Part 1

Introduction and Methods

This report follows previous reports on infectious disease in Correctional Service Canada (CSC) for 1998–2001 (CSC 2001; CSC 2003; CSC 2005). This is the first report to include surveillance data on human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV), sexually transmitted infections (STI), and tuberculosis (TB). As with previous reports on TB, data for both inmates and staff are reported here. This report summarizes the analysis of data collected during three years of surveillance, from January 2002 through December 2004.

Background

The Correctional Service of Canada (CSC) is responsible for the administration of correctional sentences of two years or more and for the preparation of offenders for their successful return and reintegration into the community. During the reporting period, CSC operated 58 correctional institutions, which included minimum-, medium-, maximum- and multi-level security facilities in five regions (Figure I). Several institutions are dedicated to women offenders: Nova Institution for Women in Atlantic Region; Joliette Institution in Quebec Region; Grand Valley Institution for Women in Ontario Region; and Edmonton Institution for Women and Okimaw Ochi Healing Lodge in Prairies Region. Prior to April 2004, federally sentenced women in the Pacific Region were housed in provincial facilities. Since then, the Fraser Valley Institution for Women in Pacific Region has housed women offenders¹ (see Appendix J, Table J.1).

CSC is mandated to provide essential health services for persons convicted of federal offences, as well as reasonable access to non-essential mental health care services. Voluntary testing for HIV, hepatitis B and C, STI and TB is offered to all inmates on admission. Inmates are considered ‘new admissions’ for 6-8 weeks after sentencing, while they complete their sentence programming and orientation. Reception units also administer the ‘Reception Awareness Program’, or RAP, which focuses on infectious disease awareness and prevention and health services available to inmates in CSC. Upon completing the orientation program, the inmate is placed in the institution that most closely fits their custody and program requirements (inmates may transfer between institutions during their sentence according to their needs). Testing is available upon request by an inmate at any time throughout his/her sentence, as well as by recommendation of the facility physician, as part of contact tracing, upon clinical indication of infection, or after involvement in an incident where exposure to an infectious agent may have occurred. Inmates are offered annual tuberculosis screening. Harm-reduction measures include the availability of condoms, dental dams, water-based lubricants and bleach at several locations in all institutions, as well as methadone treatment for opiod addictions. Routine immunization for hepatitis A and hepatitis B is offered. CSC also has a “Peer Education and Counselling” or PEC program, as well as other health education and wellness promotion programs in place.

CSC Infectious Disease Surveillance System (IDSS)

Each institution provides information on the number of tests, test results, transfers, and releases to the community for HIV and HCV. Diagnosed cases of HBV and STI are also recorded. Number of inmates on methadone maintenance therapy (MMT) per month are also reported. Data collected by the CSC-IDSS originate at the Health Care Unit of each federal correctional facility and are submitted to the Regional Infectious Disease Coordinator. Validation of the data is done at the regional level. Regional data are submitted to the epidemiologist, CSC National Infectious Disease Program at National Headquarters (NHQ). Further data validation and accuracy checks are conducted. Data are then compiled to a national level. The CSC IDSS is described in more detail elsewhere (CSC, 2003; De et al, 2004).

Figure I: Administrative Regions in Correctional Service Canada

Tuberculosis Surveillance

At admission, inmates are offered screening for tuberculosis. This includes a baseline two-step tuberculin-skin test (TST), a symptom and risk factors checklist, and a TB history (i.e. previous active TB, previous TST results, BCG history). All inmates are also offered ongoing assessment throughout their incarceration history (see glossary for details). Duplicate forms are submitted to NHQ and entered into a normalized electronic database. Staff assessments are conducted by nurses from the Workplace Health and Public Safety Program (WHPSP), Health Canada (HC). Hard copy duplicate forms are submitted directly to the Tuberculosis Prevention and Control Program (TBPC), Public Health Agency of Canada (PHAC) and are entered into the same normalized electronic database. The data flow of tuberculosis assessments has been described in more detail elsewhere (CSC, 2005).

Surveillance Data Analysis

Data are presented by region for each pathogen/disease under surveillance. Detailed regional data for 2002–2004 are presented in the Appendices, while the main text includes summary data for all years. For HIV and HCV, IDSS data include the number of tests and corresponding results by inmate status. Test positivity rates were calculated by using the number of positive disease test reports as the numerator and the number of inmates who completed testing for the disease as the denominator. Data were also pooled and overall results calculated. Data were analyzed across CSC regions and combined for overall national results. Since the IDSS data are aggregate institutional data, “gender” was determined according to institution; however, females may be housed for short periods of time under exceptional circumstances (i.e., for medical or security resons) in male institutions, which may lead to some, albeit negligible, misclassification bias.

Tuberculosis data are analyzed separately. Although some data from 2002–2004 were entered into the old CSC Tuberculosis Tracking System (TBTS), data were migrated to a new, web-enabled system (Web-IDSS²) in March 2005. This involved mapping existing fields, and creating new fields where warranted. The data used for analysis and presented in this report were exported from Web-IDSS.

The interpretation of the TST is dependent upon the time from tuberculin injection to reading. The following outcome categories are possible for each assessment:

First TST of two-step and annual follow-up TST:

1. Significant;
2. Non-significant;
3. A ‘read no-show’, where tuberculin is administered but the induration is not read;
4. An ‘invalid’ TST, where the induration is read as non-significant BUT the time to read is outside the prescribed guidelines of 48-72 hours.

The second TST of a two-step TST, in addition to the above, could also be:

1. An incomplete two-step TST, where a second TST is not performed to complete the baseline measurement where warranted based on a non- significant first step;
2. An invalid two-step TST, where the second step of the two-step is not administered within the prescribed time frame of 7-365 days³ of the first administration of tuberculin.

In addition, several instances result in no TST data:

1. A refusal;
2. A medical contraindication to TST testing, such as an allergy;
3. A blank or unknown result.

These outcome categories are coded for in the analysis in a hierarchical fashion, since the categories are mutually exclusive. A TST invalidated in both the first and second steps of the two-step TST is categorized according to the first of the two tests.

Data Updates

As data are received, entered, updated, validated, or as new records are added to the Web-IDSS database, the analysis from years previously reported are updated accordingly. This report contains results from the most up-to-date tuberculosis data as of March 2007.

Populations

The total annual incarcerated populations under health surveillance for 2002–2004 are shown in Table I. The number of new admissions rose steadily from 2002 (4,159) to 2003 (4,238) to 2004 (4,413). The increase in population from 2002–2004 was observed in both male and female populations. The number of new admissions used in this report differs from the number used in the previous report for infectious disease (CSC 2003), which used a combined figure that included all new warrants of committal, exchanges of service, transfers from provincial/territorial and international prisons, other admissions and revocations. In practice, not all admissions are treated as new admissions nor are they included in the CSC-IDSS data; therefore, they are not included in the denominator in these analyses.

Where indicated, evaluation of disease prevalence is done separately for new admissions and for general populations. In order to maintain comparability across years, the point-prevalence calculation using year-end figures is continued. However, in calculating a period-prevalence for a calendar year, the population of new admissions was added to the population that started the year in order to obtain the total number of persons at risk in the year.

Table 1: Incarcerated Populations^† Under Surveillance, 2002–2004

Region	2002			2003			2004
	Males	Females	Total	Males	Females	Total	Males	Females	Total
Atlantic	1,532	62	1,594	1,540	80	1,620	1,696	74	1,770
New Admissions	449	20	469	450	35	485	454	21	475
General Population	1,083	42	1,125	1,090	45	1,135	1,242	53	1,295
Quebec	3,966	96	4,062	3,926	114	4,040	4,144	116	4,260
New Admissions	923	29	952	922	34	956	926	38	964
General Population	3,043	67	3,110	3,004	80	3,084	3,218	78	3,296
Ontario	4,216	151	4,367	4,306	179	4,485	4,505	169	4,674
New Admissions	972	71	1,043	1,077	80	1,157	1,125	68	1,193
General Population	3,244	80	3,324	3,229	99	3,328	3,380	101	3,481
Prairie	4,044	175	4,219	3,837	190	4,027	4,159	207	4,366
New Admissions	1,190	58	1,248	1,077	76	1,153	1,200	76	1,276
General Population	2,854	117	2,971	2,760	114	2,874	2,959	131	3,090
Pacific	2,196	16	2,212	2,226	19	2,245	2,382	68	2,450
New Admissions	431	16	447	468	19	487	481	24	505
General Population	1,765	–	1,765	1,758	–	1,758	1,901	44	1,945
Canada	15,954	500	16,454	15,835	582	16,417	16,886	634	17,520
New Admissions	3,965	194	4,159	3,994	244	4,238	4,186	227	4,413
General Population	11,989	306	12,295	11,841	338	12,179	12,700	407	13,107

^† Source: CSC Program Assurance, as of April 10^th, 2005

¹ Data for Fraser Valley Institution for Women are therefore not complete for 2004 and represent April – December only.

² Web-IDSS for “Web-enabled Infectious Disease Surveillance System”. Web-IDSS facilitates the data entry of all eight surveillance forms for infectious diseases within CSC Health Services.

³ This time frame differs from that recommended in the Canadian Tuberculosis Standards 5^th Ed but was allowed in the surveillance definition used in this report.