Dear Director Ryan: Community standards for treating Hep C.

More unanswered correspondence with Director Ryan about Hep C. For all I know he's just sending me to his Spam Box now. The only way I can be relatively sure he sees this is by posting it or hand-delivering it - and I don't want them to trespass me down there if I show up too much.

Besides, this has useful info for everyone. Check out the links to the professional standards. Keep in mind when they were written, too.

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Arizona Prison Watch	Fri, Aug 20, 2010 at 10:15 AM
To: cryan kklausner
For all my criticism of them (which still stands), at least the CDC has easily-accessible information on the basics. Robertson stopped evaluating the extent of Davon's liver disease - and possible co-morbid conditions - when he should have kept going. He still needs the genotyping done to make sure he doesn't have more than one strain of HCV, and to determine the likelihood that he'll even respond to treatment. And in light of the increased risk for disorders like diabetes (and his weight loss and fatigue), his glucose should be monitored more regularly to determine what his ranges are. Davon should also be treated like a human being, not a veterinary specimen - no one seems to really be trying to educate him on his medical condition or lab results, or even ask him about his fatigue, weight loss, headaches, etc. despite hearing concerns from Julie multiple times a week. ------------------------------- CDC HCV FAQs: Testing and Diagnosis Who should be tested for HCV infection? HCV testing is recommended for anyone at increased risk for HCV infection, including: Persons who have ever injected illegal drugs, including those who injected only once many years ago Recipients of clotting factor concentrates made before 1987 Recipients of blood transfusions or solid organ transplants before July 1992 Patients who have ever received long-term hemodialysis treatment Persons with known exposures to HCV, such as healthcare workers after needlesticks involving HCV-positive blood recipients of blood or organs from a donor who later tested HCV-positive All persons with HIV infection Patients with signs or symptoms of liver disease (e.g., abnormal liver enzyme tests) Children born to HCV-positive mothers (to avoid detecting maternal antibody, these children should not be tested before age 18 months) What blood tests are used to detect HCV infection? Several blood tests are performed to test for HCV infection, including: Screening tests for antibody to HCV (anti-HCV) enzyme immunoassay (EIA) enhanced chemiluminescence immunoassay (CIA) Recombinant immunoblot assay (RIBA) Qualitative tests to detect presence or absence of virus (HCV RNA polymerase chain reaction [PCR]) Quantitative tests to detect amount (titer) of virus (HCV RNA PCR) How do I interpret the different tests for HCV infection? A table on the interpretation of HCV test results is available at http://www.cdc.gov/hepatitis/HCV/PDFs/hcv_graph.pdf [PDF - 1 page]. Is an algorithm for HCV diagnosis available? A flow chart on HCV infection testing for diagnosis is available at http://www.cdc.gov/hepatitis/HCV/PDFs/hcv_flow.pdf [PDF - 1 page]. What is the next step after a confirmed positive anti-HCV test? The level of ALT (alanine aminotransferase, a liver enzyme) in the blood should be measured. An elevated ALT indicates inflammation of the liver. The patient should be checked further for chronic liver disease and possible treatment. The evaluation should be performed by a healthcare professional familiar with chronic Hepatitis C. Can a patient have a normal liver enzyme (e.g., ALT) level and still have chronic Hepatitis C? Yes. It is common for patients with chronic Hepatitis C to have liver enzyme levels that go up and down, with periodic returns to normal or near normal levels. Liver enzyme levels can remain normal for over a year despite chronic liver disease. Management and Treatment What should be done for a patient with confirmed HCV infection? HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination. When might a specialist be consulted in the management of HCV-infected persons? Any physician who manages a person with Hepatitis C should be knowledgeable and current on all aspects of the care of a person with Hepatitis C; this can include some internal medicine and family practice physicians as well as specialists such as infectious disease physicians, gastroenterologists, or hepatologists. What is the treatment for chronic Hepatitis C? Combination therapy with pegylated interferon and ribavirin is the treatment of choice, resulting in sustained virologic response (defined as undetectable HCV RNA in the patient's blood 24 weeks after the end of treatment) rates of 40%–80% (up to 50% for patients infected with genotype 1, the most common genotype found in the United States, and up to 80% for patients infected with genotypes 2 or 3). Combination therapy using interferon and ribavirin is FDA-approved for use in children ages 3–17 years. Treatment success rates are now being improved with the addition of polymerase and protease inhibitors to standard pegylated interferon/ribavirin combination therapy. How many different genotypes of HCV exist? At least six distinct HCV genotypes (genotypes 1–6) and more than 50 subtypes have been identified. Genotype 1 is the most common HCV genotype in the United States. Is it necessary to do viral genotyping when managing a person with chronic Hepatitis C? Yes. Because there are at least six known genotypes and more than 50 subtypes of HCV, genotype information is helpful in defining the epidemiology of Hepatitis C and in making recommendations regarding treatment. Knowing the genotype can help predict the likelihood of treatment response and, in many cases, determine the duration of treatment. Patients with genotypes 2 and 3 are almost three times more likely than patients with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin When using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended. Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection. Can superinfection with more than one genotype of HCV occur? Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon. Does chronic Hepatitis C affect only the liver? A small percentage of persons with chronic HCV infection develop medical conditions due to Hepatitis C that are not limited to the liver. These conditions are thought to be attributable to the body's immune response to HCV infection. Such conditions can include Diabetes mellitus, which occurs three times more frequently in HCV-infected persons Glomerulonephritis, a type of kidney disease caused by inflammation of the kidney Essential mixed cryoglobulinemia, a condition involving the presence of abnormal proteins in the blood Porphyria cutanea tarda, an abnormality in heme production that causes skin fragility and blistering Non-Hodgkins lymphoma, which might occur somewhat more frequently in HCV-infected persons Where can I find more information about management and treatment of patients with chronic Hepatitis C? The American Association for the Study of Liver Diseases: AASLD Practice Guideline: Diagnosis, Management, and Treatment of Hepatitis C . The National Institute of Diabetes and Digestive and Kidney Diseases: Chronic Hepatitis C Current Disease Management. -- Arizona Prison Watch http://arizonaprisonwatch.blogspot.com A community resource for monitoring, navigating, surviving, and dismantling the prison industrial complex in Arizona. “The degree of civilization in a society can be judged by entering its prisons.” - Fyodor Dostoyevsky (1821-1881)

NCCHC: Hep C In Corrections Position Statement

This is what the professional correctional health care people were saying over 10 years ago...

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National Commission on Correctional Health Care

Position Statement: The Management of Hepatitis C in Correctional Institutions

Introduction

The National Commission on Correctional Health Care and the Society of Correctional Physicians are not-for-profit organizations that work toward the improvement of health services in the nation's jails, prisons, and juvenile confinement facilities. The Commission publishes health services standards and operates a voluntary accreditation program for institutions that meet these standards. The Society is an organization of physicians specializing in correctional medicine.

The issue of Hepatitis C is of great concern to the Commission and Society since it is a threat to the quality of health care provided in prisons and jails. The Commission and Society have adopted the following position statement that, along with the published standards, may assist policy makers and health professionals in designing their own policies and procedures on this matter.

Background

Chronic liver disease is the 10th leading cause of death among adults in the United States. The Centers for Disease Control and Prevention (CDC) estimates that approximately 25,000 deaths occur annually from chronic liver disease, and that hepatitis C virus (HCV) is responsible for 40 percent of that death toll (CDC, 1998).

The HCV is a bloodborne pathogen and is transmitted primarily through large or repeated direct percutaneous exposures to blood (Alter, 1997). In the United States, the relative importance of the two most common exposures associated with transmission of HCV, blood transfusion and injection drug use, has changed over time. Blood transfusion, which accounted for a substantial proportion of HCV infections acquired >10 years ago, rarely accounts for recently acquired infections.

In contrast, drug use consistently has accounted for a substantial proportion of HCV infection and currently accounts for the majority of HCV transmission in the United States. Health-care professionals who are exposed to needlestick injuries in an occupational setting and hemodialysis patients are also at risk from exposure to infectious blood, as are infants born to infected women. In addition, HCV may be transmitted by sexual or household exposure to an infected contact; however, the efficiency of transmission in these settings appears to be low. Although any percutaneous exposure has the potential for transmitting bloodborne pathogens, including HCV, no data exist in the United States indicating that persons with exposures to tattooing and body piercing alone are at increased risk for HCV infection. Further studies are needed to determine if these types of exposures and settings in which they occur (e.g. correctional institutions, unregulated commercial establishments) are risk factors for HCV infection in the United States.

An estimated 3.9 million persons in the civilian, non-institutionalized population are infected with HCV. This estimate is based on the Third National Health and Nutrition Examination Survey (NHANES III) data; however, it does not include the incarcerated, institutionalized, or homeless populations. Still, in the general population, HCV is more prevalent than human immunodeficiency virus and tuberculosis infections in the United States.

The prevalence of hepatitis C virus infection among the prison population has not been sufficiently studied. However, because many inmates have a history of drug use, it stands to reason that correctional systems will experience high HCV prevalence rates. The California Department of Corrections and the California Office of AIDS conducted a 1994 blinded study supporting this concern. The study found 41 percent of entering inmates testing positive for antibody to HCV (Nieto, 1998).

In spite of the morbidity of hepatitis C and the likely high prevalence of HCV infection in the prisoner population, there is no national policy on the screening or treatment for HCV infection in federal or state correctional systems. The following position statement provides guidance to correctional administrators in the management and treatment of hepatitis C.

Discussion

The diagnosis of hepatitis C should be considered in patients with risk factors, such as injection or inhalation drug use, symptoms such as fatigue, or a history of jaundice or hepatitis. Prior to testing, inmates should be given information about the transmission of HCV, the nature of hepatitis C and chronic liver disease, potential health consequences, the test procedure and meaning of the test results, and the benefits and side effects of treatment.

The standard initial laboratory test for anti-HCV is by enzyme immunoassay (EIA). Several factors may determine how extensive further evaluation should go. Correctional health care workers need to contemplate whether an inmate patient is a candidate for treatment before proceeding much beyond antibody testing (Spaulding, 1999). Patients with persistently normal serum transaminases probably do not benefit from treatment (NIH, 1997). Because of interferon's propensity to induce depression, inmates need to be mentally stable before treatment. Other medical problems also should be under control. The expected benefit of prolonging life with HCV treatment may only be realized decades after treatment. Inmates should have a remaining life expectancy of at least one or two decades. Because HCV disease may progress rapidly in the setting of HIV, less stringent criteria for life expectancy should apply for patients co-infected with HIV and HCV. Treatment for youths less than 18 years old is at present still controversial.

Long term adult facilities should give standard therapy to appropriate patients, in an attempt to treat and perhaps eradicate the virus. Even after treatment for HCV, a patient may reacquire HCV; drug and alcohol rehabilitation should precede HCV treatment (NIH, 1997). Expected remaining duration of incarceration can determine whether a correctional facility ethically bears a responsibility to treat disease (Anno, 1996). Because hepatitis C infection can lead to fatal liver failure and hepatocellular carcinoma, all prisons should develop criteria for appropriate treatment candidates. These criteria should not be so stringent that they exclude all prisoners from a treatment that may be lifesaving.

Prisoners who have a positive EIA test should then be given confirmatory test if treatment is contemplated. There is a high pretest probability that a positive EIA in an inmate with HCV risk factors is a true EIA, the appropriate confirmatory test is one looking for the virus itself, such as a polymerase chain reaction (PCR) test, rather than a recombinant immunoblot assay (RIBA). Prisoners who test positive on their confirmatory tests should be ruled out for other chronic liver disease such as hemochromatosis, Wilson's disease, autoimmune hepatitis, and alpha-1 antitrypsin deficiency. A liver biopsy, though it may convey some useful information, is not a cost effective part of a work up (Wong, 1998).

All inmates who test positive for HCV should receive counseling to encourage behavioral changes that may be required to prevent future contagion of others, and when appropriate, should receive intensive chemical dependency and substance abuse treatment.

HCV infected inmates should be counseled to avoid drinking alcohol. HCV infected inmates also should be encouraged to voluntarily inform their sexual and intravenous drug using partners to advise them of their potential contact with the HCV.

Correctional health care systems also should study the prevalence of hepatitis C in their inmate population and factors that contribute to disease and its transmission. They should use the results of the study to prepare guidelines for prevention, screening, and treatment aimed at reducing the prevalence of the disease.

Education on hepatitis C infection should be incorporated into prison and jail health education programs. This education should include information on modes of transmission, prevention, treatment, and disease progression. Educational programs should include culturally sensitive and scientifically accurate health information providing clear and easily understandable explanations of practices which reduce the risk of becoming infected or transmitting HCV. The target population should be involved in the development and provision of educational programs to encourage acceptance of the disease and changes to life-style and behavior.

Correctional and health staff should receive training on confidentiality as it applies to HCV. Correctional officers and health staff should also be informed about their potential occupational or personal risk for acquiring hepatitis C. When appropriate, staff should pursue testing and treatment from their personal physicians.

Most HCV infected inmates will return to their community soon. State correctional systems should work with their state public health departments to develop state specific health policy guidelines to coordinate the screening, education, and treatment of hepatitis C.

When developing HCV policies, administrators should refer to the following documents for guidance: NCCHC standards on receiving screening, infection control, health promotion and disease prevention, and health assessment, as well as NCCHC's position statement on managing hepatitis B in prisons. In addition, correctional health administrators should refer to the Centers for Disease Control and Prevention or the American Academy of Family Physicians for their most recent recommendations on the prevention and control of HCV.

Position Statement

Correctional health administrators should develop a system and/or facility policy on the management and treatment of hepatitis C.

Adopted by the National Commission on Correctional Health Care Board of Directors
November 7, 1999

References
Alter, M. J. (1997). Epidemiology of hepatitis C. Hepatology ,26(6):2S-5S.

Anno B. J. et al. (1996). A preliminary model for determining limits for correctional health care services. J Correctional Health Care 1996; 3(1):67-84.

Centers for Disease Control and Prevention (1998). Recommendations for Prevention and Control Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Morbidity Mortality Weekly Report .October 16, 1998, 47 (RR-19)

Department of Health and Human Services, National Center for Health Statistics (NCHS).
NHANES III (National Health and Nutrition Examination Survey, 1988-1994).

Marcellin P. et al., (1997) Long-term histological improvement and loss of detectable intrahepatic HCV RNA in patients with chronic hepatitis C and sustained response to interferon-alfa therapy. Annals Int Med 1997; 127:875

McHutchison J. G. et al (1998) Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. N Engl J Med 1998; 339:1493-9.

National Institutes of Health (1997). Consensus Development Conference Panel Statement: Management of Hepatitis C. Hepatology, 1997 26(Suppl 1:2S-10S).

Ruiz J. D., Mikanda J. Seroprevalence of HIV, Hepatitis B, Hepatitis C, and risk behaviors among inmates entering the California correctional system. Sacramento, California Department of Health Services, March 1996.

Spaulding A. et al (1999). Hepatitis C in State Correctional Facilities. Preventive Medicine 1999; 28: 92-100.

Wong J. B., Bennett W. G., Koff R. S., Pauker S. G. Pretreatment evaluation of chronic hepatitis C: Risks, benefits and costs. JAMA 1998; 280 (4):2088-93.

http://www.ncchc.org/resources/statements/hepc.html