A prevalence survey to assess the HBV infection status of prisoners on entry
was conducted at three Georgia prison intake centers for males and one intake
center for females during February--March 2003. Consenting inmates underwent
HBV serologic testing; all inmates at intake when the survey was conducted were
offered hepatitis B vaccine.

During January 1999--June 2002, a total of 92 cases of acute HBV infection
were identified, of which 57 (62%) were reported during January 2001--June 2002
and included in the retrospective investigation (Figure). Among the 57 inmates
with HBV infection, the median age was 34 years (range: 18--59 years); 52
(91%) were male, and 35 (61%) were non-Hispanic blacks. Ten (18%) had symptoms that included jaundice, abdominal pain, fever, and vomiting. Seven (12%)
subsequently were determined to have chronic infections. The chronic infection status of four inmates was not assessed.


Among the 57 inmates included in the retrospective investigation, the most
frequently reported reason for HBV testing was the presence of symptoms or
elevated liver enzymes (21 cases [37%]). Other reasons included reported
characteristics and behaviors that might be associated with HBV transmission (e.g.,
tattoos or unprotected sex contacts) (14 [24%]), serologic testing performed as
part of initial medical evaluation (13 [23%]), and being positive for human
immunodeficiency virus (five [9%]). Prison staff reported counseling and providing
medical follow-up for 52 (91%) of the 57 inmates.

The 57 cases were reported from 27 prisons and four probation detention
centers in Georgia, with a mean of 1.8 cases per facility and a range of one to
three cases for the 30 facilities that were not involved in the previously
recognized outbreaks (2,3). The 57 inmates had been incarcerated for a median of 2.2 years (range: 0--23.7 years) before illness onset and had been transferred
1.4 times on average (median: one time; range: one to seven times) during the 12
months before diagnosis. The majority of HBV infections (41 [72%]) were
acquired in prison. Of the remaining 16 cases, 13 (81%) occurred in persons who had been in prison or jail for 1--6 months before receiving a diagnosis. The
remaining three (19%) inmates were asymptomatic and had been in prison or jail for
10--11 months before receiving a diagnosis.

As of August 2002, the seven inmates who had chronic infections had been
transferred among prison facilities 13 times during the cumulative 89 months of
incarceration that followed their diagnosis, resulting in a mean of 1.8
transfers per person-year of incarceration (median: two transfers; range: zero to five transfers). Three inmates with chronic infection were released from prison.

Of 546 inmates surveyed at intake during February--March 2003, a total of 489
(90%) consented to serologic testing, and 428 (78%) consented to hepatitis B
vaccination. Of the 489 inmates tested, three (0.6%) had acute HBV infections,
four (0.8%) had chronic infections, 64 (13%) had evidence of resolved
infections, and 374 (76%) were susceptible to HBV infection. Two of three inmates
with acute infection had spent 5.5--11.0 months in jail before intake.

Reported by: K Arnold, MD, Georgia Dept of Human Resources, Div of Public
Health; M LaMarre, MN, J Taussig, MPH, Georgia Dept of Corrections. BP Bell, MD,
L Farrington, MS, Div of Viral Hepatitis, National Center for Infectious
Diseases; S Vong, MD, PR Patel, MD, EIS officers, CDC.

 

Editorial Note:

HBV is a bloodborne pathogen, transmitted by percutaneous or permucosal
exposure to infectious blood or body fluids. The prevalence of chronic infection is
higher among prison inmates (1.0%--3.7%) than among the general U.S.
population (0.5%) (1), reflecting an overrepresentation of persons entering prison who are at high risk for HBV infection (e.g., injection-drug users and those with
reported histories of multiple sex partners). The prevalence of chronic
infection among the intake population in this report (0.8%) suggests that high-risk
behaviors practiced within the community before incarceration might not
account entirely for the burden of HBV infection in correctional facilities.
Although studies are limited, transmission of HBV infection within correctional
settings has been documented, with incidence ranging from 0.8% to 3.8% per year
(2,4--6).

The retrospective investigation described in this report identified an
increase in HBV infections in Georgia correctional facilities, beginning in January
2001. This increase likely was related to multiple factors, including enhanced
surveillance and increased diagnostic testing by correctional medical staff.
Changes in diagnostic practices might have occurred because of increased
awareness of hepatitis B among medical staff after outbreaks at a Georgia
correctional facility in June 2000 and again in June 2001. Nonetheless, the number of reported cases probably underestimates the extent of HBV transmission in the
correctional system because the majority of persons with acute HBV infection are
asymptomatic and investigations of single cases are not conducted routinely.
In the first previous outbreak, one symptomatic patient reported to DPH was
associated with a cluster of 11 acute cases, and four chronic HBV infections
were identified (2).

The majority of inmates with identified acute HBV infections were housed in
multiple Georgia correctional facilities and were infected during their
incarceration, suggesting widespread ongoing transmission in multiple facilities.
Inmates infected with HBV were transferred frequently among facilities. Thus,
potential sources of HBV transmission were distributed throughout the prison
system.

In the Georgia correctional system, approximately one third of inmates are
released each year (7). Inmates who become chronically infected and subsequently
are released represent potential sources of infection for others in the
community. In addition, susceptible inmates who are released continue to be at
increased risk for HBV infection (1). The majority of inmates in the intake survey
were susceptible to HBV infection and consented to vaccination, suggesting
that vaccination efforts in correctional facilities might effectively capture
susceptible, high-risk populations.

Although data are lacking regarding the overall burden of HBV infection in
correctional systems, the ongoing transmission demonstrated in Georgia prisons
might be occurring in other states, where similar conditions are likely to
exist. All inmates who receive a medical evaluation should be vaccinated to
prevent HBV infection (1). However, the majority of state correctional systems in
the United States, including the Georgia system, do not have hepatitis B
vaccination programs (1). Implementation of such programs in correctional settings
nationwide could result in a considerable reduction in the hepatitis
B--associated disease burden, not only by eliminating transmission among the incarcerated population, but also by reducing transmission in the community (8).


References

1. CDC. Prevention and control of infections with hepatitis viruses in
correctional settings. MMWR 2003;52(No. RR-1).
2. Khan A, Simard E, Wurtzel H, et al. The prevalence, risk factors, and
incidence of hepatitis B virus infection among inmates in a state correctional
facility [Abstract]. In: Program and abstracts of the 130th Annual Meeting of
the American Public Health Association, Philadelphia, Pennsylvania, 2002.
3. CDC. Hepatitis B outbreak in a state correctional facility, 2000. MMWR
2001;50:529--32.
4. Decker MD, Vaughn WK, Brodie JS, Hutcheson RH Jr, Schaffner W.
Seroepidemiology of hepatitis B in Tennessee prisoners. J Infect Dis 1984;150:450--9.
5. Hull HF, Lyons LH, Mann JM, Hadler SC, Steece R, Skeels MR. Incidence
of hepatitis B in the penitentiary of New Mexico. Am J Public Health
1985;75:1213--4.
6. Macalino GE, Vlahov D, Sanford-Colby S, et al. Prevalence and incidence
of HIV, hepatitis B virus, and hepatitis C virus infections among males in
Rhode Island prisons. Am J Public Health 2004;94:1218--23.
7. Georgia Department of Corrections. Annual report 2001.
8. Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors
for acute hepatitis B in the United States, 1982--1998: implications for
vaccination programs. J Infect Dis 2002;185:713--9.

TEXT FROM SECOND ARTICLE

Hepatitis B Vaccination of Inmates in Correctional Facilities ---Texas,
2000--2002

In December 2002, approximately 2.2 million persons were incarcerated in the
United States (1); an estimated 8 million were released to the community that
year (2). In 2001, approximately 22,000 acute hepatitis B cases and 78,000 new
hepatitis B virus (HBV) infections occurred in the United States (3); an
estimated 29% of these cases were in persons who had been incarcerated previously (4). The majority of HBV infections among incarcerated persons are acquired in the community; however, infection also is transmitted within correctional settings (2). Hepatitis B vaccination of incarcerated persons is recommended to prevent transmission in correctional facilities and in previously incarcerated persons on their return to the community (2). In May 2000, the Texas
Department of Criminal Justice (TDCJ), which oversees custody of state jail and prison inmates, implemented a hepatitis B vaccination program. To determine hepatitis B vaccination rates of inmates during 2000--2002, TDCJ reviewed charts of inmates released during a 3-day period for documentation of vaccination. This report summarizes the results of that study, which indicated that rates of vaccine acceptance and vaccine series completion among inmates were high.
Establishing hepatitis B vaccination programs in prisons and jails can prevent a
substantial proportion of HBV infections among adults in the outside community.

During 2000--2002, TDCJ housed approximately 151,000 inmates in 105 adult
facilities, including prisons (median sentence of inmates: 9 years; range: 2--99
years) and jails (median sentence of inmates: 1.3 years; range: 3 months--2
years). Approximately 40,000 new offenders enter these facilities annually, and
an estimated 1% of inmates are transferred between facilities daily (5,6). In
1999, state funds were appropriated for hepatitis B vaccination of all inmates
in jails and prisons.

Before implementation of the vaccination program, a cost-effectiveness model
was developed that estimated the cost effectiveness of prevaccination testing
for immunity to HBV infection among inmates. Stored serum specimens from 889
inmates incarcerated during 1998--1999 were tested for antibodies to hepatitis
B core antigen (anti-HBc); HBV prevalence was 18%. The model estimated that at
a threshold prevalence of 25%, the cost of a program with prevaccination
testing was equivalent to that of vaccination without testing; at lower
prevalence, prevaccination testing would not be cost effective (Figure). On the basis of these findings, all of the estimated 40,000 entering inmates were offered
vaccine without prevaccination testing.

Entering inmates were offered the first hepatitis B vaccine dose at the time
of admission. Persons who were already incarcerated were offered the first
dose at the time of their annual health evaluation, which occurred on their
anniversary month of incarceration. After vaccination of incarcerated persons, only
newly admitted inmates were offered vaccine.

Vaccine was administered on a 0-, 2-, and 4-month schedule. An electronic
pharmacy auto-renewal system was used to send second and third vaccine doses to the appropriate facility for each inmate. Health-care workers also recorded
vaccine dose administration in each inmate's medical record, enabling inmates to
complete the vaccination series despite frequent transfers within the system.

In February 2002, TDCJ evaluated vaccine acceptance and series completion
rates. Charts of 232 prison inmates and 211 jail inmates released during a 3-day
period were audited for receipt of hepatitis B vaccine; 426 (96%) inmates with
no record of previous vaccination or HBV infection were considered to be
eligible for vaccination. Lack of documentation of a vaccination encounter was
interpreted as a failure to offer vaccine, and only a signed informed refusal
form was counted as a vaccination refusal.

Hepatitis B vaccine was offered to 319 (75%) of 426 inmates. Prison inmates
were more likely to be offered vaccine (185/220 [84%]) than jail inmates
(134/206 [65%]) (p<0.001), which might be related to higher inmate turnover and lack of staff contact time in jails. However, acceptance of the first vaccine dose
was higher among jail inmates (114/134 [85%]) than among prison inmates
(134/185 [72%]) (p = 0.005).

Among 125 prison and 99 jail inmates who began vaccination and were
incarcerated for >4 months, the 3-dose completion rate was 96% and 54%, respectively. In December 2002, the hepatitis B vaccination program was suspended because of a lack of funds.

Reported by: M Kelley, MD, L Linthicum, MD, Texas Dept of Criminal Justice. A
Spaulding, MD, K Billah, PhD, C Weinbaum, MD, Div of Viral Hepatitis,
National Center for Infectious Diseases; R Small, Div of STD Prevention, National
Center for HIV, STD, and TB Prevention, CDC.


Editorial Note:

Evaluation of the TDCJ hepatitis B vaccination program demonstrated that high
vaccine coverage could be achieved for inmates in a state correctional
system. Incarceration provides an opportunity to vaccinate persons at high risk
typically not served by prevention services in the public or private sectors, and
vaccination of incarcerated populations is cost effective (7).

The findings in this report illustrate the need to tailor a program to a
particular facility. Completion of the vaccine series is a more feasible goal for
long-term facilities; short-term facilities should initiate the vaccine
series, supply an immunization record and, where feasible, provide information at
discharge about facilities offering the remaining vaccine doses. Vaccination
also can be completed if the person returns to a correctional institution.

Prevaccination testing to detect existing immunity can eliminate the cost of
revaccinating persons who were vaccinated previously or infected. TDCJ's
decision not to perform prevaccination testing was based on a model that included
the costs of testing and vaccination and the series completion rate. The model
assumed that all inmates who received the first vaccine dose would return for
subsequent doses; if attrition caused by release was included in the model,
prevaccination testing would only be cost effective if the prevalence of
immunity was higher. Changes in prevalence of immunity to HBV infection or costs
(e.g., vaccine, labor, and testing) also would change the cost effectiveness of
prevaccination testing. In particular, immunity to HBV infection in young adults
is changing rapidly within most communities because of an increase in
vaccinated adolescents. If adequate immunization records are not available for
inmates, periodic monitoring of the prevalence of immunity to HBV infection using a
serologic marker to detect both infection (i.e., anti-HBc) and immunization
(i.e., antibodies to hepatitis B surface antigen) will help corrections
officials determine when prevaccination testing might reduce costs (2).

The findings in this report are subject to at least two limitations. First,
inmates with shorter sentences are more likely to be discharged and might be
overrepresented by the sampling. Because inmates with short sentences might not
have been incarcerated long enough to complete the vaccination series, more
inmates might have completed the vaccination series than this study
demonstrated. Second, lack of long-term follow-up precludes evaluation of the eventual series completion by jail inmates, who might have accessed additional doses outside the correctional system or during subsequent incarcerations.

Hepatitis B vaccination of inmates in state correctional facilities is
feasible if resources are available to purchase and administer vaccine. In 2000, a
survey of state correctional facility medical directors indicated that the
majority of prison systems would vaccinate inmates if resources were available
(8). Although hepatitis B vaccination of inmates has been recommended since the
vaccine first became available in 1982 (9), only five states (Hawaii, Michigan,
New Mexico, Vermont, and Wisconsin) vaccinate inmates routinely (D. Burnett,
M.D., Wisconsin Department of Corrections and F. Pullara, M.D., New Mexico
Department of Corrections, personal communications, 2004) (8). Collaborations
between public health and corrections authorities at the state and local level
are essential to overcome barriers to vaccination program implementation.


References

1. Harrison PM, Beck AJ. Prisoners in 2002. Washington, DC: U.S.
Department of Justice, 2003; bulletin no. 200248. Available at
http://www.ojp.usdoj.gov/bjs/pub/pdf/p02.pdf.
2. CDC. Disease burden from hepatitis A, B, and C in the United States.
Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2002.
Available at http://www.cdc.gov/ncidod/diseases/hepatitis/resource/dz_burden02.htm.
3. Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors
for acute hepatitis B in the United States, 1982--1998: implications for
vaccination programs. J Infect Dis 2002;185:713--9.
4. CDC. Prevention and control of infections with hepatitis viruses in
correctional settings. MMWR 2003;52(No. RR-1).
5. Texas Department of Criminal Justice. Statistical report fiscal year
2002.
6. Texas Department of Criminal Justice. Statistical report fiscal year
2000.
7. Pisu M, Meltzer MI, Lyerla R. Cost-effectiveness of hepatitis B
vaccination of prison inmates. Vaccine 2002;21:312--21.
8. Charuvastra A, Stein J, Schwartzapfel B, et al. Hepatitis B vaccination
practices in state and federal prisons. Public Health Rep 2001;116:203--9.
9. CDC. Hepatitis B virus: a comprehensive strategy for eliminating
transmission in the United States through universal childhood
vaccination---recommendations of the Immunization Practices Advisory Committee. MMWR 1991;40(No.
RR-13).