They then modeled the effect that vaccination would have on these estimates. Infant vaccination with 90 percent 3-dose coverage starting within 24 hours of birth could prevent 84 percent of these projected HBV-related deaths.
Despite general agreement that healthcare in prison settings is terrible, remarkably little research appears at the major infectious disease conferences to document the results of treatment or the epidemiology of disease behind bars. William Bower, of the CDC in Atlanta, presented a poster at the IDSA conference in San Diego that tracked the molecular epidemiology of HBV transmission in a Georgia state prison. Prisons are prime settings for transmitting HBV through sexual activity, shared needles, shared tattooing equipment or in fights. The CDC recommends hepatitis B vaccination for all inmates in correctional facilities without evidence of immunity.
A baseline serologic survey was conducted in June of 2000 of 1,124 participating prisoners. Of these, 11 were found with acute HBV infection, 11 had chronic infection and 208 had a resolved infection for a total of 230 or 20.5 percent of the sample. This left 894 inmates susceptible to infection. A year later, in June of 2001, a second survey of the susceptible inmates was conducted with 653 of the 894 remaining at the facility. Of these, 503 of 653 (77 percent) consented to retesting. One year after the baseline survey, 18 new infections were detected, with one of these a chronic infection. This results in an annual infection rate of 3,579 per 100,000 persons in this prison.
DNA sequence analysis identified 11 different strains within three HBV genotypes. Eight of the chronically infected and one of the acutely infected inmates had unique strains. But ten of the sequences represented the other two strains, with one of those found in four inmates with chronic infection. The other shared strain was found in six inmates, two with chronic and four with acute infection. Three of these acute infections turned up in the June 2000 survey and one in 2001. Two inmates with acute infection reported having sex with one of the inmates with chronic infection.
This study is remarkable for a number of reasons. First, it documents the sexual transmission of disease within a correctional facility, a phenomenon that is rarely acknowledged by corrections officials who then deny the need for providing condoms inside. It also confirms that, with an annual incidence of HBV infection in this facility over 120 times that of the estimated national incidence, prisons are incubators of infectious disease. It also shows the role that an individual can play in sparking an epidemic. Finally it shows that a prison in Georgia, willing to collaborate with the CDC in its research, routinely ignores its recommendation that all inmates be vaccinated against hepatitis B.
The EuroSIDA cohort reported on the impact that chronic HBV infection has on AIDS progression and response to antiretroviral therapy. Of 5,833 individuals in EuroSIDA tested for HBV surface antigen, 530 (9%) were found positive. The incidence of all-cause and liver-related death was greater in those with chronic HBV than in others (12 vs. 2.6 and 0.5 vs. 0.2/100 patient years, respectively). The authors conclude that HBV antigen status did not impact virological or immunological response in 1,752 patients receiving HAART. This confirms previous reports that, although HBV may not make HIV worse, coinfection with HBV increases the risk of dying from liver disease in people with HIV.
Back to the GMHC Treatment Issues October 2003 contents page.