Practice Guidelines

CDC Updates Guidelines for Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings



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Am Fam Physician. 2003 Jun 15;67(12):2620-2625.

The National Center for Infectious Diseases recently issued consolidated and updated guidelines for the prevention and control of infections with hepatitis viruses in juvenile and adult correctional settings. The guidelines appeared in the January 24, 2003 issue of the Recommendations and Reports series of Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr/preview/mmwrhtml/rr5201a1.htm).

Approximately 0.7 percent of the U.S. population is incarcerated in correctional systems; however, these persons have a disproportionately greater burden of infectious diseases, including infections with hepatitis viruses and other infections of public health importance, such as human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), and tuberculosis infections. At the time of incarceration, all adults and the majority of juveniles lose their access to the usual public and private health care and disease prevention services. By improving access to medical care and prevention services for incarcerated populations, communities will benefit by reducing disease transmission and medical costs. These measures also will reduce the risk of occupationally acquired infections with bloodborne pathogens among correctional facility staff members.

Epidemiology

HEPATITIS A VIRUS

The majority of cases of hepatitis A virus (HAV) in the United States occur through person-to-person transmission, most frequently by household or sexual contact with a person who has HAV infection; however, 45 to 50 percent of patients will have no known source of infection. There have been no reports of HAV outbreaks in correctional settings, although a substantial proportion of incarcerated persons have risk factors for infection such as injection-drug use or male homosexual sex. The prevalence of previous HAV infection among incarcerated persons is approximately 22 to 39 percent, which is comparable with the general U.S. population.

HEPATITIS B VIRUS

Approximately 5 percent of the U.S. population has serologic evidence of past or present hepatitis B virus (HBV) infection. Incidence of HBV is highest among blacks, followed by Hispanics and whites, and among persons 25 to 39 years of age. Sexual contact is the predominant mode of HBV transmission among adults and adolescents. Among incarcerated juveniles, the prevalence of previous HBV infection ranges from zero to 6 percent; however, no transmission of HBV in juvenile correctional settings has been reported. The prevalence of serologic markers for current or previous HBV infection among incarcerated adults ranges from 13 to 47 percent, varies by region, and is more common among women than men. The majority of HBV infections among incarcerated persons are acquired in the community; however, transmission rates within correctional settings range from 0.82 to 3.80 percent. Transmission of HBV in the prison setting can occur through sexual activity, injection-drug use, and percutaneous exposures that are not apparent. Among correctional staff, percutaneous and mucous membrane exposures to blood were relatively infrequent. The most frequently reported exposure was blood on the skin, which was not associated with HBV infection.

HEPATITIS C VIRUS

An estimated 3.9 million noninstitutionalized persons in the United States have been infected with hepatitis C virus (HCV). The highest prevalence of HCV infection is reported among persons who have substantial or repeated direct percutaneous exposure to blood. The prevalence of HCV antibody among detained or incarcerated juveniles is estimated at 2.0 to 3.5 percent and is higher among women than men. The extent of HCV transmission within juvenile correctional institutions is unknown. Among incarcerated adults, 16 to 41 percent have serologic evidence of HCV infection and 12 to 35 percent have chronic HCV infection. The risk of HCV infection during incarceration is not well established. The predominant risk behavior for juveniles and adults is injection-drug use. No studies on the prevalence of HCV infection among correctional staff have been published.

Prevention

Primary prevention of infection with hepatitis viruses includes immunization (HAV, HBV) and behavior interventions to reduce risk factors for infection (HCV). Early identification of persons with chronic HBV and HCV infection allows for counseling, treatment, or vaccination, which can prevent further disease transmission and reduce the progression of chronic liver disease.

The most effective way to prevent HAV infection and reduce disease incidence is through vaccination. In the United States, preexposure vaccination is recommended for persons at highest risk of infection and those who would have adverse consequences of infection. Routine vaccination also is recommended for persons two to 19 years of age residing in states and communities with the highest rates of disease. Postexposure immunization with immune globulin is more than 85 percent effective in preventing HAV if administered within two weeks of exposure. The majority of adult correctional systems provide hepatitis A vaccination only to inmates infected with HCV. The extent of hepatitis A vaccination in juvenile correctional institutions is unknown.

The most effective prevention of acute and chronic HBV infection is hepatitis B vaccination. The national strategy to eliminate HBV transmission includes (1) prevention of perinatal HBV infection through maternal screening and postexposure prophylaxis of newborns of mothers who test positive for hepatitis B surface antigen; (2) hepatitis B vaccination of all infants; (3) vaccination of all adolescents not previously vaccinated; and (4) vaccination of adults and adolescents in groups at increased risk for infection. Laws involving issues of legal guardianship and consent vary among the states and can pose barriers to juveniles receiving vaccinations. Immunization for hepatitis B is recommended for all adults in correctional settings because of their increased risk of infection. Approximately 25 state correctional systems and the Federal Bureau of Prisons have implemented hepatitis B vaccination programs.

There is no vaccine to prevent HCV infection; therefore, prevention is focused on risk reduction through counseling of persons who have admitted to or are at risk of illicit drug use or high-risk sexual behavior. The Centers for Disease Control and Prevention's (CDC's) national strategy for preventing HCV infection includes (1) prevention of transmission during high-risk activities through risk-reduction counseling, testing, and appropriate medical management of infected persons; (2) donor screening and product inactivation procedures to eliminate transmission from blood, blood products, donor organs, and tissue; and (3) improved infection-control practices to further reduce risk of transmission during medical procedures. In correctional settings, the high prevalence of HCV infection and risk associated with HCV infection among inmates makes HCV-prevention activities crucial. Risk reduction among this population often requires a multidisciplinary approach that addresses drug use and other medical, social, psychologic, vocational, and legal problems.

Diagnosis and Management

The diagnosis of hepatitis A is based on a positive serologic test for immunoglobulin M (IgM) antibody to HAV in persons with clinical signs or symptoms of acute viral hepatitis. Because hepatitis A cannot be distinguished from other forms of viral hepatitis on the basis of clinical presentation alone, serologic confirmation of HAV infection is required (Table 1). Although management of clinical illness is supportive, some patients may progress to acute liver failure and 10 to 15 percent of patients will have relapsing illness.

Acute HBV infection is asymptomatic in 60 to 70 percent of patients, but it can have symptoms and signs associated with acute viral hepatitis and must be confirmed by serologic testing (Table 2). Treatment of patients with acute hepatitis B is supportive, including rest, hydration, and symptomatic relief. If acute HBV infection is identified in an incarcerated person, an epidemiologic investigation should be conducted by correctional officials in collaboration with the appropriate health authorities to identify the source of the infection. Chronic HBV infection can be distinguished from acute infection by serologic testing. Inmates with confirmed chronic HBV infection require evaluation to determine the extent of liver disease, virus replication, indications for antiviral therapy and need for vaccination of contacts to prevent HBV transmission. The U.S. Food and Drug Administration (FDA) has approved interferon alfa, lamivudine, or ade-fovir dipivoxil for the treatment of chronic hepatitis B.

Although HCV infection is usually asymptomatic, it should still be considered in the differential diagnosis of inmates who have signs and symptoms of acute hepatitis (Table 1). Confirmation of acute HCV requires negative test results for IgM anti-HAV and IgM anti-HBc and a positive screening test result for anti-HCV, verified by supplemental testing. Identification of an inmate with acute hepatitis C requires initiation of an epidemiologic investigation by correctional officials in cooperation with appropriate health authorities to identify the source of the infection. Chronic HCV infection can be distinguished from acute HCV by the persistence of HCV RNA for more than six months. The FDA has approved interferon alfa, pegy-lated interferon, and interferon alfa or pegylated interferon in combination with ribavirin for at least one year in the treatment of chronic hepatitis C. Successful treatment eliminates viremia and the possibility of HCV transmission and further chronic liver disease.

TABLE 1

Diagnostic Testing for Infection with Hepatitis Viruses*

For persons with acute hepatitis, testing should be performed to differentiate among types of viral hepatitis.

Acute hepatitis A

Immunoglobulin M antibody to hepatitis A virus (IgM anti-HAV)-positive

Acute hepatitis B

IgM antibody to hepatitis B core antigen (IgM anti-HBc)-positive; and hepatitis B surface antigen (HBsAg)-positive

Acute hepatitis C

Serum alanine aminotransferase levels more than seven times the upper limit of normal;

and

Antibody to hepatitis C virus (anti-HCV) positive (repeat reactive) by screen ing immunoassay, and confirmed by a more specific assay (e.g., recombinant immunoblot assay [RIBA] for anti-HCV or nucleic acid testing for HCV RNA)

or

Anti-HCV-positive (repeat reactive) by screening immunoassay and a signal- to-cutoff ratio predictive of a true positive as determined for the particular assay (e.g., 3.8 for screening enzyme immunoassay).

Laboratory tests for diagnosis of chronic hepatitis:

Chronic hepatitis B virus infection

HBsAg-positive, total anti-HBc-positive, and IgM anti-HBc-negative,

or

HBsAg-positive two times six months apart

Chronic hepatitis C virus infection

Anti-HCV-positive (as defined above) and HCV RNA-positive six months apart


*—See Table 2 for interpretation of other markers of HBV infection.

From Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. Morbid Mortal Wkly Rep MMWR 2003;52(RR-1):9.

TABLE 1   Diagnostic Testing for Infection with Hepatitis Viruses*

View Table

TABLE 1

Diagnostic Testing for Infection with Hepatitis Viruses*

For persons with acute hepatitis, testing should be performed to differentiate among types of viral hepatitis.

Acute hepatitis A

Immunoglobulin M antibody to hepatitis A virus (IgM anti-HAV)-positive

Acute hepatitis B

IgM antibody to hepatitis B core antigen (IgM anti-HBc)-positive; and hepatitis B surface antigen (HBsAg)-positive

Acute hepatitis C

Serum alanine aminotransferase levels more than seven times the upper limit of normal;

and

Antibody to hepatitis C virus (anti-HCV) positive (repeat reactive) by screen ing immunoassay, and confirmed by a more specific assay (e.g., recombinant immunoblot assay [RIBA] for anti-HCV or nucleic acid testing for HCV RNA)

or

Anti-HCV-positive (repeat reactive) by screening immunoassay and a signal- to-cutoff ratio predictive of a true positive as determined for the particular assay (e.g., 3.8 for screening enzyme immunoassay).

Laboratory tests for diagnosis of chronic hepatitis:

Chronic hepatitis B virus infection

HBsAg-positive, total anti-HBc-positive, and IgM anti-HBc-negative,

or

HBsAg-positive two times six months apart

Chronic hepatitis C virus infection

Anti-HCV-positive (as defined above) and HCV RNA-positive six months apart


*—See Table 2 for interpretation of other markers of HBV infection.

From Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. Morbid Mortal Wkly Rep MMWR 2003;52(RR-1):9.

TABLE 2

Interpretation of Hepatitis B Virus Serologic Testing

Serologic markers
Interpretation HBsAg Total anti-HBc IgM anti-HBc Anti-HBs

Susceptible, never infected

Acute infection, early incubation period*

+

Acute infection

+

+

+

Acute resolving infection

+

+

Past infection, recovered and immune

+

+

Chronic infection

+

+

False positive (i.e., susceptible), past infection, or low-level chronic infection

+

Immune from vaccination if antibody concentration 10 mlU per mL

+


HBsAg = hepatitis B surface antigen; anti-HBc = antibody to hepatitis B core antigen; IgM = immunoglobulin M; anti-HBs = antibody to hepatitis B surface antigen.

*—Transient HBsAg positivity (lasting 21 days) might be detected in certain patients during vaccination.

From Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. Morbid Mortal Wkly Rep MMWR 2003;52(RR-1):12.

TABLE 2   Interpretation of Hepatitis B Virus Serologic Testing

View Table

TABLE 2

Interpretation of Hepatitis B Virus Serologic Testing

Serologic markers
Interpretation HBsAg Total anti-HBc IgM anti-HBc Anti-HBs

Susceptible, never infected

Acute infection, early incubation period*

+

Acute infection

+

+

+

Acute resolving infection

+

+

Past infection, recovered and immune

+

+

Chronic infection

+

+

False positive (i.e., susceptible), past infection, or low-level chronic infection

+

Immune from vaccination if antibody concentration 10 mlU per mL

+


HBsAg = hepatitis B surface antigen; anti-HBc = antibody to hepatitis B core antigen; IgM = immunoglobulin M; anti-HBs = antibody to hepatitis B surface antigen.

*—Transient HBsAg positivity (lasting 21 days) might be detected in certain patients during vaccination.

From Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. Morbid Mortal Wkly Rep MMWR 2003;52(RR-1):12.

Health Education and Release Planning

Health education concerning the prevention of viral hepatitis should include information related to the disease, routes of transmission, risk factors for infection, methods of prevention, disease outcomes, and treatment options. Various forms of education material include videos, brochures, formal classroom presentations, and face-to-face sessions. Comprehensive release planning for incarcerated persons includes transitional housing, continued access to discharge medications and immunizations, and coordination and case management of long-term specialized care for persons with chronic conditions. Persons with chronic hepatitis B or chronic hepatitis C can benefit from counseling, referrals to substance-abuse treatment programs, and medical referrals to subspecialists for future treatment.



Copyright © 2003 by the American Academy of Family Physicians.
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