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

2. 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

3. 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

4. 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.

5. 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)

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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