Prisons and infectious diseases - time for a robust response

27 November 2001

PAPERS

Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk

factors in entrants to Irish prisons: a national cross sectional survey •

Commentary: efficient research gives direction on prisoners' and the

wider public healthexcept in England and Wales

Jean Long, Shane Allwright, Joseph Barry, Sheilagh Reaper Reynolds,

Lelia Thornton, Fiona Bradley, John V Parry, and Sheila M Bird

BMJ 2001; 323: 1209

Prisons and infectious diseases - time for a robust response

Oscar Simooya, Nawa sanjobo   (27 November 2001)

Tattooing and hepatitis C infection

Tweg Abraham   (28 November 2001)

Failure to control for duration of injecting causes results to be misleading

Bobby Smyth   (11 December 2001)

High prevalence of viral and other sexually transmitted diseases in Indian prisons

Sarman Singh   (19 December 2001)

Web versus printed version of BMJ papers

Jean Long, Shane Allwright, Joseph Barry, Lelia Thornton, Sheilagh Reaper Reynolds, Fiona Barry, John Parry

(8 January 2002)

Oscar Simooya,

University Medical

Officer: Senior Clinical

Oficer

Copperbelt University,

P O Box 21692, Kitwe,

Zambia,

Nawa sanjobo

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Re: Prisons and infectious

diseases - time for a robust

response

Email Oscar Simooya, et al.:

cbumed@zamnet.zm

The study reported by Long et al(1),is yet another reminder to us all, that prison health

is still a poor cousin of public health outside jail. In particular, the response to the

threat of blood borne diseases in prisons throughout the world has been slow and at

times largely ineffectual.

We have recently concluded a survey of HIV seroprevalance and risk behaviours in

Zambian prisons (2) and found an HIV seroprevalance rate of 27%(421/1566

inmates). This finding is much higher than the national average of 19% but is

comparable to the high HIV rates of up to 32% in the large cities. The main risk factor

identified for HIV positive inmates was a past history of an STI.

Although we did not find a link between male to male sex (MSM)and HIV result, we

believe there are some inmates who may be getting infected inside. Only 3.8% of

inmates agreed to having MSM relationships in one to one interviews but indirect

questioning suggested much larger numbers of men having sex with other men. No

condoms were available in all prisons.

We did not test our samples for antibodies to hepatitis B and C, but we found that

17.4% of inmates had been tattoed in prison while 63.4% of prisoners reported

sharing razor blades. The possibility of blood borne infections in this situation can not

be ruled out. We therefore plan to screen our samples for both hepatitis B and C in

the next phase of our study.

However, and unlike in Irish prisons, only 4(0.2%)inmates reported injecting drugs

and this may therefore be a minor risk behaviour for transmission of blood borne

infections in Zambian prisons.

The main thrust of current efforts to prevent HIV transmission in Zambian jails is still

intensive health education (3). Condoms are not distributed and conjugal visits are not

yet permitted. We believe that health education alone may not be sufficient to stop the

spread of HIV and propose that more robust and bold policies be considered

including the use of non custodial sentences for first entrants and juvenile offenders. At

a time when HAART has become fashionable it is sad that in prisons, the HIV/AIDS

debate is still in the late 1980s.

1. Long J, Allwright S, Barry J, Reynolds SR, Thornton L, Bradley J, Parry JV.

Prevalance of antibodies to hapatitis B, hapatitis C, and HIV and risk factors in

entrants to Irish prisons: a national cross sectional survey. BMJ 2001;

323(7323):1209

2. Simooya OO, Sanjobo N, Kaetano L, Sijumbila G, Munkonze F, Tailoka F,

Musonda R. AIDS 2001;15(13):1741-1744

3. Simooya O0, Sanjobo N. Culture Health & Sexuality 2001;3(2):214 -251

Competing interests: We are both interested in prison health and have conducted

research in Zambian prisons.

Tattooing and hepatitis C infection

28 November 2001

Tweg Abraham,

Director Personel

andOccupational

Medicine Clinic

Tel- Aviv Sourasky

Medical Center, Israel

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Re: Tattooing and hepatitis

C infection

Email Tweg Abraham:

tweig_a@tasmc.health.gov.il

Tattooing is an independent risk factor for hepatitis C infection not just in prisoners. In

the general population, at least in the U.S, tattooing in commercial tatto parlos may

have been resposible for more hepatitis C infections than injecting-drug use(1).

1.Haley RW, Fischer P.Commercial tattooing as apotentially important source of

hepatitis C infection.Medicine 2001;80:134-151.

Competing interests:none

Sincerely

Dr. Tweg Abraham

Failure to control for duration of injecting causes results to be

misleading

11 December 2001

Bobby Smyth,

Specialist registrar in

child psychiatry

Seymour House, 41-43

Seymour St., Liverpool,

L3 5TE

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Re: Failure to control for

duration of injecting causes

results to be misleading

Email Bobby Smyth:

bobbypsmyth@hotmail.com

Editor - The provision of harm reduction in the prison setting remains a contentious

political and scientific issue. Long et al, in their cross sectional survey of Irish

prisoners, have provided further data which will certainly add to this debate(1). The

Irish prison services are to be applauded for their proactive stance against hepatitis B

infection through their vaccination program.

Long’s study also reports that testing positive for hepatitis C was significantly

associated with having previously spent a greater length of time in prison. This finding

emerged from a multivariate analysis, suggesting that it is an ‘independent’ association.

Although the authors acknowledge the limitations of the study design, they do seem to

suggest that unsafe injecting practices in prisons are responsible for the elevated rates

of infection among recidivist prisoners. Interestingly, the reported rates of needle

sharing and hepatitis C are no higher than rates found among Irish injecting drug users

recruited from therapeutic settings(2,3). There is a burgeoning literature on hepatitis C

infection among injecting drug users which demonstrates that the most consistent

predictor of infection is the duration of the injecting history(2,4). Unfortunately, the

multivariate analysis conducted in this study made no attempt to control for the

duration of the injecting history, despite that fact that this data was available to the

authors. Injecting drug users commit acquisitive crime in order to fund their drug

misuse, and therefore find themselves in prison frequently. It seems likely that the

length of time that they have spent in prison will correlate quite closely to the duration

of their injecting history. Consequently, the detected association between

imprisonment and hepatitis C may simply result from the fact that the former is a proxy

measure for duration of injecting.

This study had the opportunity to examine for higher rates of hepatitis C among

injecting drug users with longer prison histories, while controlling for the number of

years of injecting. If this had been demonstrated, it could then, and only then, be

vigorously argued that prison was genuinely an independent risk factor for hepatitis C.

Why the authors failed to examine this issue is unclear. Despite my belief in value of

needle exchanges in the community, this study fails to provide solid evidence to

support proposals for such provision in prisons. There are opposing and unexplained

findings such as the large proportion of injectors who cease injecting while

imprisoned(4) and the detection of a reduced incidence of hepatitis C among injectors

imprisoned for longer periods(5).

Competing Interests - Nil.

1 Long J, Allwright S, Barry J, Reaper Reynolds S, Thornton L, Bradley F 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: 1209-13.

2 Smyth BP, Keenan E, O’Connor JJ. Bloodborne viral infection in Irish injecting

drug users. Addiction 1998; 93: 1649-56.

3 Smyth BP, Barry J, Keenan E. Syringe borrowing persists in Dublin despite harm

reduction interventions. Addiction 2001; 96: 717-727.

4 Stark K, Bienzle U, Vonk R, Guggenmoos-Holzmann I. 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:

1359-65.

5 Crofts N, Stewart T, Hearne P, Ping XY, Breschkin AM, Locarnini SA. Spread of

bloodborne viruses among Australian prison entrants. BMJ 1995; 310: 285-288.

High prevalence of viral and other sexually transmitted diseases in

Indian prisons

19 December 2001

Sarman Singh,

Additional Professor &

Head of Clinical

Microbiology

All India Institute of

Medical Sciences, New

Delhi-110029 (India)

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Re: High prevalence of viral

and other sexually

transmitted diseases in

Indian prisons

Email Sarman Singh:

ssingh56@hotmail.com

High prevalence of viral and other sexually transmitted diseases in Indian prisons

I read with great interest a recently published article in the esteemed BMJ (24

November, 2001), on Prevalence of antibodies to hepatitis B, hepatitis C, and HIV

and risk factors in entrants to Irish prisons: a national cross sectional survey by Long J,

et al. 1 The authors have found prevalence of anti-HBc antibodies in 6%, anti-Hepatitis C Virus in

22% and anti- HIV in 2% Irish prisoners. They a conclude that use of injecting drugs

could be single most important factor for high hepatitis C virus infection in Irish

prisons. They suggest need for increased infection control and harm reduction

measures in Irish prisons. I fully agree with the authors on their recommendations.

However, the authors fail to acknowledge the similar reports published from around

the world and particularly from the countries where HIV infection is highly epidemic.

I myself and my colleagues for the first time from Indian sub- continent conducted a

study in 1998 on Indian prisoners.2 In the study 240 male and nine female jail inmates

confined in a district jail near Delhi were screened for sexually transmitted and blood

borne diseases including HIV, syphilis and hepatitis B & C viral infections. The

inmates aged 15-50 years with a mean of 24.8 yr. + 0.11. Out of the 240 males, 115

were married and 125 unmarried. 184 (76.6%) males gave history of penetrative sex.

Of the 184, 53 (28.8%) were homo-or bisexuals and 131 (71.2%) had sex with

women only. Sixty of 131 (45.8%) were faithful to their partners while 124 gave a

history of having multiple sexual partners and 100 of them (80.6%) had unprotected

sex. 83 of these 100 also had had sex with commercial sex workers (CSW). One

hundred twenty six were addicted for alcohol, 44 for smack/charas and only 8 had a

history of intravenous drug abuse. On examination 28 of the 240 (11.6%) had active

hepatitis with or without history of jaundice in last two years, 25 (10.4%) active

pulmonary TB and 11 (4.6%) had syphilitic ulcers on the penis. Four fifth of the

teenagers confined to a particular barrack had moderate to severe scabies. Three

males (1.3%) were found to be western blot confirmed HIV-1 positive while 28

(11.1%) men & 2 (22.2%) women were positive for HBsAg. Twelve (5.0%) males

but no women, were found to be positive for anti-Hepatitis C Virus antibodies. Out of the three

HIV positive persons, one was a IVD user, second was a drug addict and frequent

CSW visitor while the third was a homosexual.

This study gave clear indications that sexually transmitted and blood borne infections

are highly prevalent in jail premises and pose a threat of rapid spread of these

infections through IVD use and homosexuality. Interestingly our study differed from

Long’s findings that we had more Hepatitis B infection than the Hepatitis C infection.

Also in our study intravenous use was less frequent as compared to Irish prisons and

homosexuality was probably the most important risk factor in Indian prisons. The

study emphasized on more awareness about HIV and hepatitis virus infection in Indian

prisons.

Sincerely,

Sarman Singh, MD

Head,

Clinical Microbiology Division, All India Institute of Medical Sciences, New

Delhi-110029 (India)

Email: ssingh56@hotmail.com

1. Long J, Allwright S, Barry J, Reynolds SR, Thornton L, Bradley F, Parry JV. BMJ

2001;323:1209 ( 24 November )

2. Singh S, Prasad R, Mohanty A. High prevalence of Sexually transmitted and blood

borne infections amongst the inmates of a District Jail in North India. Int J STD AIDS

1999 ; 10 (7) : 475-78.

Web versus printed version of BMJ papers

8 January 2002

Jean Long,

Lecturer in international

health

Department of

Community Health &

General Practice, TCD,

AMNCH, Tallaght,

Dublin 24, Rep. of

Ireland,

Shane Allwright, Joseph

Barry, Lelia Thornton,

Sheilagh Reaper

Reynolds, Fiona Barry,

John Parry

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Re: Web versus printed

version of BMJ papers

Email Jean Long, et al.:

jelong@tcd.ie

Editor - We were happy to have our recent paper (1) published in the new dual

format of short printed paper with full web version. However we would like to point

out that this can create difficulties for readers who may read the paper version only

and miss essential explanatory details.

This would seem to have been the case with Dr B. Smyth. He takes us to task

(electronic response for Long et al - Failure to control for duration of injecting causes

results to be misleading) for ascribing 'independent' association status to length of time

in prison without controlling for time since first injecting. In fact, as the web version

makes clear, in the injector group we did control for both time since first injecting and

length of time in prison. Time since first injecting was not significant and length of time

in prison remained significant. This was not clear from the paper version, but it is clear

in table 3 (see also table 3 footnotes) of the full text version on the BMJ website.

May we suggest that in future the BMJ recommend that readers wishing to comment

on journal articles read the full text versions on the website?

Yours sincerely,

Jean Long

Shane Allwright

Joe Barry

Lelia Thornton

1 Long J, Allwright S, Barry J, Reaper Reynolds S, Thornton L, Bradley F, 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: 1209-13

© BMJ 2002.