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PAPERS: Shane Allwright, Fiona Bradley, Jean Long, Joseph Barry, Lelia Thornton, and John V Parry Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey BMJ 2000; 321: 78-82 [Abstract] [Full text]

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We need evidence of the risks and benefits of introducing needle exchange schemes in prison

Bobby P Smyth   (20 July 2000)

The criminal justice system, health inequalities, the medical profession and the BMJ..

Noel McCarthy   (28 July 2000)

The BMJ and the health aspects of imprisonment

Richard Smith   (29 July 2000)

OF THE IMPORTANCE OF GENOTYPING HCV

Malik T Qayyum   (4 August 2000)

Low levels of hepatitis B vaccination uptake in hepatitis C positive prisoners

Matthias L Schmid   (8 August 2000)

The risks of syringe exchange program in prisons prevail

Herbert Langkamp   (17 August 2000)

We need evidence of the risks and benefits of introducing needle exchange schemes in prison 20 July 2000
Bobby P Smyth Send response to journal: Re: We need evidence of the risks and benefits of introducing needle exchange schemes in prison	Editor - In their study of bloodborne viral infection in Irish prisons, Allwright et al found that hepatitis C infection was associated with continued injecting drug use in that setting1. A study by Stark in Germany has also demonstrated this finding2. The authors of both studies have highlighted the discrepancy between the existence of well developed harm reduction programs in the community, which include needle exchange and methadone maintenance, and the absence of such services in prisons. I would support the principle that imprisonment should not deprive an individual of access to services that have a proven harm reduction effect. However, examination of the currently available research evidence indicates that it is possible that provision of needle exchange could actually cause an increase in transmission of bloodborne viral infection in prisons. The findings reported by Allwright and Stark actually support this concern as they indicate that large numbers of injectors stop injecting while imprisoned. In the Irish prison study, 51% of injectors had not injected in the month prior to interview1. In the German study, 53% of injectors had never injected while in prison2. An Australian study, examining incidence of hepatitis C among prisoners, found that longer stay in prison (with no access to needle exchange) protected injectors against infection3. One plausible interpretation of this research evidence is the following; injectors who inject in prison tend to do so unsafely, but as so many injectors cease injecting during their sentence, the incidence of infection (and other adverse events such as accidental overdose) drops among the total population of imprisoned injectors. There has been insufficient examination of the reasons why so many injectors cease or curtail injecting while in prison. There are many possible explanations for this finding but the absence of available sterile injecting equipment could be an important factor. Although there is no evidence that provision of needle exchange encourages individuals to commence injecting in the community, implementation of such a service could cause many more of these established injectors to opt to continue injecting while in prison. While I acknowledge that introduction of needle exchange in prison could ultimately be demonstrated to have a very beneficial harm reduction effect, its introduction now would be premature while we have a poor understanding of these factors which mediate the observed reduction of injecting in this setting. Bobby P Smyth, specialist registrar, Academic Unit, Young People's Centre, 79 Liverpool Rd., Chester CH2 1AW References: 1 Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000;321: 78-82. 2 Stark K, Bienzle U, Vonk R, Guggenmoos-Holzmann I. History of syringe sharing in prison and risk of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus infection among injecting drug users in Berlin. Int J Epidemiol 1997;26: 1359-1365. 3. van Beek I, Dwyer R, Dore GJ Luo K, Kaldor JM. Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study. BMJ 1998; 317: 433-437.
The criminal justice system, health inequalities, the medical profession and the BMJ.. 28 July 2000
Noel McCarthy, SpR in Public Health Oxfordshire Health Authority Send response to journal: Re: The criminal justice system, health inequalities, the medical profession and the BMJ..	Editor – Allwright et al are to be congratulated for obtaining and presenting further solid evidence of the unacceptable health effects of prisons (1). They also emphasise in their closing statement what is well known, that imprisonment adds “to the health risks of this already disadvantaged population.” This evidence from Ireland extends similar earlier findings available relating to Scotland 2. The BMJ has a good record of publishing studies describing the health damage wrought by European punishment systems (1,2,3,4) including robust editorial comment by researchers on the lack of evidence based health protection measures in UK prisons. However the journal does not go further to editorially address the legitimacy of these punishment systems from a health viewpoint. It is salutary to contrast our silent assent to health damage caused by of our own punishment regimens with our willingness to criticise other cultures. A well reasoned piece from Médecins Sans Frontières described the difficulties in expressing dissent against the Sharia punishment system in Afghanistan (5). Given findings that 21% of drug using prisoners started injecting in prison and a dose response relationship between time in prison and risk of hepatitis C infection (1) can we really say that punishment systems in the British Isles are less barbaric than those which amputate a hand? The BMJ “Editor’s choice” accompanying the articles on Sharia punishment describe judicial amputation as a challenge to the ethics of humanitarian organisations, but the journal is silent on the ethics of judicial elevation of the risk of drug addiction and hepatitis C infection. This highlights real challenges to the medical profession. Should the medical profession support widespread punishment by imprisonment in our current society? Should the profession take the lead in conducting a health impact assessment of imprisonment? Also, given that many of the factors predicting poor health and other disadvantage also predict imprisonment, a health inequalities impact assessment is needed. It seems safe to assume that no major political party will make this debate a priority in the near future. If the medical profession in the UK and the BMJ as their most representative journal has a duty to the health of the worst off in our society then they must take a lead in this area. Surely the BMJ should be trying to facilitate the debate on the medical profession’s relationship with UK punishment systems at least as overtly as it has done in relationship to more distant lands. 1. Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000;321:78-82. 2. Gore SM, Bird AG, Burns SM, Goldberg DJ, Ross AJ, Macgregor J. Drug injection and HIV prevalence in inmates of Glenochill prison. BMJ 1995; 310: 293-296. 3. Gore SM, Bird AG. Drugs in British prisons. Editorial. BMJ 1998; 316: 1256-1257. 4. Rotily, M, Delorme, C, Obadia, Y, Escaffre, N, Galinier-Pujol, A (1998). Survey of French prison found that injecting drug use and tattooing occurred. BMJ 316: 777-777. 5. Perrin P, Nolan H. Ethical dilemma: Sharia punishment, treatment, and speaking out. Supporting Sharia or providing treatment: the International Committee of the Red Cross • Learning to express dissent: Médecins Sans Frontières. BMJ 1999 319: 445-447.
The BMJ and the health aspects of imprisonment 29 July 2000
Richard Smith, Editor BMJ Send response to journal: Re: The BMJ and the health aspects of imprisonment	I always tell young editors that if they are going to criticise a book then they need to read every word carefully. It's hard on Dr McCarthy to suggest that he should read every word of the BMJ back to 1840, but if he had done so he would have found that the BMJ has a long history of commenting on the health aspects of imprisonment. I'm particularly sensitive to this because I wrote a long series of articles on almost all aspects of imprisonment from a health point of view back in the early 80s. These articles were then published as a book in 1984,(1) and I will arrange for Dr McCarthy to be sent a copy. He will see that it takes a long historical view, discusses what prison is for, and makes many criticisms of prison health care. These articles sent a strong signal that the BMJ was interested in the health aspects of imprisonment, and that's one of the reasons that we've published much more since then. But I'm conscious that saying that we published a lot on this 20 years ago is not an adequate answer to Dr McCarthy, and we perhaps need to publish more now. Perhaps Dr McCarthy would like to submit something-- because most of what we publish is submitted not commissioned or written by us. Richard Smith Editor, BMJ 1 Smith R. Prison health care. London: BMA, 1984.
OF THE IMPORTANCE OF GENOTYPING HCV 4 August 2000
Malik T Qayyum Send response to journal: Re: OF THE IMPORTANCE OF GENOTYPING HCV	Editor - Shane Allwright et al present an interesting paper about the prevalence of antibodies to hepatitis B core antigen , hepatitis C virus , and HIV in an Irish prison population . (1). This study reveals that more than a third of the studied population and more than 80% of injecting drug users in Irish prisons , are positive for antibodies to hepatitis C virus . These results are informative though not surprising as the prevalence of antibodies to hepatitis C virus in other prisons mentioned in the article are nearly similar . The authors also mention that sharing needles in the prison emerges as a significant risk factor for hepatitis C in injectors . Besides intravenous drug abusers ,the other group which has a high prevalence of antibodies to hepatitis C virus is haemodialysis patients ( 17.7% of patients on EDTA registry EDTA data 1993 ) and 30.25% of patients on haemodialysis in Dammam Central Hospital . (2) In some studies the duration of heamodialysis appears as anz important risk factor besides blood transfusion. (3). Similarly Allwright et al finds that prisoners who have spent more time in prison over the past ten years are significantly more likely to be positive for antibodies to hepatitis C virus . These results are expected, as the main route of transmission of hepatitis C virus are parenteral . But apart from high risk groups such as drug abusers , dialysis patients and haemophiliacs treated before 1986 , surprisingly a very high prevalence ( 18.14% ) of antibodies to hepatitis C virus has been found in healthy Egyptian volunteer blood donors (2). Genotype 4 is mainly found in Egypt and Central Africa , and Genotypes 1a , 1b are predominant in Western Europe where as subtype 3 is more frequently found in intravenous drug abusers. (4) Strain genotyping ( which was not part of Allwright's study ) not only permits tracing infection but it may also help in answering the question " Does different strains of hepatitis C virus have the same mode of transmission ? " Strain genotyping has opened a new scope of investigations and may prove crucial in epidemiological research of hepatitis C virus which has become a major new public health challenge. A wide epidemiological survey needs to be done in this area and it may provide new insights in the transmission routes as , 20 - 50% of cases with hepatitis C virus liver diseases , depending or risk factors , remain with out any recognized aetiology. (5) Dr. Malik T Qayyum MRCP Consultant Physician/Nephrologist, Dammam Central Hospital P.O. Box 12723, Dammam 31483, Saudi Arabia . Dr. Youmbissi T. Joseph. MSC, MD, FRCP. Consultant Physician/ Nephrologist, Dammam Central Hospital Honorary Professor of Medicine King Faisal University. P.O. Box 12723, Dammam 31483, Saudi Arabia. Dr. Al- Khurasany I. A. MBBS. PHD ( Newcastle ) Consultant Nephrologist, Hospital Director . Dammam Central Hospital P.O. Box 12723, Dammam 31483, Saudi Arabia . 1. Allwright S, Bradley F, Long J , Barry J, Thornton L , Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000 ; 321: 78-82 ( 8July ) 2. Fathalla SE, Al-Jama AA, . Badawy MS, Sabry HS, Awad OA, Abdulaziz FM,El- Najar MKM et al . Prevalence of Hepatitis C virus infection in the Eastern Province of Saudi Arabia by RE-DNA Second Generation and Supplemental EIA Tests . Saudi Medical J 1994; 15 (4): 281-5 3. Natov SN, Pereira BJG. Hepatitis C infection in patients on dialysis. Semin Dial 1994; 7: 360-368. 4. Choo QL , Kuo G, Weiner AJ, Over by LR , Bradly DW, Houghtlon M. Isolation of a C DNA derived from a blood borne non - A, non B hepatitis genome. Science 1989; 244: 359-362. 5. Botte Cand Janot C. Epidemiology of HCV in the general population. Nephrol Dial Transplant 1996; 11 ( Supp 4 ) : 19-21.
Low levels of hepatitis B vaccination uptake in hepatitis C positive prisoners 8 August 2000
Matthias L Schmid, Consultant Physician Department of Infection & Tropical Medicine, Newcastle General Hospital, Newcastle upon Tyne Send response to journal: Re: Low levels of hepatitis B vaccination uptake in hepatitis C positive prisoners	Editor - Allwright et al (1) have produced a highly commendable insight into blood-borne infections among prisoners in the Irish Republic, highlighting in particular the high prevalence of hepatitis C (HCV) in that group. Data for England and Wales suggest a similarly high HCV prevalence rate in the same population (2). In the UK it is recommended (3) that prisoners should be vaccinated against hepatitis B (HBV), particularly injecting drug users (IDUs) and HCV+ve individuals. With this in mind, there is a paucity of information in Allwright et al’s paper relating to HBV vaccination uptake among Irish HCV and HIV+ve inmates. In 1999 we carried out an unselected prospective study of a proportion (132/550 HCV+ve patients) of the Sheffield HCV cohort (4). The majority of the 132 were IDUs or ex-IDUs (>80%) and a significant proportion of these had previously been incarcerated in prison (over 40% admitted to prison sentence). Serological testing revealed 60% had no evidence of previous HBV exposure. Only 20% of the 132 had protective antibody levels against HBV. Harm minimisation should start with a properly executed vaccination programme targeting all prisoners thus minimising the risk of acquiring or disseminating HBV and reducing the risk of more aggressive liver disease (5). Furthermore, hepatitis A vaccination may also be worth considering for similar reasons (5). Matthias L Schmid, Consultant Physician Department of Infection & Tropical Medicine, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE Stephen T Green, Consultant Physician. Michael W McKendrick, Consultant Physician. North Trent Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF References: 1. Allwright S, Bradley F, Long J, Barry J, Thornton L, and Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000; 321: 78-82. 2. Weild AR, Gill ON, Bennett D, Livingstone SJM, Parry JV, Curran L. Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey. Commun Dis Public Health 2000; 3: 121-6. 3.Wool R. Hepatitis B protocol for immunisation of inmates. London: HM Prison Service Directorate of Health Care, 1996 (DDL (96)2). 4. Schmid ML, Green ST, Bremner J, Kudesia G, Webster J, McKendrick MW. Hepatitis A & B sero-prevalence and vaccination uptake in Hepatitis C positive patients. Poster abstract. Sixth FIS meeting, 1999, Manchester, UK. 5. Pramoolsinsap C, Poovorawan Y, Hirsch P, Busagorn N, Attamasirikul K. Acute, hepatitis-A super-infection in HBV carriers, or chronic liver disease related to HBV or HCV. Ann Trop Med Parasitol 1999; 93: 745-51.
The risks of syringe exchange program in prisons prevail 17 August 2000
Herbert Langkamp, Anstaltsarzt JVA Nuremberg Germany Mannertstr. 6 90429 Nürnberg Send response to journal: Re: The risks of syringe exchange program in prisons prevail	Since the beginning of the AIDS epidemic, more than 95% of the prisoners in Bavarian prisons (in Germany) have been tested for HIV when placed under detention. Altogether, 203,366 tests have been conducted between 1985 and March 3, 1998. Upon entering prison, 1379 prisoners were diagnosed as infected with HIV for the first time, among them 797 were drug-users. During the course of their detention, approximately 35,000 prisoners have been tested, predominantly drug addicts. Among those 35,000 examinations, only one “fresh” infection, which must have taken place during imprisonment, was found. These figures prove the protective character of detention in Bavaria. In recent years, HIV prevalence has been about 0.4%. In order to estimate the situation regarding infections of Hepatitis B and C, the Bavarian Department of Justice set up a work group, whose members are mainly prison doctors. In 1999, extensive examinations were conducted in several Bavarian prisons. ____________________________________________________________ Prison N HCV positive % of all prisoners HCV positive IDUs Remarks __________________________________________________________ Nuremberg 1014 11,9 61% Predominantly male prisoners, aver. number of IDUs, many first-time prisoners, results represent Bavarian average Aichach 888 22,2 61% Women, very high number of IDUs Bernau 1588 18,4 75% Exclusively men, repeat offenders, highest number of IDUs Kaisheim 220 19,0 64% Men, long-term imprisonment, very large number of IDUs __________________________________________________________ On average, 2.3% of the inmates were HBsAg positive. They were mostly foreign prisoners from Eastern Europe, Africa, and Asia, who were not drug addicts. Among the high-risk group of injecting drug users (IDUs) only 2.4% (Nuremberg) or 2.7% (Bernau) were HbsAg positive. In Nuremberg 1.2% of IDUs were infected with the HI-Virus. A 1999 inquiry of the doctors of the largest of the 37 Bavarian prisons (12,300 inmates) showed that there was not a single case of acute clinical Hepatitis C during the course of detention! In Kaisheim and Aichach, the prisoners were systematically examined upon their release. In Aichach, among the 76 prisoners tested not a single case of serum conversion could be found; in Kaisheim, there was one case out of 137. The number of refusals was high in Kaisheim and in Aichach the observation period lasted for only eight months. In Bernau prison, one case of serum conversion was observed during detention. When the doctor’s files of 130 HCV-positive inmates at Nuremberg’s prison were evaluated, there was indication that two juvenile prisoners had possible been infected during the course of their detention. One may have been infected by a “blood- brother” ritual and the other by IDU or tattooing. Though it is not certain that these infections took place in prison, they indicate that infections are occurring in prison. The overwhelming number of infections is being brought into prison by inmates who had been infected before. A multitude of studies show that drug users are most likely to become infected with HCV at the beginning of their addiction(2-6) – usually long before being imprisoned for the first time. In Germany, one can observe this phenomenon very well among young emigrants of German background coming from areas of the former Soviet Union. Most of them have lived in Germany only a few years, began consuming drugs intravenously, and are – to an alarming degree – infected with HCV before their first prison sentence. In Laufen-Lebenau, a prison for juvenile delinquents, for example, this group represents only 10% of all inmates, but 52% of the infected prisoners (HCV-RNA or HBV-DNA positive). All in all, the incidence rate of Hepatitis C among prison inmates is considerably lower than outside prison walls. Detention protects against infection according to the results of a study concerning serum conversion in Maryland(11). Syringe exchange programs have been successful in the prevention of HIV outside prisons, yet the results concerning prevention of Hepatitis C are not quite as promising(7,8,9). Probably drug and work-sharing plays a big role with Hepatitis C (12,13,14). The scientific evaluation of a project concerning a syringe exchange program in a prison in Hamburg has shown that many prison inmates, who had dispensed with drug use before, started abusing drugs again. Also, many inmates went from inhaling back to intravenous drug abuse. At the same time, they continued regular needle- sharing. It was therefore not recommended to continue the syringe exchange program under the conditions of the Hamburg pilot project (10). Contrary to the Irish survey, there was hardly any indication of new drug users in Hamburg. The decisive factor in the incidence of Hepatitis C in prisons has been the availability of Heroine. If there is little Heroine in a given prison, the transfer rate is low, since there is a lower rate of intravenous drug abuse. The “going rate” of Heroine in prisons is comprised of the street-price plus an extra charge for smuggling it into the penal system. In Bavarian prisons, a strict zero-tolerance-policy is followed concerning drugs. Under these circumstances, a syringe exchange program would be misunderstood as accepting drugs. In no time at all, precautions would be useless and prisons flooded with Heroine. The situation would be out of control and infection rates would rise considerably. All things considered, the Bavarian drug policy is conservative, yet even in liberal Amsterdam, nobody sees a reason to introduce syringe exchange programs into prisons(1) In Nuremberg, 50% of the inmates who were infected only found out about their condition during imprisonment. A complete screening of the high-risk group of IDUs records those who are HCV-positive and holds them responsible for not transferring their infection. Those who were tested HCV-negative are encouraged to further protect themselves. During imprisonment, detailed information can reach groups of people who would not be reached by systems of aid outside the prison walls. This is especially true for the imprisonment of juvenile delinquents. Dr. Herbert Langkamp Anstaltsarzt JVA Nürnberg Mannertstraße 6 , 90429 Nürnberg, Germany for the Arbeitsgruppe Hepatitis im bayerischen Strafvollzug (Dr. Braun, Munich; Dr. Döring, Aichach; Dr. Hartmann-Llanos, Kaisheim; MD Geißler, RD Rieger-Kaiser, Bayreuth; Dr. Strigl, Bernau) References: 1. van Haastrecht HJ, Bax JS, van den Hoek JA: Little HIV risk behavior in drug users during detention in Dutch penitentiaries.Ned Tijdsch Geneeskd 1;14(9);429-33 (1997 ) 2. Alter MJ, Moyer LA: The importance of preventing hepatitis C virus infection among injection drug users in the United States. J Acquir Immune Defic Syndr Hum Retrovirol 18 Suppl 1:S6-10 (1998) 3. Villano SA, Vlahov D, Nelson KE, Lyles CM, Cohn S, Thomas DL: Incidence and risk factors for hepatitis C among injection drug users in Baltimore, Maryland. J Clin Microbiol Dec;35(12):3274-7 (1997) 4. Lamden KH, Kennedy N, Beeching NJ, Lowe D, Morrison CL, Mallinson H, Mutton KJ, Syed Q: Hepatitis B and hepatitis C virus infections: risk factors among drug users in Northwest England. J Infect Nov;37(3):260-9 (1998) 5. Chang CJ, Lin CH, Lee CT, Chang SJ, Ko YC, Liu HW: Hepatitis C virus infection among short-term intra-venous drug users in southern Taiwan Eur J Epidemiol Aug;15(7):597-601 (1999) 6. Rezza G, Sagliocca L, Zaccarelli M, Nespoli M, Siconolfi M, Baldassarre C : Incidence rate and risk factors for HCV seroconversion among injecting drug users. Scand J Infect Dis 28(1):27-9 (1996) 7. Lamden KH, Kennedy N, Beeching NJ, Lowe D, Morrison CL, Mallinson H, Mutton KJ, Syed Q: Hepatitis B and hepatitis C virus infections: risk factors among drug users in Northwest England. J Infect Nov;37(3):260-9 (1998) 8. Hagan H, McGough JP, Thiede H, Weiss NS, Hopkins S, Alexander ER: Syringe exchange and risk of infection with hepatitis B and C viruses. Am J Epidemiol Feb 1;149(3):203-13 (1999) 9. Henrion R: Effectiveness of measures taken in France to reduce the risks of heroin addiction via intravenous route. Bull Acad Natl Med Jun- Jul;181(6):1177-85; disc. (1997) 10. Gross U: Wissenschaftliche Begleitung und Beurteilung des Spritzentauschprogramms im Rahmen eines Modellversuchs der Justizbehörde der Freien und Hansestadt Hamburg Evaluationsbericht eines empiri-schen Forschungsprojekts. Kriminologisches Forschungsinstitut Niedersachsen, Forschungsbericht Nr. 73 November 1998 11. Vlahov D, Nelson KE, Quinn TC, Kendig N : Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. Eur J Epidemiol Sep;9(5):566-9 (1993) 12. Jose B, Friedman SR, Neaigus A, Curtis R, Grund JP, Goldstein MF, Ward TP, Des Jarlais DC: Syringe-mediated drug-sharing (backloading): a new risk factor for HIV among injecting drug users. AIDS Dec;7(12): 1653- 60(1993) 13. Stark K, Muller R, Bienzle U, Guggenmoos-Holzmann I: Frontloading: a risk factor for HIV and hepatitis C virus infection among injecting drug users in Berlin. AIDS Mar;10(3):311-7 (1996) 14. Ingold FR, Toussirt M: Attitudes and practices of drug users confronted with the risks of contamination by human immunodeficiency virus (HIV) and hepatitis B Bull Acad Natl Med Mar 18;181(3):555-67; discussion (1997)