Hepatitis B vaccination of prisoners Josiah D. Rich MD MPH Brown University/The Miriam Hospital

Why vaccinate in prison? Incidence study in women at RI DOC (1996-7) blinded study of discarded serum serum drawn at intake, redrawn if inmate reincarcerated Incidence of HBV among reincarcerated women was 12.2 per 100 person-years a public health emergency! 6th Conference on Retroviruses and Opportunistic Infections In light of this, the medical director of the RI DOC, Dr. Spaulding, who is now here at the CDC, included HBV vaccines into the prison medical budget for several years, but the funds were always turned down - Recurring theme of conflicting priorities As an aside: since the routine testing was implemented, roughly 1/3 of HIV cases in RI are identified at the prison - speaks to the potential of the prison as a key site for public health interventions in high risk populations

Funding to vaccinate? Medical director (Anne Spaulding MD) included vaccine in budget every year - every year denied VHIPS funding RI department of health vaccine coordinator Susan Shepardson Federal 317 money Perinatal prevention program

National survey Conducted in 2000 National survey of prison medical directors 36 respondents 70% response rate accounts for 77% of all inmates in federal or state prisons and jails Public Health Reports 2001;116:1-12.

National survey: findings Only 2 state prison systems routinely vaccinate for HBV 9 offer no HBV vaccination Cost prohibitive (1) ‘Medically unnecessary’ (2) 26 states and the Federal Bureau of prisons offer vaccination in limited circumstances: When ordered by physician (15) When inmate considered ‘at risk’ (11) When inmate HIV+ (10)

National survey: findings 25 states and the Federal Bureau of Prisons responded that they would routinely vaccinate inmates if funds were available This represents 927,615 inmates Of the 25 states that would routinely vaccinate, 14 do not use the VFC program

Correctional facilities’ vaccination practices Routinely vaccinate inmates Do not vaccinate inmates Vaccinate under limited circumstances

Update Several additional state correctional facilities have begun to offer routine hepatitis B vaccination: Pennsylvania Indiana Wisconsin Arizona Hawaii Rhode Island Other facilities that offer routine vaccination: Hampden County Jail (MA) Denver County Jail ?? Texas’s program on hold due to funding problems

Vaccinating at RI DOC Started at women’s March 2002 Starting at men’s this month Nice thing - medical intake is already in place - inmate comes into DOC already gets a brief medical hx, TB test, blood drawn for HIV testing - relatively simple to piggyback HBV vaccination onto procedure that’s already in place Initially approached DOC with our project - told them we wanted to develop a computerized tracking system of inmates who had received vaccination - they told us that the nurses were already too busy, we could save them time by computerizing the entire intake process - OK, we did that, sent it to information services for approval - competing priorities again - our project got put on the back burner for 5-6 months Finally convinced them to allow us to computerize just HBV portion Started vaccinating about 3 weeks ago

Vaccinating at RI DOC Institutional barriers Funding for vaccine Structure of intake process Day-to-day barriers Resistance to change Computerphobia Knowledge about HBV among staff/inmates

Vaccinating at RI DOC Successes at women’s Achieved buy-in from staff Integrated HBV vaccination into intake process Secured ongoing 317 funding for vaccine Developed partnership with clinic in community to provide follow-up vaccine doses after release

Preliminary Data As of December 6th: 474 women vaccinated 65% acceptance rate Reasons not accepted : ‘Didn’t want the vaccine’ - Mistrust of prison system Don’t want to get poked again Haven’t heard of HBV - don’t know why it’s important Scared off by the list of potential side effects Different nurses having different rates of acceptance

Looking towards the future Getting men’s program up and running ‘Giving the program legs’ so it will continue on after our project is over Ongoing funding for men’s