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Hepatitis C and the correctional population
Hepatitis C and the Correctional Population Robert W. Reindollar, MD
The hepatitis C epidemic has extended well into the correctional population where individuals predominantly originate from high-risk environments and have high-risk behaviors. Epidemiologic data estimate that 30% to 40% of the 1.8 million inmates in the United States are infected with the hepatitis C virus (HCV), the majority of whom were infected before incarceration. As in the general population, injection drug use accounts for the majority of HCV infections in this group—one to two thirds of inmates have a history of injection drug use before incarceration and continue to do so while in prison. Although correctional facilities also represent a high-risk environment for HCV infection because of a continued high incidence of drug use and high-risk sexual activities, available data indicate a low HCV seroconversion rate of 1.1 per 100 person-years in prison. Moreover, a high annual turnover rate means that many inmates return to their previous high-risk environments and behaviors that are conducive either to acquiring or spreading HCV. Despite a very high prevalence of HCV infection within the US correctional system, identification and treatment of atrisk individuals is inconsistent, at best. Variable access to correctional health-care resources, limited funding, high inmate turnover rates, and deficient follow-up care after release represent a few of the factors that confound HCV control and prevention in this group. Future efforts must focus on establishing an accurate knowledge base and implementing education, policies, and procedures for the prevention and treatment of hepatitis C in correctional populations. Am J Med. 1999;107(6B):100S–103S. © 1999 by Excerpta Medica, Inc.
H
epatitis C is of increasing concern in correctional populations where the prevalence of this disorder is particularly high. A dramatic growth in the number of prisoners associated with high-risk behaviors and high rates of community reentry emphasizes the need for detection and treatment of hepatitis C virus (HCV) infection in this unique group. Wide variations in correctional health-care, low funding, and limited access to specialty care further compound the dilemma. Given an eight-fold increase in state and federal incarcerations for drug-related offenses since 1977,1 we are likely just arriving at the tip of the iceberg in realization of the hepatitis C problem within the prison system.
HEPATITIS C AND THE CORRECTIONAL PATIENT: THE POPULATION DEFINED We now know a great deal about the pathogenesis and epidemiology of hepatitis C in the general population, but few data are available specific to correctional populations. What we can define, however, is the high-risk nature of this special population that makes hepatitis C a particular concern. As a result of more stringent criminal codes and longer sentences, the correctional system has experienced dramatic growth over the past decade. The entire US correctional population consists of approximately 5 million individuals, the majority on probation or parole (Figure 1).2 Approximately 1.8 million are inmates in correctional facilities, with the vast majority residing in state systems (1.2 million). The distribution of this population is highly variable geographically: federal prisons and state prisons in California and Texas account for approximately one third of the US inmates, whereas 15 states, including Nebraska and Rhode Island, make up only 3% of the entire prison population, each having fewer than 5,000 prisoners. Of female inmates, who comprise 7% of the entire incarcerated population, over three quarters are characterized by high-risk behaviors, such as injection drug use and prostitution.
EPIDEMIOLOGY OF HCV INFECTION IN CORRECTIONAL POPULATIONS From the Center for Liver Diseases, Carolinas Medical Center, Charlotte, North Carolina, USA. Requests for reprints should be addressed to Robert W. Reindollar, MD, Center for Liver Diseases, Carolinas Medical Center, 1900 Brunswick Avenue, Charlotte, North Carolina 28207. 100S © 1999 by Excerpta Medica, Inc. All rights reserved.
Correctional populations are unique in that they represent a focused concentration of individuals most at risk for contracting hepatitis C, including those who come from medically underserved and minority communities and/or have a history of injection drug use, alcohol abuse, 0002-9343/99/$20.00 PII S0002-9343(99)00394-0
A Symposium: Hepatitis C and the Correctional Population/Reindollar
Figure 1. Distribution of the United States correctional population (1980 –1995).2
Figure 2. Worldwide prevalence of hepatitis C in correctional populations.6 –12
and multiple sex partners.2 As in the community at large, high-risk drug behaviors remain the predominant mode of HCV transmission risk in prison systems.2,3 Approximately 60% of federal prisoners and 25% of state prisoners are incarcerated for drug-related crimes.2 One to two thirds of inmates have a history of injection drug use before incarceration, and many continue to do so while in prison. About one fourth of drug-injecting inmates apparently start their addiction while incarcerated. Additionally, there have been a number of anecdotal reports of HCV infection related to tattoos performed with shared and dirty needles, which needs further study. The high prevalence of hepatitis C in correctional facilities is, thus, associated with a cycle defined by individuals predominantly originating from high-risk environments and with high-risk behaviors, incarceration-related experiences that may augment risk status, and return to high-risk communities. In contrast to a seroprevalence of 1.8% in the general
US population,4 the prevalence of HCV infection is much higher in prison-based cohorts. Limited available data indicate the majority of HCV infections are acquired before incarceration. Blood serum evaluations among 265 male prison inmates in Maryland (1985 to 1986) revealed a hepatitis C prevalence of 38% at intake.5 Of the HCVpositive prisoners, 55% were over the age of 25 years, and 55% were incarcerated for drug-related offenses and 31% for violent offenses. Upon follow-up in 1987, the HCV seroconversion rate was 1.1 per 100 person-years in prison. A 1994 hepatitis C prevalence study of entrants to the California correctional system (n ⫽ 5,000) documented similar results, with 41.8% of inmates HCV positive (males, 39.4%; females, 54.5%).6 Worldwide hepatitis C data similarly report significant prevalence figures in correctional populations ranging from 31% to 50% (Figure 2), with intravenous drug use being the predominant risk factor.7–12
December 27, 1999
THE AMERICAN JOURNAL OF MEDICINE威
Volume 107 (6B)
101S
A Symposium: Hepatitis C and the Correctional Population/Reindollar
HEPATITIS C HARM-REDUCTION PROGRAMS Because hepatitis C remains a major public health concern, prevention strategies for all individuals that may be affected are a social imperative. In correctional populations with such striking disease prevalence rates, and figures indicating release of over 400,000 inmates each year back into their often high-risk communities,2 the need for harm-reduction programs is obvious. Evidence suggesting low knowledge of HCV risk factors among prison inmates further substantiates the necessity of such programs.13 Because inmates represent an easily accessible audience, many experts believe behavior modification may be possible. Recent Centers for Disease Control and Prevention (CDC) recommendations for the prevention and control of HCV infection may be applied to correctional populations in the form of primary and secondary interventions.14 According to these guidelines, primary concern would focus on not only identification of those most at risk but also on provision of appropriate treatment. Because only patients not currently abusing drugs should be treated, a primary concern must be the institution of programs to reduce substance abuse. Specific harm-reduction strategies directed toward preventative education and counseling and reducing high-risk sexual activities are also crucial. Some systems have instituted needle exchange programs and have made available needle sterilizing tablets to combat infectious disease spread. Services may also need to be made available for support after incarceration release. In addition, correctional personnel, particularly enforcement officers, should be part of educational initiatives. With very little literature available regarding the efficacy of harm-reduction interventions, future directions in correctional health care must focus on the implementation and evaluation of HCV prevention programs.
HEALTHCARE ISSUES IN CORRECTIONAL POPULATIONS Resource Variability The highly variable nature of correctional health care, despite laws mandating equal access to medical care, is a major concern of those involved in reform of the criminal justice system (Table 1). Medical intake at remand is not standardized and does not always include screening and follow-up for risk factors. Although inconsistencies still exist, an effort is being made to standardize access to correctional health care. The addition of managed care agencies in some facilities is reportedly having a great impact on inmate health. Whereas in some systems all services are provided for, in others, high-risk human immunodeficiency virus and HCV groups are excluded. 102S December 27, 1999 THE AMERICAN JOURNAL OF MEDICINE威
Table 1. Correctional Health-Care Issues ● ● ● ● ● ● ● ●
HCV prevalence: 30%–40% Inmates: high-risk behaviors and environments System stressed by high census and turnover rates Inadequate harm-reduction programs Low HCV diagnosis and treatment rates Variable access to health-care resources Lack of follow-up after release Limited HCV epidemiology, prevention, and control data in correctional population ● Difficulty of performing clinical trials ● Inadequate federal and state funding ● Lack of consensus on policies/procedures HCV ⫽ hepatitis C virus.
Public Policy Issues Although the CDC and National Institutes of Health have published clear guidelines regarding HCV prevention and treatment,14,15 there is a lack of a similar consensus within the National Commission on Correctional Healthcare.16 Standardized policies and procedural guidelines for HCV screening, diagnosis, or treatment do not exist within the correctional health-care system, resulting potentially in substandard health care. However, many states are individually forming task forces in order to address the hepatitis C dilemma within their correctional systems. Correctional health care will remain fragmented and inconsistent until national guidelines are enacted guaranteeing appropriate screening, treatment, and prevention of hepatitis C. Treatment Constraints Although a great deal of information is available about treatment of hepatitis C in the general population, there are few data available specific to correctional populations regarding the number of inmates that are appropriate for treatment, the number that will go through a full course of treatment, or the success rates of treating inmates for hepatitis C. This, in part, is because of FDA regulations that make clinical trials in prisons and jails almost impossible to perform. In some instances, this lack of documentation for treatment efficacy in correctional populations has translated into justification for lack of action, thereby perpetuating the cycle of dangerously unmet health-care needs. Experts in the field report that a minimal number of those believed to be HCV infected are actually identified and subsequently treated (⬍20%), with limited state and federal funding for hepatitis C harm-reduction programs cited as being a contributing factor. In most systems, an inmate will not even be considered for treatment unless at least 15 to 24 months remain in their prison sentence. Thus, high annual facility turnover rates and the frequent movement of inmates between facilities complicate HCV identification and treatment. For many with shorter sentences, this also represents opportunity Volume 107 (6B)
A Symposium: Hepatitis C and the Correctional Population/Reindollar
missed. The presence of comorbidities that preclude or complicate treatment, such as alcohol and/or continuing drug abuse and mental illness, is also common. Finally, inmate attitudes often preclude treatment. Many of those who are identified as having HCV infection either refuse diagnostic measures (e.g., liver biopsy) or will not be treated because they have heard of the side effects or do not wish to be transferred to a medical ward for the duration of treatment.
SUMMARY Hepatitis C is highly prevalent in correctional populations because of a concentration of individuals predominantly characterized by coming from high-risk environments and having high-risk behaviors. Even though there is a substantial knowledge base regarding HCV epidemiology, treatment, and prevention within the general population, very few data exist specific to correctional populations. The majority of inmates appear to have been infected with HCV before incarceration, and the incidence of new cases appears to remain low even though high-risk behaviors often continue within the correctional facility. Despite laws mandating equal access to medical care for correctional populations, identification and treatment of at-risk individuals is inconsistent, at best. Highly variable access to correctional health-care resources, inadequate harm-reduction programs, limited funding, high inmate turnover rates, and deficient follow-up care upon release represent a few of the variables confounding the control and prevention of HCV infection in this group. Future efforts must focus on establishing an accurate knowledge base and implementing education, policies, and procedures for the prevention and treatment of hepatitis C in correctional populations.
REFERENCES 1. NIH News Release. Washington, DC: National Institutes of Health, 1998. National Institutes of Health publication NIDA Press 301-443-6345.
2. Data on file, United States Department of Justice, Bureau of Justice Statistics, 1998. 3. Alter MJ. Epidemiology of hepatitis C. Hepatology. 1997; 26:62S– 65S. 4. National Institutes of Health. Chronic hepatitis C: current disease management. Washington, DC: National Digestive Diseases Clearinghouse; 1998. National Institutes of Health publication NIH 97-4230. 5. Vlahov D, Nelson KE, Quinn TC, Kendig N. Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. Eur J Epidemiol. 1993;9:566 –569. 6. Data on file, California Department of Health Services, Office of AIDS, 1996. 7. Ford PM, White C, Kaufman 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. CMAJ. 1995;153:1605–1609. 8. Pinducciu G, Arnone M, Piu G, et al. Prevalence of hepatitis virus (HBV and HCV) and HIV-1 infections in a prison community. Ann Ig. 1990;2:359 –363. 9. Nara K, Kawano M, Igarashi M. Prevalence of hepatitis C virus and human immunodeficiency virus infection among female prison inmates in Japan. Nippon Koshu Eisei Zasshi. 1997;44:55– 60. 10. Crofts N, Stewart T, Hearne P, Ping XY, Breshkin AM, Locarnini SA. Spread of blood borne viruses among Australian prison entrants. BMJ. 1995;310:285–288. 11. Holsen DS, Harthug S, Myrmel H. Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. Eur J Clin Microbiol Inf Dis. 1993;12:673– 676. 12. Seroprevalence of hepatitis C virus infection at the time of entry to prison in the prison population in the north-east of Spain [in Spanish]. Rev Esp Salud Publica. 1998;72:43–51. 13. Butler TG, Dolan KA, Ferson MJ, McGuinness LM, Brown PR, Robertson PW. Hepatitis B and C in New South Wales prisons: prevalence and risk factors. Med J Aust. 1997;166: 127–130. 14. Centers for Disease Control. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47;1–39. 15. National Institutes of Health. Management of hepatitis C. NIH consensus statement online. 1997;15:1– 41. 16. Data on file, United States Government, National Commission on Correctional Health Care, 1999.
December 27, 1999
THE AMERICAN JOURNAL OF MEDICINE威
Volume 107 (6B)
103S
The hepatitis C epidemic has extended well into the correctional population where individuals predominantly originate from high-risk environments and have high-risk behaviors. Epidemiologic data estimate that 30% to 40% of the 1.8 million inmates in the United States are infected with the hepatitis C virus (HCV), the majority of whom were infected before incarceration. As in the general population, injection drug use accounts for the majority of HCV infections in this group—one to two thirds of inmates have a history of injection drug use before incarceration and continue to do so while in prison. Although correctional facilities also represent a high-risk environment for HCV infection because of a continued high incidence of drug use and high-risk sexual activities, available data indicate a low HCV seroconversion rate of 1.1 per 100 person-years in prison. Moreover, a high annual turnover rate means that many inmates return to their previous high-risk environments and behaviors that are conducive either to acquiring or spreading HCV. Despite a very high prevalence of HCV infection within the US correctional system, identification and treatment of atrisk individuals is inconsistent, at best. Variable access to correctional health-care resources, limited funding, high inmate turnover rates, and deficient follow-up care after release represent a few of the factors that confound HCV control and prevention in this group. Future efforts must focus on establishing an accurate knowledge base and implementing education, policies, and procedures for the prevention and treatment of hepatitis C in correctional populations. Am J Med. 1999;107(6B):100S–103S. © 1999 by Excerpta Medica, Inc.
H
epatitis C is of increasing concern in correctional populations where the prevalence of this disorder is particularly high. A dramatic growth in the number of prisoners associated with high-risk behaviors and high rates of community reentry emphasizes the need for detection and treatment of hepatitis C virus (HCV) infection in this unique group. Wide variations in correctional health-care, low funding, and limited access to specialty care further compound the dilemma. Given an eight-fold increase in state and federal incarcerations for drug-related offenses since 1977,1 we are likely just arriving at the tip of the iceberg in realization of the hepatitis C problem within the prison system.
HEPATITIS C AND THE CORRECTIONAL PATIENT: THE POPULATION DEFINED We now know a great deal about the pathogenesis and epidemiology of hepatitis C in the general population, but few data are available specific to correctional populations. What we can define, however, is the high-risk nature of this special population that makes hepatitis C a particular concern. As a result of more stringent criminal codes and longer sentences, the correctional system has experienced dramatic growth over the past decade. The entire US correctional population consists of approximately 5 million individuals, the majority on probation or parole (Figure 1).2 Approximately 1.8 million are inmates in correctional facilities, with the vast majority residing in state systems (1.2 million). The distribution of this population is highly variable geographically: federal prisons and state prisons in California and Texas account for approximately one third of the US inmates, whereas 15 states, including Nebraska and Rhode Island, make up only 3% of the entire prison population, each having fewer than 5,000 prisoners. Of female inmates, who comprise 7% of the entire incarcerated population, over three quarters are characterized by high-risk behaviors, such as injection drug use and prostitution.
EPIDEMIOLOGY OF HCV INFECTION IN CORRECTIONAL POPULATIONS From the Center for Liver Diseases, Carolinas Medical Center, Charlotte, North Carolina, USA. Requests for reprints should be addressed to Robert W. Reindollar, MD, Center for Liver Diseases, Carolinas Medical Center, 1900 Brunswick Avenue, Charlotte, North Carolina 28207. 100S © 1999 by Excerpta Medica, Inc. All rights reserved.
Correctional populations are unique in that they represent a focused concentration of individuals most at risk for contracting hepatitis C, including those who come from medically underserved and minority communities and/or have a history of injection drug use, alcohol abuse, 0002-9343/99/$20.00 PII S0002-9343(99)00394-0
A Symposium: Hepatitis C and the Correctional Population/Reindollar
Figure 1. Distribution of the United States correctional population (1980 –1995).2
Figure 2. Worldwide prevalence of hepatitis C in correctional populations.6 –12
and multiple sex partners.2 As in the community at large, high-risk drug behaviors remain the predominant mode of HCV transmission risk in prison systems.2,3 Approximately 60% of federal prisoners and 25% of state prisoners are incarcerated for drug-related crimes.2 One to two thirds of inmates have a history of injection drug use before incarceration, and many continue to do so while in prison. About one fourth of drug-injecting inmates apparently start their addiction while incarcerated. Additionally, there have been a number of anecdotal reports of HCV infection related to tattoos performed with shared and dirty needles, which needs further study. The high prevalence of hepatitis C in correctional facilities is, thus, associated with a cycle defined by individuals predominantly originating from high-risk environments and with high-risk behaviors, incarceration-related experiences that may augment risk status, and return to high-risk communities. In contrast to a seroprevalence of 1.8% in the general
US population,4 the prevalence of HCV infection is much higher in prison-based cohorts. Limited available data indicate the majority of HCV infections are acquired before incarceration. Blood serum evaluations among 265 male prison inmates in Maryland (1985 to 1986) revealed a hepatitis C prevalence of 38% at intake.5 Of the HCVpositive prisoners, 55% were over the age of 25 years, and 55% were incarcerated for drug-related offenses and 31% for violent offenses. Upon follow-up in 1987, the HCV seroconversion rate was 1.1 per 100 person-years in prison. A 1994 hepatitis C prevalence study of entrants to the California correctional system (n ⫽ 5,000) documented similar results, with 41.8% of inmates HCV positive (males, 39.4%; females, 54.5%).6 Worldwide hepatitis C data similarly report significant prevalence figures in correctional populations ranging from 31% to 50% (Figure 2), with intravenous drug use being the predominant risk factor.7–12
December 27, 1999
THE AMERICAN JOURNAL OF MEDICINE威
Volume 107 (6B)
101S
A Symposium: Hepatitis C and the Correctional Population/Reindollar
HEPATITIS C HARM-REDUCTION PROGRAMS Because hepatitis C remains a major public health concern, prevention strategies for all individuals that may be affected are a social imperative. In correctional populations with such striking disease prevalence rates, and figures indicating release of over 400,000 inmates each year back into their often high-risk communities,2 the need for harm-reduction programs is obvious. Evidence suggesting low knowledge of HCV risk factors among prison inmates further substantiates the necessity of such programs.13 Because inmates represent an easily accessible audience, many experts believe behavior modification may be possible. Recent Centers for Disease Control and Prevention (CDC) recommendations for the prevention and control of HCV infection may be applied to correctional populations in the form of primary and secondary interventions.14 According to these guidelines, primary concern would focus on not only identification of those most at risk but also on provision of appropriate treatment. Because only patients not currently abusing drugs should be treated, a primary concern must be the institution of programs to reduce substance abuse. Specific harm-reduction strategies directed toward preventative education and counseling and reducing high-risk sexual activities are also crucial. Some systems have instituted needle exchange programs and have made available needle sterilizing tablets to combat infectious disease spread. Services may also need to be made available for support after incarceration release. In addition, correctional personnel, particularly enforcement officers, should be part of educational initiatives. With very little literature available regarding the efficacy of harm-reduction interventions, future directions in correctional health care must focus on the implementation and evaluation of HCV prevention programs.
HEALTHCARE ISSUES IN CORRECTIONAL POPULATIONS Resource Variability The highly variable nature of correctional health care, despite laws mandating equal access to medical care, is a major concern of those involved in reform of the criminal justice system (Table 1). Medical intake at remand is not standardized and does not always include screening and follow-up for risk factors. Although inconsistencies still exist, an effort is being made to standardize access to correctional health care. The addition of managed care agencies in some facilities is reportedly having a great impact on inmate health. Whereas in some systems all services are provided for, in others, high-risk human immunodeficiency virus and HCV groups are excluded. 102S December 27, 1999 THE AMERICAN JOURNAL OF MEDICINE威
Table 1. Correctional Health-Care Issues ● ● ● ● ● ● ● ●
HCV prevalence: 30%–40% Inmates: high-risk behaviors and environments System stressed by high census and turnover rates Inadequate harm-reduction programs Low HCV diagnosis and treatment rates Variable access to health-care resources Lack of follow-up after release Limited HCV epidemiology, prevention, and control data in correctional population ● Difficulty of performing clinical trials ● Inadequate federal and state funding ● Lack of consensus on policies/procedures HCV ⫽ hepatitis C virus.
Public Policy Issues Although the CDC and National Institutes of Health have published clear guidelines regarding HCV prevention and treatment,14,15 there is a lack of a similar consensus within the National Commission on Correctional Healthcare.16 Standardized policies and procedural guidelines for HCV screening, diagnosis, or treatment do not exist within the correctional health-care system, resulting potentially in substandard health care. However, many states are individually forming task forces in order to address the hepatitis C dilemma within their correctional systems. Correctional health care will remain fragmented and inconsistent until national guidelines are enacted guaranteeing appropriate screening, treatment, and prevention of hepatitis C. Treatment Constraints Although a great deal of information is available about treatment of hepatitis C in the general population, there are few data available specific to correctional populations regarding the number of inmates that are appropriate for treatment, the number that will go through a full course of treatment, or the success rates of treating inmates for hepatitis C. This, in part, is because of FDA regulations that make clinical trials in prisons and jails almost impossible to perform. In some instances, this lack of documentation for treatment efficacy in correctional populations has translated into justification for lack of action, thereby perpetuating the cycle of dangerously unmet health-care needs. Experts in the field report that a minimal number of those believed to be HCV infected are actually identified and subsequently treated (⬍20%), with limited state and federal funding for hepatitis C harm-reduction programs cited as being a contributing factor. In most systems, an inmate will not even be considered for treatment unless at least 15 to 24 months remain in their prison sentence. Thus, high annual facility turnover rates and the frequent movement of inmates between facilities complicate HCV identification and treatment. For many with shorter sentences, this also represents opportunity Volume 107 (6B)
A Symposium: Hepatitis C and the Correctional Population/Reindollar
missed. The presence of comorbidities that preclude or complicate treatment, such as alcohol and/or continuing drug abuse and mental illness, is also common. Finally, inmate attitudes often preclude treatment. Many of those who are identified as having HCV infection either refuse diagnostic measures (e.g., liver biopsy) or will not be treated because they have heard of the side effects or do not wish to be transferred to a medical ward for the duration of treatment.
SUMMARY Hepatitis C is highly prevalent in correctional populations because of a concentration of individuals predominantly characterized by coming from high-risk environments and having high-risk behaviors. Even though there is a substantial knowledge base regarding HCV epidemiology, treatment, and prevention within the general population, very few data exist specific to correctional populations. The majority of inmates appear to have been infected with HCV before incarceration, and the incidence of new cases appears to remain low even though high-risk behaviors often continue within the correctional facility. Despite laws mandating equal access to medical care for correctional populations, identification and treatment of at-risk individuals is inconsistent, at best. Highly variable access to correctional health-care resources, inadequate harm-reduction programs, limited funding, high inmate turnover rates, and deficient follow-up care upon release represent a few of the variables confounding the control and prevention of HCV infection in this group. Future efforts must focus on establishing an accurate knowledge base and implementing education, policies, and procedures for the prevention and treatment of hepatitis C in correctional populations.
REFERENCES 1. NIH News Release. Washington, DC: National Institutes of Health, 1998. National Institutes of Health publication NIDA Press 301-443-6345.
2. Data on file, United States Department of Justice, Bureau of Justice Statistics, 1998. 3. Alter MJ. Epidemiology of hepatitis C. Hepatology. 1997; 26:62S– 65S. 4. National Institutes of Health. Chronic hepatitis C: current disease management. Washington, DC: National Digestive Diseases Clearinghouse; 1998. National Institutes of Health publication NIH 97-4230. 5. Vlahov D, Nelson KE, Quinn TC, Kendig N. Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. Eur J Epidemiol. 1993;9:566 –569. 6. Data on file, California Department of Health Services, Office of AIDS, 1996. 7. Ford PM, White C, Kaufman 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. CMAJ. 1995;153:1605–1609. 8. Pinducciu G, Arnone M, Piu G, et al. Prevalence of hepatitis virus (HBV and HCV) and HIV-1 infections in a prison community. Ann Ig. 1990;2:359 –363. 9. Nara K, Kawano M, Igarashi M. Prevalence of hepatitis C virus and human immunodeficiency virus infection among female prison inmates in Japan. Nippon Koshu Eisei Zasshi. 1997;44:55– 60. 10. Crofts N, Stewart T, Hearne P, Ping XY, Breshkin AM, Locarnini SA. Spread of blood borne viruses among Australian prison entrants. BMJ. 1995;310:285–288. 11. Holsen DS, Harthug S, Myrmel H. Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. Eur J Clin Microbiol Inf Dis. 1993;12:673– 676. 12. Seroprevalence of hepatitis C virus infection at the time of entry to prison in the prison population in the north-east of Spain [in Spanish]. Rev Esp Salud Publica. 1998;72:43–51. 13. Butler TG, Dolan KA, Ferson MJ, McGuinness LM, Brown PR, Robertson PW. Hepatitis B and C in New South Wales prisons: prevalence and risk factors. Med J Aust. 1997;166: 127–130. 14. Centers for Disease Control. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47;1–39. 15. National Institutes of Health. Management of hepatitis C. NIH consensus statement online. 1997;15:1– 41. 16. Data on file, United States Government, National Commission on Correctional Health Care, 1999.
December 27, 1999
THE AMERICAN JOURNAL OF MEDICINE威
Volume 107 (6B)
103S