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Alan Franciscus
Editor-in-Chief
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In This Issue:
• Know the Myths about
Hepatitis C
• Volunteer Arrested at Needle Giveaway
• 25,000 in County Have Potentially Fatal
Hepatitis C
• Heterozygous Hemochromatosis Ggene Mutations
and Chronic Hepatitis C
• Certain Genes Fight Hepatitis C Better
• Early Mortality in Liver Transplantation
• Unsafe Injections Cause 390,000 Deaths
in China
• Hepatitis B Vaccination of Inmates in
Correctional Facilities, Texas 2000 to 2002
August
1st, 2004
Know
the Myths about Hepatitis C
Dr. Ken Eden –IR Your Turn
Source: Independent Record
An article in the June 22 Independent
Record contained useful information about an important
disease, Hepatitis C. Unfortunately, it also perpetuated several
myths. I would like to give another perspective on Hepatitis
C, its treatment, the need for "informed consent"
in discussing treatment options with patients, and why the
makers of Hepatitis C drugs have discouraged such discussion.
I'll give examples of how unethical financial
incentives are used to encourage treatment of all Hepatitis
C patients and explain why I believe pharmaceutical marketing
and a distorted profit motive do not serve patients or the
public.
Myths: The most misleading
statement in the article is attributed to Dr. Dan Phillips,
an Oregon physician whose Helena presentation was sponsored
by Schering Plough, the maker of Hepatitis C medications.
Dr. Phillips called Hepatitis C a "preventable terminal
illness." The implication was clear: get treated or die!
In fact, Hepatitis C results in death or liver failure leading
to transplantation in only 10 percent of patients. In other
words, nine out of 10 Hepatitis C patients will not die of
their disease. In my practice, it is a rare patient who understands
this fact when they first come for consultation. However,
it's very important that they do understand because many of
them cannot tolerate the medications and cannot receive treatment
or simply do not need treatment. Also, almost half of the
patients treated for the disease will not have a successful
response. Those patients need to know that they have a serious
disease but that MOST who have had no treatment or unsuccessful
treatment for Hepatitis C will live out a normal life span.
In the IR article and most information provided in lay publications
there is the implication that treating Hepatitis C with medication
is the most important aspect of their health care. No perspective
is given. Many other aspects of a person's health care are
more important. Two specific examples:
• Stopping alcohol consumption is
critical. Frankly, if I had to choose between treating a patient
with medication and stopping excessive alcohol intake, I'd
choose the latter and the patient would have a better chance
of improving her health.
• Smoking a pack of cigarettes daily
for 25 or 30 years (the time it takes for Hepatitis C to cause
serious problems) represents a far greater risk to a person's
health than does untreated Hepatitis C.
Neither of these examples lessens the seriousness
of Hepatitis C, but they do help put the disease in perspective.
Informing patients of these important facts allows them to
make an informed decision about whether to go forward with
treatment.
Pharmaceutical industry practices:
Recent revelations of unethical practice by pharmaceutical
companies underscore the need for a careful understanding
of the pros and cons of drug treatment. The New York Times
(6/27/04) recently reported that Schering Plough is under
federal and state investigation for payments made to providers
to encourage them to treat patients with Hepatitis C. This
offer was extended to me a couple of years ago and rejected.
For filling out a few simple forms three times a year, I would
have been paid $2,000 for each Hepatitis C patient I treated.
Drug companies can offer such inducements because treatment
costs more than $25,000 per year. There's still a lot of profit
left after a clear conflict of interest payment is made.
Marketing: The media is
saturated with ads for prescription drugs, which exaggerate
benefits and minimize risks. As a result, expensive allergy
medications outsell equally effective and far less expensive
over-the-counter remedies. Four-dollar-a-day pills are used
to treat minor heartburn on the erroneous assumption that
this symptom is commonly associated with serious disease.
Does this make any sense? Only if greed is driving the marketing
program of an industry now spending three times as much on
marketing as what it spends on research!
So what should you do if you have Hepatitis
C? First, find a qualified primary care provider whom you
trust. When necessary, seek appropriate consultation in collaboration
with that provider. Do research on your own, either online
or at the library. Ask questions. Don't be intimidated by
lists of side effects but be sure that the potential benefits
of a medication outweigh its risks. Finally, regard the claims
of pharmaceuticals in the same light you would regard those
that glamorize cigarettes and tout the "sex appeal"
of Coors Light.
KEN EDEN is a Helena physician.
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August 2nd 2004
Volunteer
Arrested at Needle Giveaway
Source: Associated Press
LAWRENCE, Mass. - Advocates for making
clean syringes more easily accessible to intravenous drug
users set up needle giveaways and information booths across
the state Monday to raise awareness of an issue they say has
been neglected by state lawmakers.
One volunteer was arrested in New Bedford when she swapped
a new syringe for a dirty one.
Massachusetts is one of five states that still requires a
prescription to buy syringes. Health care experts and advocates
of needle programs say the state is missing an opportunity
to stem the spread of blood-born illnesses such as HIV-AIDS
and hepatitis C by failing to pass a law allowing statewide
needle exchanges and sale of syringes without prescriptions.
Several bills that would have allowed the sale of syringes
without a prescription stalled on Beacon Hill during the session
that ended Saturday, despite support from health care officials,
law enforcement and others.
Opponents say distribution of needles promotes drug use. But
supporters say addicts would use clean needles if they had
the chance.
"They're human beings, they don't want to get infected,''
said Harry Leno, 68, a recovering drug addict, who set up
a small table with clean syringes and information in front
of a boarded storefront in Lawrence.
Other than a prescription, intravenous drug users in Massachusetts
have one other legal remedy to get clean syringes: through
a registered needle exchange program. However, only four communities
- Boston, Cambridge, Provincetown and Northampton - have such
programs.
Eliza Wheeler, who works at the Cambridge program, said it's
"culturally inappropriate and unrealistic'' to expect
that people at high risk would travel long distances to get
to those four communities. State law mandates local approval
of these programs, so they have been slow to catch on, advocates
say.
The New England Prevention Alliance coordinated the information
and distribution booths Monday, setting up needle exchanges
in New Bedford, Lawrence, and Worcester and information-only
tables in Springfield and Lynn.
Kelli Dorsey, 28, of Boston, was arrested in New Bedford after
she gave away a clean syringe in exchange for a dirty one.
She is registered with the state's needle exchange program
to possess needles but authorities say she is not allowed
to distribute.
There were no takers for needles in the first hour in Lawrence,
and police who checked on Leno and his table of syringes let
it remain undisturbed. In Worcester, a handful of exchanges
were made without police interruption.
The latest figures from the state Department of Public Health
show clean needles may make a difference in rates of HIV and
AIDS infection. The communities where needle exchanges are
running have a lower percentage of cases attributed to intravenous
drug use or related transmission - such as sex with a user
or a mother to a newborn - than the five cities targeted by
advocates Monday.
In Boston, 28 percent of AIDS or HIV cases were related to
intravenous drug use; in Cambridge, 24 percent; Northampton
44 percent and Provincetown 7 percent.
However, in New Bedford 69 percent of AIDS or HIV cases are
intravenous drug related; in Lynn and Worcester 60 percent;
in Springfield 56 percent and in Lawrence 51 percent. Statewide,
40 percent of HIV and AIDS cases are related to intravenous
drug use.
Jaime Rodriguez, 41, of Worcester, a current drug user who
showed up at the booth in Worcester, says he would spend the
money to buy needles if it were legal.
"I've got to pay now for a dirty needle,'' he said.
Legislation to make sale of needles legal without a prescription
made it out of the Health Care committee but stalled in Ways
and Means. Health care chairman Rep. Peter Koutoujian, D-Waltham,
said changing the law makes good sense.
"Every single health official that testified was unanimously
in support of this legislation as reducing the rates of HIV
and AIDS and reducing hepatitis C without increasing drug
usage or criminal activity,'' he said.
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25,000
in County Have Potentially Fatal Hepatitis C
Joelle Babula
Source: The Arizona Republic
On good days, Ricky James feels well enough
to crawl out of bed, hug his wife and two little girls and
wait in his chair for the temporary relief that comes each
Friday, when doctors drain nearly 10 liters of fluid from
his bulging stomach.
On bad days, James, 45, of Chandler, can't
get out of bed because his bones ache. Sometimes, he suffers
from confusion and can barely speak to his wife.
James is one of more than 25,000 people
in Maricopa County infected with hepatitis C, according to
the Arizona Department of Health Services, and state officials
fear there are thousands more Arizonans like him who don't
know it.
Now, Arizona officials are trying to identify
other victims with the potentially fatal liver disease who
remain undiagnosed because symptoms often don't appear in
victims for decades after they have been infected by the virus.
To identify those victims, get them early
treatment and quell the virus' spread, state health officials
have launched an education program called the Live Longer
Project.
Tests and treatment
The program is designed to encourage those at high risk to
get tested and get into treatment early, before the virus
destroys the liver, said Judy Norton, hepatitis C program
manager for the Arizona Department of Health Services.
Hepatitis C educators in the program also
offer support services, educational materials and referrals
for those infected.
"We're starting to see a lot of people
diagnosed with the disease now who were actually infected
over 25 years ago and had no idea they were at risk,"
Norton said, adding that up to 80 percent of Arizonans who
have the virus do not know they are infected.
People are at high risk for hepatitis C
if they have ever used intravenous drugs, shared drug paraphernalia
or had a blood transfusion before 1992, when blood supplies
were not screened for the virus.
There is no cure or vaccine for hepatitis
C, the most deadly of all the hepatitis viruses. Hepatitis
A and B are usually not as serious because they normally don't
develop into chronic conditions. There are vaccines for A
and B.
People also can become infected through
unsanitary tattooing, body piercing or sex with an infected
person, according to the Centers for Disease Control and Prevention
in Atlanta.
Information important
State health officials say it is vital that potential victims
receive up-to-date health information and understand how the
virus is transmitted so they can help prevent its spread.
"We've talked to 1,000 people through
the program already," Norton said. "A lot of them
are newly diagnosed and don't understand the disease or their
treatment options. We had a grandma call us who was scared
to let her grandchildren come over to hug and kiss her. We
really need to educate the public about this disease."
Valley liver specialist Dr. Richard Manch
said victims have a better chance of survival and leading
a normal life if they are diagnosed early and either get into
treatment or change their lifestyles.
"In most cases, if you catch it early,
we can control it and you won't ever have to be on a liver
transplant list," Manch said. "Unfortunately, most
people don't know they have the disease until it's very advanced.
We're going to be seeing a big bump in these cases over the
next 10 to 15 years if people don't get tested."
Most people with hepatitis C do not experience
any symptoms for years, if at all, according to the CDC. Those
who do develop symptoms experience extreme fatigue, loss of
appetite, nausea, vomiting and fever. Less common symptoms
include jaundice, which is the yellowing of the skin and eyes.
10,000 die annually
Nearly 4 million people nationwide are infected with hepatitis
C and 10,000 die each year, the CDC says. About 92,000 Arizonans
are infected, 14,000 of whom will develop severe liver disease.
Hepatitis C patient James said he was infected
while shooting up heroin in the 1970s but wasn't diagnosed
until February. He said that up until his diagnosis, he felt
healthy, worked 70 hours a week and regularly biked and swam
with his wife and two children.
Today, he remains in bed or at home in a chair most of the
time.
He swallows more than a dozen pills a day
and endures five daily injections to combat the side effects
of his failing liver, which include failing kidneys as well.
He gets his stomach drained once a week and goes for kidney
dialysis four days a week for four hours at a time.
"I can't work anymore," said
James, who is waiting for a liver transplant.
"I'm exhausted and some days I can
hardly move because my bones hurt so bad. I don't get to really
play with my girls anymore either, but I am able to give them
hugs once in a while."
James' liver is too diseased for treatment,
so all he can do is wait for a liver transplant, which can
take months or years to receive. Without it, James will most
likely die within the next six months to a year.
"He has severe cirrhosis of the liver,"
James' wife, Patty, said. "We're just waiting for that
phone call that tells us we have a donor."
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August 3rd, 2004
Heterozygous
Hemochromatosis Gene Mutations and Chronic Hepatitis C
Source: www.gastrohep.com
Common heterozygous hemochromatosis mutations are associated
with greater inflammation and hepatic fibrosis in patients
with chronic hepatitis C, find researchers in the latest issue
of Liver International.
Chronic hepatitis C is frequently associated with increased
hepatic iron stores.
It remains controversial whether heterozygous mutations of
hemochromatosis genes affect fibrosis progression.
In this study, researchers from Germany assessed the associations
between HFE mutations, and hepatic inflammation and stage
of fibrosis in German hepatitis C patients.
The team scored liver biopsies from 166 patients for inflammatory
activity and hepatic fibrosis.
In addition, gene mutations were determined using LightCycler,
restriction fragment length polymorphism analysis, or direct
sequencing.
The researchers found that the frequencies of common HFE mutations
C282Y and H63D are 4% and 21%. The S65C substitution and the
Y250X mutation in the transferrin receptor 2 gene are very
rare.
The team determined that heterozygous carriers of C282Y or
H63D mutations have significantly higher inflammatory activity
and more advanced fibrosis than patients without mutations.
They found that C282Y mutations were associated with increased
serum iron and aminotransferase levels.
H63D heterozygotes have higher transferrin saturation, serum
iron, and ferritin concentrations compared to wild-type.
Dr Andreas Geier and colleagues concluded, "Common heterozygous
hemochromatosis mutations are associated with higher grades
of inflammation and more severe hepatic fibrosis".
"Our findings support a role of HFE mutations as primary
risk factors for fibrogenesis and disease progression in chronic
hepatitis C".
Liver Internat 2004; 24(4): 285-94
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August 5th, 2004
Certain
Genes Fight Hepatitis C Better
Source: The Associated Press
Scientists Say Certain Genes Make It Easier for Some People
to Fight Hepatitis C
WASHINGTON — Scientists may have
figured out why some people infected with liver-destroying
hepatitis C essentially cure themselves: Their genes seem
to unleash a faster immune attack.
The research, reported Thursday in the
journal Science, may point to new ways to prevent
or treat hepatitis C, widely considered the most serious of
a family of liver viruses.
About 20 percent of people infected with
hepatitis C somehow clear the virus from their bodies without
treatment. But about 3 million Americans and 180 million people
worldwide remain chronically infected, at risk of eventually
developing liver cancer or failure. The virus claims 10,000
to 12,000 U.S. lives annually.
Doctors have long hoped that learning why
some people are lucky enough to spontaneously recover might
help them create a vaccine to prevent hepatitis C.
Now research by a team of U.S. and British
scientists suggests one key to that recovery is genes that
take the brakes off the body's front-line immune defense,
so-called natural killer cells.
The work won't benefit patients any time
soon.
However, "It brings us closer to understanding
how the virus works," said Dr. Chloe Thio of Johns Hopkins
University, who co-authored the study with researchers from
Britain's Southampton University and the U.S. National Cancer
Institute.
"In the long term, whether we can
use this information to modulate the body's immune system
to improve therapeutics or vaccine design that is the ultimate
goal," she said.
Hepatitis C studies in chimpanzees suggested
natural killer cells were more active in animals that recovered.
To find the genes involved in that immune response, the researchers
analyzed the DNA of 1,037 hepatitis C patients, 352 of whom
spontaneously recovered.
Natural killer cells are continually poised
to attack if a virus strikes. Inhibitory receptors called
KIRs (pronounced "keers") keep them in check between
infections, to ensure they don't attack healthy tissue.
The scientists discovered a particular
gene combination that controls one KIR receptor, and the molecule
attached to it was twice as common in recovered patients than
in the still-infected.
But how would an immune-inhibiting system
fight hepatitis?
When the body senses viral infection, it
has to activate the natural killer cells by switching off
inhibiting receptors, Thio explained. This KIR combination
seems weak, "so it's easier to overcome," she said.
There's a caveat: The genetic protection
was found only in patients thought to have received an initial
low dose of hepatitis C, because they were infected by contaminated
drug or tattoo needles instead of a blood transfusion. It
may be that the extra virus from tainted blood long a common
cause of hepatitis C was simply too much for those patients'
first-line defenses to handle, Thio said.
Since 1992, the U.S. blood supply has been
strictly tested for hepatitis C, so new transfusion-related
cases have plummeted. Today the disease is most commonly spread
here through injecting drug use.
Other factors also play a role in spontaneous
hepatitis C recovery, Dr. Peter Parham of Stanford University
said in an accompany editorial.
But he noted that doctors already help
treat a type of leukemia by releasing natural killer cells
from a different KIR receptor, so the question now is whether
a similar strategy could be developed for hepatitis.
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Early
Mortality in Liver Transplantation
Source: www.gastrohep.com
Doctors, in the may issue of Transplant
Proceedings, find that pre-transplant bilirubin is a
predictor of early mortality following liver transplantation.
The shortage of donor organs has increased the need for better
selection of liver transplant candidates.
In this study, doctors from Brazil reviewed the results of
29 liver transplantations performed between 2002 and 2003.
The team analyzed early mortality, pre-transplant laboratory
data, warm ischemia time, intra-operation blood unit transfusions,
and post-operative complications.
Early mortality occurred in 27%.--Transplant Proceedings
The doctors found that early mortality occurred in 27% and
fulminant hepatic failure in 44%. There were also 4 retransplants
with 1 death, and 2 intraoperative deaths.
The team determined that pre-transplant bilirubin and post-operative
lactate levels were related to patient survival.
Dr Medeiros and colleagues concluded, “In this small
population bilirubin was more related to death than the MELD
score”.
“Lactate levels, nonspecific predictor of death in shock
syndromes were probably related to septic complications”.
Transplant Proc 2004 36(4): 931-2
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August 6th, 2004
Unsafe
Injections Cause 390,000 Deaths in China
Source: Indo-Asian News Service Beijing
About 390,000 Chinese have died of AIDS and Hepatitis B infections
caused by the widespread reuse of disposable syringes, Xinhua
reports.
Quoting statistics released by the Thinktank
Health Research Centre at a seminar, China's Ministry of Health
said in poor western regions and rural areas, more than 70
percent of disposal syringes are reused at grassroots clinics
without disinfecting them properly.
Statistics show that 30 percent of immune
injections and 50 percent of therapeutic ones are unsafe.
Unsafe injections have also caused 6.89
million Disability Adjustment Life Year losses.
The direct medical spending on unsafe injection
has reached $142 million.
Unsafe injections have also infected doctors
and nurses, an official said. About one million medical workers
have been hurt by needles annually, some of whom contracted
HBV or AIDS.
China has 840,000 HIV carriers and 120
million HBV carriers, 10 percent of the total population.
Two thirds of the latter caught the virus before the age of
five.
Ye Lei, national director of the United
States Centre for Disease Control and Prevention Global AIDS
Program-China, believes that the best way to avoid unsafe
injections is to use Auto-Disabled (AD) Syringes, which can
be self-destructed after the injection.
However, the product is far from popular
in the country. Despite 30 manufacturers with an annual capacity
of 1.7 billion, the annual sale of AD Syringes lingers at
100 million due to low domestic demand.
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Hepatitis
B Vaccination of Inmates in Correctional Facilities, Texas
2000 to 2002
Source: CDC
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 (Table).
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.
Table
Figure
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. Available at http://www.tdcj.state.tx.us/
publications/executive/statsum-fy02.pdf.
6 Texas Department of Criminal Justice.
Statistical report fiscal year 2000. Available at http://www.tdcj.state.tx.us/stat/publications/
fy2000statsum.pdf.
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).
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