Hepatitis C virus transmission in the prison/inmate population

HCV is transmitted through contact with blood, blood products, or bodily fluids contaminated with the virus either directly or through an exposed object(8,11-14). The majority of HCV transmission occurs through direct and indirect exposure to infected blood(12). Risk factors associated with HCV in Canada include injection drug use (IDU)(8,11) when drug injection paraphernalia is shared(8,13,15) without adequate sterilization(16); receipt of unscreened blood or blood products(11,13) as a consequence of unproven blood screening practices before 1992(17); vertical and sexual transmission(13) either at birth or from engaging in high risk sexual practices; and parenteral exposure from tattooing, body piercing, or sharing of personal hygiene items contaminated with HCV(13).
Incidence and prevalence in correctional facilities
Worldwide estimates of the prevalence of HCV have been reported to range from between 19.2% and 84.0%(10,15,17-33).
Women are reported to have greater variability than men in the prevalence rate. Studies done in Canada, the United States and Australia, have shown that the prevalence of HCV among females ranges from 25.3% to 67.0%(18,28,30,34), as compared with 4.0% to 39.4% among men(18,28,34). Butler et al. reported that the higher rate among females was the result of a higher concentration of females in prison for drug-related offences(18). Overall, the prevalence of HCV in the Canadian correctional population seems less variable, ranging from 19.2% to 39.8%(19,24-26,29,30,32,33).
A number of studies have reported that the inmate population engages in risk behaviours that place them at greater risk of HCV infection than that observed in the general population. Prevalence data indicate that serving time in prison increases the likelihood that an inmate will become infected with HCV. Many offenders are confined together for long durations, which increases risk exposures(5), and in the United States inmates typically have poorer health than the general population because of poverty, poor access to health care, and high rates of self-abuse outside of prison(35). The types of risk factors identified and described in this review are injection drug use, previous imprisonment, tattooing, and sexual activity.
Injection drug use and sharing drug injection paraphernalia
IDU, improper sterilization and sharing of IDU paraphernalia, and other associated behaviours are often referred to as proxy risk behaviours known to lead to HCV infection in non-infected IDUs(21). The prevalence of inmates reporting injection drug use in Canadian prisons has doubled, from 12.0% in 1995 to 24.0% in 1998(24,31). The increasing numbers of injection drug users being incarcerated and bringing their habits with them into the prison system correlates with an increase in incident cases in prison(24,29,36).
Prospective, longitudinal and cross-sectional studies from Canada, the United States, the United Kingdom, Ireland and Denmark indicate a prison inmate odds ratio of 5.5(21) for IDU and a prevalence of HCV infection ranging between 46.0% and 89.9%(16,19-21,28,29,36,37). Injection drug users, especially males(38), have a much higher risk of becoming infected with HCV, and the risk grows exponentially with each year that they inject drugs(15,17,18,23). Multivariate analysis shows that injection drug users who inject both inside and outside of prison have a higher prevalence of HCV infection than those who inject only inside or outside prison(24,29). One explanation for this is that inmates in prison inject less overall but share needles more frequently(39), since drugs are readily available and injecting apparatus is scarce in the prison system(27). These circumstances favour repeated use of a limited number of syringes by many prisoners(27).
Malliori et al. conducted a cross-sectional study of 544 drug users imprisoned for drug-related offences and found that 39% of IDUs who were aware of their own or a fellow inmate?s positive hepatitis infection status continued to share syringes with fellow inmates; 40% had injected drugs in the previous 30 days(21). Thus, non-infected injection drug users who continue to engage in high-risk behaviours are unknowingly being infected with HCV as a result of fellow inmates not disclosing their hepatitis status.
Drug sniffing and/or snorting is cited as a major risk factor for the acquisition of HCV infection. Cocaine and heroin can cause bleeding in the nose as a result of nasal irritation and trauma to the nasal cavity(37). The blood from the nose can remain on the surface of sniffing and snorting equipment, such as straws or rolled money, which can be passed on to the next person. Individuals who sniff or snort heroin and cocaine at the same time are more likely to be infected with HCV because of the damaging effects of the combination on the delicate nasal mucosal lining(37). Ironically, many individuals sniff or snort drugs in an attempt to avoid acquiring HCV and other infectious viruses through injection. Regardless of the method used, inmates who share equipment contaminated with HCV place themselves and others at risk of HCV infection.
Previous imprisonment
Previous imprisonment has been reported as a risk factor for HCV infection(17,18,21,23,38). The odds of HCV infection increase with increasing frequency of incarceration, increased duration of each imprisonment, and an increase in the time between release and re-incarceration(17,18,21,23,38). In one study, individuals who were incarcerated more than five times were significantly more likely to become HCV positive (odds ratio of 21.7)(21). The chance of HCV positivity gradually increases with each additional month spent in prison(38).
Inmates re-incarcerated < 5 years after their release show an odds ratio of 23 and a positivity value of 76.7% for HCV infection(17). This increased risk is primarily the function of inmates continuing to engage in high-risk injecting practices, such as sharing IDU paraphernalia with a large and homogeneous cohort of inmates.
Tattooing
Various studies have reported an association between tattooing and transmission of HCV in the inmate population whereas others have not(35). In voluntary, cross-sectional seroprevalence studies of over 3000 prison inmates from Canada, the United States and Australia, 18.0% to 93.2% of inmates with tattoos were HCV positive(15,18,19,24,31). In addition, the odds of being infected with HCV increase with multiple tattoos as compared with only single tattoos. One study found that inmates with a single tattoo had an odds ratio of 5.4 with an 11.6% HCV positivity rate, and among those with multiple tattoos the odds ratio was 9.2 with a 16.7% positivity rate(40).
For the most part correctional facilities lack appropriate protocols for the safe administration of tattoos such as proper use of equipment, sterilization facilities(41,42), and licensed tattooists (or trained prisoners)(35). Also, IDUs have a high number of tattoos, which at times are used to cover injection drug use track marks(35). The motivation for tattooing in the prison system is commonly reported by inmates to be boredom(43). These unsafe and unhygienic practices make tattooing a proxy risk behaviour for the sharing of tattoo devices and subsequent HCV infection.
Sexual behaviour
Engaging in high-risk sexual practices is a known risk behaviour associated with the transmission of HCV in the prison/inmate population. High-risk sexual practices associated with HCV infection in this population include a history of sexually transmitted disease (STD); sexual intercourse (SI) with a known past or current IDU; SI with five or more lifetime partners; and, for females, SI during menses(44). Homosexual behaviour is identified as a significant risk behaviour in some studies, but not in others(17,44). Such behaviour may be underreported, given that it is prohibited in prisons and carries a negative stigma(17).
Of all high-risk sexual practices, a history of STD has been found to have the strongest association with HCV infection, presenting an odds ratio of 29.3(44). SI, not considered an inefficient route of transmission of HCV, carries a greater risk if one or more partners are infected with an STD or engage in unsafe sexual practice. HCV transmission presumably requires that both partners have lesions in the skin located in or around the genitalia, permitting the virus to pass from one partner to the other. Such a situation is more likely to be found in individuals with genital infectious diseases(44). When one partner or both engage in IDU, spouses or regular sexual partners of persons with HCV are at greater risk of infection(44). SI during menses places women at significantly greater risk of HCV infection since there is a chance that the endometrium may become a portal for the HCV virus during menstruation(44).
High-risk sexual behaviours are considered to be proxy behaviours, as they may be the identified route of HCV transmission. However, infection generally results indirectly from an individual with a history of IDU and/or sharing drug injection paraphernalia and engaging in sexual practices with other individuals.
Discussion
There is no vaccine to prevent HCV infection (10). Compared with vaccine- preventable diseases, therefore, transmission of HCV is more probable and its effect greater in the prison inmate population. Inmates, especially in the United States, generally suffer from poorer health than the general population because of specific socio-economic factors such as poverty, poor access to health care, and high rates of self-abuse – IDU, alcohol abuse, multiple sexual partners (33) – outside prison (35). Moreover, their prison-related experiences may augment their risk status. When released back into the community ? often to the same high-risk communities as before incarceration (33) ? this group can present a significant risk to the general population if there is no proper follow-up support (27).
IDU in conjunction with sharing of improperly sterilized drug paraphernalia, previous imprisonment, tattooing and high-risk sexual behaviours account for the majority of new infections in prisons. Those who inject drugs and share equipment outside of prison are at the highest risk, and these individuals continue their habits upon incarceration (24,29,31). The risk factors mentioned cannot be interpreted as direct and independent risk behaviours for HCV infection; rather, they are more likely associated with sharing drug injection paraphernalia or constitute a marker for other, undetermined high-risk behaviours (20,21).
Attempts to control drug use in prisons have not been successful, and inmates continue to inject drugs and transmit bloodborne pathogens such as hepatitis C. The availability of sterile injection equipment has been shown to substantially reduce the transmission of bloodborne pathogens in areas where needle exchange programs (NEPs) are used and in selected prison settings(22). Several European prisons are piloting the implementation of NEPs (7,45,46) ? one clean needle and syringe provided in exchange for one used needle and syringe (45). In one particular example, preliminary findings indicate that the use of an NEP in a prison in Switzerland (Hindlebank) contributed significantly to a reduction in the number of new cases of hepatitis, to improved health status of prisoners, and to a decrease in the frequency of needle sharing, although there was no significant reduction in drug consumption (46). Needles were not used as weapons.
The issue of needle exchange is both complex and controversial. Providing sterile needles to inmates is widely recommended as a health measure necessary to reduce the spread of infectious diseases in Canadian prisons (45,46). However, since CSC is concerned about the health of inmates, the security of the institution, and the encouragement of law-abiding behaviour, it does not provide needle exchange services to inmates (47). According to CSC, such a policy would compromise its current zero tolerance policy towards drug use and drug trafficking in prison and would be seen as condoning illegal drug use. In spite of this, CSC currently provides bleach kits for cleaning needles to all inmates of federal institutions(47). Regardless of the correctional system?s acknowledgement of the extent of drug injection practices in its facilities, it is clear that this population lacks resources and education on safer injecting practices in order to prevent the spread of HCV infection.
Globally, preventive measures promoted in the community are not transferable wholesale into the correctional system because prison populations turn over rapidly. This limits the effectiveness of unplanned prevention initiatives(48). Furthermore, many correctional health care practitioners in the United States routinely consider the duration of incarceration in their decision about whether to treat HCV-infected inmates, while Canadian inmates diagnosed with hepatitis C are treated according to the same health care guidelines as are applied to the general population. In some cases, treatment in the US is justified only if an offender will not have access to outside care for an extended period(28) and correctional facilities have set criteria to determine who should be screened and treated(28). This further complicates the implementation of consistent and routine checks for all inmates in this population. These factors contribute to significant barriers in HCV education and treatment within this setting.
Limitations of the review
In correctional facilities the variability in estimated HCV prevalence is partially attributable to inmates who participate in research studies but may not be representative of all inmates. Many inmates decline to participate in studies or provide blood samples because they claim not to have engaged in any high-risk behaviours(26). These two factors result in low generalizability and underreporting of risk behaviours affecting prevalence statistics in correctional facilities worldwide. As well, inmates who do participate can be reluctant to give data regarding risk behaviours, the majority of which constitute institutional offences(17,32).
The literature reviewed is often plagued with inadequate collection of inmate behavioural characteristics or an incomplete depiction of past history and lifestyle behaviours known to contribute to HCV status. Therefore, it is unclear whether study findings are confounded by other high-risk behaviours inside or outside prison that the researchers fail to consider in their study design.
Many research studies confirm and support past findings on the risk behaviours that prison inmates typically engage in. Independent risk factors and behaviours are difficult to pinpoint since the majority of studies focus on a cluster of known risk behaviours. Research studies lack more in-depth details regarding the motivations behind risk behaviours, which could aid in more effective planning and implementation of preventive measures.

Conclusion
Correctional facilities are not isolated communities. The inmate population engages in a wide variety of high-risk behaviours before incarceration, and many continue to engage in two or more such behaviours while in prison. Unfortunately, the interventions that may be effective in the community are not having the greatest potential effect in prisons because of the high turnover rate in these facilities. Future research should aim to identify the motivations of the prison population in engaging in high-risk conduct rather than elucidating specific behaviours and factors. This approach could help develop more tailored and effective prevention and intervention initiatives aimed at reducing the spread of bloodborne disease both within prisons and in the outside community once prisoners have been released.
References
1. Correctional Service of Canada. The national drug strategy for the Correctional Service of Canada. Forum on Corrections Research 2001;13(3):5-6.
2. Statistics Canada. A graphical overview of crime and the administration of criminal justice in Canada. 1997.
3. Correctional Service of Canada. Infectious diseases and control in Canadian federal penitentiaries 2000-2001. 2003.
4. Correctional Service of Canada. Backgrounders: The government's balanced approach. 2003.
5. Correctional Service of Canada. Just punishment? HIV infection and AIDS in correctional facilities. Enhancing Community Corrections 1994;6(3):1-5.
6. Correctional Service of Canada. Substance abuse program. 2003.
7. Sibbald B. Methadone maintenance expands inside federal prisons. CMAJ 2002; 167(10):1154-1157.
8. Zou S, Forrester L, Giulivi A. Hepatitis C update. Can J Public Health 2003;94(2):127-29.
9. Remis R, Hogg R, KrahnMD, et al. Estimating the number of blood transfusion recipients infected by hepatitis C virus in Canada, 1960-85 and 1990-92. Report to Health Canada. June 1998.
10. Centers for Disease Control and Prevention. Hepatitis C fact sheet. URL: <http://www.cdc.gov/hepatitis>.
11. Zou S, Tepper M, Giulivi A. Hepatitis C in Canada. Can Commun Dis Rep 2001;27S3 <http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/01vol27/27s3/27s3f_e.html>
12. Memon MI, Memon MA. Hepatitis C: An epidemiological review. Can Commun Dis Rep 2002;9:84-100.
13. Zou S, Tepper M, Giulivi A. Current status of hepatitis C in Canada. Can J Public Health 2000;91(suppl 1):S10-S15.
14. Lino S. Natural history of hepatitis B and C virus infections. Oncology 2002;62(suppl 1):18-23.
15. Samuel MC, Doherty PM, Bulterys M, et al. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect 2001;127:475-484.
16. McBride AJ, Ali IM, Cleee W. Hepatitis C and injecting drug use in prisons. BMJ 1994;309(6958):876b-877b.
17. Pallas J, Farinas-Alvarez C, Prieto D, et al. Risk factors for monoinfections and coinfections with HIV, hepatitis B and hepatitis C viruses in northern Spanish prisoners. Epidemiol Infect 1999;123:95-102.
18. Butler T, Spencer J, Cui J et al. Seroprevalence of markers for hepatitis B, C and G in male and female prisoners – NSW, 1996. Aust N Z J Public Health 1999;23(4):377-85.
19. Prefontaine RG, Chaudhary RK, Mathias RG. Analysis of risk factors associated with hepatitis B and C infection in correctional institutions in British Columbia. Can J Infect Dis 1994;5(4):153-156.
20. Long J, Allwright S, Barry J, et al. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in entrants to Irish prisons: A national cross sectional survey. BMJ 2001;323(7323): 1209-1222.
21. Malliori M, Sypsa V, Psichogiou M, et al. A survey of bloodborne viruses and associated risk behaviors in Greek prisons. Addiction 1998;93(2):243-251.
22. Stark K, Bienzle U, Vonk R, et al. History of syringe sharing in prison and risk of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus infection among injecting drug users in Berlin. Int J Epidemiol 1997;26(6):1359-1366.
23. Butler TG, Dolan KA, Ferson MJ, et al. Hepatitis B and C in New South Wales prisons: Prevalence and risk factors. MJA 1997;166:127-134.
24. Ford PM. HIV/AIDS in prisons. Can HIV AIDS Policy Law Rev 1999;4(2/3)
25. Ford PM. Seroprevalence of hepatitis C in a Canadian federal penitentiary for women. Can Commun Dis Rep 1995;21(14):F3-F4.
26. Pearson M. Voluntary screening for hepatitis C in a Canadian federal penitentiary for men. Can Commun Dis Rep 1995;21(14):F4-F5.
27. Haber PS, Parsons SJ, Harper SE, et al. Transmission of hepatitis C within Australian prisons. MJA 1999;171:31-33.
28. Spaulding A. Hepatitis C in state correctional facilities. Prev Med 1999;28:92-100.
29. Ford PM, Pearson M, Sankar-Mistry P, et al. HIV, hepatitis C and risk behavior in a Canadian medium-security federal penitentiary. Q J Med 2000;93:113-119.
30. Correctional Service of Canada. The management of hepatitis C in federal penitentiaries. 2001.
31. Ford PM. Report of Joyceville/Pittsburgh study of HIV and hepatitis C seroprevalence. Correctional Service of Canada 2000.
32. Ford PM,White C, Kaufmann H, et al. Voluntary anonymous linked study of the prevalence of HIV infection and hepatitis C among inmates in a Canadian federal penitentiary for women. CanMed Assoc J 1995;153(11):1605-1609.
33. Reindollar RW. Hepatitis C and the correctional population. Am J Med 1999;107(6B):100S-103S.
34. Ruiza JD, Molitorb F, Plagenhoefc JA. Trends in hepatitis C and HIV infection among inmates entering prisons in California, 1994 versus 1999. AIDS 2002;16(16):2236-2238.
35. Long GE, Rickman LS. Infectious complications of tattoos. Clin Infect Dis 1994;18:610-619.
36. Gore SM, Bird AG, Cameron SO, et al. Prevalence of hepatitis C in prisons: WASH-C surveillance linked to self-reported risk behaviors. Q J Med 1999;92:25-32.
37. Waldron T. Sniffing, snorting drugs may raise hepatitis C risk. Medline Plus Health Information. 2003.
38. Gore SM, 38. Allwright S, Bradley F, Long J, et al. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: Results of a national cross sectional survey. BMJ 2000;321(7253):78-100.
39. Christensen PB, Krarup HB, Niesters HGM et al. Prevalence and incidence of bloodborne viral infections among Danish prisoners. Eur J Epidemiol 2000;16:1043-1049.
40. Ko YC, Ho MS, Chiang TA, et al. Tattooing as a risk of hepatitis C virus infection. J Med Virol 1992;38:288-291.
41. Tsang THF, Horowitz E, Vugia DJ, et al. Transmission of hepatitis C through tattooing in a United States prison. AJG 2001;96(4):1304-1305.
42. Post JJ, Dolan KA, Whybin LR, et coll. Acute hepatitis C virus infection in an Australian prison inmate: Tattooing as a possible transmission route. MJA 2001;174:183-184.
43. Crofts N, Thompson S, Wale E, et coll. Risk behaviors for blood-borne viruses in a Victorian prison. Aust N Z J Criminol 1996;29:20-28.
44. Balasekaran R, Bulterys M, Mazen Jamal M, et coll. A case-control study of risk factors for sporadic hepatitis C virus infection in the southwestern United States. Am J Gastroenterol 1999;94(5):1341-1346.
45. Jurgens R. Update on needle and syringe exchange in Swiss prison. CanHIV AIDS Policy Law Newsl 1995;1(4).
46. Jurgens R. Needle exchanges in prisons: An overview. Can HIV AIDS Policy Law Newsl 1996;2(4).
47. Service correctionnel du Canada. Correction service of Canada releases results of inmate survey at Joyceville institution near Kingston, Ontario. 2003.
48. Gill O, Noone A, Heptonstall J. Imprisonment, injecting drug use, and bloodborne viruses. BMJ 1995;10(6975):275-276.
Source: S Skoretz, BSc, University of Guelph; G Zaniewski, MHSc, NJ Goedhuis, BSc, Blood Safety Surveillance & Health Care Acquired Infections Division, Centre for Infectious Disease Prevention and Control, Health Canada.