C Skipper, J M Guy, J Parkes, P Roderick, and W M Rosenberg

Evaluation of a prison outreach clinic for the diagnosis and prevention of hepatitis C: implications for the national strategy
Gut 2003; 52: 1500-1504 [Abstract] [Full text] [PDF]

epidemiologia.int{at}tin.it Maurizio Montella, et al.

• general population (n=1,972; prevalence=8.5%)
• imprisonment (n=524; prevalence=37.4%)
• intravenous drug use (n=1,436; prevalence=31.8%)
• hemodialysis (n=678; prevalence=2.9%)
• routine medical examination of patients (n=453; prevalence=12.6%)
• health care workers at the National Cancer Institute of Naples (n=781; prevalence=6.4%)

Our findings confirmed a high prevalence amongst drugs users (31.8%), but the highest prevalence was found amongst the male prisoners group (37.4%), particularly those in the 30-49 age range, with a prevalence of 47.3%. In fact, we concur with what Skipper et al. noted in their paper, that "those involved with IDU frequently pass through the penal system and spend time in prisons," thus indicating a probable interrelationship between these two groups.

Our other findings from this study shed light on the unusually high prevalence of this disease in the general population of Southern Italy. Previous reports have shown that the prevalence of HCV infection is generally low in the general population of most industrialized countries (<5%).[8] In Southern Italy, the high prevalence of HCV infection may be the result of past iatrogenic transmission, aggravated by:

1. extensive use of glass syringes or non-sterile syringes,[9]

2. social conditions which may indirectly favor the spread of infection:

• general poverty
• poor education etc.[10,11], and
• especially amongst females, hemodialysis procedures.

Prisons do play a significant role in the hepatitis C epidemic, especially as the same social conditions mentioned above which may facilitate the spread of infection also predict imprisonment.[12] As a matter of fact, a disproportionate share of the burden of HCV infection is found among people who pass through correctional facilities.[13] As stated before, HCV seroprevalence is high amongst this group. Histories of incarceration are among the strongest associations with HCV seropositivity.[14] Yet despite these high levels, reports of HCV transmission in the prison setting are uncommon.[15,16] In fact, studies have revealed that an overwhelming number of these infections are being brought into the prisons, via inmates who are already previously infected; that drug users are most likely to become infected with HCV at the beginning of their addiction – long before being imprisoned for the first time.[17-19] Yet it must be taken into account the fact that the dynamic movement of people in and out of prisons makes it very difficult to detect transmission.[20] And while the available data do not prove that infections are acquired in prison, they do indicate prisons as high risk institutions for the spread of HCV.[21]

What is of great concern to us are the implications of the previous and following data:

• HCV is easily transmitted parenterally.
• Our prisons are overcrowded (the Secondagliano prison located in Naples, for example, has 1350 prisoners and only 750 beds).
• In Southern Italy, the health system in general is less efficient and less meticulous than that in the north of Italy (and in the rest of the EU and in the US).[9]
• And, we have no harm reduction programs in place.

The limited availability of prevention methods has been linked to the transmission of HCV infection.[22] This association, and its relation to inadequate management of a manageable problem, surely opens up our National Health System to costly retaliations. If it can be proven that an inmate contracted HCV while incarcerated, due to a lack of sufficient care and prevention on the part of the system, he then has the right to seek judicial indemnification – a costly process for all concerned.

How much more economical to initiate admission screening programs in our overcrowded prisons, where, as detailed above, there is an identifiable elevated risk. By so doing, we move one step closer to correcting a problem that is grossly out of control. As HCV is associated with different kinds of neoplasms (liver, possibly non-Hodgkins lymphoma) and with autoimmune diseases (criglobulinemia, thyroiditis, Hashimoto thyroiditis), which develop after the virus has caused immune system alterations,[3,23] routine health screening on admission to prison presents a unique opportunity to identify health needs and plan health services at an early stage.[24] In fact, studies have found that screening provides a preventive function, as those who had previously presented for a hepatitis C test, regardless of the result, were less likely to have recently engaged in high-risk behavior (i.e., sharing injecting equipment).[25]

How much more economical to initiate a good, educational harm reduction program like that implemented by Skipper et al. Correctional interventions of this kind stand to benefit not only the inmates themselves and their families and partners, but also the public health of the communities to which the vast majority of inmates return.[13] By implementing such a program, the Healthcare System would be doing its job, demonstrating efficient management of a crucial problem and sustaining the welfare of its people.

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