Incarceration for Drug Use Can Become a Death Sentence

CDC DVH - HCV National Prevention Strategy for Health Professionals:

'via Blog this' 
More than 80 percent of the nation’s estimated 1.7 million current injecting drug users have been incarcerated.

Figure 2 - Source: CDC.

Sources of Infection for Persons with Hepatitis C

* Hemodialysis; health-care work; perinatal

Sexual exposures account for about 15 percent of cases of Hepatitis C. Although the risk for transmitting HCV infection through sexual intercourse is low, sex is a common behavior in the general population, a substantial proportion of the adult population has had unprotected sex with multiple partners, and there are a large number of persons with HCV infection.

HCV is most efficiently transmitted by exposures that involve direct passage of blood through the skin, i.e., a percutaneous exposure.

Consequences of HCV infection.  About 15 percent to 25 percent of persons with acute Hepatitis C resolve their infection without further problems. The remainder develop a chronic infection and about 60 percent to 70 percent of these persons develop chronic hepatitis. Cirrhosis of the liver develops in 10 percent to 20 percent of persons with chronic Hepatitis C over a period of 20-30 years, and hepatocellular carcinoma (liver cancer) in 1 percent to 5 percent. For individuals with cirrhosis, however, the rate of development of liver cancer might be as high as 1 percent to 4 percent per year.

Treatment for Hepatitis C. In 1997, an NIH Consensus Development Conference established guidelines for the medical management of Hepatitis C¹ ,which have since been updated to reflect the evolving nature of antiviral therapy. A combination of alpha-interferon and ribavirin currently is the most effective therapy and achieves the sustained elimination of HCV infection for at least 6 months in 30 percent to 40 percent of patients.

At-Risk Populations 
Development and distribution of educational messages for groups of persons at increased risk for infection should include persons transfused prior to July 1992;incarcerated populations; substance abusers including those in treatment and outreach programs; persons at risk for HIV/AIDS and STDs; and persons attending other community health programs.

Recent data indicate that prevalence of HCV infection among incarcerated populations is 3-5 times greater than prevalence in the general population. In addition, messages need to be developed for individuals who may have experimented with injecting drug use only in the distant past, since these persons may not regard themselves as being at risk for infection because they did not become long-term or habitual users.

HCV prevalence among prison inmates is 3-5 times greater than in the general population.

Less than 50 percent of state and local public health laboratories have the capacity to perform HCV testing.

Surveillance and Research

Surveillance. Surveillance is essential to determine the effectiveness of national, state, and local Hepatitis C prevention efforts. However, surveillance for Hepatitis C is complicated by the absence of a laboratory test that can differentiate newly acquired infections from infections acquired in the past. Although acute hepatitis (i.e., clinical illness) is reportable in all states, only a few states conduct surveillance for acute cases of Hepatitis C to monitor disease incidence. However, approximately 30 states have requirements for reporting of HCV positive laboratory tests, most of which represent persons with resolved or chronic HCV infection.

The challenge is how to use laboratory-based reports of HCV to monitor disease trends and the effectiveness of prevention programs.

National trends in new cases of infectious disease are monitored by CDC’s National Notifiable Disease Surveillance System (NNDSS). However, for Hepatitis C, the data reported by states are not reliable because most reports to NNDSS represent persons with chronic or resolved HCV infection and not acute disease. To determine national trends in disease incidence and risk factors for infection, CDC has relied on intensive sentinel surveillance conducted in 6 counties⁴ -- the Sentinel Counties Study of Viral Hepatitis. Until such time that persons with acute HCV infection can be identified either through a single diagnostic test or some combination of tests (e.g., antibody testing and liver enzyme levels), estimates of HCV infection incidence will primarily depend on data from the Sentinel Counties Study.

Epidemiologic and Laboratory Investigations. A number of unanswered questions significantly impact the direction of Hepatitis C prevention and control activities. Priority areas in which studies are underway or in the planning stages include those that determine: 1) incidence and risk factors for HCV transmission among household contacts of infected persons; 2) risk factors for transmission from mother to infant at birth; 3) risk of infection from intranasal cocaine use, tattooing, and body-piercing; 4) prevalence and incidence of infection in incarcerated populations; 5) risk of infection among steady heterosexual partners of HCV-infected persons; 6) risk factors for infection among persons on chronic hemodialysis; 7) risk for infection among persons with occupational exposure to HCV and effectiveness of therapy during acute infection; 8) the dynamics of HCV acquisition among injection drug users and the effectiveness of harm reduction strategies in preventing infection; 9) the frequency and consequences of infection with multiple HCV strains among injection drug users; and 10) development and performance of rapid screening tests for HCV infection.

While prevention of all bloodborne virus infections (HIV, HCV, HBV) is a major goal of the National Hepatitis C Prevention Strategy, there is limited experience with the integration of Hepatitis C and Hepatitis B prevention activities into public health programs for persons at risk for bloodborne viral infections, including incarcerated persons⁷. Demonstration projects to examine the feasibility and operational aspects of integrating Hepatitis C prevention into existing public health and correctional health programs were first funded by CDC in FY 1999, were expanded to include several county and city health departments in FY 2000, and should be further expanded to include state-wide projects.