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Proactive Disclosure

Part 2

Results

Participation in Testing

In accordance with Commissioner’s Directive 800, inmates are seen by a nurse within 2 days of admission and are given a thorough health assessment within 14 days (CSC 2004a). Further, it is the policy of Correctional Service Canada to engage all newly admitted inmates in risk screening and to offer testing for bloodborne and sexually transmitted infections (CSC 2004b).

The CSC-IDSS provides a count of the number of both HIV and HCV tests requested by calendar year. Table II shows the total number of HIV and HCV tests done for CSC inmates between 2000 and 2004 by inmate status. There were 5,822 HIV tests in 2002, 5,830 in 2003, and 5,679 in 2004. Similarly, there were 5,730 tests for HCV in 2002, 5,874 in 2003, and 5,506 in 2004.

These results for 2002–2004 by region, gender, and inmate status for HIV are shown in Appendix A, Tables A.1-A.3 and for HCV in Appendix B, Tables B1–B.3. Prairies region reported the highest number of tests in 2002 (1,870), Ontario in 2003 (1,620), and Prairies in 2004 (1,637). Prairies reported the highest number of HCV tests in 2002 (1,763), Ontario in 2003 (1,549) and in 2004 (1,446).

A measure of participation such as a “crude” proportion receiving a test is difficult to interpret and is not warranted. The CSC-IDSS does not capture reasons for non-testing. For instance: an inmate may refuse testing regardless of the recommendation from the nurse on admission; the inmate may have recently been tested in a provincial/territorial facility or in the community; or, the inmate may not have risk factors warranting testing. In the absence of this information, a crude measure of participation could be misleading.

Table 2: Total Number of HIV and HCV Tests Performed, CSC 2000–2004
HIV
	2000	2001	2002	2003	2004
New Admissions (% tested)	1,596 (37.1%)	1,768 (41.2%)	2,317 (55.7%)	2,059 (48.6%)	2,112 (47.9%)
General Population	2,573 (20.8%)	2,770 (22.2%)	3,505 (28.5%)	3,771 (31.0%)	3,567 (27.2%)
Total	4,169	4,538	5,822	5,830	5,679
HCV
New Admissions (% tested)	1,583 (36.8%)	1,908 (44.5%)	2,307 (55.5%)	1,987 (46.9%)	2,074 (47.0%)
General Population	2,151 (17.4%)	2,512 (20.1%)	3,423 (27.8%)	3,887 (31.9%)	3,432 (26.2%)
Total	3,734	4,420	5,730	5,874	5,506

The percent tested among new admissions provides a rough measure of participation in screening. Inmates who self-report a positive status on admission for either HIV or HCV are tested to confirm their status (note that these confirmatory tests are not reported as screening tests). The participation rate reported here is likely an underestimate, since some inmates on admission will have had recent screening tests either in the community or in the provincial system. These inmates would be offered a test in an appropriate 6-month seroconversion window depending on the date of last risk exposure.

A measure of participation among general population inmates is more difficult to interpret. Some of these tests may be those recommended by the infectious disease nurse and brought forward from the inmate’s admission. In addition, general population inmates are not routinely tested on an annual basis.

1. Human immunodeficiency virus (HIV)

Newly Diagnosed HIV Cases

The number of newly diagnosed positive HIV cases, where the inmate’s HIV status was previously unknown⁴, is shown in Table 1.1 (also see Appendix A, Tables A.1–A.3). The number of newly diagnosed HIV cases was 45 in 2000 and 5 in 2004. The HIV positivity rate (number of positive tests divided by the number of tests) is also shown in Table 1.1. Among new admissions, the HIV test positivity rate was 1.50% in 2000 and 0.14% in 2004. Among the general population, the HIV test positivity rate was 0.90% in 2000 and 0.06% in 2004.

Table 1.1: New HIV Diagnosis Among New Admissions and General Population Inmates in Canadian Federal Penitentiaries 2000–2004
Inmate Status	2000	2001	2002	2003	2004
New Admissions
Frequency	24	11	15	13	3
Test Positivity Rate	1.50%	0.60%	0.65%	0.63%	0.14%
General Population
Frequency	21	5	12	20	2
Test Positivity Rate	0.90%	0.20%	0.34%	0.53%	0.06%
Overall
Frequency	45	16	27	33	5
Test Positivity Rate	1.12%	0.35%	0.46%	0.57%	0.09%

Appendix A, Table A.1 shows that Quebec had the highest HIV test positivity rate in 2002 (0.65%), Prairies in 2003 (1.01%), and Quebec in 2004 (0.23%). Appendix A, Table A.2 shows that the test positivity rate for females was higher among new admissions compared to general population inmates for 2002–2004, and was higher among females compared to men (Appendix A, Table A.3).

HIV Prevalence

The year-end point-prevalence estimate for HIV among inmates in Canadian federal penitentiaries is shown in Figure 1.1 (see also Appendix A, Table A.4). The HIV prevalence peaked in 2002 at N=251 and 2.04%; since then, the prevalence rate has fallen to N=188 and 1.43%. HIV prevalence was highest in Quebec and Pacific Regions (Appendix A, Table A.4).

Figure 1.1: Prevalence of HIV at Year-end 1989–2004 in Canadian Federal Penitentiaries

The year-end point prevalence also shows variance by gender (see Figure 1.2 and Appendix A, Tables A.4). Although the estimated HIV prevalence among women has fallen from 5.0% in 2000 to 3.44% in 2004, women continue to have a higher rate compared to men. Regionally, the rates for both women and men were highest in Quebec and Pacific regions.

Figure 1.2: Year-end Prevalence of HIV among Inmates by Gender, 2000–2004

Table 1.2 (also see Appendix A, Table A.4) provides an estimate of the total known number of inmates living with HIV that were inside Canadian federal penitentiaries in a given year. The number of inmates known to be HIV positive on admission rose from 104 in 2000 to 139 in 2002 and 128 in 2004. By combining the information on the number of HIV positive inmates at the beginning of the year with the number of new admissions known to be infected and the number of newly diagnosed HIV positive inmates, a period-prevalence for HIV can be calculated. For example, even though there were an estimated 188 HIV positive inmates in CSC at year-end in 2004 (1.43% HIV point prevalence), a total of 344 HIV positive inmates were cared for in 2004 (1.96% HIV period-prevalence).⁵

Table 1.2: HIV Period Prevalence ¹: Known Positive at Admission and Newly Diagnosed Cases, 2000–2004
	2000	2001	2002	2003	2004
Number of Known HIV cases at the start of the year	149	210	225	235	211
Known HIV Positive at Admission	104	123	139	118	128
Newly Diagnosed HIV Positive	45	16	27	33	5
New Admissions	24	11	15	13	3
General Population	21	5	12	20	2
Annual Number of Known HIV Cases	298	349	391	386	344
Annual Period Prevalence	1.51%	1.75%	2.38%	2.35%	1.96%

¹Data do not compute across years due to data discrepancies, transfers in and transfers out of institutions, and releases over the calendar year.

HIV Prevalence Among New Admissions

By combining information on the number of known prevalent infections and the number of newly diagnosed infections among new admissions, an estimated HIV prevalence can be calculated for new admissions. These data are reported in Table 1.3 (see also Appendix A, Table A.4). HIV prevalence among new admissions was 2.98% in 2000, 3.70% in 2002, and 2.97% in 2004. The highest HIV prevalence rate among new admissions for 2002-2004 was in Quebec Region (6.83%, 5.96%, 6.02% respectively). High HIV prevalence rates among new admissions were also seen in Pacific Region (4.92%, 5.54%, 4.55%). The lowest rates for HIV prevalence among new admissions was in Ontario Region (1.73%, 1.21%, 1.09%).

Table 1.3: HIV Frequency and Prevalence Rate Among New Admissions to Canadian Federal Penitentiaries, 2000–2004
	2000	2001	2002	2003	2004
Population	4,302	4,288	4,159	4,238	4,413
Number of Reported HIV Infections (Prevalent on admission plus newly diagnosed)	128	134	154	131	131
Prevalence Rate	2.98%	3.13%	3.70%	3.09%	2.97%

HIV Treatment

For each month, the IDSS provides the number of inmates initiated on treatment and the number of inmates currently on treatment for HIV infection (see Appendix A, Table A.5). Table 1.4 shows that the number of inmates initiated on treatment was 68 in 2000, 50 in 2003 and 55 in 2004. Overall the proportion of HIV positive inmates on therapy rose from 54.2% in 2000 to 58.7% in 2004. The proportion on therapy shows regional variation, with the Pacific Region at 41.9% and Quebec at 66.4% in 2004. While HIV treatment uptake for the years 2002 and 2003 was lower for women than men (35.6% vs 56.0%, and 48.4% vs 52.4% respectively), treatment uptake among women increased by 2004 so that women showed a larger uptake compared to men (60.5% vs 58.5% respectively).

It should be noted, however, that current treatment approaches include delayed initiation of Highly Active Anti-retroviral treatment (HAART) and planned treatment interruptions (“drug holidays”); thus, even though an HIV positive person may not currently be on medication, it does not mean that he/she is not being medically managed.

Table 1.4: HIV Treatment Initiation and Uptake, CSC Inmates, 2000–2004
	2000	2001	2002	2003	2004
Number of Inmates Initiated on HIV Treatment	68	41	46	50	55
Treatment Uptake (%)	54.2%	50.7%	55.0%	52.1%	58.7%

Releases to the Community–HIV

The majority of federal inmates return to their communities upon sentence completion. Table 1.5 (see also Appendix A, Table A.4) shows that the total number of inmates known to be living with HIV released to the community from 2000–2004 has been steadily increasing to 214 in 2004.

Table 1.5: Number of Known HIV Positive Inmates Released to the Community, CSC, 2000–2004
	2000	2001	2002	2003	2004
Number of Known HIV Positive Inmates Released to the Community	162	173	183	205	214

2. Hepatitis C (HCV)

Newly Diagnosed HCV Cases

The number of newly diagnosed positive HCV cases, where the inmates HCV status was previously unknown, is shown in Table 2.1 (also see Appendix B, Tables B.1-B3). The number of newly diagnosed HCV cases was 570 in 1999 and 445 in 2004. The overall HCV positivity rate (number of positive tests divided by the number of tests), shown in Table 2.1, was 14.27% in 2000, 7.90% in 2003, and 8.08% in 2004. Among new admissions the HCV test positivity rate was 15.41% in 2000, 9.80% in 2002, and 12.25% in 2004. Among the general population, the rate was 14.6% in 2001 and 5.57% in 2004. Test positivity was highest in Quebec region for 2002 (9.45%), 2003 (9.75%), and 2004 (13.68%). The proportion of positive tests among new admissions was also highest in Quebec Region for 2002 (14.58%), 2003 (22.18%), and 2204 (28.63%) (see Appendix B, Table B.1).

HCV Prevalence

The year-end point-prevalence estimate for HCV is shown in Figure 2.1 (see also Appendix B, Table B.4). The number of reported HCV cases was 2,317 in 1999 and 3,303 in 2004, an increase of 43% over 6 years. HCV prevalence has shown a corresponding increase, from 18.1% in 1999 to 26.8% in 2003, and 25.2% in 2004.

The HCV prevalence rate shows regional variation (see Appendix B, Table B.4). In 2004, the lowest HCV prevalence was seen in the Quebec Region (16.7%) and the highest rate was seen in the Pacific Region (40.7%). The prevalence also varies by gender (see Figure 2.2, and Tables B.3 and B.4). Women continue to have higher prevalence rates compared to men; however the rate among women has been decreasing since 2000 (from 42.4% to 37.6% in 2004) while the rate among men has been increasing since 2000 (from 19.7% to 24.8% in 2004). Prairie (45.8%) and Pacific (38.6%) Regions had the highest rate among women in 2004; Quebec had the lowest (32.1%).

Table 2.1: New HCV Diagnosis Among New Admissions and General Population Inmates, 1997–2004
Inmate Status	1997	1998	1999	2000	2001	2002	2003	2004
New Admissions
Frequency	–	–	–	244	195	226	220	254
Test Positivity Rate	–	–	–	15.41%	10.22%	9.80%	11.07%	12.25%
General Population
Frequency	–	–	–	289	367	257	244	191
Test Positivity Rate	–	–	–	13.44%	14.61%	7.51%	6.28%	5.57%
Overall
Frequency	407	560	570	553	562	483	464	445
Test Positivity Rate	–	–	–	14.27%	12.71%	8.43%	7.90%	8.08%

Figure 2.1: Prevalence of HCV at Year-end 1999–2004 in Canadian Federal Penitentiaries

Figure 2.2: Year-end Prevalence of HCV by Gender, Inmates, 2000 – 2004

Table 2.2: HCV Period Prevalence¹: Known Positive at Admission and Newly Diagnosed Cases, 2000–2004
	2000	2001	2002	2003	2004
Number of Known HCV cases at the start of the year	1,097	2,720	2,937	3,192	3,277
Known Positive at Admission	747	858	937	989	1,074
Newly Diagnosed Positive	533	562	483	464	445
New Admissions	244	195	226	220	254
General Population	289	367	257	244	191
Annual Number of Known HCV Cases	2,377	4,140	4,357	4,645	4,796
Annual Period Prevalence	12.0%	20.8%	26.5%	28.3%	27.4%

¹Data do not compute across years due to data discrepancies, transfers in and out of institutions, and releases over the calendar year.

Table 2.2 (also see Appendix B, Table B.4) provides an estimate of the total known number of HCV positive inmates in Canadian federal penitentiaries in a given year. The results show that the number of new admissions known to be HCV positive on admission has been increasing from 747 in 2000 to 1,074 in 2004, a 44% increase. By combining the information on the number of HCV positive inmates at the beginning of the year with the number of new admissions known to be infected, and the number of newly diagnosed HCV positive inmates, a period-prevalence for HCV can be calculated. For example, even though there were an estimated 3,303 HCV positive inmates in CSC at year-end in 2004 (25.2% HCV point prevalence), a total of 4,796 HCV positive inmates were cared for in 2004 (27.4% HCV period-prevalence).⁶

HCV Prevalence Among New Admissions

By combining information on the number of known prevalent infections and the number of newly diagnosed infections among new admissions, an estimated HCV prevalence can be calculated for this group. These data are reported in Table 2.3 (see also Table B.4). The HCV prevalence rate among new admissions was 23.1% in 2000, increasing to 30.1% in 2004. Pacific had the highest prevalence rate of HCV among new admissions in 2002 (44.3%) and in 2003 (45.2%); in 2004, Quebec Region had the highest rate (40.9%). The lowest rates were seen in Ontario Region (18.9%, 18.3%, and 20.5% respectively).

Table 2.3: HCV Frequency and Prevalence Rate Among New Admissions to Canadian Federal Penitentiaries, 2000–2004
	2000	2001	2002	2003	2004
Population	4,302	4,288	4,159	4,238	4,413
Number of Reported HCV Infections (Prevalent on admission plus newly diagnosed)	991	1,053	1,163	1,209	1,328
Prevalence Rate	23.1%	24.6%	28.0%	28.5%	30.1%

HCV Treatment

For each month, the IDSS provides the number of inmates initiated on treatment and the number of inmates currently on treatment for HCV infection (see Appendix B, Table B.5). The number of inmates initiated on HCV treatment was 91 in 2000 and 252 in 2004 (Table 2.4). Overall, the proportion of HCV positive inmates on therapy (based on the average number of inmates on HCV treatment per month divided by the number of HCV positive per month) was 1.9% in 2000 and 4.0% in 2004. The proportion on therapy does show regional variation. Pacific Region reported the highest proportion on treatment (7.7%, 9.1%, 8.0%) while the lowest treatment uptake was observed in Prairie in 2002 (0.9%), in Ontario in 2003 (1.1%) and in 2004 (1.5%).

A review of treatment rates for HCV infection by gender shows that while the treatment rate among women was lower than that among men for 2002 and 2003 (for 2002: 1.2% vs 3.0% respectively; for 2003: 0.9% vs 3.9% respectively); the rates among women and men were virtually identical by 2004 (4.1% vs 4.0% respectively).

Table 2.4: HCV Treatment: Treatment Initiation and Uptake
	2000	2001	2002	2003	2004
Number of Inmates Initiated on HIV Treatment	91	123	163	271	252
Treatment Uptake (percent)	1.9%	1.9%	2.9%	3.8%	4.0%

Releases to the Community–HCV

The majority of federally incarcerated inmates return to their communities upon completion of their sentences. Table 2.5 (see also Appendix B, Table B.4) shows that the total number of known HCV positive inmates released to the community from 2000–2004 has been steadily increasing to 2,472 in 2004.

Table 2.5: Number of Known HCV Positive Inmates Released to the Community, CSC, 2000–2004
	2000	2001	2002	2003	2004
Number of Inmates Released to the Community	1,156	1,506	1,856	2,354	2,472

3. Hepatitis A (HAV) and Hepatitis B (HBV)

HAV / HBV Immunization

At admission, all inmates are offered screening for serological evidence of both hepatitis A and B. Those without evidence of either natural immunity or past immunization are offered immunization. The IDSS did not track the number of immunizations in 2002–2004; however, since vaccines are paid for from a national fund, the number of vaccine units ordered per region can provide an estimate of the immunization coverage. Twinrix® provide both HAV and HBV immunity, while Vaqta® and Engerix® are specific for HAV and HBV respectively.

The data for fiscal year 2003–2004 are shown in Figure 3.1⁷. These data suggest that, in FY 2003–2004, a total of 2,120 (991 + 1,129) inmates were immunized against HAV and 2,072 (943 + 1,129) inmates were vaccinated for HBV.

Figure 3.1: Hepatitis A and B Vaccines Ordered by Region, Fiscal Year 2003–2004: Number of Inmates Immunized

HBV Case Reporting

Serological results for HBV immunity or susceptibility for 2002–2004 are not available. However the IDSS does track the number of acute HBV cases and HBV carriers diagnosed (based on symptoms and/or serology). Table 3.1 shows the results for 2000 to 2004 by gender (see also Appendix C, Table C.1). There were 43 cases diagnosed in 2001, 30 in 2002, 17 in 2003, and 16 in 2004. The overall prevalence rate for acute HBV was 0.24% in 2002, 0.14% in 2003 and 0.12% in 2004 (Table 3.1).

Regional variation is observed in the prevalence of reported HBV cases. In 2002 and in 2003, the highest rates were observed in Quebec Region (0.45%, 0.19% respectively), while the lowest were in Atlantic Region (0.09%, 0.00% respectively). In 2004, the highest rate was in Ontario Region (0.20%) and the lowest in Atlantic and Pacific Regions (0.00%).

HAV case reporting was not included on the IDSS reporting templates for 2002–2004.

Table 3.1: Reported Hepatitis B Infections among inmates in Canadian Federal Penitentiaries, 2000–2004
	2000	2001	2002	2003	2004
Total	13	43	30	17	16
Males	13	41	29	17	16
Females	0	2	1	0	0
Acute HBV Prevalence Rate	0.10%	0.34%	0.24%	0.14%	0.12%

4. Sexually Transmitted Infections (STI)

The IDSS provides the number of cases diagnosed with genital chlamydia, gonorrhoea, syphilis, and ‘other’ (which includes herpes simplex, genital warts, and any other non-specific STI such as urethritis). The overall frequency of cases reported and the corresponding prevalence rates for STI are shown in Table 4.1.

Table 4.1: Reported Frequency and Prevalence of Sexuality Transmitted Infections in Canadian Federal Penitentiaries by Gender, 2000–2004
STI (N/%)	2000	2001	2002	2003	2004
Chlamydia	21 (0.17%)	23 (0.18%)	53 (0.43%)	58 (0.48%)	53 (0.40%)
Male	19 (0.16%)	21 (0.17%)	49 (0.41%)	55 (0.46%)	48 (0.38%)
Female	2 (0.64%)	2 (0.60%)	4 (1.31%)	3 (0.89%)	5 (1.23%)
Gonorrhoea	11 (0.09%)	13 (0.10%)	20 (0.16%)	7 (0.06%)	11 (0.08%)
Male	11 (0.09%)	11 (0.09%)	19 (0.16%)	6 (0.05%)	7 (0.06%)
Female	0 (0.00%)	2 (0.60%)	1 (0.33%)	1 (0.30%)	4 (0.98%)
Syphilis	0 (0.00%)	0 (0.00%)	3 (0.02%)	4 (0.03%)	10 (0.08%)
Male	0 (0.00%)	0 (0.00%)	3 (0.03%)	3 (0.03%)	9 (0.07%)
Female	0 (0.00%)	0 (0.00%)	0 (0.00%)	1 (0.30%)	1 (0.25%)
Other STI	60 (0.49%)	35 (0.28%)	53 (0.43%)	85 (0.70%)	91 (0.69%)
Male	20 (0.17%)	10 (0.08%)	45 (0.38%)	71 (0.60%)	69 (0.54%)
Female	40 (12.74%)	25 (7.53%)	8 (2.61%)	14 (4.14%)	22 (5.41%)

Chlamydia

The number of chlamydia cases reported through IDSS was 21 in 2000, 53 in 2002, 58 in 2003, and 53 in 2004. The reported prevalence of chlamydia were 0.17% in 2000, 0.43% in 2002, 0.48% in 2003, and 0.40% in 2004. The rates of infection among women are two to three times higher than those among men (Table 4.1). Table D.1 indicates that the highest prevalence rates of chlamydia infection for both men and women in 2002-2004 were in the Prairies Region (for women, 1.71%, 1.75%, and 3.82% respectively; for men, 0.46%, 1.05%, and 0.84% respectively). In fact Prairies Region accounted for almost all the chlamydia reported in CSC 2002–2004.

Gonorrhoea

Gonorrhoea prevalence was 0.09% in 2000, 0.16% in 2002, 0.06% in 2003, and 0.08% in 2004. The number of cases is small, ranging from 7-20; thus the rate is statistically unstable. Table 4.1 indicates that the rates among women were higher than the rates among men (0.98% vs 0.06% in 2004). Prairie Region accounted for almost all of the gonorrhoea reported in CSC 2002–2004.

Syphilis

Although there were no syphilis cases in 2000–2001, CSC saw an increase in the number of cases reported from 3 in 2002 to 10 in 2004. This represents an increase in prevalence of 0.02%, 0.03%, to 0.08% from 2002–2004. The rates in 2003 and 2004 were higher among women than among men (0.30% vs 0.03% and 0.25 vs 0.07% respectively). However, these rates are based on small numbers (1 each in Ontario and Prairie regions – see Table D.1) and are therefore statistically unstable. The majority of cases were reported from Quebec in 2002, Ontario in 2003, and Quebec in 2004.

The increase in reported cases and prevalence of syphilis among inmates is mirrored by a similar increase in the general Canadian population (PHAC, 2006a). Figure 4.1 shows the syphilis case rate per 100,000 in Canada compared to the rate in CSC. In CSC, the case rate increased from 0 in 2000–2001, to 57.7/100,000 in 2004; in Canada, the overall rate has risen from 0.6 in 2000 to 3.9/100,000 in 2004. The rise in the syphilis case rate in Canada may reflect increases in unsafe sexual behaviour, which may lead to an increase in other infectious diseases.

Figure 4.1: Syphilis Rates per 100,000 in Canada and CSC, 2000-2004

Other STI

The prevalence of other STI (which includes Human Papilloma Virus (HPV), herpes-simplex virus (HSV), non-specific urethritis, etc) reported through the IDSS system was 0.28% in 2001, 0.43% in 2002, 0.70% in 2003, and 0.69% in 2004. In absolute numbers, the number of cases reported increased from 2001 (n=35) to 2004 (n=91). As was observed with the other STI, the rate among women was higher than that among men. In 2004, the rate of ‘other’ STI was highest in Quebec (1.67%), followed by Atlantic (1.31%). Ontario did not report any ‘other’ STI in 2002–2004.

5. Tuberculosis Screening: Inmates

Participation in TB Screening

Participation in tuberculosis screening for inmates from 1998–2004 is shown in Table 5.1. Among inmates participation in TB screening was 75.8% in 2002, 77.2% in 2003, and 72.7% in 2004. A high participation in tuberculosis screening on admission is important for several reasons: first, it is important to detect any active cases among new admissions before they can spread infection to other inmates; and second, it is important to establish an accurate baseline tuberculosis status in order to evaluate subsequent assessments.

Table 5.1: Participation in TB Screening, Inmates, 1998–2004
	1998¹	1999	2000	2001	2002	2003	2004
Inmates	12,213 (84.8%)	13,404 (77.4%)	13,008 (78.1%)	12,905 (77.0%)	12,470 (75.8%)	12,681 (77.2%)	12,735 (72.7%)

¹Participation rate calculated using 1998 midpoint population as the denominator; for 1999–2004, the calculation was done by adding annual new admissions to the inmate population as of Jan 1^stof that year

Initial Assessment–Inmates

The results of the initial assessment for inmates 2002 –2004 by region are shown in Appendix E, Table E.1. Overall, the proportion that tested significant for tuberculosis infection on initial assessment was 17.5% in 2002, 16.5% in 2003, and 11.6% in 2004. Figure 5.1 indicates a general decrease in the proportion significant for LTBI on initial assessment since a high of 21.2% in 1998. The proportion invalid (see Introduction and Methods section) was 9.1% in 1999, 14.6% in 2002, and 11.1% in 2004. The proportion of assessments that were refusals was 1.8% in 2001, 2.2% in 2002, and 4.4% in 2004.

In 2002, the proportion significant on Initial Assessment was highest in the Prairie (19.4%) and Quebec (19.3%) Regions; in 2003, highest in Quebec (18.8%) and Ontario (18.0%); and in 2004, higher in Quebec (19.9%) and Prairie (11.3%) Regions. The lowest proportion testing significant was Atlantic in 2002 (9.9%) and 2003 (8.8%), and Pacific and Atlantic in 2004 (6.0%) (Appendix E, Table E.1). The proportion of records that were deemed invalid was highest in Prairie in 2002 (28.9%) and 2003 (22.0%), and in Atlantic in 2004 (18.4%), and lowest in Ontario Region for 2002 (4.9%), 2003 (3.5%), and 2004 (4.3%). The proportion of refusals was highest in Quebec Region in 2002 (5.2%), 2003 (5.5%), and in 2004 (9.5%). The lowest refusal rate was observed in Ontario for 2002 (0.1%), 2003 (0.0%), and 2004 (0.5%).

BCG Vaccination Status–Inmates

As part of the Initial Assessment, a TB medical history is taken that includes a history of Bacille Calmette-Guérin (BCG) vaccination. The proportion of inmates reporting a history of BCG vaccination by region and origin is shown in Appendix E, Table E.2. The overall proportion of inmates with a BCG history was 9.3% in 2002, 11.4% in 2003, and 12.9% in 2004. Apart from the origin unknown category, the highest proportion with BCG was observed among the foreign-born for 2002, 2003, and 2004 (13.5%, 17.3%, and 18.0% respectively), followed by Aboriginals in 2002 (10.3%), 2003 (11.5%), and by Canadian-born non-Aboriginals in 2004 (12.2%).

Figure 5.1 – Selected Results: Initial Assessment, Inmates, 1998–2004

Regionally, Quebec had the highest overall proportion with a BCG history for 2002–2004 (18.2%, 21.7%, and 29.2% respectively). The region with the lowest proportion of inmates reporting a history of BCG was Atlantic for 2002–2004 (1.6%, 1.2%, and 0.9% respectively).

BCG history and age at vaccination on initial assessment for inmates are shown in Table 5.2. Age at vaccination was available for 58.8% of inmates reporting a BCG history. Data availability varied by origin (Canadian-born non-Aboriginal [68.1%], Aboriginal [46.3%], foreign-born [51.3%], and unknown [58.9%]). These data indicate that Aboriginal inmates report a lower mean age at vaccination (roughly half that of other origin categories); in fact, half of all Aboriginal inmates who reported a BCG history were vaccinated at birth. Among inmates with a significant result on initial assessment, 25.2% had a history of BCG compared to 11.7% of those with a non-significant TST result and 14.3.% of those with an ‘other’ result.

Table 5.2: BCG Vaccination and Age at Vaccination at Initial Assessment, Inmates, 1998–2004
Category	Number	Number (%) BCG History	Number (%) with Age at Vaccination	Mean (Median) Age at Vaccination
Origin
Canadian	13,326	1,572 (11.8%)	1,071 (68.1%)	9.7 (7)
Aboriginal	5,275	875 (16.6%)	405 (46.3%)	4.8 (0)
Foreign-born	2,761	511 (18.5%)	262 (51.3%)	11.2 (8)
Unknown	8,404	1,253 (14.9%)	740 (58.9%)	9.7 (7)
TST Status
Significant	4,342	1,094 (25.2%)	657 (60.1%)	9.1 (7)
Non-significant	19,975	2,340 (11.7%)	1,383 (59.1%)	8.8 (7)
Other	5,449	777 (14.3%)	438 (56.4%)	9.7 (7)
TOTALS	29,766	4,211 (14.1%)	2,478 (58.8%)	9.0 (7)

Ongoing Nonsignificant Assessment–Inmates

The results of the ongoing screening of inmates with a previous nonsignificant TST for 1998–2004 are shown in Figure 5.2 (see also Appendix E, Table E.3). The proportion of inmates testing significant was 1.4% in 2000, 2.6% in 2001 and 1.5% in 2004. The proportion of invalid records was 1.8% in 1998, 2.8% in 2002, 2.7% in 2003, and 3.2% in 2004. The proportion that refused the TST on follow-up assessment was 10.8% in 2002, 9.3% in 2003, and 8.8% in 2004.

Figure 5.2: Selected Results: Ongoing Nonsignificant Assessment, Inmates, 1998–2004

Appendix E, Table E.3 shows that the highest proportion testing significant on an ongoing assessment was in Quebec in 2002 (3.4%), in Prairies in 2003 (2.6%), and in Quebec in 2004 (3.0%). The lowest proportion was in Atlantic in 2002 (0.9%), 2003 (0.8%), and 2004 (0.4%). The highest proportion of invalid records from 2002-2004 were from the Pacific Region (6.4%, 6.7%, and 9.5% respectively). Quebec Region had the highest proportion of refusals between 2002–2004 (20.3%, 19.9%, and 19.6%) respectively.

Converters and Conversion Rate–Inmates

Analysis of the previous TST history for those who tested significant on an Ongoing Nonsignificant Assessment allows the estimation of the conversion rate (see Glossary for definition). Table 5.3 shows the number of inmates with a newly significant TST, the number of those with a previous documented negative assessment (“true” converters), the number of inmates with a previous valid result (total number with a current significant or non-significant result who had a previous valid non-significant result), and the estimated conversion rate for 2002–2004. These data show that the conversion rate among inmates was 1.51% in 2002, 1.35% in 2003, and 0.84% in 2004. Figure 5.3 shows the number of true converters and the estimated conversion rate for inmates for 1998–2004.

Table 5.3: Newly Significant TST, Converters, and Conversion Rate, Inmates, 2002–2004
	2002	2003	2004
Number Newly Significant	119	110	88
Number with Previous Nonsignificant	72	67	44
Number with Valid Result	4,770	4,960	5,256
Conversion Rate	1.51%	1.35%	0.84%

Figure 5.3: True Converters and TST Conversion Rate, Inmates, 1998–2004

^* Since there was no routine surveillance for tuberculosis prior to 1998, the TBTS database contains ad hoc and sporadic records for earlier assessments. Therefore the conversion rate for 1998 is simply the proportion significant on the ongoing nonsignificant assessment.

Ongoing Significant Assessments–Inmates

The number of assessments for inmates known to have had a previous significant TST (and therefore assumed to be latently infected with tuberculosis) by year and region is shown in Table 5.4. The number of ongoing significant assessments reported to NHQ was 1,674 in 2002, 1,734 in 2003, and 1,654 in 2004.

Table 5.4: Number of Ongoing TST-Significant Assessments¹by Region, Inmates, 1998–2004
Region	1998	1999	2000	2001	2002	2003	2004
Atlantic	88	126	95	90	83	76	88
Quebec	364	601	438	632	567	581	486
Ontario	655	758	584	424	279	276	322
Prairie	458	509	609	535	507	572	553
Pacific	114	134	154	205	233	204	174
Unknown	3	0	0	0	5	25	31
Canada	1,682	2,128	1,880	1,886	1,674	1,734	1,654

¹For inmates already known to be TST significant (includes symptom and risk screen, chest x-ray and medical referral if warranted).

Latent Tuberculosis Infection–Inmates

The overall proportion of inmates considered to be infected with Mycobacterium tuberculosis is calculated by adding the number of inmates with a newly significant TST in a year with those already considered to have latent tuberculosis infection (LTBI). The regional distributions of LTBI by age, origin, and gender for 2002–2004 are shown in Appendix E (Table E.4, E.5, and E.6 respectively).

The overall proportion of inmates considered to have LTBI was 19.1% in 2002, 19.2% in 2003, and 16.7% in 2004. Figure 5.4 shows the estimated proportion of inmates assumed to have LTBI by region for 1998–2004. The region with the highest proportion of inmates having LTBI was Quebec for 2002 (23.3%), 2003 (23.5%) and 2004 (20.9%). The region with the lowest proportion having LTBI was Atlantic for 2002 (10.7%), 2003 (9.2%), and 2004 (8.5%).

LTBI by Age Category

The proportion of inmates who are assumed to have LTBI increases with age (Appendix E, Table E.4). For example, in 2004, the proportion LTBI was 7.5%, 8.7%, 15.2%, 23.4%, 27.0%, and 32.8% respectively for ages 17-19, 20-29, 30-39, 40-49, 50-59, and 60 plus.

LTBI by Origin

Figure 5.5 shows the proportion of inmates having LTBI by origin 1998–2004. The rank-order of the proportion having LTBI across origin does not change from year-to-year. Foreign-born inmates consistently have the highest LTBI rate: 36.3% in 2001, 35.0% in 2002, 35.0% in 2003, and 27.6% in 2004. Among Canadian-born Aboriginals, the LTBI rate was 28.1% in 2001, 24.7% in 2002, 26.2% in 2003, and 22.9% in 2004. Among Canadian-born non-Aboriginals, the LTBI rate was 12.4% in 2001 and 9.3% in 2004.

Figure 5.4: Latent Tuberculosis Infection by Region, Inmates, 1998–2004

Analysis of Appendix E, Table E.5 reveals regional differences in proportions across regions. Among the foreign-born, the highest rates were observed in Quebec Region in 2002 (39.7%), in Ontario in 2003 (40.9%), and in Quebec Region in 2004 (34.2%). Among Aboriginals, the highest proportions were observed in Prairie Region for 2002 (26.5%) and 2003 (28.7%), and 2004 (26.6%). Among Canadian born non-Aboriginals, the highest rates were reported among inmates in the Quebec Region for 2002 (16.5%), 2003 (15.7%), and in 2004 (14.6%).

LTBI by Gender

Figure 5.6 shows the proportion of LTBI by gender for 1998-2004. Among males, the proportion having LTBI was 21.0% in 2001, 19.2% in 2002, 19.4% in 2003, and 17.1% in 2004. Among females, the proportion having LTBI was 20.1% in 2001, 15.7% in 2002, 13.3% in 2003, and 8.4% in 2004.

Inspection of Appendix E, Table E.6 indicates regional differences between LTBI rates among genders. The highest proportion LTBI among males were observed in the Quebec Region for 2002 (23.3%), 2003 (23.7%), and in 2004 (21.4%). Among women, the highest proportion having LTBI were observed in Quebec Region in 2002 (20.7%), in Ontario in 2003 (20.0%) and in Pacific in 2004 (16.7%). Note that prior to April 2004, federally incarcerated women in Pacific Region were held in a provincial facility and limited data are available.

Figure 5.5: Latent Tuberculosis Infection by Origin, Inmates, 1998–2004

Risk Factor and Symptoms Screening–Inmates

The results of the checklist screening for risk factors and symptoms for 2002–2004 are shown in Tables E7.i, E7.ii, and E7.iii respectively. Risk factors included in the screen are those that are risks for progression to active tuberculosis, and are not necessarily risk factors for acquiring tuberculosis infection.

Overall, the most frequently reported risk factor was a history of injection drug use for 2002–2004 (10.7%, 11.2%, 11.6% respectively). This was followed by HIV/AIDS in 2002 (1.9%), TB case contact in 2003 (2.0%), and HIV/AIDS in 2004 (1.7%). Among those with a significant TST, a history of injection drug use was the most commonly reported risk factor in 2002–2004 (9.5%, 9.8%, and 9.9% respectively). This was followed by case contact with an active TB case in 2002 (2.4%) and 2003 (2.6%), and by diabetes in 2004 (1.9%).

Overall, the most frequently reported symptoms in 2002 were fatigue (8.1%), chest pains (6.2%), coughing sputum (4.7%), night sweats (4.7%), and loss of appetite (4.7%). The same symptom rank-order was observed among those with a significant TST in 2002 (fatigue: 10.8%; chest pains: 8.4%; coughing sputum: 6.5%; and loss of appetite: 6.0%). The most frequently reported symptoms in 2003 were fatigue (8.2%), chest pains (7.2%), night sweats (5.1%), and loss of appetite (5.0%). Among those with a significant TST in 2003, the most common symptoms were fatigue (11.2%), chest pains (9.6%), coughing sputum (7.3%), and loss of appetite (6.7%). In 2004, the most commonly reported symptoms were fatigue (7.6%), chest pains (6.6%), night sweats (4.9%), and coughing sputum (4.9%). Among those with a significant TST in 2004, the most common symptoms were fatigue (12.1%), chest pains (9.4%), coughing sputum (8.5%), and night sweats (7.2%). Although the overall prevalence of individual symptoms varies from year to year, the rank–order is virtually preserved in each case with a higher prevalence observed amongst those with a significant TST.

Figure 5.6: Latent Tuberculosis Infection by Gender, Inmates, 1998–2004

LTBI Treatment–Inmates

The proportion of inmates having LTBI who are on treatment is estimated using aggregate data submitted via the CSC IDSS system. Each institution reports the number of inmates on prophylactic LTBI therapy⁸ in a given month. Thus it is possible to calculate the average number of inmates on LTBI therapy per month by region, and by aggregating across Regions, for CSC overall.

Since LTBI therapy takes many months, it is not possible to calculate a simple sum of the number of inmates on treatment; rather, the average number of inmates on therapy per month can be calculated. By dividing the average number of inmates on therapy in a given month by the total number of inmates assumed to have LTBI, an estimate of treatment coverage can be made.

Table 5.5: Average Monthly Number of Inmates on Therapy and LTBI Treatment Coverage by Region, 1999–2004
	1999	2000	2001	2002	2003	2004
Atlantic	2 (14.9%)	4 (32.1%)	2 (19.0%)	2 (18.3%)	2 (23.9%)	3 (28.4%)
Quebec	5 (7.3%)	10 (16.9%)	7 (9.1%)	11 (17.2%)	5 (8.3%)	8 (13.5%)
Ontario	22 (27.8%)	17 (25.8%)	27 (47.9%)	29 (75.3%)	23 (53.8%)	38 (100.0%)
Prairie	13 (19.9%)	21 (30.4%)	27 (44.2%)	18 (30.3%)	15 (24.4%)	23 (40.4%)
Pacific	3 (16.1%)	7 (33.2%)	10 (38.1%)	4 (17.7%)	4 (17.6%)	12 (70.7%)
Canada	45 (18.3%)	57 (25.9%)	72 (32.0%)	64 (32.6%)	49 (24.3%)	84 (47.0%)

Note: Totals may not add up due to rounding.

Table 5.5 shows the average monthly number of inmates on prophylactic therapy for LTBI by region for 1999 to 2004. In brackets is the estimated LTBI treatment coverage. Overall, the average number of inmates on LTBI therapy per month was 45 in 1999 and 84.2 in 2004. This corresponds to an estimated treatment coverage of 18.3% and 47.0%. Regionally, the highest estimated treatment coverage was observed in Ontario (1999), Pacific (2000), and Ontario (2001, 2002, 2003, and 2004).

Active TB Disease Among Inmates

Cases of active tuberculosis disease (Active TB) are reported via the CSC IDSS (see Figure 5.7). The number of active TB cases diagnosed and reported in CSC rose from 1 in 2002, to 3 in 2003, and to 4 in 2004, translating into yearly case rates per 100,000 of 6.1, 18.3, and 22.8 respectively.

Since the absolute number of active TB cases is small, a centred 3-year moving average was calculated (see Figure 5.7). This operation has the effect of smoothing the solid black line depicting the annual CSC active TB case rate; however, it does not remove the overall trend of a drop in the case rate to a low of 6.0/100,000 in 2001, rising to 15.7/100,000 in 2003.

Compared to the active TB case rate for Canada, the rate in CSC is generally higher than in the Canadian population. For 2003 and 2004, the TB case rate in Canada was 5.1 and 4.9 per 100,000 respectively (PHAC, 2006b). Apart from 2001 when there were no cases in CSC, the active TB case rate has been higher among inmates.

Figure 5.8 shows the active TB rate in CSC and the rate in the Canadian population by origin. In Canada, the highest rates are observed among Aboriginal and foreign-born Canadians, at 23.7 and 16.0 per 100,000 in 2004 (PHAC, 2006b). Among Canadian-born non-Aboriginals, the rate was 0.8 per 100,000 in 2004. The variability in the CSC rate is highlighted when juxtaposed against these other data.

Figure 5.7: Active Tuberculosis Case Frequency and Rate, Inmates, CSC 1998–2004

^* Case Rate: rate per 100,000

^** LTBI Rate: Proportion having LTBI (percent)

Figure 5.8: Active TB in CSC vs Active TB in Canada by Origin, 1998–2004