Download hepatitis c action plan for scotland

HEPATITIS C ACTION PLAN FOR SCOTLAND(1)
PRISON-BASED NEEDS ASSESSMENT
Introduction
Prisons can contribute to the control and management of the Hepatitis C epidemic in
Scotland. SPS' commitment to the Hepatitis C Action Plan is clear, through relevant work
on blood borne virus strategy, sexual health, health promotion and health protection.
Purpose
This document sets out ways in which prison and prison health care can contribute to:

improving health and wellbeing of prisoners through prevention, treatment and
care;

improving public health through reducing the supply of and demand for
injectable material, reducing harm from injecting, and reducing the risk to
injecting partners and intimate partners; and

reducing the harm from, and burden of care for, Hepatitis C in Scotland in the
future.
General Approach
This document will concentrate on 2 matters:

controlling the spread of Hepatitis C as a transmissible virus; and

reducing harm from injecting drug use as the chief risk factor.
Matters of sexual health, and the prevention of sexually transmitted infection is dealt with
in a separate document circulated in 2005,(2) available on request.
Hepatitis C in the Prison Population
An estimated 17% of prisoners carry Hepatitis C. Estimated prevalence is highest in the
26-35 year category at 24% for men, and 38% for women(3)(4). A minority are aware of their
infection, although good testing programmes now exist in long-term prisons and the
ascertainment rate is rising towards the expected level. For a total prison population
of 7,200, a prevalence rate of 17% means that there are approximately 1,700 Hepatitis C
positive carriers in custody at any one time - almost 3% of the estimated prevalence
Hepatitis C population in Scotland. Over one year, the figure is 3,700 or over 7.4% of the
Hepatitis C positive Scottish population, in that approximately 22,000 individuals pass
through prison in a year.
Intravenous Drug Use (IDU)
Prison is an incidental hazard in an IDU career. Of the Glasgow population, an IDU with a
10 year career can expect to have a 90% chance of being in prison during that time. For a
(1)
(2)
(3)
(4)
Hepatitis C Action Plan for Scotland, Phase 1: August 2006-July 2008, Scottish Executive, August 2006
Sexual Health Status of Prisoners: Fraser A, Scottish Prison Service, May 2005
Incidence of Hepatitis C Virus Infection and Associated Risk Factors Among Scottish Prison Inmates: A Cohort
Study: Champion J K, 2004, American Journal of Epidemiology, Vol 159, No 5
Prevalence of Hepatitis C in Prisons: WASH-C Surveillance Linked to Self-Reported Risk Behaviours: Gore S M,
1999, QJ Med, 92:25-32
SLA00423.106
1.
2-5 year career, the figure is 75%(5). In a recent English study, half of IDUs in prison had
been in custody before or around the time of starting to inject. Thirty per-cent of
these IDUs had been in prison more than 6 times.(6)
The prison population is 96% male.(7) However, the relatively few women have more severe
problems in every respect, including IDU.
In most other measures of Hepatitis C,
epidemiological characteristics are likely to reflect the general population.
There is strong evidence to suggest transmission of Hepatitis C in prison.(8)
There is good evidence of needle use and needle sharing in prison. A consistent annual
survey self-report figure of 3% reporting injecting, and 60-70% of them sharing (n=c.125)
illustrate the scale of injecting.(9)(10) Qualitative data document wide sharing of injecting
equipment by anything up to 20 users. Injecting is less frequent in prison than on the
outside, but each injecting episode is probably a higher risk. Evidence is only anecdotal
relating to IDUs starting their injecting career whilst in prison. Recent studies describe
qualitatively the types of influence at work that encourage injecting. (11)
Interventions
There are several distinct groups of interventions that are specific to prison, and others to
which prison can play a support role.
The lead roles are as follows:

health promotion, general and specific;

prevention, both of injecting behaviour, and transmission of Hepatitis C;

early detection through testing,
opportunities of that contact; and

primary prevention of other blood borne viruses through immunisation.
together
with
educational
and
other
Support roles include:

referral to NHS specialist care, with set protocols for clinical investigation prior
to first specialist consultation;

commitment to follow-up in a manner similar to long-term conditions;
sewing in the prison's commitment to Hepatitis C along with other aspects of rehabilitation
and care, health and wellbeing.
Health Promotion
Relevant interventions of a general nature include programmes to build self-esteem,
problem solving skills, cope with mental health problems, give relevant information about
(5)
(6)
(7)
(8)
(9)
(10)
(11)
Presentation made by Professor David Goldberg (Health Protection Scotland) at the 2003 (Chicago) Interscience
Conference on Antimicrobial Agents and Chemotherapy (American Society for Microbiology); "Prisons as
Amplification Systems for Infectious Diseases: Hepatitis C Virus Infection"
Duncan G, Prison Health Research Network Conference, Manchester, October 2006
Annual Report 2005-06, Scottish Prison Service
The Incidence of Hepatitis C Virus Infection and Associated Risk Factors Among Scottish Prisoners: A Cohort
Study: Champion J K, Taylor A, Hutchinson S J, Cameron S, McMenamin J, Mitchell A, Goldberg D J; The
American Journal of Epidemiology, 2004; 159(5), 514-519
Annual Prisoner Survey 2005, Scottish Prison Service
Annual Prisoner Survey 2006, Scottish Prison Service
"Examining the Injecting Practices of Injecting Drug Users in Scotland": Taylor A et al, 2004, Effective
Interventions Unit, Scottish Executive. Edinburgh
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2.
general self-care, hygiene and health matters; a range of matters relating to wider life
circumstances including housing and accommodation, basic life skills and employability.
Underpinning these initiatives is the need to encourage prospects of sustaining a drug-free
lifestyle through replacement with better prospects.
Specific matters both relating to health promotion and harm reduction are addictions
information, drugs information, availability of counselling and support services relating to
drug and other addiction problems, resuscitation and management of overdose.
Specific health promotion relating to Hepatitis C and injecting include information on
injecting and hazards, all blood borne viruses, Hepatitis C, information on alcohol problems
in general, poly-drug use especially with cocaine, and specifically relating to accelerating
the process of cirrhosis.
Disease Prevention
On injecting behaviour, SPS will develop strategies which include those set out above to
prevent prisoners starting an injecting career, or continuing an IDU career. SPS is
currently proposing a pilot project to offer a full set of clean injecting equipment to those
unable to discontinue the habit, as an avenue into treatment and non-injecting
alternatives. Some prisons already provide a range of paraphernalia without specific
injecting equipment for the purpose of harm reduction, although practice varies.
Measures to prevent the transmission of Hepatitis C include methadone for opiatedependent addicts as part of a supported drug treatment programme - programmes of
supported detoxification and other means of support for people with other addictions that
involve IDU. There is evidence that methadone programmes continued for a sufficiently
long time and adequately covering opiate craving will cut down the risk of re-entry into
prison and improve health.(12)
Currently, the Prison Service provides methadone
substitution therapy to 17% of the prison population, in collaboration with outside
prescribers. Eighty-three per cent say, on survey this year, that the programme controls
their craving.(9)
The matter of steroid injection and tattooing is not one that has recently been specifically
addressed within Scottish prisons. Steroid injection is probably rare, and tattooing more
common. Australian data suggests widespread tattooing practice in prison, with re-use of
equipment.(13)
Testing
Testing for Hepatitis C, with associated counselling, has focused on prisoners in long-term
establishments. These programmes are well established and organised. Elsewhere,
approaches and commitments vary. A review has just been completed ( (14)Milne, 2006) and
SPS intends to implement its recommendations to improve its commitment to Hepatitis C
testing. Recommendations are attached in Annex A. Currently, prison yields 3% of testing
activity in Scotland, and this proportion has progressively fallen over time. The report will
stimulate standard good practice and a more structured approach. The opportunities
presented by testing include a broader and deeper educational intervention for hundreds of
prisoners, and an avenue into care for those who turn out to be Hepatitis C positive.
Primary Prevention of Other Viruses
SPS delivers an effective programme of Hepatitis B immunisation. For those who are shown
to be Hepatitis C positive, it also offers Hepatitis A immunisation.
Uptake rates of
(12)
(13)
(14)
Status Paper on Prisons, Drugs and Harm Reduction, May 2005, World Health Organisation (Europe)
NSW Young People on Community Orders Health Survey 2003-2006 - Key Findings Report: Kenny D T,
Nelson P, Butler T, Lennings C, Allerton M, Champion U, University of Sydney, Australia
Detection of Hepatitis C in Scottish Prisons - An Audit of Current Practice: Milne D, July 2006
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3.
Hepatitis B vaccine are unevaluated but commitment is consistently high across prisons.
Accurate data will be available in 2007.
Improving Referral to NHS Specialist Care
There are well established procedures for referral to Specialist care from prisons. Generally
speaking, commitment and links are good. One prison has an in-reach clinic, while other
prisons have out-reach clinics and appointment times from prison. Two long-term prison
establishments (HM Prisons, Glenochil and Shotts) have established protocols for prereferral. This is an example of good practice and prison health services anticipate a steady
rise in referral activity following the agreement of more open criteria for inclusion in antiviral treatment, from a low base.
Commitment to Follow-Up
Prisoners:
(a) move often between prisons; and
(b) all but a few are eventually released back into the community.
Both of these offender movements are a challenge to continuity of care and constitute the
biggest single step that the Prison Service could take in improving its commitment to
prisoner patients with Hepatitis C.(15)
Prevention, Treatment and Care in Context
Care of a prisoner-patient who might have or carries Hepatitis C should be seen within the
overall life circumstances, health and wellbeing, and prospects in the future. Overall
commitment to holistic health, care and good prospects that lead away from injecting drug
use and problem drinking are important components of successful management. The
understanding of all prison staff of health issues, and health staff of prison issues, is an
important contribution to success, and training is of high value.
Monitoring and Performance Measurement
The following measures might be suitable indicators of performance in prisons with key
partners, relevant to the Hepatitis C Action Plan.
Surveillance

Both of testing activity and outcome, and the relative contribution of prison to
national testing endeavours.

Use of injecting equipment, opportunities to access clean and hygienic materials,
adhere to good clean practices, and the converse.

Use and sharing of unhygienic injecting equipment, including needles.
Service Activity

Growing trend of educational, testing and referral, prescribing and review activity.
Information Sharing
(a)
(15)
To support care; and
P Bramley, Personal Communication, 2006
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(b)
to enhance surveillance.
Research
Research has either taken place in Scotland, or is planned in the following categories:

empirical and interventional on IDU and Hepatitis C;

observational research, both qualitative and quantitative;

evaluation of planning interventions and specific screening plans; and

cohort study describing continuing risk activity and the consequences.
These are important measures that relate to outcomes, are infrequent but form the
backdrop to performance measurement.
Costs

Staff clinical time, and training, is the main cost to the Prison Service. Lack of time,
with other pressing priorities, has hampered efforts in the past. The main marginal
costs would fall to specialist NHS clinical, laboratory and pharmacy resources.
Priorities for Action
The Scottish Prison Service is keen to work with NHS Boards and other agencies, including
voluntary sector and contracted service providers to prisoners and offenders, to tackle the
epidemic of Hepatitis C in Scotland. It has set up its own Hepatitis C National Forum to
develop and co-ordinate action.
The document above sets out possible interventions. Based on the capacity of prisoner
patients to benefit, and the cost effectiveness of these interventions, we judge that priorities
should be in the following areas:
1.
long-term benefit, prevention and promotion of health, alternatives to injecting
and harm reduction measures - to cut down transmission of the Hepatitis C virus;
2.
medium-term benefit, through anticipatory care - routes that promote access to
treatment and care, to include awareness of the virus, risks, consequences, treatment
and care opportunities;
(a)
primary health treatment and care;
(b)
care and interventions to control excessive alcohol intake;
(c)
referral and investigation protocol with specialist services; and
(d)
better care of the long-term condition of Hepatitis C. Components include
well managed movement of prisoners between settings, information sharing to
support direct patient care, public health and surveillance, management of
resources, clinical protocols for the local management of the jaundiced patient,
and involvement of patients in decisions about their care
3.
immediate survival and epidemic benefit from reducing harm of injection drug
use - adequate drug and alcohol problem services.
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5.
Conclusion
The Scottish Prison Service is committed to the prevention, treatment and care of people
with Hepatitis C. It aims to make its contribution to:

promote health equity - of access, experience and outcomes;

reduce the cost of late stage disease through earlier intervention; and

reduce age-specific mortality through death soon after release and in later life.
The document sets the scene, describes current work and planning priorities and
underlines its commitment to work in partnership. Several hundred prisoner-patients
could start to benefit from testing into treatment. Thousands of prisoners and staff could
live and work in a safer environment. Full engagement of health services with the prisons
could improve the outlook for public health and care in Hepatitis C.
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6.
ANNEX A
RECOMMENDATIONS FROM HEPATITIS C SCREENING REVIEW REPORT 2006(14)
Short-Term Actions Within 12 Months
1.
As much of the health care within SPS is nurse led, consideration should be given to
establishing a BBV Nurses' Forum to provide opportunities for training, education, evidence
review and development of best practice.
2.
All establishments should assess their current practice against the criteria used in
this audit to identify promising practice and gaps in service.
3.
Existing local protocols should be adapted for national use across SPS to support the
implementation of the SPS Health Care Standards.
4.
Prior to developing an action plan for SPS based upon the above recommendations,
consultation should take place with the relevant NHS Consultants and Health Board
Planning Departments providing Specialist Hepatitis C treatment services to fully consider
the implications of the above.
5.
Improvements should be made to the recording of tests and vaccinations relating to
blood borne viruses within individual prisoner health care records.
6.
Consideration should be given to the introduction of the accelerated programme of
Hepatitis B vaccination across SPS.
Medium-Term Actions Within 2 Years
1.
A targeted screening programme for Hepatitis C should be phased in to Scottish
prisons beginning with former and current IDUs within long stay establishments, and IDUs
in short stay establishments with a sentence of more than 12 months. Lessons from this
should be considered prior to targeting IDUs with shorter sentences.
2.
All establishments should be required to provide a BBV service, either through
dedicated clinics or skills in the form of nurse specialists; this service should have effective
links with local NHS treatment providers. If this cannot be achieved locally, national
agreements should be sought through NHS Scotland and the Director of Health and Care
at SPS.
3.
Evaluation of a screening programme should include questions to determine prisoner
acceptability and reasons for uptake to learn lessons for possible wider implementation.
4.
Data collection methods should be standardised and collated monthly for submission
to SPS Headquarters who should collate the data, provide additional commentary on
epidemiology across other settings in Scotland and share across appropriate SPS staff
annually. This may not be required if the forthcoming National Hepatitis C database can
take on this role - this requires further investigation.
5.
Further consideration needs to be given to effective educational and awareness
programmes within prisons which reduce initiation into injecting practices as this is a clear
expectation of SPS within the proposed Hepatitis C action plan in Scotland. Other harm
reduction measures shown to be effective in the community should be considered for
implementation, including injecting equipment exchange and condom provision.
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7.
ANNEX B
REFERENCES
(1)
Hepatitis C Action Plan for Scotland, Phase 1: August 2006-July 2008, Scottish
Executive, August 2006
(2)
Sexual Health Status of Prisoners: Fraser A, Scottish Prison Service, May 2005
(3)
Incidence of Hepatitis C Virus Infection and Associated Risk Factors Among Scottish
Prison Inmates: A Cohort Study: Champion J K, 2004, American Journal of
Epidemiology, Vol 159, No 5
(4)
Prevalence of Hepatitis C in Prisons: WASH-C Surveillance Linked to Self-Reported
Risk Behaviours: Gore S M, 1999, QJ Med, 92:25-32
(5)
Presentation made by Professor David Goldberg (Health Protection Scotland) at the
2003 (Chicago) Interscience Conference on Antimicrobial Agents and Chemotherapy
(American Society for Microbiology); "Prisons as Amplification Systems for Infectious
Diseases: Hepatitis C Virus Infection"
(6)
Duncan G, Prison Health Research Network Conference, Manchester, October 2006
(7)
Annual Report 2005-06, Scottish Prison Service
(8)
The Incidence of Hepatitis C Virus Infection and Associated Risk Factors Among
Scottish Prisoners: A Cohort Study: Champion J K, Taylor A, Hutchinson S J,
Cameron S, McMenamin J, Mitchell A, Goldberg D J; The American Journal of
Epidemiology, 2004; 159(5), 514-519
(9)
Annual Prisoner Survey 2005, Scottish Prison Service
(10)
Annual Prisoner Survey 2006, Scottish Prison Service
(11)
"Examining the Injecting Practices of Injecting Drug Users in Scotland": Taylor A et al,
2004, Effective Interventions Unit, Scottish Executive. Edinburgh
(12)
Status Paper on Prisons, Drugs and Harm Reduction, May 2005, World Health
Organisation (Europe)
(13)
NSW Young People on Community Orders Health Survey 2003-2006 - Key Findings
Report: Kenny D T, Nelson P, Butler T, Lennings C, Allerton M, Champion U,
University of Sydney, Australia
(14)
Detection of Hepatitis C in Scottish Prisons - An Audit of Current Practice: Milne D,
July 2006
(15)
P Bramley, Personal Communication, 2006
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8.