Infection Control Today - 08/2003: Criminal Element

Criminal Element
Silent Infectious Invaders from theU.S. Correctional System

By Kathy Dix

How many of your patients have close contact withpeople who have been in prison? Do you know if they have been exposed totuberculosis (TB), Human Immunodeficiency Virus (HIV) or hepatitis C virus (HCV)?

The incidence of all three diseases isexponentially higher inside correctional settings compared to the outside.People from a variety of settings enter your facility every day, for surgery,for outpatient procedures like endoscopy, for visits to current patients, or tomake use of the emergency room.

Has anyone in your care or of your acquaintancebeen in a correctional facility or worked in one? Even pastors ministering totheir imprisoned flocks can be exposed to airborne TB particles if a prisoner isundiagnosed and not isolated. Chances are good that any of these patients prison guards, ministers, former prisoners, social workers, parole officers or their families are entering your facility on a daily basis. And any of themmay have been exposed.

Correctional settings are unique in that they area perfect setting for communicable disease large (often overcrowded)concentrated populations of people who interact with the same people daily andwho have ample time to be exposed to other prisoners with infections.Overcrowding often leads to early release, thus allowing potentially infectedinmates into the outside population to spread disease among non-prisoners.

Whats more, after release, many formerprisoners have no insurance or access to healthcare. If they do seek treatment,it may be at the local emergency room. If they do not, illnesses that could becured go untreated; former prisoners may sicken or be exposed to new pathogens.If they commit new crimes and are imprisoned again, they can bring not onlytheir existing diseases but any new ones back into the correctional facility.

In addition to the overcrowding, poor ventilationand sexual contact are risk factors for these inmates. Healthcare facilitieswithin the correctional environment are rarely top-notch. The diet may not beideal, either carbohydrate-rich, and devoid of fresh fruits and vegetables.In the United States, hygiene and sanitation are not quite the issue they mightbe in other countries, but still, probably do not live up to the standards offive-star hotels. All of these factors can contribute to the spread of disease.

Treatment

Even if inmates are diagnosed and there is timeto treat them before theyre released, it may be difficult to enforcecompliance with a treatment protocol. People who (obviously) have issues withrules and regulations may be contrary by nature to any dictate from an authorityfigure.

Regimens for countering viral infections can beparticularly onerous; the National Institutes of Health Consensus Committeerecommends that HCV be treated with 3 million units of interferon subcutaneouslythree times a week for one year. HIV treatment for patients without symptomscan require 20 pills a day for life. And tuberculosis treatment may call for upto 16 pills a day for two months, followed by up to nine pills a day for fourmore months.1

It is possible that even though the patient is acaptive audience, the pharmaceutical protocol will not be followedappropriately, or will be followed for only a fraction of the recommendedduration. Patients may share drugs, sell them or simply refuse to take them. Itis crucial to educate inmates about their diseases, about the possibility ofdeveloping resistant microorganisms, and about the possibility of contagionuntil the disease is eliminated.

Hepatitis

Studies have shown that 80 percent of inmatesadmit to using illegal drugs; 25 percent have used parenteral drugs. Annually,1.4 million HCVinfected people as much as 30 percent of HCV-infected peopleoverall are sent through the correctional system each year. Many HCV casesgo undiagnosed, as prison systems rarely test for the disease unless it ismedically necessary. The possibility of transmission is staggering over amillion infected carriers and a subculture of IV drug use. Since HCV isblood-borne, it takes full advantage of the ease of transmission provided byshared needles, which may be epidemic in prison populations. It can be spread byIV drug use, tattooing and needlestick injuries.2

Currently, a combination of interferon andribavirin is recommended to treat HCV; therapy can last from six months to oneyear, depending on the genotype of the virus (genotype 1 should be treated for afull year). Non-response to interferon monotherapy can be assessed at threemonths.

Adverse events associated with interferon therapycan include flu-like side effects, irritability, depression or anemia. Moreserious side effects can include severe depression, seizures and bacterialinfections, which may be alleviated by reducing the dosage of interferon.

Ribavirin side effects can include hemolyticanemia; this medication is teratogenic, so patients taking it should usereliable birth control throughout treatment and for six months afterward.

HIV

A study presented at a CDC-sponsored conferencefound that 13 to 17 percent of Americans with HIV or AIDS are recently-releasedprisoners.3

As many as 50 percent of patients who arerecently infected/seroconverted with HIV will be symptomatic, say Piliero etal.4 Acute infection should be treated as early as possible; patients with bothchronic and acute infection should be referred to a physician experienced in thetreatment of HIV.

Opportunistic infections associated with AIDS aremany and include pneumocystitis carinii pneumonia, cytomegalovirus, disseminatedmycobacterium avium complex, syphilis, febrile neutropenia and cellulitis.

A program sponsored by a BrownUniversity-affiliated hospital outpatient clinic aims to improve theretention of HIV positive ex-offenders in outpatient medical care through socialstabilization. Project Bridge, an extension of a continuing alliance betweenthe hospital and the Rhode Island State Department of Corrections, improvescontinuity of care for inmates re-entering the community. The process involvesdischarge planning before release, combined with intensive community follow-upfor 18 months after release.5

Inmates undergo two to three interviews beforerelease and, if they are reincarcerated during the 18-month program, theyreceive follow-up care while in prison. This follow-up allows healthcare staffto re-examine the continuing healthcare and to revise a treatment plan for thenext release.

Tuberculosis

Tuberculosis rates are three times higher inprison populations than in the general public. The study at the CDC conferenceannounced that newly-released inmates make up 35 percent of Americans infectedwith TB.

The World Health Organization (WHO) notes that TBtransmission is aided by common prison conditions such as overcrowding, poornutrition and inadequate ventilation. Other factors include weak health careprovision, a lack of continuity and equivalence of care between civilian andprison health services, the high mobility of the population, corruption,violence and legislation.

There is more to preventing TB than diagnosingand treating patients.

Other steps appear less direct but are just asimportant in ensuring that healthcare staff members are seen as allies, notenemies:

• Establishing who is responsible for inmates health once they have been released, and ensuring appropriate follow-up care

• Cooperation between prison and civilian health authorities

• Ensuring that healthcare staff within the prison are not also responsible for security or custody of the prisoner

• Allowing only healthcare staff to have access to patients medical records

• Basing clinical decisions exclusively on health criteria

• Being aware of how administrative choices can affect the prison populations health Because prisoners are often transferred or relocated many times, continuity of care is difficult; ensuring communication between the old and new locations and ensuring adequate continuing care are essential.

Corruption within the prison system is expected;patients may have incentive to either join or ignore a TB treatment program.They may want to appear TB-positive because of real or perceived benefitsto being in the program; they may want to leave the program because they worrythat a positive diagnosis will prevent early release or family contact.For these reasons, fresh or dried sputum may be traded between prisoners toallow the positive or negative diagnosis. TB drugs may even be used as currencywithin the prison system.

The role of civilian healthcare systems cannot beemphasized enough; TB can start in prison and travel to the outside community.This, says the WHO, Occurs as a result of releases, amnesties or prisonertransfers, plus the regular contact through staff and visitors ... Ex-prisonersmay also account for a significant proportion of community cases ... For thesereasons, it is clearly in the interest of a civilian TB service to actively seekgood TB control in prison.

It is possible that prisons could adopt civilianTB prevention programs; regardless of the specific prevention effort in use,continuity of care for released prisoners is crucial. This is important forindividuals to ensure their cure, but also for the prison administration asthese cases may well be re-arrested in the future and bring their uncured ordrug-resistant TB back with them to prison society, says the WHO.

Studies demonstrate that recidivism is rampant,and that 60 percent of current prisoners have been imprisoned before; 45 percenthave three or more prior sentences.

The World Health Organization dictates thatdirect observation of treatment (DOT) be non-negotiable in the correctionalsetting. DOT should be performed each and every time TB treatment isadministered.

WHO also recommends that the various treatmentduties dispensing tablets, administering injections, etc. be rotateddaily or weekly. Staff members should wear personal protective equipment insmear-positive and drug-resistant areas.

Specific recommendations are also provided forthe alleviation of side effects:

• If minor side effects occur with rifampicin (anorexia, nausea, abdominal pain), give the drugs at bedtime. If joint pain occurs from pyrazinamide, treat with aspirin. If isoniazid causes a burning sensation in the feet, offer pyridoxine 100 mg daily. Advise patients that rifampicin can cause urine to turn orange and that it is a natural (and harmless) side effect.

• Major side effects such as itching, skin rash, jaundice, vomiting, confusion, shock, deafness, dizziness, thrombocytopenia or acute renal failure call for the drug to be stopped immediately. In many cases, an alternate drug can be used.