Transcript Implementing routine hepatitis B vaccination at the Rhode Island

Implementing routine hepatitis B
vaccination at the Rhode Island
Department of Corrections
(RIDOC) Women’s Division
Beth Schwartzapfel
Jennifer Clarke MD, Susan Shepardson MA, Stephanie
Sanford-Colby MPH, Jennifer Pomposelli RN, Gerald
Dornhecker RN, Josiah D. Rich MD MPH
The Miriam Hospital/
Brown Medical School
Providence RI
[email protected]
Prisons in the United States
• The incarcerated population in the U.S. has
skyrocketed in the past two decades
• Reached 2 million for the first time in 2002
• Incarcerations from drug offenses have
pushed this growth
• Since 1980 the number of people
incarcerated for drug offenses has grown
from 40,000 to 450,000.
Bureau of Justice Statistics 2003;NCJ 198877
www.cdc.gov.idu/facts/druguse.htm
Incarcerated persons comprise 0.7% of the US
population
The incarcerated setting: a public
health opportunity
• TURNOVER
– 528,848 individuals released from prison each year
– 10 million jail releases = ~7.2 individuals released
from jail each year
• Missed opportunities for HBV vaccination
– Incidence study in sentinel counties, 1982-1998
– 29% of acute HBV patients reported incarceration
prior to becoming infected
Hammett et al. Am J Pub Health 2002;92:1789.
Goldstein et al. J Infect Dis 2002;185:713.
The incarcerated setting: a public
health opportunity
• Routine HIV screening implemented at the
RIDOC in 1989
– Prevalence = 2% - 8x higher than RI population
– 31% of HIV cases in RI identified at RIDOC
– 43% of IDU-associated cases and 43% of
MSM&IDU cases in RI identified at RIDOC
Desai et al. AIDS Education and Prev 2002;14(Supp B):45.
Hepatitis B in prisons and jails
• Evidence of past infection among inmates
ranges from 30-43%
– General population (NHANES), 1988-1994: ~5%
• Prevalence higher among women than men
• 12-15% of all Americans with HBV (155,000
people) were releasees from prison or jail the
previous year
J Infect Dis 1984;150:529 / Am J Public Health 1985;75:1213
Clin Ther 1987;9:622. / Am J Public Health 1990;80:471.
MMWR 2003;52(RR-1): 2.
Public safety vs. public health
• Estelle vs. Gamble, 1978: Prisons
constitutionally mandated to provide health
care
• Conflicting priorities?
– Proactive vs. Reactive health care
– Public safety = public health
Why NOT vaccinate in prisons
and jails?
• Inmates often not incarcerated long enough
to complete series
• High refusal rates
• $$$$$$$$$$$$$$$$$
Charuvastra et al. Public Health Reports 2001;116:1-12.
Hepatitis B in Rhode Island
prisons and jails
• Epidemiologic study in female prisoners (1996-7)
– Prevalence among incoming women 36%
– Community incidence among re-incarcerated women
was 12.2 per 100 person-years
• Epidemiologic study in male prisoners (19982000)
– Prevalence among incoming men was 20%
– Incidence among incarcerated men 2.7 per 100 p-y
Macalino et al. 6th Conference on Retroviruses and Opportunistic Infections, 1999.
Macalino et al. Am J Pub Health 2004. In press.
RI Department of Corrections
• Single state correctional facility
• Jail and prison
• Average daily population
– Total: 3,426
– Women’s: 217
• Average length of stay:
– Non-sentenced: 2 weeks
– Sentenced: 10 months
– Women’s: 24 hours
RI Department of Corrections
• Intakes/year
– Total: 16,000
– Women’s: 2,000
• At intake:
–
–
–
–
HIV testing
Syphillis testing
PPD
Preliminary medical history
History of our program
• Medical director put $$ for HBV vaccine in
budget every year
– Every year this $$ was cut
• Vaccinations were offered non-systematically to
inmates with risk factors at medical visits
• 2000: 200 soon-to-expire doses of vaccine
donated to Women’s Division by DOH
– 93% of eligible inmates were vaccinated
• 73% received 2 doses
• 40% completed series
Clarke et al. Journal of Health Care for the Poor and Underserved 2003;14:318-323.
History of our program
• VHIPS, 1999-2003
• Meetings with wardens, medical staff,
director of RI DOC, MIS
– Agreed that nurses in Women’s Division would
administer HBV vaccine at intake
– Compromise: computerize
• Trainings with nursing staff
– Hepatitis B
– Benefits of vaccination
– Use of computer/database
History of our program
• Initiated vaccination of all incoming women
in 3/2002
• Initiated vaccination of sentenced men in
3/2003
• Goals for future: expand vaccination to all
incoming men
Acceptance rates
(as of 10/03)
• Women’s = 59%
• 1 dose: 65%
• 2 doses: 21%
• 3 doses: 14%
• Men’s = 95%
Cost
• Vaccine paid for by Federal 317 $$ under
state perinatal HBV prevention program
• Once vaccine was paid for, little additional
$$ was spent
– Some additional staff hours
– Infrastructure already exists
• HBV vaccination in prison is cost saving to
the health care system even when only 1
dose is administered
Pisu et al. Vaccine 2002;21:312.
Why not vaccinate in prisons and
jails?
• Inmates often not incarcerated long enough
to complete series
– Even 1 or 2 doses can confer 50-80% immunity
– Incomplete series does not need to be restarted
• Inmates who are released and reincarcerated can
pick up where they left off
• Alternative vaccination sites in the community
– Needle exchange/methadone clinics/drug treatment centers
– STD clinics (San Diego!)
– Homeless shelters/soup kitchens
Why not vaccinate in prisons and
jails?
• High acceptance rates
– Our #s are comparable to acceptance rates in
other high-risk settings
– Success in Men’s suggests that rates are
improved when:
• Staff is enthusiastic
• Inmates are not offered vaccine just hours after
being arrested
Why vaccinate in prisons and
jails?
• $$$$$$$$$$$$$$$$
– Be creative!!
– Be flexible!!
• Soon-to-expire doses
– Work with state vaccine coordinator
Conclusions
• Given cost of vaccine, routine HBV
vaccination can be implemented in the
correctional setting with little additional
effort or funds
• Requires communication and education
among all players
• Future directions
– Wraparound viral hepatitis program
– Peer education
Acknowledgements
• Centers for Disease Control and Prevention,
Viral Hepatitis Integration Program
– Cooperative agreement #U50/CCU119078
• RI Department of Health
• RI Department of Corrections
– A.T. Wall, Director
– Scott Allen, MD, medical director