HEPATITISC ACTION PLAN FOR SCOTLAND[(1)]
PRISON-BASED NEEDS ASSESSMENT
Introduction
Prisons can contribute to the control and management of the HepatitisC epidemic in Scotland. SPS' commitment to the HepatitisC 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, HepatitisC in Scotland in the future.
General Approach
This document will concentrate on 2matters:
controlling the spread of HepatitisC 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 in2005,[(2)] available on request.
HepatitisC in the Prison Population
An estimated 17%of prisoners carry HepatitisC. Estimated prevalence is highest in the 26-35year category at24% for men, and 38%for women[(3)(4)][(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 of7,200, a prevalence rate of17% means that there are approximately 1,700HepatitisC positive carriers in custody at any one time- almost 3%of the estimated prevalence HepatitisC population in Scotland. Over one year, the figure is3,700 or over 7.4%of the HepatitisC positive Scottish population, in that approximately 22,000individuals pass through prison in a year.
Intravenous Drug Use(IDU)
Prison is an incidental hazard in an IDUcareer. Of the Glasgow population, anIDU with a 10year career can expect to have a 90%chance of being in prison during that time. For a 2-5year career, the figure is75%[(5)]. In a recent English study, half of IDUsin prison had been in custody before or around the time of starting to inject. Thirtyper-cent of theseIDUs had been in prison more than 6times.[(6)]
The prison population is96% male.[(7)] However, the relatively few women have more severe problems in every respect, includingIDU. In most other measures of HepatitisC, epidemiological characteristics are likely to reflect the general population.
There is strong evidence to suggest transmission of HepatitisC in prison.[(8)]
There is good evidence of needle use and needle sharing in prison. A consistent annual survey self-report figure of3% reporting injecting, and 60-70%of them sharing (n=c.125) illustrate the scale of injecting.[(9)(10)][(10)] Qualitative data document wide sharing of injecting equipment by anything up to 20users. 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 IDUsstarting 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 HepatitisC;
early detection through testing, together with educational and other opportunities of that contact; and
primary prevention of other blood borne viruses through immunisation.
Support roles include:
referral to NHSspecialist 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 HepatitisC 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 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 HepatitisC and injecting include information on injecting and hazards, all blood borne viruses, HepatitisC, 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 IDUcareer. 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 HepatitisC include methadone for opiate-dependent addicts as part of a supported drug treatment programme- programmes of supported detoxification and other means of support for people with other addictions that involveIDU. 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-threepercent 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 HepatitisC, 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 HepatitisC testing. Recommendations are attached in AnnexA. Currently, prison yields3% 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 HepatitisC positive.
Primary Prevention of Other Viruses
SPS delivers an effective programme of HepatitisB immunisation. For those who are shown to be HepatitisC positive, it also offers HepatitisA immunisation. Uptake rates of HepatitisB vaccine are unevaluated but commitment is consistently high across prisons. Accurate data will be available in2007.
Improving Referral to NHSSpecialist 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. Twolong-term prison establishments (HMPrisons, Glenochil and Shotts) have established protocols for pre-referral. 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 anti-viral 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 HepatitisC.[(15)]
Prevention, Treatment and Care in Context
Care of a prisoner-patient who might have or carries HepatitisC 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 HepatitisC 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)To support care; and
(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 HepatitisC;
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 NHSclinical, laboratory and pharmacy resources.
Priorities for Action
The Scottish Prison Service is keen to work with NHSBoards and other agencies, including voluntary sector and contracted service providers to prisoners and offenders, to tackle the epidemic of HepatitisC in Scotland. It has set up its own HepatitisC 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 HepatitisC 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 HepatitisC. 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.
Conclusion
The Scottish Prison Service is committed to the prevention, treatment and care of people with HepatitisC. 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 HepatitisC.
SLA00423.1061.
ANNEXA
RECOMMENDATIONS FROM HEPATITISC SCREENING REVIEW REPORT2006(14)
Short-Term Actions Within 12Months
1.As much of the health care withinSPS is nurse led, consideration should be given to establishing a BBVNurses' 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 acrossSPS to support the implementation of the SPSHealth Care Standards.
4.Prior to developing an action plan forSPS based upon the above recommendations, consultation should take place with the relevant NHSConsultants and Health Board Planning Departments providing Specialist HepatitisC 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 HepatitisB vaccination acrossSPS.
Medium-Term Actions Within 2Years
1.A targeted screening programme for HepatitisC should be phased in to Scottish prisons beginning with former and currentIDUs within long stay establishments, and IDUs in short stay establishments with a sentence of more than 12months. Lessons from this should be considered prior to targetingIDUs with shorter sentences.
2.All establishments should be required to provide a BBVservice, either through dedicated clinics or skills in the form of nurse specialists; this service should have effective links with local NHStreatment providers. If this cannot be achieved locally, national agreements should be sought through NHSScotland and the Director of Health and Care atSPS.
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 SPSHeadquarters who should collate the data, provide additional commentary on epidemiology across other settings in Scotland and share across appropriate SPSstaff annually. This may not be required if the forthcoming National HepatitisC 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 ofSPS within the proposed HepatitisC 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.
ANNEXB
REFERENCES
(1)HepatitisC Action Plan for Scotland, Phase1: August2006-July2008, Scottish Executive, August2006
(2)Sexual Health Status of Prisoners: FraserA, Scottish Prison Service, May2005
(3)Incidence of HepatitisC Virus Infection and Associated Risk Factors Among Scottish Prison Inmates: A Cohort Study: ChampionJ K, 2004, American Journal of Epidemiology, Vol159, No5
(4)Prevalence of HepatitisC in Prisons: WASH-C Surveillance Linked to Self-Reported Risk Behaviours: GoreS M, 1999, QJ Med, 92:25-32
(5)Presentation made by ProfessorDavid 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: HepatitisC Virus Infection"
(6)DuncanG, Prison Health Research Network Conference, Manchester, October2006
(7)Annual Report 2005-06, Scottish Prison Service
(8)The Incidence of HepatitisC Virus Infection and Associated Risk Factors Among Scottish Prisoners: A Cohort Study: ChampionJ K, TaylorA, HutchinsonS J, CameronS, McMenaminJ, MitchellA, GoldbergD J; The American Journal of Epidemiology, 2004; 159(5), 514-519
(9)Annual Prisoner Survey2005, Scottish Prison Service
(10)Annual Prisoner Survey2006, Scottish Prison Service
(11)"Examining the Injecting Practices of Injecting Drug Users in Scotland": TaylorA etal, 2004, Effective Interventions Unit, Scottish Executive. Edinburgh
(12)Status Paper on Prisons, Drugs and Harm Reduction, May2005, World Health Organisation (Europe)
(13)NSWYoung People on Community Orders Health Survey2003-2006- Key Findings Report: KennyD T, NelsonP, ButlerT, LenningsC, AllertonM, ChampionU, University of Sydney, Australia
(14)Detection of HepatitisC in Scottish Prisons- An Audit of Current Practice: MilneD, July2006
(15)PBramley, Personal Communication, 2006
SLA00423.1061.
[(1)]HepatitisC Action Plan for Scotland, Phase1: August2006-July2008, Scottish Executive, August2006
[(2)]Sexual Health Status of Prisoners: FraserA, Scottish Prison Service, May2005
[(3)(4)](3)Incidence of HepatitisC Virus Infection and Associated Risk Factors Among Scottish Prison Inmates: A Cohort Study: ChampionJ K, 2004, American Journal of Epidemiology, Vol159, No5
[(4)]Prevalence of HepatitisC in Prisons: WASH-C Surveillance Linked to Self-Reported Risk Behaviours: GoreS M, 1999, QJ Med, 92:25-32
[(5)]Presentation made by ProfessorDavid 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: HepatitisC Virus Infection"
[(6)]DuncanG, Prison Health Research Network Conference, Manchester, October2006
[(7)]Annual Report 2005-06, Scottish Prison Service
[(8)]The Incidence of HepatitisC Virus Infection and Associated Risk Factors Among Scottish Prisoners: A Cohort Study: ChampionJ K, TaylorA, HutchinsonS J, CameronS, McMenaminJ, MitchellA, GoldbergD J; The American Journal of Epidemiology, 2004; 159(5), 514-519
[(9)(10)](9)Annual Prisoner Survey2005, Scottish Prison Service
[(10)]Annual Prisoner Survey2006, Scottish Prison Service
[(11)]"Examining the Injecting Practices of Injecting Drug Users in Scotland": TaylorA etal, 2004, Effective Interventions Unit, Scottish Executive. Edinburgh
[(12)]Status Paper on Prisons, Drugs and Harm Reduction, May2005, World Health Organisation (Europe)
[(13)]NSWYoung People on Community Orders Health Survey2003-2006- Key Findings Report: KennyD T, NelsonP, ButlerT, LenningsC, AllertonM, ChampionU, University of Sydney, Australia
[(14)]Detection of HepatitisC in Scottish Prisons- An Audit of Current Practice: MilneD, July2006
[(15)]PBramley, Personal Communication, 2006