2.1 Epidemiology of hepatitis CThe hepatitis C virus is blood borne and may cause a multi-system infection that has become a major health epidemic for Australia in the 21st century. Nationally, it is the most commonly reported notifiable infectious condition after chlamydia (DoHA 2005). In 2005 an estimated 264,000 people living in Australia had been exposed to the hepatitis C virus. Of these 66,700 were estimated to have cleared their infection and 197,300 had chronic hepatitis C infection including 43,400 with moderate to severe liver disease (National Centre in Epidemiology and Clinical Research (NCHECR) 2006). According to current estimates around 9,700 new infections occur each year (Hepatitis C Virus Projections Working Group 2006). Dependent on the rates of uptake of treatment, it is projected that between 148,000 and 190,000 people will still be living with chronic hepatitis C in 2025, (Hepatitis C Virus Projections Working Group 2006).
The virus is primarily spread by the blood of a person with hepatitis C entering the bloodstream of another person. In Australia, the sharing of injecting drug use equipment is the most common mode of exposure. Approximately 82 per cent of current infections and 89 per cent of new infections are estimated to be due to unsafe injecting drug use practices including the sharing of needles, syringes and other injecting equipment (Hepatitis C Virus Projections Working Group 2006).
While it is difficult to estimate the number of injecting drug users in Australia, the 2004 National Drug Strategy Household Survey found that there were over 73,800 people (0.4 per cent) who had injected illicit drugs at least once in the previous 12 months (recent use). The survey also identified that the proportion of the Australian population who reported injecting at some time in their life was 1.9 per cent, which represents over 313,500 people.
Less commonly, hepatitis C may be transmitted by blood and blood product transfusion. The introduction of universal screening of blood donors in Australia in 1990 has virtually eliminated this risk in Australia. Other means of transmission include unsterile medical procedures in countries of high hepatitis C prevalence, by re-use of unsterile equipment for tattooing, body piercing and other body art, by mother-to-child transmission and by other miscellaneous exposures to blood, such as through needle stick injuries in the healthcare setting.
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The risk of sexual transmission of hepatitis C is extremely low. While there have been some reported cases of hepatitis C being sexually transmitted, these cases have involved exposure to infected blood in the course of some sexual activity. Hepatitis C is not classified as a sexually transmitted infection.
2.2 Prevention of hepatitis C infectionThere is no vaccine to prevent hepatitis C infection. Prevention of transmission relies primarily on behavioural change and access to the tools for prevention, such as sterile injecting equipment, drug withdrawal or maintenance programs. Successful antiviral treatment provides the benefit that the patient is no longer infectious.
People with, or at risk of, hepatitis C come from all sectors of the Australian community and their experience of hepatitis C varies dramatically according to individual and community circumstances. Many with chronic infection are at a much lower risk of transmitting infections because their behaviour has changed. The population groups at greatest risk of hepatitis C infection are injecting drug users, people in custodial settings, Aboriginal and Torres Strait Islander people, young people, people from culturally and linguistically diverse backgrounds and people from rural and remote areas. Incarceration is an independent risk factor for acquiring hepatitis C. The groups at high risk for infection in the community remain at risk in prison. Women in prison are at even higher risk than males because of the high prevalence of hepatitis C in incarcerated females.
2.3 Hepatitis C in custodial settingsThere is no national surveillance system for hepatitis C infection in custodial facilities. A number of studies report the estimated prevalence of hepatitis C infection amongst inmates in Australia to be around 34 to 47%a , and between 50 to 70% for female inmates (Black 2004, Butler 2005). This is many times higher than hepatitis C prevalence in the general community, which is estimated at approximately 1%. In contrast to the hepatitis C prevalence rates in prison, the HIV rates in prison are approximately 0.1%, compared with 0.07% in the community. This underscores the importance of, and urgency for, addressing the epidemic of hepatitis C in Australian prisons. Additionally, individuals can be infected with two or more blood-borne viruses at the same time (eg hepatitis C, HIV and hepatitis B). Co-infection can increase the severity and rate of the infection, including an increased death rate and disease progression (Dore 2005). While the viruses can share routes of transmission, the variation between incidence rates of these infections reflects their differential infectivity, community infection rates and routes of transmission. These interactions are a matter of concern for prison populations and those responsible for their welfare during periods of imprisonment.
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It is difficult to measure the incidence of hepatitis C infection in custodial settings as incubation periods are similar in length to the duration of an average sentence and the early stages of hepatitis C are often asymptomatic. Inmates with a history of injecting drug use are also likely to experience multiple imprisonment episodes, further complicating the task of defining the source of any hepatitis C infection in this population.
Transmission of hepatitis C undoubtedly occurs in custodial settings, though few cases have been documented in Australia or overseas (because of the factors mentioned previously) and estimates vary considerably (Haber 1999, O’Sullivan 2003). In one study, inmates were estimated to have 156 times the risk of acquiring hepatitis C in prison, compared to those who might be considered ‘at risk’ in the community (Miller 2002).
Hepatitis C poses a special threat to inmates and staff in custodial settings because of:
- participation by inmates in risk behaviours - the same behaviours that confer risk in the community setting take place in prison, but they pose a greater transmission risk because of the prison setting itself; and
- factors associated with being in a custodial facility that increase the propensity for blood exposure incidents that contaminate the environment and create difficulties in maintaining adequate standards of personal and environmental hygiene.
- the high prevalence of hepatitis C amongst inmates and increased risk of infection within some sub-groups, reflecting the same population groups at greatest risk within the community. These effects are amplified in custodial settings;
2.3.1 Groups at high risk for hepatitis C infection in custodial settingsHepatitis C incidence has been reported at 38 per 100 person-years among males with a history of injecting drug use entering Victorian prisons; incidence was also higher in injecting drug users with a history of imprisonment than those without. (Crofts in Crofts 2001). One study reported that 44% of inmates had a history of injecting drug use with approximately half reporting they had injected in prison (Butler 2003). People who inject illicit drugs are more likely to have encountered the custodial system than those who do not inject.
Aboriginal and Torres Strait Islander people are significantly overrepresented in adult and juvenile custodial settings. As at June 2002, 20% of all adult inmates identified as Aboriginal and Torres Strait Islander (Australian Bureau of Statistics (ABS) 2003). On a per capita basis, Indigenous Australians have an incarceration rate which is ten times higher than non-Indigenous Australians (ABS 2003). Custodial settings may provide an important point for initiation into injecting drug use (Rutter et al 2001). The high rates of injecting drug use in custodial settings, coupled with higher incarceration rates, place Aboriginal and Torres Strait Islander people at increased risk of initiation into drug use, drug use and hepatitis C transmission.
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There are limited data available on ethnicity and crime; however this is not available for all inmates nor is it standardised between jurisdictions (Mukherjee 1999). While there is evidence about the high levels of hepatitis C in injecting drug users from some culturally and linguistically diverse backgrounds, this cannot be generalised across custodial settings.
The high rates of hepatitis C in women in prison (46-73%) were noted earlier (Black 2004). This is the opposite of the gender ratio for hepatitis C infection in the general community. For the period 2000-2004, the number of notifications of hepatitis C in men nationally was nearly double that reported in women (NCECHR 2005). Females in custodial settings are more likely than their male counterparts to be hepatitis C infected. They also report a higher incidence of continued injecting while in prison (Dolan 2001), thus leading to continued risk of exposure if they are not already infected. The logical extension of this is that women with chronic hepatitis C infection will have a greater need to access hepatitis C treatment to prevent or delay the onset of hepatitis C related liver disease.
Research has shown that the median age of initiation into injecting drug use is 18 years (Drug and Alcohol Medical Teaching Project 2005) and custodial facilities may expose at risk young people to injecting drug use.
2.3.2 isk behaviours in custodial settingsThere are numerous key risk behaviours that allow blood-to-blood contact in custodial settings – to a greater degree than in the broader community. These are important issues both for inmates and for the occupational health and safety of custodial staff. They include sharing injecting equipment and needles and syringes, tattooing and body piercing without appropriate infection control, injury and self harm, fighting and assaults (including sexual assault), barbering without appropriate infection control and sporting activities (especially contact sports).
While injecting drug use is less frequent in most prisons than in the community, it is usually far less safe in relation to the transmission of blood borne viruses because of the scarcity and re-use of injecting equipment (Crofts in Crofts 2001). Prisons and juvenile justice institutions are also settings in which some people start injecting. In NSW, 10 per cent of injecting drug users in prison reported that they commenced injecting in prison (Black 2004). Harm reduction measures addressing tattooing and the sharing of injecting equipment are urgently needed, as are occupational health and safety protocols concerning needle-stick injury, self-harm, fighting, assaults and recreational sport.
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2.3.3 Factors associated with custodial facilitiesThe spread of hepatitis C into communities may be increased by bringing together people (many of whom may be infected and do not know it) from different social networks and geographical locations into an environment where the risk of transmission is high and the full range of harm reduction measures is not available. Once released, inmates who have acquired hepatitis C while they have been incarcerated may unknowingly spread this virus to family members and friends. Therefore, when people living with hepatitis C are released following incarceration, prison health issues necessarily become community health issues.
In a study in NSW prisons, approximately 50% of inmates reported a history of injecting drug use (Butler 1997) and approximately 24% of male inmates and 43% of female inmates continued to inject whilst in custody (Dolan 2000). This group reported extremely high rates of sharing injecting equipment (Crofts 1997).
Access to harm reduction strategies such as education, the means of preventing transmission via needle and syringe programs and infection control is severely limited within custodial settings. There are also often restrictions on the distribution of a number of personal hygiene items such as bleach, razors, and scissors. Sterile tattooing and injecting equipment is not available and the means to clean such equipment is limited. A study conducted in NSW which found that inmates requesting bleach reported that they were sometimes searched and had their names recorded (Dolan 1998) highlights the barriers to safe practice.
The lack of differential sanctions for injected versus non-injected illicit drug use and variation in detection efficacy may cause inmates to switch from cannabis which holds no blood borne virus transmission risk, to using heroin, which poses considerable risk (Dolan 2000).
2.4 Natural history of hepatitis C infectionBetween 25-35% of people with hepatitis C will clear the virus naturally within six months of infection. They will continue to have detectable antibodies, but are no longer infectious. The remaining 65-75% have chronic infection. People with chronic hepatitis C are at risk of progressive liver disease.
Without effective treatment, an estimated 20% of chronically infected people will develop cirrhosis over a 20–40 year period. Complications from hepatitis C related cirrhosis include liver cancer (hepatocellular carcinoma) and liver failure. Hepatitis C related advanced liver disease has become the major single reason for liver transplantation in Australia.
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People with non-progressive liver disease may have considerable hepatitis C related symptoms. Hepatitis C can complicate and exacerbate other medical conditions and impact on quality of life. It is estimated that 37,800 quality years of life were lost in 2005 due to hepatitis C (Hepatitis C Virus Projections Working Group 2006).
Chronic Hepatitis C outcomes chart (natural history)
This chart shows the different outcomes that may occur with chronic hepatitis C. It does not aim to show individual outcome. Personal factors such as alcohol intake, age when hepatitis C was acquired and current level of liver inflammation may all influence a person’s prognosis.
On average, one of every four people who contract HCV will clear their infection naturally within the first 12 months. Three of every four people will have chronic (ongoing) hepatitis C infection.
Of 100 people with chronic hepatitis C who remain untreated…
After 20 years
45 may not develop liver damage
47 may develop mild to moderate liver damage
7 may develop cirrhosis of the liver
1 may develop failure of the live
After 40 years
45 may not develop liver damage
31 may develop mild to moderate liver damage
20 may develop cirrhosis of the liver
4 may develop failure of the liver or liver cance
(reproduced from Hepatitis C Council NSW factsheet – www.hepatitisc.org.au)
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2.5 Hepatitis C and treatment and careThe burden of disease from hepatitis C will continue to have serious implications in Australia. Projections indicate that without a substantial increase in people accessing treatment, the number of people with hepatitis C related cirrhosis will continue to increase through 2015 and beyond (Hepatitis C Virus Projections Working Group 2006). Rates of hepatocellular carcinoma (HCC) and hepatitis C related liver failure are expected to show even greater patterns of growth due to numbers infected in the 1970’s and 80’s reaching the 20-30 year point in the natural history of hepatitis C (Hepatitis C Virus Projections Working Group 2006).
Between 50 per cent and 80 per cent of people who undergo treatment can achieve a cure (Hadziyannis 2004). Despite this, only about one per cent of those diagnosed with hepatitis C (approximately 2,000 people) are being treated annually. It is therefore essential that new transmissions of hepatitis C are minimised, chronic infections are identified and effective treatment is instituted for those with signs of liver disease progression.
In considering health care provision there are a number of significant operational barriers to inmates that may impede the delivery of hepatitis C services. These include availability of specialist services, transport and security concerns and competing custodial, health and funding priorities.
These issues clearly demonstrate that preventing and managing hepatitis C is a major challenge for health services in custodial settings. The challenge is to ensure that services respond to the epidemiological drivers of infection, are responsive to the needs of inmates and staff, whilst meeting the demands of a custodial setting. The period of incarceration should be viewed as a public health window of opportunity.
Hepatitis C treatment is relatively new and there has been a slow uptake of treatment in the community. The number of treatment centres is limited and currently only a specialist can initiate hepatitis C antiviral treatment. Post release management needs to be considered when any treatment or management strategy is developed in the custodial setting.
Given high rates of turnover among inmates and poor post-release follow-up, the significant risk of hepatitis C transmission in custodial settings has the potential to increase infection rates in the general community once inmates are released.