000.

Table 8.
Hepatitis C virus (HCV) antibody testing among men offenders in Canadian federal penitentiaries, 2000-01.

Conclusion

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In Canada, overall estimates of the prevalence of HCV in provincial and federal correctional facilities have ranged from 25-40% and correspond to findings in this report.^12,13 Reported rates of HCV infection in CSC appear to be within the range found by inmate surveys from England and Wales¹⁶ (7%), Scotland¹⁷ (20%), Ireland¹⁸ (22%), Brazil1⁹ (34%), the United States²⁰ (38%), and Australia (39%).²¹

Several studies have documented high prevalence and transmission rates of infection with HCV among injecting drug users.^21,22 Infection with HCV can occur within a short period of time after initiation to IDU²³, with the result that many offenders with a history of IDU may already be infected upon entry to correctional facilities. Spread of infection may occur in settings such as correctional facilities where IDUs are likely to share unsterilized or improperly cleaned injection equipment.^13,21,22,24 In 1996, a study of 192 inmates at Springhill Institution in Nova Scotia revealed that 28% of inmates were HCV-positive, but that rates were sharply higher among IDUs (52%) than among non-IDU inmates (3%).²⁵ A twofold higher prevalence rate for HIV and hepatitis B virus was found among IDUs compared to non-IDU inmates. Of the inmates self reporting a history of IDU, 14% indicated that they were first-time injectors inside a correctional institution and 30% indicated that they had injected in Springhill Institution during the six months prior to the study. A 1995 CSC inmate survey similarly showed that 11% of 4,285 inmates self-reported IDU at their current institution.²⁶

The higher HCV case identification in CSC's general population inmates compared to new admissions remains unexplained. This finding may suggest that many prevalent infections are not being detected at entry to the facilities or that transmission of HCV continues among inmates while incarcerated. Although infection within prison may occur, there have been no studies in Canada to provide evidence of this phenomenon.

Persons at highest risk of infection may be less likely to be tested, leading to biased testing patterns and possible continued transmission of infection. In addition, the reported testing rates in CSC point to a need for increased screening, especially in regions that report low rates of testing uptake. While no clear explanation exists for the variation in testing rates between regions, the finding is likely the result of differences across regions with regard to HCV screening practice and promotion.

In correctional facilities around the world, the harm reduction approach is being recognized as an effective strategy for addressing risky behaviours. The CSC methadone maintenance program is one such strategy that reaches a population which might otherwise be difficult to access through traditional channels. The methadone program aims to reduce the transmission of bloodborne pathogens by decreasing the sharing of drug injecting equipment. Another strategy in CSC has been the provision of bleach for disinfection of injecting equipment as a means of reducing the transmission of bloodborne pathogens among IDU.

Care for CSC inmates integrates treatment with prevention to provide a holistic approach to HCV management. Pre- and post-test counselling assists inmates in making informed decisions, in coping better with their health condition and in educating them to prevent further transmission of disease. Focusing efforts on reducing the risk of HCV transmission through prevention and harm reduction can greatly impact rates of hepatitis C among federal inmates.

References

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