These Guidelines reflect the implementation of established hepatitis C prevention programs in Australia and overseas in the context of custodial settings. Prevention activities target behaviours that place people at risk and the settings where people may be exposed to infection. Such activities, in custodial settings will include an expansion of proven interventions as well as investigation of other innovative measures. Harm reduction measures employed in the wider community and custodial settings aim to complement each other.
The Australian National Council on Drugs (ANCD) (ANCD 2002) has stressed that the “failure to reduce the risk of hepatitis C and other blood-borne viral infection transmission in prisons severely undermines the work being conducted in the community with injecting drug users.” The National Hepatitis C Strategy 2005 – 2008 prioritises the need to establish collaboration between Australian state and territory governments to develop and implement hepatitis C education and prevention in custodial settings (DoHA 2005).
For the benefit of the broader community and inmates alike, it is critical that there is equity of access to these prevention programs within custodial services.
3.1 Education about hepatitis C and the routes of transmission for inmatesEducation of inmates about the prevention and management of hepatitis C, including treatment, is a fundamental, necessary and effective preventive intervention.
The provision of health education is a fundamental and universal part of strategies to improve individual and population health (World Health Organization 1986, DoHA 2005). Peer based education programs for inmates are recognised as best practice and encouraged. Evidence supports the use of peer based organisations to best provide these services (Australian Injecting and Illicit Drug Users League (AIVL) 2006). If community peer based education services are not available, resources and education are provided by custodial facility health, welfare and education staff. Content should include, but is not limited to:
- natural history of hepatitis C;
- modes of transmission, especially in the prison setting, and strategies to reduce/minimise harm;
- access to the means of minimising transmission; and
- testing and opportunities for health monitoring and treatment, including post-release.
3.2 Infection control in custodial settingsEach institution needs to have in place appropriate infection control procedures. Staff education and training about infection control measures is an integral part of the proper application of these procedures.
Infection control procedures in custodial establishments are identical in principle and practice to those faced in other institutions that care for groups of people (day-care centres, nursing homes, mental health establishments, boarding schools). These principles range from building design and availability of facilities for maintaining personal hygiene, through to minimising work practices and procedures that pose a threat of cross-infection. Each institution will have particular issues for infection control to be identified and addressed in line with the national infection control guidelines (DoHA 2004) and standard precautions.
The potential transmission of infectious conditions is always an area of concern in the workplace. Testing for hepatitis C or other bloodborne viruses is not a substitute for the rigorous application of universal precautions (DoHA 2006, DoHA 2006a).
Infection control is an important aspect of institutional policy and practice. Implementation requires policy tailored to local needs and trained staff. The development and maintenance of infection control standards are outlined in Infection Control Guidelines for the prevention of transmission of infectious diseases in the health care setting (DoHA 2004).
The key aspects of infection control that apply to the custodial setting may be found in Appendix 3.
Education about these guidelines and their local application and implementation should be provided to inmates (in particular if they undertake any activities which potentially expose them to blood such as cleaning up blood spills) and staff and included in routine induction and on the job training.
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3.3 Recreational sport and exerciseCompliance with the Guidelines on HIV/Hepatitis and Other Blood Borne Viruses in Sport (ANCAHRD 2001) reduces the risk of exposure to blood during sport and recreational activities within custodial settings.
Recreational sport and exercise are commonly undertaken in custodial settings, with estimates of in excess of 75% of inmates participating in the 2001 NSW Inmate Health Survey (Butler 2003a) undertaking exercise in the preceding month. The risk of transmission of blood borne viral infections in sport in the community is estimated at less than one percent (ANCAHRD 2001). Significantly, a survey of Victorian prisons (Heale 2003) reports that 18% of inmates were exposed to blood during sport. These exposures ranged from direct person to person contact in football and karate to exposure via potentially contaminated boxing gloves, where inmates shared boxing gloves and protective inserts were not consistently worn.
3.4 Provision of bleach and disinfectant and education about their useProvision of, and access to bleach and disinfectants is supported in custodial settings where no other safer alternatives are provided for decontaminating spills, surfaces or equipment. Education about the proper use of bleach is an essential component of its provision.
Bleach and other disinfectants are currently provided in a number of custodial settings in Australia. Theoretically, bleach and disinfectants are active against HIV and hepatitis B.
In the absence of other effective strategies such as use of sterile or single use equipment for skin penetration, the use of bleach is recommended (Morbidity and Mortality Weekly Report (MMWR) 1993). However, reliance on bleach and disinfectants alone for infection control is sub-optimal and undesirable. It is clearly an intervention to be used when there are no safer alternatives (US Department of Health and Human Services 1997, Public Health Agency of Canada 2004, World Health Organisation 2005).
Disinfection of used injecting equipment, and other potentially contaminated items, can theoretically reduce the likelihood of transmission of blood borne viruses and other pathogens. While studies on the effectiveness of bleach in inactivating the hepatitis C virus are limited, laboratory studies do indicate that bleach may reduce viral infectivity. However factors that reduce bleach's effectiveness against the virus include the amount of organic material, e.g., fresh, dried or clotted blood, left in, or on, the equipment, how long the blood has been sitting in the syringe, the length of time bleach is in contact with the equipment, the "freshness" of the bleach and whether or not the bleach is used properly. Overall the available literature is not conclusive and further research is required (Public Health Agency of Canada 2004).
The provision of bleach and disinfectants may have other benefits apart from a decrease in the transmission of blood borne viruses. It may also provide a practical way in which to identify a potentially at risk group for targeting delivery of health education messages and facilitating contact with hepatitis C related health services. Bleach and other disinfectants should be available to clean spills, contaminated surfaces and equipment which can be decontaminated (Betteridge 2005).
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Disinfectants provide some protection to inmates and staff. Providing open and unrestricted access to effective, but inert disinfectants will address inmates’ concern that custodial authorities may use provision of bleach as an opportunity to identify those who engage in illicit activities (Dolan 1998) and occupational health and safety concerns about bleach being used as a weapon (Betteridge 2005).
Disinfectant, and education about how to use it, including the need to clean injecting equipment immediately following its use, should be made readily available, free and confidential in all custodial and custodial health settings and its use should not be associated with punitive measures.
The selection of disinfectants for use in custodial settings should be made with reference to the safety and efficacy of disinfection agents across a range of uses including cleaning or injecting equipment.
3.5 Access to razors, toothbrushes and safe barberingThe risk of transmission from sharing personal items is reduced if each inmate receives free razors and toothbrushes that can be readily replaced and any razors and toothbrushes left in ablutions areas are removed.
Adoption and application of infection control procedures for barbering equipment in custodial settings significantly reduces the risk of transmission.
Hepatitis C is readily transmitted through contact with microscopically contaminated equipment. There is a risk of hepatitis C transmission through shared equipment that breaches skin or mucosal surfaces such as razors, toothbrushes and hair clippers/shears. Theoretically, this risk increases if oral or skin health is poor. Barbering has been identified as the most likely route of transmission of hepatitis C in an Australian gaol (Haber 1999). Sharing of razors has been reported to be a possible source of HIV infection (Centre for Disease Control 1993, French 2003) and hepatitis C infection (Tumminelli 1995, Crofts 1999).
Strategies that support easy access to personal care items such as toothbrushes and razors and that ensure strict infection control for barbering/hairdressing eliminate equipment sharing and the consequent risk of blood borne virus transmission. Some jurisdictions have instituted an inmate barber system where appropriately skilled inmates provide hairdressing and /or peer education on the use of barbering equipment to minimise cross contamination. It is generally accepted that prisons should employ external professional hairdressers to provide barbering services to inmates to reduce the risk of cross infection (Prison Officers Association of Australia (POAA), 2006). Preventive measures for transmission are strengthened, providing that inmates’ access to these personal care items and services is equitable with that of the general community.
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3.6 Education and counselling related to injecting drug useEasily accessible education and counselling about hepatitis C and injection drug use is a fundamental health promotion technique to support behaviour change. Tailoring the information to different groups’ needs is an important component of accessibility.
The National Hepatitis C Strategy 2005-2008 (DoHA 2005) recognises the need to inform all people about the harms associated with drug use. It calls for the strengthening of drug education, including delaying the onset of injecting drug use and encouraging people who are dependent on drugs to seek drug treatment if this is clinically indicated. Initiatives under the National Drug Strategy 2004 – 2009 (DoHA 2004) include the development of a comprehensive approach to dealing with drug use and related harms in custodial settings.
There are many educational models that have a demonstrated effect on behaviour change and prevention of infection for hepatitis C and HIV (King 1999). Collaboration with existing services in the community, particularly those provided by peer based organisations, will allow for the translation of community strategies to custodial settings and tailoring of programs for high priority groups such as people from Aboriginal and Torres Strait Islanders or culturally and linguistically diverse populations, women and young people. Evidence supports the use of peer based organisations as the preferred providers of these services (AIVL 2006). If community organisation peer based education services are not available, resources and education can be provided by custodial facility health, welfare and education staff.
The provision of free and confidential education and counselling (and referral as appropriate) about hepatitis C and injecting drug use will support opportunities for behaviour change in custodial settings.
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3.7 Drug treatment programsOpportunities are provided for inmates to access a range of drug treatment programs, including detoxification, drug free rehabilitation and drug substitution (e.g. methadone) programs.
While incarceration exposes inmates to injecting drug use, it can also provide an opportunity to access drug treatments including pharmacotherapy and counselling programs. It is important for all inmates to have access to these programs and appropriate information on the nature of the programs. Pharmacotherapy programs are a demonstrably effective strategy to reduce injecting drug use and consequent transmission of blood borne viruses within the Australian custodial setting. By reducing the reliance on injecting to a similar level to that found in the community, these programs support the prevention of the transmission of hepatitis C in custodial facilities, particularly where there is no access to clean injecting equipment (Dolan 1996, Dolan 1998). Dolan’s study reported a significant reduction in the frequency of injecting and sharing of injecting equipment by inmates enrolled in methadone maintenance programs in contrast to those who were not provided with substitution therapy (Dolan 1996).
Prison based methadone maintenance programs were first introduced in 1986 in NSW as a pre-release program. Since then the program has been extended to inmates in all security classifications. Methadone maintenance treatment is more effective than abstinence-based therapies in reducing injecting drug use and blood borne virus transmission (Dolan 1998). In the custodial setting, methadone maintenance therapy has been shown to confer benefits to the individual and the community by reducing the reliance on injecting and the potential for needle stick exposure.
3.8 Tattooing and body art under appropriate infection control proceduresCompliance with Australian infection control standards for tattooing and body art reduces the risk of transmission of hepatitis C in custodial settings.
Australian data show that being tattooed in prison is an independent risk factor for hepatitis C infection (Hellard 2004). The risk of transmission from tattooing cannot be entirely eliminated even in the community setting where tattooing practices are relatively well regulated under skin penetration guidelines administered by health or local government jurisdictions. However, in the custodial setting where these practices are widespread this risk factor is magnified many times if tattooing is not safely performed or well regulated.
A number of strategies to prevent hepatitis C transmission through unsterile tattooing in custodial settings have been considered including the introduction of tattoo guns into custodial settings with various sanctions against their use thereby facilitating inmates’ use of sterile practices when tattooing or painting henna body art. Similar programs have been trialled in overseas prisons, including a one-year pilot safer tattooing project (including provision of education to all inmates about safer tattooing practices) which was conducted in six Canadian federal prisons and concluded in September 2006 (Betteridge 2005, Corrective Services Canada 2005).
While it is recognised that there are divergent views among custodial officers on this issue, opportunities for Australia to trial a program to reduce the spread of hepatitis C through unsterile tattooing should be considered.
The benefits associated with professional tattooist visits include the use of sterile equipment and correct infection control procedures. It is important to recognise that there are costs associated with safe tattooing which will be incurred by the system and by inmates and that this may limit access to, and hence the effectiveness of the program. However, this cost must be weighed against the cost of potential infection and transmission of blood borne viruses such as hepatitis C.
Tattooing and body art that is not conducted under accepted infection control procedures increases the risk of transmission of hepatitis C and other blood borne viruses. Australasian standards and evidence from overseas programs about safe procedures are available to guide custodial services to develop and implement their own protocols to reduce the risk of infection associated with tattooing and body art.
Custodial facilities are encouraged to explore effective and sustainable strategies to reduce harm associated with tattooing and body art practices. The document, Regulation of Infection Control in the Body Art Industry in Australia and New Zealand (NPHP 2002) could be used as a guide for program development in this area.
3.9 Body piercing under appropriate infection control proceduresCompliance with Australian infection control standards for body piercing and other skin penetration practices reduces the risk of transmission of hepatitis C in custodial settings.
Some custodial facilities require the removal of metal body piercing jewellery, often resulting in inmates using unsafe practices to ensure that the piercing remains open during the period of incarceration. This is a complex area of infection control and there are risks associated with jewellery that can be torn out with consequent bleeding and subsequent bacterial infection. Body piercing and other skin penetration practices (including other esoteric practices such as genital adornment and scarification) that are not conducted under infection control procedures risk the transmission of hepatitis C and other blood borne viruses, particularly in the custodial setting. There are Australasian standards to guide custodial services in the development and implementation of their own protocols to prevent infection. Again, the document, Regulation of Infection Control in the Body Art Industry in Australia and New Zealand (National Public Health Partnership (NPHP) 2002) is a very suitable guide for appropriate strategy development.
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3.10 Prison-based needle syringe exchangeThe provision of sterile injecting equipment in prisons is a controversial and complex issue. Any needle and syringe exchange trial which is being considered by the Australian States and Territories would need to be supported by custodial staff and fully evaluated to assess occupational health and safety, impact on hepatitis C transmission and any other indirect effects.
Harm minimisation of injecting drug use in prisons is addressed by many interlinked strategies - there is no single intervention that can successfully stand alone. Some of these strategies include supply reduction through custodial surveillance, demand reduction by providing drug treatment programs and harm reduction through infection preventions programs ranging from staff and inmate education to needle/syringe exchange programs. Consistent with this principle, the Standard Guidelines for Corrections in Australia (revision 2004), states that:
- Prison systems should have a comprehensive and integrated drug strategy that seeks to prevent the supply of drugs into prison, reduce the demand for drugs and minimise the harm arising from drug use in prisons through education, treatment and enforcement.
In Australia, Needle and Syringe Programs (NSPs) are an important public health measure to reduce the spread of blood borne viral infections such as HIV and hepatitis C among injecting drug users. They are supported by the National Drug Strategy’s harm minimisation framework. Community NSPs provide a range of services that include provision of injecting equipment and disposal facilities, education and information on reducing drug-related harms, referral to drug treatment, medical care and legal and other social services. Equipment provided includes needles and syringes, swabs, vials of sterile water and ‘sharps bins’ for the safe disposal of used injection equipment (Health Outcomes International 2002).
The primary aim of providing sterile injecting equipment is to prevent the shared use of injecting equipment, which can lead to the transmission of blood borne viral infections. Secondary benefits include education about reducing harm associated with drug use and injecting practices and referral for the diagnosis and management of blood borne viruses and drug related health problems. The engagement of injecting drug users with health services is shown to reduce the harm to themselves and society. NSPs are also an important point for collection of used injecting equipment (Health Outcomes International 2002).
Prison needle/syringe exchange programs are currently operating in corrective facilities in six European jurisdictions with favourable results to date. Different models have been applied to different facilities to take into consideration the needs of inmates and staff. The Swiss Federal Office of Justice introduced a prison-based needle and syringe program in 1998 following an evaluated pilot which demonstrated neither any increase in consumption of drugs nor any account of needles being used as weapons. Overall there was a decrease in needle sharing and improved health status of inmates (Nelles 1995).
Evaluations of six programs from prisons in Spain, Switzerland and Germany have also been positive. The 2001 National Drug and Alcohol Research Centre (NDARC) report Prison-Based Syringe Exchange: A Review of International Research and Program Development (Rutter 2001) reported that: drug use remained stable or decreased over time; there were no reports of drug initiation; equipment sharing decreased significantly to almost zero at the end of the pilot period; and there were no reported cases of HIV, hepatitis B or C seroconversion.
At the same time, a range of issues associated with the establishment of NSPs exchanges in custodial settings have been identified by stakeholders. One of the key arguments against needle and syringe exchange or distribution in prison is that needles could be used as weapons against other inmates and staff and that the risk of accidental needle stick injury may increase. Some also argue against a needle and syringe exchange program in prisons because use of prohibited drugs is illegal and inmates would be thereby encouraged to persist in the same behaviour which may have led to their arrest and conviction. Other practical considerations include identification of drug users through inmates participation in the program and operational and distribution issues (Wallace 2005).
Based on the expectation that the introduction of a trial needle and syringe program would provide an opportunity to reduce the movement and use of an unknown quantity of illicit needles and syringes in prisons, and hopefully improve the occupational safety of all persons working in, visiting or living within the prison system, the Australian National Council on Drugs has recommended that needle/syringe exchange programs are trialled in custodial settings in Australia (ANCD NSP position paper 2002). In considering this recommendation in 2004, the Corrective Services Ministers’ Conference did not support the implementation of a needle and syringe exchange program within Australian prisons. It is also noted that POAA members oppose any sanctioned program of supply of needles and syringes in prisons (POAA, 2006). However, if any jurisdiction were to trial a needle and syringe exchange program in the future it would be important for data derived from that trial to be used to guide any subsequent decisions on such a program in other prisons.
As long as needle and syringe exchange programs continue to be unacceptable, it is critical that bleach and disinfectants are readily available and used effectively (refer Section 3.4) and that much more effort is directed towards other demand reduction programs such as education and meeting the need for drug treatment.