Optimizing hepatitis B vaccination in prison

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ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses 46 (2016) 96–99

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Optimizing hepatitis B vaccination in prison Optimisation de la vaccination contre le virus de l’hépatite B en centre pénitentiaire F. Perrodeau a,∗, M. Pillot-Debelleix a, J. Vergniol b, F. Lemonnier a, M.-C. Receveur c, P. Trimoulet d, I. Raymond e , G. Le Port a , S. Gromb-Monnoyeur f a UCSA de la Maison d’arrêt Bordeaux-Gradignan, BP 109, 33173 Gradignan cedex, France Service d’hépato-gastro-entérologie et d’oncologie, groupe hospitalier Sud, groupe hospitalier Haut-Lévêque, 1, avenue Magellan, 33600 Pessac, France c Unité des maladies tropicales et du voyageur, service des maladies infectieuses et tropicales, groupe hospitalier Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France d Laboratoire de microbiologie fondamentale et pathogénicité, UMR-CNRS 5234, bâtiment 2A, 3e étage, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France e Service de médecine interne et des maladies infectieuses (Sud), groupe hospitalier Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France f Unité de médecine légale, institut médico-judiciaire, groupe hospitalier Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France b

Received 24 June 2015; accepted 18 January 2016 Available online 19 February 2016

Abstract Objective. – We aimed to establish the current status of hepatitis B virus (HBV) vaccination in prison. Methods. – We carried out two evaluations within a 1-year interval with inmates incarcerated for 6 to 12 months. A monitoring process was introduced in-between the two evaluations. Results. – We included 231 inmates. Overall, 42.9% were immunized because of a previous vaccination and 14.3% because of a previous exposure. Inmates born in an area of medium or high endemicity for HBV were significantly more exposed to HBV. The proportion of nonimmunized inmates was 42.8% at the time of incarceration and 27.5% after 6 to 12 months. Vaccination coverage with two doses, after 6 to 12 months, was 63% among patients who were initially non-immunized. Conclusion. – The recently developed accelerated vaccination schedule should help improve HBV vaccination coverage. © 2016 Elsevier Masson SAS. All rights reserved. Keywords: HBV; Vaccination; Prison

Résumé Objectif. – État des lieux de la vaccination contre le virus de l’hépatite B (VHB) en incarcération. Méthodes. – Deux évaluations, espacées d’un an, ont été réalisées auprès de détenus incarcérés depuis 6 à 12 mois. Mise en place de procédures de suivi entre les deux évaluations. Résultats. – L’étude incluait 231 détenus : 42,9 % avaient une immunité vaccinale et 14,3 % avaient été exposés au VHB, dont un nombre significativement plus important de personnes originaires d’une zone de haute ou moyenne endémie. Le taux de détenus non immunisés est passé de 42,8 % au moment de l’incarcération à 27,5 % après un suivi de 6 à 12 mois. Le taux de couverture vaccinale pour deux doses après 6 à 12 mois était de 63 % dans la population initialement non immunisée. Conclusion. – Le passage à un schéma vaccinal accéléré devrait permettre d’optimiser cette vaccination. © 2016 Elsevier Masson SAS. Tous droits réservés. Mots clés : VHB ; Vaccination ; Prison ∗

Corresponding author. E-mail addresses: [email protected] (F. Perrodeau), [email protected] (M. Pillot-Debelleix), [email protected] (J. Vergniol), [email protected] (F. Lemonnier), [email protected] (M.-C. Receveur), [email protected] (P. Trimoulet), [email protected] (I. Raymond), [email protected] (G. Le Port), [email protected] (S. Gromb-Monnoyeur). http://dx.doi.org/10.1016/j.medmal.2016.01.002 0399-077X/© 2016 Elsevier Masson SAS. All rights reserved.

F. Perrodeau et al. / Médecine et maladies infectieuses 46 (2016) 96–99

1. Introduction Hepatitis B virus (HBV) vaccine was introduced into the French vaccination schedule in 1996. Its introduction was due to study results [1,2] supporting the reduction in pediatric cancer and fulminant hepatitis after HBV vaccination. In 2014, the number of French individuals imprisoned was 67,075 and almost 70% served time in remand centers [3]. The mean length of stay in remand centers in 2013 was 9.9 months. Individuals who have not yet been convicted as well as people sentenced to jail for less than 2 years are sent to remand centers. All prisons have a medical facility affiliated with a public hospital. Its role is defined in the methodological guide on healthcare provisions for individuals remanded in custody [4]. The HBV risk reduction program included in the 2010–2014 strategic action plan [5] now mentions HBV prevention. Risk factors for HBV contamination in prison are numerous [6]: overcrowding, personal hygiene products used by several persons, needle sharing, unprotected sex, and higher HBV prevalence than in the general population. We carried out two evaluations on the immune and vaccination status of remand inmates incarcerated for 6 to 12 months. We detailed all the steps required to initiate HBV vaccination in the medical facility. Our vaccination schedule was D0, M1, and M6. As of March 2013, we tried to implement follow-up measures, in-between the two evaluation periods, that were recommended in the strategic action plan [5]: repeated screening offers in case of an initial refusal, compulsory consultations to share results with inmates, information on infectious disease transmission modes, remand inmates called in for vaccine injections.

2. Patients and methods We conducted the study in the medical facility of the prison of Gradignan. The medical facility is affiliated with the Teaching hospital of Bordeaux. The prison can host 407 inmates, including 324 remand inmates. The prison occupancy rate was 186% in 2013, with an average of 47 new arrivals per week. We conducted a retrospective evaluation with a 1-year interval inbetween the two evaluations (March 1st, 2013 and March 1st, 2014). We collected data from the medical records of remand inmates incarcerated for 6 to 12 months (time required for the vaccination schedule). Collected data included age, sex, place of birth, alcohol abuse (> 3 units of alcohol/day for men and > 2 for women), history of intravenous or nasal drug abuse, serological status for HBV, HIV, and HCV. We took note of the dates serological tests and vaccine injections were performed. Patients with anti-HBs antibodies prior to being incarcerated or patients who had already received two doses of the vaccine were considered unlikely to contract HBV in prison [7] (Fig. 1). Data was analyzed using the Epi InfoTM 7 software. Qualitative data was analyzed using Pearson’s Chi2 test. Quantitative data was analyzed using the Anova test. When a P-value < 0.05 was obtained with the Bartlett’s test, the

North Africa Eastern Europe 9% 11% Western Europe 6%

97

Sub-Saharan Africa 6% South America 1% Asia 1% French overseas departments and territories 3%

Metropolitan France 63%

Fig. 1. Place of birth of the 231 patients included in the study. Lieux de naissance des 231 patients inclus.

Mann-Whitney-Wilcoxon test was instead used. A P-value of 0.05 was considered statistically significant. 3. Results We included 231 individuals in the study (Table 1). Mean age was 34.6 ± 11.3 years. No significant difference was observed between the two evaluation data, with the exception of the proportion of inmates who agreed to be tested on arrival in prison: a higher proportion was observed in 2013 (P < 0.01). No significant difference was observed in terms of documented serological status between 2013 and 2014, with 100 (82.6%) and 89 (80.9%) serological tests performed, respectively. Inmates had either already been tested the year before or agreed to be tested on arrival in prison. Overall, 25.9% of inmates presented with alcohol abuse; 18.1% had a history of intravenous or nasal drug abuse; and 37.2% had already been incarcerated in the prison of Gradignan. We observed that 5.8% of tested inmates were carriers of replicating HCV and 1.6% were HIV-infected. Overall, 29.9% were born in an area of medium endemicity (Mediterranean basin, Central or South America, Eastern Europe) or high endemicity (Asia, Sub-Saharan Africa) for HBV. We performed a pooled analysis as no significant difference was observed between the 2013 and 2014 data. Serological test results revealed that 42.9% of inmates had already been vaccinated against HBV (positive for anti-HBs antibodies and negative for anti-HBc antibodies) and that 14.3% had already been exposed to HBV (positive for anti-HBc antibodies, regardless of the HBs antigen status). HBV vaccination could be offered to 42.8% of inmates. When HBV immunity was assessed by age group (±30 years), we observed a correlation between being aged < 30 years and having been vaccinated, respectively 54.2% vs. 35.9% (P < 0.02).

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F. Perrodeau et al. / Médecine et maladies infectieuses 46 (2016) 96–99

Table 1 Population characteristics on March 1st, 2013 and March 1st, 2014. Caractéristiques de la population aux 1er mars 2013 et 2014. Data collection – March 2013 % Sex Male Female Screening Agreed on arrival in prison Agreed at a later stage or already performed < 1 year before incarceration Not performed during the study period Alcohol use Excessive Not excessive History of intravenous or nasal drug abuse Yes No Repeat offender Yes No Endemicity in place of birth Low Medium or high Initial HBV status Exposed including AgHBs carriers Vaccinated Non-immunized Replicating HCV Yes No HIV-infected Yes No Vaccination coverage with 2 doses among initially non-immunized inmates Proportion of inmates tested and non-immunized after the study period

98.4 1.6 80.2 2.4 17.4

Data collection – March 2014 n 121 119 2 121 97 3

% 92.7 7.3 64.6 16.4 19.1

0 100 61.2

21 114 30 84 120 18 102 121 38 83 121 85 36 100 12 2 39 49 100 6 94 99 0 99 30

31.0

31

26.3 73.7 15.0 85.0 31.4 68.6 70.2 29.8 12.0 2.0 39.0 49.0 6.0 94.0

P (0.05)

n 110 102 8 110 71 18

NS NS 0.008 < 0.001 NS

3.4 96.6 65.6

21 106 27 79 106 23 83 110 48 62 110 77 33 89 15 2 42 32 89 5 84 89 3 86 21

23.6

21

NS

25.5 74.5 21.7 78.3 43.6 56.4 70.0 30.0 16.9 2.3 47.2 36.0 5.6 94.4

NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS

NS: non-significant; AgHBs: HBs antigen.

Being born in an area of high or medium endemicity for HBV was also significantly associated with HBV exposure: 35.6% vs. 8.7% for those born in an area of low endemicity (P < 0.01). We observed a reduction in the proportion of inmates likely to contract HBV (from 42.8% to 27.5%; P < 0.001). The reduction was however not significant between 2013 and 2014. Vaccination coverage with two doses among inmates who required initial vaccination was 63.0%. The mean length of prison stay was 266.1 ± 50.3 days (< 9 months). Time between date of incarceration and date of serological tests dropped from 22 to 18 days (P = 0.013) between 2013 and 2014 (Table 2). However, the median time between date of incarceration and date of third injection remained stable with an overall median time of 225.5 days (IQ: 216.5–238.5). 4. Discussion An interviewer-related study bias may have occurred as different physicians collected the data during the study period. The

physician’s awareness of the importance of screening may vary. This may explain the different 2013 and 2014 rates observed in terms of patients initially agreeing to be tested. Median time between the first and the third injection was 188 days, while our objective had been set at 180 days. This may explain why we did not observe any improvement in vaccination rate. The number of inmates lost to follow-up between the first and the second injection was smaller in 2014 than 2013 (20% and 4.6%, respectively) but the difference was not significant. In 2014, most inmates were lost to follow-up during the 5-month interval between the second and the third vaccine injection. The use of an accelerated vaccine schedule and of a computerized notification system should help solve this problem. The study period was relatively short and, as a result, we did not manage to implement all measures, such as those relating to software configuration, in less than a year. We were thus not able to correctly measure time to third vaccine injection.

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Table 2 Length of the several steps required for the vaccination process during the two evaluations of March 1st, 2013 and March 1st, 2014. Délais des différentes étapes menant à la vaccination des détenus au cours des recueils de données des 1er mars 2013 et 2014. Data collection March 2013

Data collection March 2014

Median time (days) between

Median (IQ 25–75)

n

Median (IQ 25–75)

n

P

Time of incarceration and first injection Time of incarceration and serological tests Serological tests and vaccine prescription Vaccine prescription and first injection First and third injections (schedule: 180 days) First and second injections (schedule: 30 days) Second and third injections (schedule: 150 days) Time of incarceration and third injection

48.0 (36.0–96.0) 22.0 (17.0–29.0) 12.5 (6.0–56.0) 7.0 (6.0–9.0) 188.0 (181.5–193.0) 34.0 (30.5–77.0) 150.5 (107.5–160.0) 229.5 (216.5–264.5)

36 100 36 36 16 30 16 16

48.0 (38.0–102.5) 18.0 (13.5–29.0) 14.0 (9.5–53.0) 6.0 (4.5–8.0) 187.0 (183.0–196.0) 35.0 (33.0–38.0) 150.0 (146.0–153.5) 225.0 (216.0–229.5)

21 85 22 21 8 21 8 8

NS 0.013 NS NS NS NS NS NS

NS: non-significant.

The mean length of prison stay for inmates included in the study was higher than that of all remand inmates incarcerated in the prison (266 days vs. 112 days for men in 2012). Inmates included in the study had thus been imprisoned for the longest time but it was still not long enough to achieve a full vaccination course for most of them. Vaccination coverage of remand inmates on arrival in prison (42.9%) was higher than expected as it was estimated at 32.6% in 2002 among adults [8]. This may be due to a better vaccination coverage since the completion of that study and to the relatively young mean age of our study population. The proportion of non-immunized inmates significantly dropped from the first evaluation period to the second. The reduction thus supports the high protection induced by the HBV vaccine. 5. Conclusion An accelerated HBV vaccination schedule should be offered in prison to minimize the risks incurred by a population with many risk factors for infection, especially for remand inmates serving a short sentence. Vaccination coverage with two doses observed among the atrisk population was 63.0%. The accelerated HBV vaccination schedule (three doses within a month) has been implemented since February 2014 [9]. It will probably improve immunity as the third vaccine injection leads to increased immunity (from 75% to 90%). This accelerated vaccination schedule has now been implemented at the prison of Gradignan, alongside a computerized data system and an accurate list of inmates requiring a vaccine injection. We therefore expect the proportion of remand inmates receiving a full HBV vaccination course to increase. Disclosure of interest The authors declare that they have no competing interest.

Acknowledgement We would like to thank the authors for the work provided. Florence Perrodeau collected data and designed the study protocol. Marie Pillot Debelleix reviewed the study protocol and performed the statistical analysis. Fabienne Lemonnier and Gildas Le Port scheduled the inmates’ consultations. Pascale Trimoulet agreed to the analysis of data obtained from the virological department. Isabelle Raymond contributed to implementing therapeutic education programs. Julien Vergniol, Marie Catherine Receveur, and Sophie Gromb reviewed the article. References [1] Chang M-H, Chen C-J, Lai M-S, Hsu H-M, Wu T-C, Kong M-S, et al. Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. N Engl J Med 1997;336(26):1855–9. [2] Kao JH, Hsu HM, Shau WY, Chang MH, Chen DS. Universal hepatitis B vaccination and the decreased mortality from fulminant hepatitis in infants in Taiwan. J Pediatr 2001;139(3):349–52. [3] Direction de l’administration pénitentiaire, ministère de la Justice et des Libertés. Statistique mensuelle de la population écrouée et détenue en France : situation au 1er janvier 2014; 2014. [4] Ministère de la Justice, ministère des affaires sociales et de la santé. Guide méthodologique – Prise en charge sanitaire des personnes placées sous main de justice; 2012. [5] Ministère de la Justice et des Libertés, ministère de la Santé et des Sports. Plan d’actions stratégiques 2010–2014 portant sur la politique de santé des personnes placées sous main de justice; 2010. [6] Michel L, Jauffret-Roustide M, Carrieri P. Prévention du risque infectieux dans les prisons franc¸aises. L’inventaire ANRS-PRI2DE. Bull Epidemiol Hebd 2011;39. [7] Van Herck K, Leuridan E, Van Damme P. Schedules for hepatitis B vaccination of risk groups: balancing immunogenicity and compliance. Sex Transm Infect 2007;83(6):42632. [8] Guthmann J, Fonteneau L, Lévy-Bruhl D. Mesure de la couverture vaccinale en France : sources et données actuelles. Institut de veille sanitaire; 2012. [9] Haut Conseil de la santé publique. Avis relatif aux schémas vaccinaux accélérés contre l’hépatite B par les vaccins Engerix B® 20 ␮g/1 mL et Genhevac B Pasteur® 20 ␮g/0,5 mL. Haut conseil de la Santé publique; 2014.