AZ Republic: Ignore the prisons at our own peril...

 AZ Department of Corrections

(November 1, 2010)

Excellent editorial from the folks at the AZ Republic. They've been doing a great job covering the prisons this past year - which takes a lot of courage for mainstream media to do  in this town.

This exposure incident is potentially devastating for those men affected - up to 20% will likely die from liver cancer or cirrhosis as a result, if they don't get successfully treated. Hep C is epidemic in our state prisons already, though -that incident was a drop in the bucket compared to the 12,000 already infected (almost 6,000 confirmed cases alone, compared to less than 200 with HIV/AIDS...it's pretty bad).

As long as they aren't treating addictions inside or doing an aggressive harm reduction campaign, though, the disease will continue to be spread by needles among IV users and tattoo recipients - 95% of whom ultimately return to the community, becoming a serious public health concern. One of the things that could do most to reduce the incidence and impact of Hep C in the community is to provide adequate substance abuse treatment and Hep C education, screening and treatment in prison, but neither is really happening.

According to the DOC 75% of prisoners are coming in with serious substance abuse issues, yet they aren't providing substance abuse treatment for more than 4% of the total prison population in a year - not even for all those guys being sent off to DUI prison, where everyone thinks we pay for a special treatment setting so they don't relapse and kill someone on the road next time. Coming into the mess we already have in the DOC medical system, I don't see how Wexford is going to do any better by prisoners - especially those with Hep C - AND turn a profit.

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Out of sight, out of mind

Sept. 8, 2012 01:26 PM
The Republic | azcentral.com

On Aug. 27, a nurse working for a company called Wexford Health Sources Inc. administered a dose of insulin to a diabetic patient who has hepatitis C, a deadly and extremely infectious liver disease.

The nurse then inserted the needle into another vial of insulin to draw still more of the drug for the patient.

She put that second vial, and the remainder of its contents, onto a shelf with other vials of insulin.

You can well imagine where this health-horror story is going: More than 100 other diabetes patients who later were given insulin treatments may have been infected with hepatitis C.

Mistakes happen. Including potentially tragic ones like this. But there is a bit more to this story.

Wexford is a private company that just this spring won a $349 million, three-year contract to provide health services to Arizona's nearly 40,000 prison inmates. The nurse, who already was under investigation for providing slipshod care, worked for Wexford at the Arizona state prison at Buckeye.

State rules require health-care providers, including those working out of prisons, to alert county and state health authorities about a potential outbreak of an infectious disease within five business days.

Wexford alerted public health officials of the incident on Sept. 4, more than a week afterward -- and only after Wendy Halloran of 12 News learned what happened from an inmate's family and The Republic's Craig Harris broke the story online.

In Arizona's seemingly inexorable march toward privatizing ever more of its prison system, this incident is but one more red flag about the pitfalls of that policy.

Sure, it was an accident. Accidents happen. But are more such accidents occurring at prisons whose profit motives tempt supervisors to cut corners?

Corner-cutting appears to have been a factor in the escape of three prisoners on July 30, 2010, from a Kingman prison operated by Management & Training Corp. A faulty alarm system appears to have contributed to the incident, during which the escapees murdered a New Mexico couple.

Another private contractor hired by Arizona, GEO Group Inc., has lost at least 27 of its prisoners around the country since 2004, including one from a facility in Florence, albeit from mostly low-security facilities.

The Wexford incident, however, raises a still more unsettling concern: Are there more accidents and incidents than we know about? Is Wexford's slow-mo reaction to following established protocol evidence of other incidents being swept under the rug?

The state Legislature's most ardent Republican critic of private prisons, Mesa Rep. Cecil Ash, argues that private prisons "are the wrong business model" for exactly that reason: "They are out of sight, out of mind."

If private-prison operations were cheaper to operate, that might mitigate the more minor operational concerns. But they are nearly 10 percent more expensive to operate. Lawmakers like them because of the up-front cost savings on construction, which the private firms often bear.

Legislators need to take this Wexford incident for what it is: stark evidence that transparency is a serious issue with private prisons.

Prisons are out of sight, out of mind, at our peril.

Hep C Epidemic: Harvard Health Letter

From the September 2010 Harvard Health Letter. 

Simple but good background on the HEP C EPIDEMIC.

No time like the present to put an end to it.

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The smoldering epidemic

The number of new cases of hepatitis C is down, but millions are chronically infected and may not know it.

The identification of the virus that causes hepatitis C, a disease that affects the liver, has probably saved millions of lives. Before the discovery, two other hepatitis viruses — the hepatitis A and B viruses — had been identified, but neither was present in many cases of this disease. Patients were said to have "non-A, non-B hepatitis" — an awkward name that spoke of medicine's ignorance. In 1989, the mystery was solved. The viral culprit responsible for most cases of non-A, non-B hepatitis was found. Thereafter, those cases were called hepatitis C and their cause, the hepatitis C virus.

The hepatitis C virus is transmitted through blood, so before the virus was identified, the disease was spreading through blood transfusions, medical procedures such as kidney dialysis and organ transplantation, and needle sharing by intravenous drug users. The discovery of the virus meant that screening tests could be developed to find it in the blood supply. Diagnosis and treatment of the infection in people also became possible. Prior to the virus being discovered, about 200,000 Americans were newly infected with hepatitis C each year, according to federal government estimates. Today, it's estimated to be about a tenth of that number (and the number of confirmed cases is far fewer than that). Hepatitis C has also become a disease of middle age in the United States as people who were infected in the peak years in the 1980s have survived and gotten older. Hepatitis C is now more common among Americans in their 40s and 50s than in any other age group.

This isn't to say that hepatitis C is a conquered disease. Globally, as many as 170 million people are believed to be chronically infected with the virus. In the United States, it may be just over three million. Many infected people don't realize they have the disease because a lack of symptoms, or that they can unknowingly spread it to others. Hepatitis C can lead to liver cirrhosis and liver cancer, and about 10,000 American deaths each year are attributed to the disease. There's no vaccine, and the current treatments for chronic infection have bad side effects and aren't effective in many cases.

The A and the B of hepatitis The hepatitis A virus is spread through the fecal-oral route. Fecal-oral transmission can occur if someone handles food after not washing his or her hands properly, or if the food (or water) came from tainted sources. The classic example is shellfish harvested from sewage-contaminated waters. Roughly 25,000 Americans are estimated to get hepatitis A each year, but the incidence — the number of new cases — is at record lows. Perhaps the single most important reason for the decline is the hepatitis A vaccine, which was introduced in 1995 and is now one of the vaccines that young children routinely receive. An increasing proportion of American hepatitis A cases are the result of infections acquired overseas in countries where the illness is more common, such as Mexico. The symptoms of hepatitis A include fever, nausea, abdominal pain, and the like. People can be sick for weeks, even months, but hepatitis A doesn't turn into a chronic infection like hepatitis B and C. Most people recover completely without treatment (except for symptom relief) and without liver damage. Like the hepatitis C virus, the hepatitis B virus is transmitted in blood, although semen and saliva can also be infectious. In the United States and other parts of the world where hepatitis B is relatively rare, the virus is spread primarily through unprotected sexual intercourse and the sharing of contaminated needles during intravenous drug use. Like the hepatitis C virus, the hepatitis B virus can survive outside the body for prolonged periods, so it's possible to get infected from sharing toothbrushes, razors, or other objects that might have blood on them. Federal health officials estimated that 43,000 new cases of hepatitis B occurred in the United States in 2007, the latest year for which such an estimate has been made. Hepatitis B incidence has been in steady decline in this country since 1991, when children began to be vaccinated against the disease.

Symptoms and diagnosis

Frequently initial infection with the hepatitis C virus doesn't cause any notable symptoms. Some people (about 25%) may feel tired or feverish, lose their appetite, or have some pain in the upper right part of the abdomen, where the liver is located. When symptoms do occur, it's often one to three months after the exposure, so they may not prompt a visit to a doctor. Jaundice, the yellowing of the skin and whites of the eyes that's a classic sign of liver trouble, usually happens only when the disease gets more advanced.

Even when the infection persists and becomes a chronic condition, which happens about 80% of the time, hepatitis C often doesn't cause symptoms and can lurk undetected for decades. As a result, an infection is often discovered incidentally when a routine blood test shows a spike in certain liver-related enzymes. The doctor may follow up with more blood tests, like a special one that detects antibodies to the virus. Those tests aren't done routinely, but they are recommended for patients in the high-risk groups for hepatitis C, which in the United States includes, among others, those who received donated blood or organs before 1992 or blood clotting factors before 1987 and past or current users of intravenous drugs.

If the antibody test comes back positive, another test will probably be ordered to identify the genetic makeup of the virus. The hepatitis C virus has at least six different genotypes, which are referred to by numbers. In the United States, most people are infected with genotype 1, with most of the remaining infections being genotypes 2 and 3.

Avoiding cirrhosis

Even without symptoms, chronic hepatitis C can cause the liver to become inflamed as it fights the infection. Over time, the inflamed liver tissue can become scarred (this is called fibrosis) and replace healthy tissue. The liver is a resilient organ and can heal if the illness is caught and treated successfully. But if the scarring continues and becomes serious, the person is said to have cirrhosis (pronounced sir-ROW-sis). The most common causes of cirrhosis in the United States are alcohol abuse and chronic hepatitis B and C infections.

Once cirrhosis develops, a lot may go wrong and there's no shortage of symptoms. Fluids may accumulate in the legs (edema) or abdomen (ascites). Veins in other parts of the body may expand and bleed because blood doesn't flow properly through the liver. The blood itself can become laden with toxins that a healthy liver would normally filter out. Eventually the cirrhotic liver may fail altogether, which leaves a liver transplant as the only treatment option. Cirrhosis also greatly increases the risk for hepatocellular carcinoma, the most common type of liver cancer. A third of such cancers in the United States can be attributed to hepatitis C infections that led to cirrhosis.

Cirrhosis

The good news amid this gloom is that pretty much all of the serious consequences from chronic hepatitis C infection occur only after cirrhosis has developed, and that happens in a fraction of people with chronic hepatitis C infections. Studies have come up with different percentages, but 20% is a commonly cited figure.

Why some people get cirrhosis while others live with chronic hepatitis C infections that cause little, if any, harm to their livers isn't completely understood, but several factors have been identified. People are more likely to develop cirrhosis if they drink alcohol, for example, or if they're also infected with HIV or hepatitis B. Age may matter: the risk of cirrhosis seems to go up if you were infected between the ages of 40 and 55. Some evidence suggests that African Americans are less likely than whites to develop cirrhosis. Results from a few studies suggest coffee might be protective.

The uncertainty of whether a chronic hepatitis C infection is going to lead to cirrhosis, along with the gradual nature of the process, often makes starting treatment a bit of a judgment call. Some people with chronic hepatitis C choose to delay treatment if tests show that their livers are healthy. Blood tests, ultrasound exams, and biopsies can be used to monitor how the liver is doing, so treatment can start later if the virus starts to cause liver damage.

Naturally, there's great interest in anything that might reduce the chances of that liver damage happening. The standard advice is pretty limited, though. People are told to avoid alcohol entirely because it both encourages replication of the hepatitis C virus and damages the liver on its own. Most medicines are safe for people with hepatitis C, although acetaminophen (Tylenol) use should be limited.

Some people with chronic hepatitis C infections take silymarin, an extract of the milk thistle plant. Milk thistle has long been thought to promote liver health, and some lab experiments have shown that it might protect liver cells, but solid proof is lacking. Trials are under way that may provide more evidence.

Treatment

The most effective current treatment for a chronic hepatitis C infection is a combination of pegylated interferon, taken as a weekly shot, and ribavirin (Copegus, Rebetol), taken as a pill. Eliminating the virus is the goal, so treatment is deemed successful if there's no evidence of the virus in the blood six months after therapy has stopped.

Interferon, a protein produced naturally by the body to fight viruses, is used to treat various cancers and other diseases. There are three major types of synthetic interferon, and the alfa variety has been used as a therapy for hepatitis C since the early 1990s. To help the interferon last longer in the body — and reduce the number of injections — it is "pegylated" by adding the chemical polyethylene glycol. Ribavirin, an antiviral medication, was approved as an add-on drug in 1998. The pairing of ribavirin with interferon has proved to be two or three times more effective than interferon alone.

The chances of successful treatment depend partly on the type of hepatitis C. About 80% of people in the United States infected with genotypes 2 and 3 respond well to pegylated interferon and ribavirin, but only about half of those infected with genotype 1 do.

Side effects are a problem: up to 80% of patients experience them. Generic "flu-like" symptoms, as well as fatigue, are common. But interferon-based therapy also has unusual effects on emotions and mood, and is associated with depression, emotional swings, or bouts of anger. Another drawback to the current regimen is that the medications need to be taken for a long time: six months for treatment of genotypes 2 and 3 and almost a year for genotype 1.

Doctors have tinkered with the interferon-based therapy with mixed results. One approach has been to combine it with novel compounds designed to interfere with replication of the hepatitis C virus, which mutates quickly inside cells. Two of the most promising drugs being tested in patients, telaprevir and boceprevir, inhibit protease enzymes, which is how many of the HIV drugs work.

Dr. Raymond Chung, a leading hepatitis C researcher at Massachusetts General Hospital, says scientists are looking at ways to attack the virus at different stages in its life cycle. One strategy is to prevent the hepatitis C virus from entering or exiting liver cells, so the virus can't assemble itself inside and then leave to infect other cells. Researchers are also looking for ways to boost the body's immune response to the hepatitis C virus. Dr. Chung heads a research consortium that received a $15 million federal grant to investigate how the virus manages to elude the immune system so well.

Source: https://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2010/September/the-smoldering-epidemic

© 2000-2010 Harvard University. All rights reserved.

C. Everett Koop and the Hep C Epidemic: Calling it what it is.

Just came across a Hep C website set up by the The C. Everett Koop Institute at Dartmouth, interestingly titled www.epidemic.org. Some of their general info seems a little out of date, but I though the following quote was useful to keep in mind, and I'm posting their page of links for people to take political action.

The Forum : Political Action

Take action! Learn how you can join Dr. Koop and thousands of others in the fight against Hepatitis C.

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Prisoner Health is Public Health

Prison's deadliest inmate, hepatitis C, escaping

Public-health workers warn of looming epidemic of ‘silent killer’

The Associated Press / MSNBC.com

March. 14, 2007

VACAVILLE, Calif. - The most dangerous thing coming out of prison these days may be something most convicts don’t even know they have: hepatitis C.

Nobody knows how many inmates have the disease; by some estimates, around 40 percent of the 2.2 million in jail and prison are infected, compared with just 2 percent of the general population.

Eventually, when they are released, medical experts predict they will be a crushing burden on the health care system, perhaps killing as many people as AIDS in years to come. At the same time, they will be carriers, spreading the disease.

Hepatitis C can be treated, but many prisons do not test for it. Among the reasons: Budgets are tight, and treatment is expensive. So prison officials close their eyes to the gathering emergency and pass it along to the outside world.

“Right now there’s a golden opportunity to bring solutions to this problem before it hits,” said Dr. John Ward, director of viral hepatitis at the National Center for HIV/AIDS at the Centers for Disease Control and Prevention in Atlanta.

Hepatitis C is already the most common disease of its sort in the United States — a chronic, life-threatening, blood-borne infection. It is most commonly linked to infected needles used for drugs, though prison tattoos and body piercing with non-sterile equipment are also risky.

'Silent killer'
What makes this virus particularly insidious is that as many as half of the people who have hepatitis C don’t even know they have it. The “silent killer,” already considered epidemic by the World Health Organization, often remains dormant for decades.

Some of the infected are lucky: One in five people who get hepatitis C will clear it out of their system naturally. But without treatment, one in four will suffer liver failure or develop liver cancer. Last year liver cancer was the only one of the top 10 fatal cancers in this country to increase, in large part because of hepatitis C.

More than $1 billion is already spent each year on this country on hepatitis C, and those costs are expected to soar unless prevention and treatment are expanded.

Without those changes, researchers project that liver-related deaths will triple from around 13,000 in 2000 to 39,000 by 2030. It’s also estimated that 375,000 Americans with hepatitis C will develop cirrhosis by the year 2015.

Anita Taylor, 48, is already there, in end-stage liver disease. Taylor speaks very slowly and moves with care. She often finds that she can’t say the words she wants to — they just won’t come out. Her body hurts most of the time. Her nose bleeds a lot.

'Doctor gave me a death sentence'
A mother of two and former heroin addict, Taylor said she learned she had hepatitis C when she was jailed in Nevada in 1991 for being under the influence of drugs.

“They tested me and told me I had hepatitis C. They didn’t tell me there was a treatment and a cure,” she said. “And I didn’t know to ask.”

Taylor’s experience is not unusual.

“The doctor gave me a death sentence, recalls Leslie Czirr, a 36-year-old parolee. “He told me, ’There’s no cure for this and you will die from it unless you are hit by a truck first,”’

Czirr learned she had hepatitis C during a prenatal examination in 1996, at a time when she wasn’t in prison. Czirr has been arrested 10 times for drug possession and served almost eight years in prison on various drug possession and dealing charges.

She has started to suffer exhaustion, brain fog and aches. She recently enrolled in a county program to be treated — treatment, she said, she was denied at California’s Norco State Prison.

“I asked and asked, but they barely want to give you a Motrin,” she said. “I really want to get well, not just for myself, but so I’m not putting anyone else at risk.”

Limited studies indicate that fewer than 10 percent of prisoners who have contracted hepatitis C are treated. The reason vary. Medical staff have other priorities, and not all are well-informed about the disease. Prisoners with short sentences are often excluded because they won’t be able to complete treatment, and drug addicts who are inclined to return to risky behavior are often turned away because it is assumed they will simply reinfect themselves.

No funding for treatment
Usually, though, it comes down to money. Prison officials say that even if they wanted to provide the treatment, it is extremely expensive — about $9,500 per patient per year — and no federal funds have been earmarked to pay for it.

“It’s a hard sell to convince taxpayers why additional resources should be spent on the health care of the incarcerated when there are a lot of people who aren’t incarcerated who don’t have adequate health care,” said Dr. Joseph Bick, chief medical officer at the California Medical Facility at Vacaville.

Many of the inmates in Vacaville’s hospice unit — reserved for those given six months or less to live — are dying from hepatitis C-related ailments. Bick said half of the prison’s 3,200 inmates have a history of having been infected with hepatitis C, and at any given time about 40 of those men are receiving the intensive drug treatment to cure it.

“I’m pretty sure this is how I got it,” said Anthony Harris, an inmate at Vacaville. He rubbed his forearm hard, as if trying to remove the prison tattoo bearing his children’s names.

Harris, 51, is a former barber serving a life sentence for second-degree murder. In 2003, a doctor at another prison told him he had Hepatitis C; he researched the disease in the prison library and has sought treatment ever since.

“They gave me shots for Hep A and B, got rid of them. I’d like to get rid of the C too,” he said. “I’m entitled to that. But some docs will give you the treatment and others won’t. I keep making appointments. I keep asking.”

The course of treatment can take a year, and involves taking pills twice a day and weekly injections. Side effects are like those associated with chemotherapy — nausea, exhaustion, depression, debilitating aches and pains — and the cure only works about half the time.

But Bick said the high cost of treating prisoners for hepatitis C is a bargain compared to the bill that would come due if these cases are left untreated. “It’s a tremendous opportunity for us to have an impact on the larger health of the community,” he said.

Dr. Lynn Taylor, an assistant professor of medicine at Brown University’s medical school, agrees that prison is “perhaps one of the best setting for treatment of high-risk individuals.”

'Window of opportunity' for public-health efforts
“Prison can be a window of opportunity to reduce the reservoir of infection,” she said.

But there are no federal rules about testing and treating hepatitis C. Federal guidelines, issued by the CDC in 2003, said correctional facilities should “become part of prevention and control efforts in the broader community.” But they don’t recommend screening for all inmates.

Instead, the CDC urged medical staff to ask new inmates about their risk factors, and only those prisoners who seem likely to be exposed should undergo screening, which costs $5 to $10.

The CDC guidelines fell short, said Dr. Josiah Rich, a professor at Brown who directs the university’s Center for Prisoner and Human Rights. Rich’s studies confirm that convicted criminals are almost always willing to be tested for hepatitis C, but will often lie to prison authorities about their past drug use.

“We already know that more than one in three people coming through corrections has Hep C, so by definition everyone coming in is high risk. It’s absurd that they’re not testing everyone,” he said.

Rich concedes that testing every inmate will “jack up costs” for prisons.

“An individual is going to say, ’Hey, you tested me, you said I was positive, and now I want to be treated, and I’m going to sue you if I don’t get treated,”’ he said.

Lawsuits on the rise
Lawsuits are, indeed, on the rise.

The first significant case came in 1999, when officials at the Luther Luckett Correctional Complex in La Grange, Ky., refused to allow inmate Michael Paulley access to free hepatitis C treatment. Paulley, who was serving a 25-year sentence for rape and burglary, sued and won.

But the treatment came late and he died in 2004, the year he would have been eligible for parole. The litigation prompted broader testing and treatment in Kentucky, but Paulley’s physician, Dr. Bennet Cecil, a Louisville, Ky.-based hepatitis C specialist, said prisoners still die “all the time” for untreated hepatitis C.

“I think it’s immoral if a country, a state a society is going to incarcerate somebody and then deny them necessary medical care. I think that’s an outrage,” he said.

Prisons in at least a dozen states — Alabama, California, Delaware, Florida, Georgia, Idaho, Michigan, Mississippi, Nebraska, New York, Oklahoma and Virginia — are being sued over failure to treat hepatitis C.

But it’s tough going, said Oregon civil rights attorney Michelle Burroughs. Although she’s won a settlement that mandated testing for at risk inmates and treatment for those who are eligible, five of the 10 inmates she’s representing in a class-action lawsuit have died while the litigation proceeds.

5-year wait
“It’s appalling, horrendous, horrifying. Prisoners wait five years just to be evaluated,” she said.

Rep. Barbara Lee, D-Calif., recently reintroduced legislation that would mandate prison testing and treatment of hepatitis C. Earlier similar proposals in recent years have failed.

“The plain fact is that prisoners do not stay in prison. With more than 90 percent of incarcerated persons returning to their communities, it is clear that when a prisoner is infected, we are all affected,” Lee said.

In North Dakota, it didn’t take legislation, court orders or new regulations to prompt medical services director Kathleen Bachmeier to begin screening every inmate for hepatitis C after a methamphetamine epidemic tripled her state’s prison population in about a decade. As the intravenous drug addicts arrived, so did the hepatitis C.

“It became obvious to me that these people are going to cost the state a lot of money if we don’t do something about it,” she said.

North Dakota now treats anyone who meets certain medical criteria, whose sentence is long enough to complete the course of treatment and who is willing to try to quit using drugs.

“We look at this as a huge public health initiative,” she said.

© 2009 The Associated Press.