Infection Control Today - 08/2003: Criminal Element

Criminal Element
Silent Infectious Invaders from the U.S. Correctional System

By Kathy Dix

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

The incidence of all three diseases is exponentially 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 to make use of the emergency room.

Has anyone in your care or of your acquaintance been in a correctional facility or worked in one? Even pastors ministering to their imprisoned flocks can be exposed to airborne TB particles if a prisoner is undiagnosed 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 them may have been exposed.

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

Whats more, after release, many former prisoners 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 be cured 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 only their existing diseases but any new ones back into the correctional facility.

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

Treatment

Even if inmates are diagnosed and there is time to treat them before theyre released, it may be difficult to enforce compliance with a treatment protocol. People who (obviously) have issues with rules and regulations may be contrary by nature to any dictate from an authority figure.

Regimens for countering viral infections can be particularly onerous; the National Institutes of Health Consensus Committee recommends that HCV be treated with 3 million units of interferon subcutaneously three times a week for one year. HIV treatment for patients without symptoms can require 20 pills a day for life. And tuberculosis treatment may call for up to 16 pills a day for two months, followed by up to nine pills a day for four more months.1

It is possible that even though the patient is a captive audience, the pharmaceutical protocol will not be followed appropriately, or will be followed for only a fraction of the recommended duration. Patients may share drugs, sell them or simply refuse to take them. It is crucial to educate inmates about their diseases, about the possibility of developing resistant microorganisms, and about the possibility of contagion until the disease is eliminated.

Hepatitis

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

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

Adverse events associated with interferon therapy can include flu-like side effects, irritability, depression or anemia. More serious side effects can include severe depression, seizures and bacterial infections, which may be alleviated by reducing the dosage of interferon.

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

HIV

A study presented at a CDC-sponsored conference found that 13 to 17 percent of Americans with HIV or AIDS are recently-released prisoners.3

As many as 50 percent of patients who are recently infected/seroconverted with HIV will be symptomatic, say Piliero et al.4 Acute infection should be treated as early as possible; patients with both chronic and acute infection should be referred to a physician experienced in the treatment of HIV.

Opportunistic infections associated with AIDS are many and include pneumocystitis carinii pneumonia, cytomegalovirus, disseminated mycobacterium avium complex, syphilis, febrile neutropenia and cellulitis.

A program sponsored by a Brown University-affiliated hospital outpatient clinic aims to improve the retention of HIV positive ex-offenders in outpatient medical care through social stabilization. Project Bridge, an extension of a continuing alliance between the hospital and the Rhode Island State Department of Corrections, improves continuity of care for inmates re-entering the community. The process involves discharge planning before release, combined with intensive community follow-up for 18 months after release.5

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

Tuberculosis

Tuberculosis rates are three times higher in prison populations than in the general public. The study at the CDC conference announced that newly-released inmates make up 35 percent of Americans infected with TB.

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

There is more to preventing TB than diagnosing and treating patients.

Other steps appear less direct but are just as important in ensuring that healthcare staff members are seen as allies, not enemies:

  • 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 benefits to being in the program; they may want to leave the program because they worry that a positive diagnosis will prevent early release or family contact. For these reasons, fresh or dried sputum may be traded between prisoners to allow the positive or negative diagnosis. TB drugs may even be used as currency within the prison system.

The role of civilian healthcare systems cannot be emphasized enough; TB can start in prison and travel to the outside community. This, says the WHO, Occurs as a result of releases, amnesties or prisoner transfers, plus the regular contact through staff and visitors ... Ex-prisoners may also account for a significant proportion of community cases ... For these reasons, it is clearly in the interest of a civilian TB service to actively seek good TB control in prison.

It is possible that prisons could adopt civilian TB prevention programs; regardless of the specific prevention effort in use, continuity of care for released prisoners is crucial. This is important for individuals to ensure their cure, but also for the prison administration as these cases may well be re-arrested in the future and bring their uncured or drug-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 percent have three or more prior sentences.

The World Health Organization dictates that direct observation of treatment (DOT) be non-negotiable in the correctional setting. DOT should be performed each and every time TB treatment is administered.

WHO also recommends that the various treatment duties dispensing tablets, administering injections, etc. be rotated daily or weekly. Staff members should wear personal protective equipment in smear-positive and drug-resistant areas.

Specific recommendations are also provided for the 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.

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