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In search of the correct strategy for preventing the spread of HCV infection
  1. M Montella,
  2. A Crispo,
  3. J Wynn-Bellezza
  1. National Cancer Institute, Naples, Italy
  1. Correspondence to:
    Dr M Montella;

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Hepatitis C virus (HCV) infection is an emerging global healthcare issue. Apart from affecting approximately 3% of the world population, HCV is also a silent disease—the majority of incidences go unrecognised and serve unknowingly as sources of infection to others.1,2 Add to that the scant information defining the transmission routes and rates of HCV, the programme presented by Skipper et al in their paper evaluating the diagnosis and prevention of HCV in a prison outreach clinic (Gut 2003;52:1500–4) seems a model that could significantly constrain a situation that appears to be reaching epidemic proportions, especially here in Southern Italy.

Studies on the epidemiology of HCV infection in Italy have shown that this infection represents a major health problem throughout Southern Italy, with a prevalence of up to 12.6% in the general population.3–5 Also, HCV has been linked to the high incidence and mortality rates for liver cancer found in our region (standardised incidence rates per 100 000 inhabitants: 18.9 male, 13.2 female; mortality rates 15.2 male, 9.0 female).6 Between January 2000 and December 2001, we performed a cross sectional study of 5844 individuals (4260 men; 1584 women) from the general population and from five select groups in the city of Naples, with the purpose of assessing the prevalence of HCV infection in select groups with different exposure patterns in Southern Italy. Below are the preliminary data from this study:

  • general population (n = 1972; prevalence 8.5%);

  • imprisonment (n = 524; prevalence 37.4%);

  • intravenous drug use (n = 1436; prevalence 31.8%);

  • haemodialysis (n = 678; prevalence 2.9%);

  • routine medical examination of patients (n = 453; prevalence 12.6%); and

  • health care workers at the National Cancer Institute of Naples (n = 781; prevalence 6.4%).

Our findings confirm the high prevalence among drugs users (31.8%) but the highest prevalence was found among male prisoners (37.4%), particularly those in the 30–49 year age range (47.3%). In fact, we concur with Skipper et al 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 industrialised countries (<5%).7 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 syringes8; and

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

    • general poverty,

    • poor education etc,9,10, and

    • especially among females, haemodialysis procedures.

Prisons do play a significant role in the hepatitis C epidemic, especially as the same social conditions mentioned above which may facilitate spread of infection also predict imprisonment.11 In fact, a disproportionate share of the burden of HCV infection is found among those who pass through correctional facilities.12 As stated previously, HCV seroprevalence is high among this group. A history of incarceration is one of the strongest associations with HCV seropositivity.13 Yet despite these high levels, reports of HCV transmission in the prison setting are uncommon.14,15 In fact, studies have revealed that an overwhelming number of these infections are being brought into prisons via inmates who are already previously infected; drug users are most likely to become infected with HCV at the beginning of their addiction—long before being imprisoned for the first time.16–18 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.19 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.20

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 USA).8

  • We have no harm reduction programmes in place.

The limited availability of prevention methods has been linked to the transmission of HCV infection.21 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 programmes 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 (criglobulinaemia, thyroiditis, Hashimoto thyroiditis), which develop after the virus has caused immune system alterations,22 routine health screening on admission to prison presents a unique opportunity to identify health needs and plan health services at an early stage.23 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 behaviour (that is, sharing injecting equipment).24

How much more economical to initiate a good educational harm reduction programme such as 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.12 By implementing such a programme, the healthcare system would be doing its job, demonstrating efficient management of a crucial problem and sustaining the welfare of its people.