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STATE OF WASHINGTON
Department of COITections

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REPORT ON THE MAl'iAGEMENT OF
HEPATlTIS C IN THE CORRECTIONAL
El'\VIRONMENT
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Report to the Legislature
December, 1999

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TABLE OF CONTENTS

PAGE
NUMBER

Executive Summary

1.

Introduction and Background

1

Overview of Hepatitis C

1

Phannacological Treatment of Chronic Hepatitis C
ChroniC Hepatitis C in Correctional Settings
Prevalence of Hepatitis C in the Department of Corrections'
Offender Population

2
4

Washington State Department of Corrections and the
Cost Effective Management of Hepatitis C
Current Approach to Treating this Disease
The Offender Health Plan Sets the Standard
Reviewing the Current Treatment Guideline

5

6
6
7

8

The Department's Proposed Plan to Implement a Disease
State Management Protocol for Hepatitis C

10

Reassessment of Previously Identified Cases

13

Evaluation of Options

14
14
14

Option 1: Continue Current Approach
Option 2: Mandatory Testing and Implementation of the
Disease State Management Protocol
Option 3: Voluntary Testing and Implementation of the
Disease State l\tlanagement Protocol

15

Recommendations

16

Conclusions

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EXECUTIVE SUMMARY
Introduction

Sec~i~n 22.2 , chapte~ 309 Law~ of 1999: ~equir~s the Departn:ent of Corrections to prepare a report
outhnmg Its plan tor managmg hepatitis C m the correctional environment. In response, the
Department broadened the efforts begun in March 1999 and developed not only a guideline for
identifying offenders eligible for pharmacological therapy, but a disease state management protocol
for hepatitis C, as described below. In addition to clinical management. this approach addresses
public health concerns about preventing transmission of the virus. As required, the Department
worked with recognized experts and used information available from the National Institute of Health
and other states' correctional departments as resources to develop the guideline for pharmacological
treatment that is part of this protocol.

Background
Hepatitis C is a blood-borne infectious disease annually infecting approximately 30,000 people in the
United States. Over the 20 years following infection, the disease can become chronic and lead to a
serious liver condition called cirrhosis. Increasingly smaller subsets of infected people develop lifethreatening complications, including liver cancer. Cancer and other life-threatening outcomes appear
in about 3 percent of the original infected population. Hepatitis C is currently the leading reason for
liver transplants in the country.
Approximately 1.8 percent of Washingtonians may be infected with this virus. In a recent study, 25
percent of offenders entering the Department of Corrections tested positive for the hepatitis C virus.
Fifty percent of these offenders had laboratory results indicating a potential for having chronic
hepatitis C.
In 1995. the Department began researching a uniform approach to managing hepatitis C. Interferon,
the only therapy then recognized in the medical literature. had a success rate of about 12-15 percent.
It also had serious side effects and was very expensive. A group of Department physicians
developed clinical criteria to help identify offenders who might best respond to the therapy. In 1996,
the Department adopted a policy including these clinical criteria and requiring authorization prior to
rendering interferon therapy: This policy is still in effect.
Since that time, the Federal Food and Drug Administration approved a new, more effective
pharmacological treatment for hepatitis C with a 40 percent success rate. Also, the National Institute
of Health and the Centers for Disease Control and Prevention published recommendations for
diagnosing and treating hepatitis C. In March 1999, given these new developments, the Department
began a literature review for the purpose of evaluating its current policy and guideline.

Disease State Management Protocol for Hepatitis C
The Department has developed a plan of action. referred to above as the disease state management
protocol for hepatitis C, for managing offenders who are infected with this virus and are in a state
correctional facility. This proposed plan is consistent with Legislative request.

The disease state management protocol for hepatitis C includes:
.:. A guideline for determining eligibility for pharmacological therapy;
.:. Medical case management by the Department's primary care prov,!iders and infection
control nurses;
.:. Offender education to prevent the transmission of the virus;
.:. Chemical dependency treatment to prevent the transmission and reinf~ction of the virus;
.:. Mental health assessment and intervention as appropriate to addt!ess adverse mental
health responses to the medication;
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.:. Oversight and technical assistance by the Department's medical dir~ptor and the Central
Utilization Review Committee to assure appropriate mana~ment and timely
interventions; and
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.:. Clinical data collection to track offenders participating in the protoco;J.
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Options

C041

The Department evaluated three options for how to manage offenders in the
ctional setting. The
first option proposes the Department continue its current practice, w,' ich is to provide
pharmacological intervention to only the few offenders who met very specific .linical criteria. This
can be done within existing resources. However, this option is not consistent }'lith current national
guidelines. it is not consistent with the mandate of the Legislature, it will hate limited impact on
effectively managing the condition, and it does not address preventing trans~ission of the virus.
However, this approach is less costly. .
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The second option proposes the Department institute mandatory testing of all current and incoming
offenders and implement the disease state mar.agement protocol for hepatitis C described above.
This approach assures all offenders infected with the virus are identified and a@,ropriately managed,
but mandatory testing is not consistent with what is done in the community o~ in other correctional
systems. The cost of this option is estimated to be $9,715,816 to manage the c'prrent population and
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an additional $3,568.626 for the incoming population each year.
The third option includes the disease state management protocol for hepatitis cr., as described above,
with a voluntary testing component. This option provides the Department t~e opportunity to test.
manage, and treat, if eligible. all offenders who request testing and are positi~e for the virus. It is
hoped offenders will self refer as a result of the Department's prevention educdtion program because
they recognize they participated in high-risk behavior. It is assumed those wh~ want to be tested are
truly concerned about their health and will be compliant with the protocoLj Voluntary testing is
consistent with other correctional and community models. It will also prom~te appropriate use of
state resources and a prudent return on the invested cost of the program. The ,.F'stimated
s
cost for this
program is $4,180,465 for the current population and $1,606,512 for the inc~ing population each
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year.

Recommendation
Assuming funding is provided. the Department of Corrections recommends implementation of option
. 3. voluntary testing with management according to the disease state manageijnent protocol of those
offenders who test positive for the virus. This comprehensive plan for mar
. ·•.' ging hepatitis C best
addresses the total health needs of infected offenders in a cost-effi' ctive manner, while
acknowledging the Department's role in contributing to the public's health. .'
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Introduction and Background

Section 222, chapter 309 Laws of 1999, directs the Secretary of the Department of
Corrections to report on how the Department plans to manage hepatitis C in the offender
population.
As specified. the Department developed a treatment guideline for
phannacological intervention in conjunction with experts in the field and in a manner that
is similar to or consistent with those produced by the National Institute of Health and
other state correctional systems. The other components of the recommended plan include
offender prevention education about the disease, a process for how and when offenders
will be tested, and a description of how the disease will be managed whether or not the
offender is eligible for pharmacological treatment. The Department" evaluated three
different options. The analysis of these options is' included in this report. This report also
includes an estimate of the number of offenders that have hepatitis C in the Washington
prison system. As required. an estimate of funding needed to implement the
Department's recommendation is provided.
Overview of Hepatitis C

Hepatitis C, formerly referred to as non-A, non-B hepatitis, is the most common blood
borne infection in the United States. Through the 1980s, blood product transfusions and
intravenous drug use were the primary sources of infection. After 1992, when a n~w test
for hepatitis became available to screen blood donor products, transmission through
blood products became rare. For unknown reasons, infection transmitted through
intravenous drug use also began to decline in the late 1980s. As a result, the rate for new
infections has dropped 80 percent from the peak in the mid-1980s. Intravenous drug use
accounts for about 60 percent of the new infections that have occurred since the mid1990s. Other risk factors for transmission of hepatitis C are tattooing' without sterilized
needles, and using intranasal cocaine. l
Whether sexual contact is a risk factor for the spread of hepatitis C is unclear. Most
people in a long-term monogamous relationship appear to be at low risk of spreading or
contracting the disease. The Centers for Disease Control statistics show that 1 in 65
people who have a'hepatitis C partner will contract the disease in this manner. However,
having sex with multiple partners seems to increase the risk of transmitting hepatitis C.
Women seem to become infected this way from male partners more frequently than the
,
reverse.-

1 Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C
virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47 (No. RR-19)::1-37.
Alter, MJ. Epidemiology of Hepatitis C. Hepatology 1997.625-655.
2 Colin. Molly. Being in Charge A Guide to Living with Chronic Hepatitis Band C. 5chering
Corporation:1998.28.

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Of the approximately 30,000 members of the non-incarcerated population who become
infected annually, 80 percent, or 24,000, develop a chronic infection.) Studies show that
of those who develop chronic infection, approximately 4,800 (20 percent) will develop
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cirrhosis of the liver in an average of 20 years from the time they were infected. Regular
consumption of alcohol expedites the development of this condition. S~bsequently, 960
(20 percent) of these people, or 3.2 percent of the originally infected population, will
develop serious symptomatic and life threatening liver complication~ related to the
cirrhosis. Of those who develop serious complications of cirrhosis, 1~92, less than 1
percent of the original population, will develop cancer of the liver in ap average of 30
years from the time they were infected5 (See Attachm~nt A). Hepatitis is the leading
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indication for liver transplantation in the United States.

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Many people with hepatitis C do not realize they are ill because they ha~e no symptoms.
Some experts estimate that 10 to 70 percent of patients with hepatitis C~have mild, nonspecific symptoms, described as flu-like, muscle and/or joint aches, h~adaches, nausea
and loss of appetite, and sometimes stress and depression. An estimatedJ2,O to 30 percent
develop jaundice. Fatigue seems to be the most prevalent symptom for tllJose infected. ' .
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PhannacololZical Treatment of Chronic Hepatitis C
Treatment for chronic hepatitis C has long been controversial. 8 Varieties of interferon
have been the primary drug of choice for treatment since the 19805. However, the
sustained response rate with the different types of interferons alone lingered around 15
percent for all patients treated and there are serious side effects tei the medication
includiI1;g depression and suicidal behavior or ideation. 9 Since it cou](#not be predicted
which patients with the virus would be among those 15 percent who wo~ld respond to the
drug and who would progress to serious health problems, treatin$ everyone with
interferon has not been popular in the medical community. Physicians/:onsider whether
or not the risk for side effects outweighs the risk to the patient, who !i may or may not
develop a serious complication and mayor may not respond. In light of the low efficacy
rate and the lack of long term studies, some conununity physicians h~e chosen not to
treat and to wait and see what new information becomes available or "hat new drug is
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3 Alter, Mj, et. at. The prevalence of hepatitis C virus infections in the United States, 1$88 through 1994.
New England Journal of Medicine 1993:341: 5 5 6 - 6 2 . ;
4 Alter, MJ. et. a!. The natural history of community-acquired hepatitis C if! the United'~tates. New
England Journal of Medicine ed 1992; 3 2 7 : 1 8 9 9 - 9 0 5 . [
5 Seeff, LS, et. al. Long term mortality after transfw,ion-associated non-A, non-B hep~itis. New England
Journal of Medicine ed 1992; 327:1906-11.
6 Primary liver disease of liver transplant recipients 1991 and 1992 (from the UNOS S([#entific Registry).
UNOS Update. 1993;9:27.·
'
7 Centers for Disease Control and Prevention. Recommendations for prevention and fntro' of hepatitis C
virus (HCV) infection and HCV-related chronic disease. MMWR 1998: 47 (No. RR-19)'I: 1-37.
8 Koretz. RL. Interferon aAd chronic non-A, non-S hepatitis: whqm are we treating?'l
Hepatology1990;1 2 : 6 1 3 - 5 . 1
9,McHutchison JG et.a!. Interferon Alpha-2b alone or in combination with ribarvirin as t~itia( treatment for
chronic hepatitis C. New England Journal medicine 1998;339;1485-92.
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Bennett WG, et. al. Estimates of the cost effectiveness of single course of interferon-a!pha-2b in patients
with histologically mild chronic hepatitis C. Ann Intern Med 1997; 127:855·65.

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approved. This is a safe approach given that chronic hepatitis C is a slow progressing
condition and most complications do not develop for about 20 years after the onset of the
disease.
However, current research; including large studies published in the leading medical
journals last year and this year, demonstrate that by combining interferon with the antiviral drug, ribavirin, better outcomes are achieved than using interferon alone. The
combining of these two drugs, referred to as combination therapy, now increases the
response rate to 40 percent. In other words, 40 percent of the patients who receive this
therapy will not show the presence of the virus in their body 6 months after completing
the therapy.
Although this is a marked improvement, much controversy still exists. The long-tenn
benefits of the treatment are still unknown. Most research equates successful treatment to
eradicating the virus from the blood, nonnlilizing blood tests that measure liver function,
and improving the microsGopic appearance of the liver. Since chronic hepatitis C
progresses very slowly and this treatment has just become available, researchers have had
difficulty in assessing the effects of the treatment on the development of cirrhosis and its
complications. liver cancer, and death. Definitive data to answer the questions, "Does it
prevent these conditions from developing or do infected persons continue to progress to
this state?" will not be available for many years.
Consequently, some physicians are still hesitant to treat, because of insufficient outcome
data to justify the high cost and potential adverse side effects. However, in university
centers and larger cities the therapy is being used. Many providers treating patients are
collecting data regarding treatment interventions and outcomes to help them evaluate and
adjust their own practice.
Other researchers have evaluated the cost-effectiveness of the treatment of chronic
hepatitis C with interferon therapy. Three of these studies published in prominent
medical journals estimate that treating individuals between the ages of 18 and 60 years
old with chronic hepatitis C is equal to or more cost-effective than treating hypertension
or high cholesterol with medication, or treating severe coronary artery disease with
Preliminary cost-effectiveness studies comparing monotherapy, using
surgery. 10
interferon alone, to combination therapy, found the latter more cost-effective, although
definitive studies remain to be done.

10 Wong JS et. al. Pretreatment evaluation of chronic hepatitis C: risks, benefits. and costs. JAMA
1998;280:2088-93.
Bennett WG. et. al. Estimates of the cost effectiveness of single course interferon-a2b in patients with
histologically mild hepatitis C. Ann Intem Med 1997;127:855-65
Kim WR et. al. Cost effectiveness of 6 months and 12 months of interferon -a-therapy for chronic hepatitis
C. Ann Intem Med 1997;127:866-74.

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Chronic Hepatitis C in Correctional Settings
There is limited information available about the prevalence of chronic heM1atitis C or its
impact in the prison population. It is not known whether the estiI;J1ates for the
complication rates in the general population are applicable to the offend~r population.
Recent statistics from the Federal Bureau of Prisons demonstrate the nwib.ber of deaths
from liver disease surpassed those from Hwnan Immuno-Deficiency Virus ~d is now the
third leading cause of death among their offender. I I Heart disease and canch remain their
leading causes of death. A 1998 analysis of offender deaths found the sam~ pattern exists
"
in this state.
The only fonnal study published about the prevalence of hepatitis C in tJ!1e correctional
setting is from the California Department of Corrections. This study",found that 39
percent of male and 55 percent of female offenders entering me Califomjia correctional
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system in 1996, were hepatitis C positive. 12
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At the time this report was prepared, the only other published study about hepatitis C in
United States correctional settings was written by staff from the Rhode IsI$d Department
of Corrections. That study surveyed state correctional departments abol1:t the screening
and treatment of chronic hepatitis C. Thirty-six states and the Distriq/t of Columbia
responded. The report was published in 1999, making the infonnation ov$' two years old
;
at the time of publication. 13
In 1996, according to the Rhode Island study, only Colorado reported roU'~nely screening
for hepatitis C. The rest of the states, including Washington, responded i"No", although
some did clarify that high risk or symptomatic offenders were screened. !

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Kendig N, Information presented at the Society of Correctional Physicians' Na~onal Meeting,
November 1999
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12 Ruiz, JOt etal. Prevalence and correlates of hepatitis c virus infection among j'rmates entering
the California correctional system. West J Med 1999;170:156-160
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13 Spaulding, Anne. Hepatitis c in state correctional facilities. Prevention Medicinj!. 1999;28;92100.
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The rest of the key indicators from the Rhode Island survey are summarized below:
Survev of States' Corrections Departments Sununarized Responses

Do you treat
hepatitis C?
Do you have an
interferon protocol?
Number of doses
used in 1995?

Type and Frequency of Response
Sometimes-27
Never-8
Yes-4

No-2r

Able to report-l 0

N/A or 0- 27

Other-2
Developing-6

This report indicates each state is addressing the condition differently (See Attachment B
for this report and more detailed survey results).
Over the last three years, the treatment of chronic hepatitis C in the correctional setting
has been in a state of transition. While working on our guideline, Department of
Corrections staff were in telephone contact and/or email correspondence with numerous
states that were somewhere in the process of developing a treatment guideline.
Guidelines available from other states were collected and used as references for the
Department's latest guideline. Many states are struggling with how to manage hepatitis
C, but some states are continuing to not address it.
Prevalence of Hepatitis C in the Washinlrton State Department of Corrections' Offender
Population
For the purpose of this report, the Department collected preliminary data about the
number of offenders entering the system who were positive for hepatitis C in the month
of October 1999. Every offender who participated in intake that month at the
Washington Corrections Center and the Washington Corrections Center for Women was
tested for the hepatitis C virus. If the hepatitis C test was positive, a liver enzyme test
(Ai T) was done to gi've a "rough measure" of the amount of liver damage present. The
Department consulted with the Department of Health on the study design and they found
the study results to be statistically valid.
The data collected was used to project the percent of the population that is hepatitis C
positive being admitted to the Department. Twenty-five percent of the offenders
admitted to the system in the month of October were hepatitis C positive. In comparison,
the information reviewed from a nation-wide study estimates 1.8 percent of the general
population in this state is hepatitis C positive. Of those offenders who tested positive in
October, 48 percent had elevated liver enzymes which may mean they are candidates for
developing or have chronic hepatitis C. (Remember, in the general population 80 percent
• This number erroneously includes Washington State. In July 1996. the Department implemented
a policy about using interferon to treat hepatitis C.

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of the acutely infected becomes chronically infected). A more detailed distribution of
these results is provided below:

WCC
WCCW
TOTAL

Number of
offenders
tested
374
61
435

Percent of
Hepatitis C
positive
24% I
33%
25%

Number
Hepatitis C
positive
89
20
109

Elevated
ALTs
~

48
4
52

Percent with
elevated
ALTs
54%
20%
48%

Extrapolating this information to the Department's total incarcerated population of
14,000 offenders, 25 percent, or 3,500, could be hepatitis C positive. The~ if the risk for
chronic infection is 80 percent, 2,800, of these infected offenders may d~e10p or have
chronic infection. Continuing to apply the rate of progressive disease"statJs found in the
general population and reported on page 2, 20 percent, or 560, of tho~e chronically
infected may go on to develop cirrhosis in about 20 years from the time of their infection.
Another 20 percent of those offenders, or 112, may develop a seriou$ complication
related to their cirrhosis: and 22 more offenders, or 20 percent, of those may develop liver
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cancer in about 30 years from the time they are infected.
In the current offender population. using the data in the Otlender Based T$cking System
for Health Services, 680 offenders are recorded as having hepatitis C. Oite hundred and
two of these offenders have co-existing liver disease, including cirrhosi$, that is most
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likely related to their hepatitis C.
Washington State Department of Corrections and the Cost-Effective; i\tlanagement
of Hepatitis C
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Current Approach to Treating this Disease
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In July 1996, the Department of Corrections implemented a policy t~ treat chronic
hepatitis C using interferon-alpha (See Attachment C). Various physician$ who practiced
in our institutions use a consensus process to develop the policy and trea1ment guideline
over a period of several months. The physicians included internists, geneIl~ practitioners,
and ~. infect~ous d~s~a.se .specialist. This ~olicy requires authorization by ~ panel of three
phySICIans pnor to InItiatIng pharmacologIcal therapy.
.
As referenced earlier, in 1996, there was limited published data available;;about the longterm outcomes and benefits of using interferon to treat chroclc hepatitis C. Some of the
physicians wanted to aggressively treat the disease, but the majority wqted to wait and
see what progress was made in available treatments and the possible imp~ct on sustained
results. In ~ddition, comm~i~ gastroenterologists who were .treating
nders were ~ot
recommendmg treatment Wlth mterferon. Even though the lIterature c "uld not prOVIde
sufficient evidence of a sustained response for everyone with the ·rus, there was

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acknowledgment there may be some specific clinical indications as to when a person with
hepatitis C may respond to .therapy. The guideline developed attempts to identify those
patients who exhibit these specitic clinical indications.
To address the issue of treatment for these specific offenders, Department physicians
agreed to a peer review process whereby three medical directors from facilities where the
offender was not housed would review a request by the attending provider to treat the
offender with Interferon. Providers disagreeing with the panel's decision could request
reconsideration of the decision through the Health Services Unit at headquarters.
Offenders could use the Department's formal grievance process to request
reconsideration of the panel's decision. Approximately, eight cases were referred by
providers for prior authorization to treat chronic hepatitis C with interferon. In all cases,
the physician peer review committee members agreed the referral did not meet the
clinical 'indications established in the Department's guideline. All these offenders
continued to receive ongoing monitoring of their condition and treatment for any
.symptoms they developed.
The Offender Health Plan Sets the Standard
In December 1996. the Department implemented the statutorily required Offender Health
Plan and supporting policy. This plan established a uniform set of standard health care
services for offenders and was based on the State of Washington Basic Health Plan. A
committee including representatives from the Departments of Health, Corrections, Social
and Health Services, the Health Care Authority, and the qffice of the Attorney General
wrote the plan. The Offender Health Plan stipulates that the Department of Corrections
will only provide aI}.d reimburse for services that are medically necessary.
Excluded services include those which are:
• not supported by sufficient evidence to indicate that the service will directly
improve the length or quality of the offender's life;
• not supported by sufficient evidence to draw conclusions. Indications of
sufficient evidence is demonstrated by:
>- concurrence through peer review (as defined by the National
Association of Insurance Commissioners);
~ well controlled studies;
>- study outcomes which are directly or indirectly related to the length or
quality of life; and
>- reproducibility, both within and outside research settings.
• not expected to have a ben~ficial effect on the length or quality of life, or not
outweigh the expected harmful effects; and
• not the most cost effective method available to address the disease, illness, or
injury.
(Cost-effective meaning there is no other equally effective
intervention available or suitable for the patient which is more conservative or
substantially less costly.)

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UntiI recently, the decision to not uniformly provide interferon therapy to treat chronic
hepatitis C was consistent with this provision of the Offender Health Plan. However,
development of a new treatment regimen producing better long-term outcomes and
sustainable results and the production of hepatitis C management guid~lines by The
National Institute of Health and the Cente.!"s for Disease Control and Prev~ntion warrant
the development of a new treatment guideline by the Department. . In addition,
correctional departments in other states and the Federal Bureau of Priso6.s are actively
addressing the issue of chronic hepatitis C in the incarcerated population.;
Reviewing the Current Treatment Guideline

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The advances cited above provides the Department with a credible ""dest practices"
approach to treating the disease. Since March 1999, representati~es from the
Department's Office of Correctional Operations Health Services Unit and Uwo physicians
who practice in Department facilities have completed a literature review~' collected and
other state's
reviewed treatment guidelines from other health care providers, payers, arid
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Department of Corrections; and drafted a new chronic hepatitis C treatII).ent guideline.
The new medical director has assumed a leadership role in establishi~g the clinical
direction in which the Department should move.
1
In September 1999, there was an educational meeting for Department provjders about the
treatment and management of hepatitis C. The guest speaker at the meetiihg was Robert
Carithers. M.D.• hepatologist from the University of \Vashington.br. Carithers'
presentation provided our physicians and mid-level providers with· more current
information about the management of hepatitis C and allowed them to 4iscuss current
trends in treatment with a recognized national expert in the field. The dra~ guideline was
presented at this meeting. Comments, concerns, and suggestions for mo~ification were
requested and e n c o u r a g e d . '
In addition to the review and input by our own providers, the Depart~ent requested
comments and input from:
~ Robert Carithers, M.D., and
~ many. of the gastroen.t~rologists and heptologis~s who pracfce in various
WashlOgton conunumtIes and regularly prOVIde care to i the offender
population, including Michael Lyons, M.D. and John Carroug!er M.D., from
Tacoma Digestive Disease Center; James Harri, M.D., from WWla Walla; and
George Cox, M.D., of Everett.
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While developing the draft guideline, it became apparent that what woul<L.!be needed was
not just a product to assure Department clinicians consistently identify optFal candidates
for pharmacological treatment, but rather a comprehensive plan that V,yould establish
appropriate and uniform management of any offender with hepatitis C. Cd~sequent1y, the
draft guideline was expanded to establish expectations for periodi~, but regular,
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monitoring of all offenders who are known to be hepatitis C positive. This approach
would allow the Department to address hepatitis C from the perspective of disease state
management, which includes strategies like prevention education and chemical
dependency treatment to prevent transmission, rather than dealing with just the issue of
rendering phannacological treatment (See Attachment D for this comprehensive
protocol).
In an effort to promote optimal outcomes from the therapy, the proposed protocol
includes specific criteria that should be met in order to receive phannacological therapy.
The decisions about inclusion and exclusion criteria were based on medical and nonmedical indications. The medical indications are consistent with the Federal Food and
Drug Administration's recommendations and warnings and other available guidelines or
protocols, both from correctional and non-correctional settings. The non-medical
indications are consistent with the guidelines· or protoco.ls available from other
correctional settings, including the Federal Bureau of Prisons (See Attachment E, a
simplified version of the draft treatment guideline detailing this inclusion and exclusion
criteria).
An example of a medical indication for why an offender could ~e excluded from
pharmacological treatment is the presence or history of an existing condition which could
be made worse, possibly resulting in death, if given the medication. An example of a
non-medical exclusion is when the offender's remaining period of incarceration is too
short to allow the offender to complete the 24 to 48 week~ of treatment prior to release.
Pharmacological treatment would not begin during the incarceration period because:

•

•
it

the Department cannot be assured it will be completed post release; If the full
course of treatment is not completed, the condition will continue to be present.
This would not be an efficient and prudent use of state resources; and
it will result in a disruption of the continuity of care; and
this would make the management of hepatitis C consistent with how other
diseases are managed under the Offender Healtb Plan.

Offenders not receiving phannacological treatinent would be regularly monitored until
the period of incarceration is complete, ber:efiting from regular evaluations and education
about their disease state. Prior to release, offenders would be provided assistance and
consultation on how to enroll for medical benefits through other programs that they may
be eligible for, including but not limited to Medical Assistance, the Veteran
Administration, and/or the Basic Health Plan. The Department cannot assure the offender
will receive treatment under any of these plans.
The proposed protocol provides for t1:..: treatment of chronic hepatitis C using
combination therapy. This regimen requires the administration of interferon three times a
week and ribavirin daily. As previously stated, this therapy now has the best-documented
outcomes. However, in those· cases where this may not be the best treatment for an

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offender's specific situation, the Department's medical director would address
exceptions.

The Department's Proposed Plan to Implement a' Disease State.!, ManaKement
Protocol for Hepatitis C
Review of the proposed "Disease State Management for Hepatitis C" protocol indicates
that management of this disease can be rather complex and detailed (See Attachment D).
In order to assure optimal management, the Department's proposed protocol, or plan,
includes:
I) Medical Case Management by the Infection Control Nurses

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All o.ffenders infected with the hepatitis C virus would be managed b this specially
trained nurse responsible for:
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• educating the offenders about their disease and prevention of
transmission and reinfection;
• assuring that all diagnostics, random drug screens, e~aluations, and
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consults are scheduled and completed;
• assisting offenders with managing adverse effects to the therapy;
• assuring the data is entered into the data system describfd below; and
• reporting infonnation to and consulting with the'l clinicians, as
indicated.
2) Tools to Case Manage

:

To assist the infection control nurses the following tools have been ~ed:
•

a "Worksheet for Screening of Hepatitis C Positive Patients for
Possible Phannacological Therapy" to support appropriate and
consistent screening (See Attachment F);
1

•

a "Hepatitis C Management Activity Sheet" to suppom the timeliness
of consultations and diagnostic tests required in th~ screening and
.treatment phases and, when possible, through the,! post-treatment
periods to assess for a sustained response (See Attacbn1ent G); and

•

a "Hepatitis C Treatment Protocol-Patient Contract". '! This document
would serve as a comprehensive informed consent fortn. It details for
offenders what they: can expect throughout the cours~ of therapy and
stipulates that their total and complete cooperation azid compliance is
required. .Without the offender's thorough commitmept to the therapy
period, the treatment would not be of any benefit aqd therefore, not
cost-effective (See Attachment H).

j

10

3) Comprehensive Data Collection Svstem
The Department would collect all pertinent infonnation about hepatitis C positive
offenders, and track them as they participate in the disease state management
protocol. The Department would be able to identify offenders who:
• do not progress to the chronic phase;
• become chronic but not eligible for treatment and why
• start treatment;
• discontinue treatment and why;
• complete treatment; and
• achieve a sustained response. when available.
4) Management bv Onsite Providers
Mid-level providers and physicians who practice at the facilities would reguiJIly
monitor the health care status of these offenders. These providers would regularly
assess the otTender's response to therapy, review lab work, adjust medication,
reinforce education, confer with the infection control nurse, and consult the
Department's medical director, as indicated. I~
5) Vaccinations for feoatitis A and B
°

Vaccinations against hepatitis A and B would be offered to all identified offenders
with chronic hepatitis C to prevent the possibility of contracting a dual infection,
which can result in death.
6) Consultation with the Department's Medical Director
The Department's medical director would provide consultation and technical
assistance for the infection control nurses and the medical providers to support
appropriate application of this protocol and assist with the special needs of any
offender's specific situation.
7) Pre-authorization through Central Utilization Review
The Department's Central Utilization Review Conunittee would authorize all
pharmacological therapy. This provides an opportunity to assure appropriate and
consistent management of all cases. It also allows the Department to apply
°

14 At any point in the protocol, including the eOndpoints where the progress towards
pharmacological treatment is stalled, the provider at the facility could consult with the
Department's medical director to discuss the status of the case to date. This discussion should
assure appropriate interventions have been taken and to determine measures needed to move
the case in the best direction for the offender, as indicated.

11

"Continuous Quality Ir:nprovement" techniques as it reviews each case and assures
quality-outcome orientated medical management.
8) Chemical Dependencv Treatment
Since the primary mode of transmission of this virus is through intra~enous drug use
and the sharing of needles, the proposed protocol includes the cpmpletion of a
chemical dependency course, if indicated. Chemically dependent offtfuders who have
not been treated for their dependency will probabl~ not benefit frotP treatment. In
addition, any offender who responded to the treatment and then retunf).s to these risky
behaviors can become re-infected, eliminating all benefits to the off~nder and to the
public's health. Successful chemical dependency treatment should lhelp assure the
offeQder is not re-infected after completing therapy or passes the ~rus to another
"
person.
Offenders with chronic hepatitis C would have to agree to submit ~o random drug
toxicology screens during the initial assessment and through the treatment phase of
the protocol. An offender who fails to pass a screen will be referredlto the chemical
dependency treatment program. If the offender had already started"i the hepatitis C
treatment, this therapy will be discontinued until the offender comple~es the chemical
dependency treatment.
9) Mental Health Assessment and Treatment
Depression and suicidal ideation are serious side effects of the IlIhannacological
treatment for hepatitis C. Consequently, the proposed protocipl includes an
assessment of the offender's mental health history and current status djuring the initial
screening phase and again immediately prior to the treatment phase.
offender may
be excluded from treatment if his or her mental health can be comptomised by this
medication. When indicated, a psychiatric evaluation would be conducted to assure
an accurate clinical assessment. This process may identify offender$ who were not
previously known to be mentally ill, but would now need intenf~ntion prior to
initiating the therapy for hepatitis C.
I,

¥

,1

It would also be necessary for the Department to provide mental heal~ intervention to
any offender receiving the hepatitis C therapy who suddenly develops psychiatric
symptoms as a side effect. The literature reports 33 percent of the res~arch subjects in
the clinical trials of this treatment developed mental health sidq effects. The
Department would add a two-hour training session to the annual nO.andatory block
training sessions regarding the signs and symptoms of depressi~n and suicidal
behavior. This training would be conducted to support timely ~ecognition and
appropriate safe intervention by non-medical staff until a referral to .~ mental health
professionals could be completed. The mental health professional ""'ould conduct a
psychiatric evaluation and implement a treatment plan, as appropriat, to manage the
.

12

I

offender. These offenders may require a more aggressive treatment plan than just
decreasing or discontinuing the therapy for the hepatitis C.
10) Offender Education and Screening
The proposed disease state management protocol incorporates sound public health
strategies. All offenders would be educated about hepatitis C at intake as part of an
educational program including information on Human Immune-Deficiency Virus,
tuberculosis, and other issues of special concern to correctional populations.
Offenders would be informed about the disease, the risk factors for contracting and
transmitting the virus. and the possible implications. In addition, educational
materials would be available in the living units and the outpatient clinics. A team of
the Department's infection control nurses would develop the prevention education
materials with the consultation of the Department's medical director. A variety of
resources would be used to produce this information, including those available from
the public health system and the pharmaceutical companies.
It is hoped education about the risk factors for hepatitis C will encourage offenders to
avoid risky behavior and to seek testing. To support this effort, the statutorily
required medical co-payment fee for offender initiated visits would not be assessed on
any offender who seeks testing/screening for this condition.
In addition to educating all offenders about the disease and the indications for
screening, otfenders who are known to be positive for hepatitis C would receive
additional education and counseling from their medical case managers. The team of
infection control nurses and the Department's medical director would also develop
this information. The focus of this education would be to reduce risky behaviors and
improve self-care, thereby preventing transmission to others and preventing reinfection of those who are successfully treated.
Reassessment of Previouslv Identified Cases
As mentioned above, there are approximately eight cases which were previously referred
to the physician peer review group for authorization to treat pharmacologically. Since
these did not meet the Department's current guideline, authorization was not granted. In
addition to these cases, there have been several offenders who have come forward
requesting treatment. The clinicians felt that the clinical indications from the guideline
currently in effect were not met, so a request for authorization was not submitted.
Assuming funding is received, the Department will adopt the new protocol. These
offenders and the other offenders known to have co-existing liver disease will be
evaluated for appropriateness for receiving the combination therapy. An assessment of
their current status will be conducted using the new disease state management protocol.
A specific plan of care will be developed and implemented for each individual depending
on what points of the protocol need to be addressed. Offenders excluded from

13

pharmacological treatment because they do not meet the eligibility crite~a will receive
the other interventions called for in the proposed protocol, inclu¢iing chemical
dependency treatment, if indicated, education, and monitoring. In addition, offenders
excluded because their rel~ase date is pending, will receive assistanc~ in filing for
medical coverage tluough a health care payer for which they may be apprppriate, just as
provided for in the protocol.
.

Evaluation of Options
The Department evaluated three options, or scenarios, as to how to be$t manage this
condition in the correctional setting. The analysis of each one is provided below:
Option 1: Continue the Current Approach:
•

j~

Option one continues managing offenders with cluonic hepatitis C ac~ording to the
current policy and guideline. Only a minimal numbers of offenders wou$ ever receive
pharmacological intervention because very few would ever meet this g*deline. This
guideline is not consistent with the guidelines now being recommended by the National
Institute of Health, the Centers for Disease Control and Prevention, or that ~f other state's
correctional systems. It places the Department at risk for failing to fC!>llow what is
becoming deemed a "best practice" in treating hepatitis C. If the Depa.rtnlent chose this
option, it would not be compliant with th~ Legislative mandate in Section. 222, chapter
309 Laws of 1999. In addition, this approach fails to recognize the ;public health
concerns about transmitting the disease to others either during or after th~ incarceration
period. However, this approach would require limited funding to support. :1
Option 2: Mandatorv Testing and Implementation of the Proposed Disease
State
,
Management Protocol:
In this option, mandatory testing for hepatitis C will be conducted on fill offenders.
Offenders in the current population who are not known to be positive will ~e tested. All
incoming offenders wi~l be tested at intake. Any offender found to be inf~cted with the
hepatitis C virus will be managed under the Department's "Disease Statei:Management
Protocol for Hepatitis e" described in this report. Consistent with the~rotocol, any
offender identified as positive for hepatitis C will be further evaluated tOI establish the
presence of cluonic hepatitis C and to determine eligibility for treatment. rfjoffenders are
not eligible for treatment, they will continue to be monitored, counseled, anU managed as
called for in the protocol, including receiving prevention education ~d chemical
dependency treatment, if it is indicated.
.
This option would assist the Department in assuring identification an~ appropriate
management of all offenders who are infected with the virus. Treatment,
those who
are eligible, education, and chemical dependency treatment, as indicated, f~r all infected
offenders should help prevent the transmission of the virus to others and the teinfection of
the successfully treated offender. However, this approach is more aggressive than that

lpr

14

used for identifying infec~ed patients in the general population or other correctional
settings. Universal screening or testing is not being done elsewhere and it would me~ a
higher standard of care is being offered to the offender population.
Estimated costs to manage the current population of approximately 14,000 offenders are
$9,715,816. In addition, an estimated $3,568,626 is needed to manage the incoming
population estimated at 6,000 per year. (See Attachment I, "Option #2: Mandatory
Testing" for a detailed accounting of the costs).
Option 3: VoluntarY Testing and Implementation of the Proposed Disease State
ManageI!lent Protocol:
The third option differs slightly from option two, in that in this option, testing is
voluntary. At reception, all offenders will receive educational information about this
disease and its infectious nature. Educational material will also be available to offenders
in their living units and in the health care clinic. Then any offender concerned about
having the virus may request testing for the virus. In addition, any offender reporting
high-risk behavior, or a blood transfusion prior to 1992, will be counseled and strongly
encouraged to request testing. Consistent with Option 2, any offender identified as being
positive for the virus will be managed under the "Disease State Management Protocol for
Hepatitis C", as described in this report. Any offender identified as positive for hepatitis
C will be further evaluated to establish the presence of chronic hepatitis C and to
determine eligibility for treatment. Offenders not eligible for pharmacological treatment
will continue to be monitored, counseled, and managed as called for in the protocol,
including receiving chemical dependency treatment, if it is indicated.
This option assures treatment for those who are probably most motivated to request
testing and treatment and therefore, most likely to complete the difficult treatment
regimen. Treating those most motivated to improve their health should prevent the
transmission of the virus to others and may prevent the development of the more
complicated liver diseases caused by hepatitis C. A voluntary approach to testing is
consistent with the approach the Department uses to manage Human Immuno-Deficiency
Virus and other conditions. All testing is consensual, except for mandatory tuberculin
tests and any court ordered testing. This option is also consistent with the model being
used in the general community and other correctional protocols reviewed. Testing for
hepatitis C is being provided to those who request it or who consent after being
encouraged by their provider because of high-risk behavior.
In addition, this option will be less costly to implement than Option 2. Estimated costs
for implementing Option 3, voluntary testing and disease state management protocol, for
the current population of 14,000 offenders is $4,180,465. In addition, an estimated
$1,606,512 is needed to manage the incoming population estimated at 6,000 per year.
(See Attachment I, "Option #3 Voluntary Testing" for a detailed accounting of the costs).

15

Recommendation
The Department of Corrections recommends implementing Option 3, as described above,
because this option assures a public health-oriented and reasonable, yet cost-effective
way to manage hepatitis C in the offender population. It allows offe~ders, who are
concerned about their health, to request testing and evaluation for eligibility of
phannacological treatment in a manner that is consistent v"ith that being used in other
correctional settings and the general population. It also includes criteria for determining
eligibility for treatment that is consistent with "best practices", while prPviding a very
comprehensive management plan that includes offender prevention educ~tion, chemical
dependency treatment and mental health therapy for those for which it ls indicated to
assure maximum benefit.
Conclusion
The Department's vision is to provide a comprehensive program, as de$cribed in this
report as a "Disease State Management Protocol for Hepatitis C". this approach,
developed by Department health services staff, should assure an optimal ~utcome in the
management of this disease through identification by testing, ongoing mo~itoring by the
provider and a medical case manager, prevention education of the entijte incarcerated
population, chemical dependency treatment, as indicated, mental health $sessment and
inten"ention, when appropriate, and pharmacological treatment, when eligilllle. However,
the funding needed to support implementation of Option 3 is not a~ailable in the
Department's base budget since an extensive treatment program like thejone described
has not been previously provided by the Department.

16

ATTACHMENTS
ATTACHNIENT A
ATTACHNlENT B
ATTACIDvIENT C
ATTACIDvIENT D
ATTACIDvIENT E
AITACHNlENTF
AITACHNIENT G
ATTACHMENT H
AITACHMENT I
ATTACHMENTJ
ATTACHMENT K
ATTACH1v1ENT L
ATTACHNfENT 1'1
ATTACHNfENT N
ATTACIDvfENT 0

Diagram: Impact of Virus on the General
Population
Publication: Hepatitis C in State Correctional
Facilities
DOC Policy 670.040: Interferon Therapy for
Hepatiti~ C
Diagram: Disease State rvlanagement Protocol
for Hepatitis C
Phannacological Therapy for Chronic Hepatitis
C: Inclusion! Exclusion Criteria
Worksheet for Screening of Hepatitis C Positive
Patients for Possible Pharmacological Therapy
Hepatitis C l\t1anagement Activity Worksheet
Hepatitis C Treatment Protocol: Patient Contract
Cost Model for Option #2: Mandatory Testing
and the Disease State Management Protocol
Option #2: Model for Determining Eligibility of
Offenders in Current Population
Option #2: Model for Determining Eligibility of
Offenders in Incoming Population
Cost Model for Option #3: Voluntary Testing
and the Disease State l\t1anagement Protocol
Option #3: Model for Determining Eligibility of
Offenders in Current Population
Option #3: Model for Determining Eligibility of
Offenders in Incoming Population
Model for Determining Response of Recipients
to Pharmacological Combination Therapy

Attachment A
~Page 1 of 1

Impact of Virus on the General
Population

Onset of
illness

Number who become infected with virus
30,000
Number who develop chronic hepatitis C
infection
24,000
Number who develop cirrhosis

20 years post
. exposure

4,800
Nu ber who develop seriou liver
com ications secondary to irrhosis

960
.,

'. ~

I

,.J

30 years post
exposure

ATIACBMENT B
Preventivlt Medici::a 2:8. 92-100 Cl999)
Artic!e ID pmed.1998..MlB., ~le online at ht;;r.//wwwldslilmuy.= oa IB£~l~
....

"

Hepatitis C in State Correctional Facilities1
~...o.ne SpauLding. M.D....p CarJ!yu Greene,

B.A...,:l: Kerith. Davi~n. B.S.,; Michelle Sclme:ide:m.3:!:l.ll, B.S.,+
and Josiah Rich. M.D.• M.P.E.~
"Diui=ion 0; W~lU D"--. ill:cd4 laUmd Eoapit=Z, ~ RiIDt!z L!aM: i'1'..~ lsl.:nd Depc.-:mc-~ W~lTedm.3.
C~ ~ !sJ4nd; ;!?n:ram rJ~ SdUJGl ar- ~ ~C!, ~ Is!.c.-.d; and iDwi:icn gl In{=ioIU iJi.ur:..u,.
Tr.tt j(';rimn Eo:pit::1l. PraoilUr.a. ~ Uk:r.t:1.

Backe'roW'ld: No previouutudies have era mined the
extent to which correctio112l bcilities in the United
States screen for and tre::1t hepatitis C CE:CVJ infection..
Merhods: MediCI! directors at state CUll ection.:1l f:1ciIi.
tie:srespouded eo a~ asse:ssingth.e degree to which
prisoas 5C::'eleA teJ:" and treat hepatit:i9 C. To estimate numhers ot inmates eliJ;tole for ii:Iter.feron b:'e:1t::rnene and l:o
e..c amiM C:~ a~at.ed vrith RCV m.:m.:s.g'!lme:at, we
constnJ.c:tQd 2 fQASil)ility mo<lei that incorporated 5C:reeni.t3g criteria used in CalitonJia and Rhode Island..
RauL~ Thirly-ro: states and W3Shin~ DC. roe-"
6pOaded,. ~ting in a survey response r:1te of 7370,
represencmg' .'T':'D ot all inmates in state facilities natiouwide. Color.ld sl
~_~.&.:_
•
o one repo~ roa"~e ~tung.
Only CalifonUaret'ortad. conda.cfu1g a ~em:atic sereprev:l1ence study, which found that S9.4% of male inmates were hepatitis C antibody positive in l.9S4_ Sevellty-~bree percent of the respondents sometimes
consider tnating with interferou. Four states follow a
sc.a..cdard pnJtocoL The feuibilHy model ~ggest.:s th.:lt
n-ea~g' suitabb" screened. inmateS is a reasoIl:lble ex·
penditare fot" correctiona.l ~
t __ ~_
'L._
••
fi
COIl.cUW".,gn: ~ ...~ m.:ay uc: ~ :lpprapn::l.te setti.D.g or
treatm 1: i h
titis C If
.
_'L.stan

D...:___

en

0

epa

-

accompmlYIng

:n......

ce

abuse issues :Jre 3ddre:ssed, instituting RCV ~tme:nt
for cert:Un eliiihie inc:s.reer:ted individ~ m3y tM: :I
worlhy t3rgQt COJ:" public health dollan_ et_ ~""-o
1'l\uIm ~ aaoi ~ Pfta
"

l!R7 Words: hepati:tis c; prisons; review; cost analysis.
IN'1'RODUC'I'ION

Hepatitis C viros c.HCV1 was recogIJized in the mid1970s ~ a distinct, "non-A, non-B,· viral cause oItz.-ansfusiou-83Sociated hepatitis; it was successfully cloned
1 or. S.il:h is Npported. by ~ gnnt 5:om tee Na.tl~l !zl.at:ib.t!:= QI1
NatUmal ~ a£Heal:!:l, Gtanc DAl102SS.
21il whom reprint Nqaesa should. be addre:rsed. F:rc (401) 462~o. E-m:W: .Aa4L.S,!l<I nId ing '4D@bl'Owu.ed.u.

~_-\bUllll with. the

1:::. the folIawUlg decs.de Uj. The development of an
enzyme-linked. i!:I=:lunosoroeni; assay (EI.IS..4.. or EIA)
made i.t pQssilile to sc::een donors for antibodies to Hev:
I

S ubsequer.tly, ';he risA". of a.cquiri:g ECV WQU:,a'h, tr:1nsfusion d....-oppee. to le::l3 I:h.an. 1 in 10,000 per unit t::ans-fused [2]." Apprc.::i:n3.tely 4. million Americ::an3 are cu:rrently infec+'..ed with. HCV [;3]. Due to the public health
implic:ation.s. cc.e National Institutes of Eealtll CNIE)
rece!li:ly held a c::r.:~e!lce to deve!otl a coasens-.:.s s-..atc- .
I!lel1t OIl ::be ::.ca:eg""....ment ofheoades C (21.
The roul:c of ECV tr.msm.issi~n can be id.~i::if.ed. i:!l
more Clan 90% of Fiev infections [21. W.cile the vi..-us
•
. .
'~L ~~
d'
""'" B
snares t:t'ansmt3S1.cn rou~ Wll;.l;l, .o.l y an aep.e.tl!::S •
H~~'
.~ d
_. .1,
all Th
...... ~ ~!:ll_:a :::lost em~~!lW.7 pa..""e~te..- y.
a major r".sk fac"..or for ac:-qw:nng ECV 10 ::he Umcad.
States today fu mj~tion drug usa, wbich ac:::oU!l.ts fot'
50% of n.ew i:liP.ctioIlS aLld over one-hl£'ofc±racic Lr:.!:et:.on.:s [31. Rec=~:ly. in~al co~e use has also beec.
li::Lked. wil:b. RCV transmission, perb.aos secondary to
epista:cis and. sb.ari:ag of straws [41. m';'en the associa..
.
b
t.:/"I"t:" _ _ ~
••
dill _ l ..1 _
tion. etweec.=vy .... ~nus...l.onaIl
ei><M ...... "'Suse.
. . 1:1--1" • t
1
..
• t:h
.
1 ed
It IS J..I..ll.I:: Y tn..." a a.",:~ proporc.an at
ose mvo v
...'to.
••• •
"
'C"CV
'. • F
W1~ tile t:r'..:::u.::La.L ]cstice system are .Q.
poSluve. or
e:cmple, in 1994. California found all HCV seroprevalance of 39.4% in in.c:J.rcerated males (5] compared. with
the HCV seroprevslen.ce of 0.5% by EtA npo~.edin the
general blood do::.ar population (4.61. Given the relatively high rate off3l.se positives by ErA in. ?l9u1ations
v.ith low RCV prevalence, this value probahly overotimates the actu.al se..'"QprevaI=.ce in donon- -<\pprcimately 83% of the !l3.tion's 2 i::nillion i..- d.."Ug users are
~ d at some time [7}. Thus, a signi:ficant POI't:i.an. of the 4- million .Ameri~ -with hepatitis C have
mvolveInent with th.e correctional system.
In R.i.OO2 Islac.d. 19.4% Ofprlsollers are serving sen·
ten.ees for drug-rd.a.ted O£feIU~, mc:luding m.a.nufac
tu..'"'e, delivery, ar.d ~ssession of d..""Ugs. Random. mine

.::s'

4

92

aC91..'~

S30.110

~t ¢ 1999 ':IT A.au:rica RaIth F~ti04.ulc1ActrWl:::c~
All ri;Il.t:I 0( ~u=.oa.:~lQ'
~

r-

93
drug tests an inmates rettI:r:l positive in about 2%, indi.
c::ltlng some in-prison drtr.g usa. S~ estimate that
np to 80% ofinma~ have a history oi~ abuse.
AppraDmataly 85% ofin.dividu.aIs infected with HCV

will develop cbrocic RCV iniecti01l (4,81. The na.turs.l
history of the infection l:ypicaJ1y follows an indolent
course (91. although. 3to.dies following patients over 2
dec:a.des e:timate that about 20% of those with chronic
HCV- infection progress to cirrhosis within 20 years
[10]. Oc.e to fIve pe..?t:e!l1: may develop hepatocenular
c:arc::noma arCC) within this period. Once c:iJ:rh.osis is
established, ECe develops at a. rata. of about 4.% per
ye.!ir tl11. E:epat:i.tis C is now the le3.diog' indic:1ticm fot"
liver t:"anspJantatiOIl, in t'l,'s country [21.
Interi"emn (IFN) iu.s ~eri used to treat chrocic hepa.titis C since the mici-1980s Ll21. Use afIPN-a2b ~
in a ~t.ained l'eSpOnse in ap~tely20'% ofncipient3 U3-16}. S~..a.ined response is defined as no detectable virus by PeR and o.ormaIization of t:r:m.sacinases at 6 to 12 months ar..ar a comole!:ed. ~l::l::::t~t
cou..-se. Patients who respond to IFN'.show re:n:is.sion oi
ix:ilammation on liver histology [16-181. Theoretically.
this should decrease the rUk of lethal sequelae of
chronic RC\'- infecciOIl. The N'IE c:::lnseIlSUS state!n.ent
er:.dorses a s~d.ard iciti3l therapy of ::hrice-weeIdy
i:ni eetioIlS ofintexi"eron for a ceriod. of12 months (21. The
statement alsa details guideim.es for initiating therapy:
Some ci:l..-oDic medic:1l condicioIl.;, such as aw:oimmtme
diseases. ar~ cont::-aindicaCoD.S to tr'e3.tJ:nent. Furi:b.ermore, substance abuse mould be treated. prior to iniliating therapy. Alcoilol use is associ.atad 'With exacerbation
of HGY-re!a~ dise~e [9,lS-21J. Injection ~ use
places peo91e at risk for reinfec;ion, and anim31 studies
demonstrate that prior RCV infection does not confer
protective im:x:.unity 1'22.231.
Applying guidelines for managing RCV is particularly important within hi~-risklloPuhtiO:as. In. Rhode
Island, prison physicians disc:1v~ !:he need. for clear
I::1anagement c..'"iteria. when they found 3 high. HCV
pre~ in ~ papuIariQll Until recently, all inmate kii:cl:um woO:Jmi wen prospectively screened for
hepatitis B, hepatitis C, and mv: Officials £'ell: scre~.;.
iIlg was necessary to appease prisoners who worried
they could ac::rWre these disea:ses from infected food
h.a.ndlers. Of those sc::eened.. approxi:na.te1y on.e-tbird
of ~O tested positive for antibodies to :a::ev: The poliq
was changed because sc:reeningfeod band1en far ~e
vir31 iIlnesses had no pnc:t:i.c:J.1 impIicati<ms. However,
a large number af HCV.posit:ve inmates were already
idantt:fied. and were ask:ing for treatment..
CotTeCtional facilities in the United S~ part:ici"pated in. a nationwide survey to determine wbieh methods are being used to evaluate and b:'eal: this potentially
curable fcn:c. a£ cbrtmic hepatitis.

ME'mODS

A one-page survey was m.aiIe4. to the Commissioner
of the Depar=tent of Cor.r-ectio'PS far each of th~ 50
:state! pltlS the District of C:Jltimbia in. Dee-mher of
1996. A caver let:ar directed. the commissione.....-s to forward the sUrvey to their medi~ program. dired:ar for
completion.: Sur;-ey C[lleSi:ians aslq,ed nspoudets for the
nu.r:nber snd ge:l.der of inmates ~ thei:rF~ct:ian3Ild
total n1J.ID..ber for the state, wheljher their system was
privatized,. what wu the HIl'1l",!eropositivity ate,
whether hepatitis e was tested. ror routi:::1ely. and the

o.umber afhe-patitis C ~ pmapneci and t.."lQ ~t'l:Qt­

age thai: retum.ed :POSitive. Det3J1J.ed. in:br:n.ation about
specific HCV SC'Qecing mathodsft;as not alicitad. Ii the
jurisdiction treated hepatitis. i:li.e sur/eY we!lt on to
ask whether liver biopsies were performed, haw many
patient:! ~e..>Ved interi"e:'OIl. hoW' many das~ of inter·
feron were ad:c:licistared, and. wh'~ther a writ-..an. treatment protocol e:risted. Responde!l.ts were invited to send
sample protocols. P;..nally, the sutTey queried. wh.ether
a syste::a.o1tic 3e...~~vale.o.ce studt had. be:.. c:mducted..
Responses were returned by m4iJ. or fax betw~-tt Decemhe:-1996 a!:.d. ~1a.rt:h 1997. MjediC21 progra..:n di.~·
tors of ncm:espcc.db::!.g state corr~OJ:2lfacilities were
teleph.ac.ed in March.:md. A~ 1997 ~ asked. to QQplete surveys at tl::Jis t:U:le. A secoxp.d copy of me orig"~
~Url~ wa.5. Wed. to conbc'"..ed nqnre:spac.de-""':S. Sub:sequent replies, returned bj' mail ~:r fax. wer-e ~llected
between April and July of 1997. ;
A hepatitis C ~o:eening
l:teal:::n.e.9}.t moc.e! was
developed based on prs.ctice guidE$nes :md data ge:J.erated from the Rhode Island prisoJ:t, pollcla.tion to determine how m.a.:y in:::lates would. be eligible far ~.
m.ent. Speci..:fc inclusion and ~u..siOI1 criteria were
applied to the total numl:er off;una!:es to arrive at
the number or pn::ouers who wo~ most benefit from
treae:tlent. Total costoCECV ~lmtin these patients was -then e:stim.ated. to de.rmine if treatment
would be eeoooc.icsD.y feasicle v4thin t:h.e prison 'SYS.
tem.. Absolute <:ost of interferon per patient was obtained. from: the m2l1uf:1ci:urer, mel the cost ofFetreatment workup was ~..a.ined
accounting records
in t:he pr..:JOIl. !a.borabn'y..
;,

;me:

fro*
"

Survey
Thirty-six ~tas and the Dist:ri.cijofColumbi.areplied..,
re:mlting i:d ::L re:spCIUlc r:U:e of 73-$ ('!'able 1). N a mare
than. one ~ was retw:ned W each state. Some
sorvey:s we..~ answered by ~ dinctors responsible for cmly: part at a giveu st:ate'$~rrectionalsystem.
The respondiAg
coneeti:v~t.;t2resc.l: 77% of all
inm.ate~ in zb.te con:ectian.al ~ '. .es nationwide, or

:;taw

.

94

SPAUlD~G

TABLE 1
~Q ai~ Stata Corract:iczud P:lc:ilities

St.:lra
A1uk:l
A.ri::ol1.2.
AdclDS'\S

c.ili1im::ia
CoLmda

~
~.

No

No
No
No

No

No. of
~ces

'!I-Mala

BIV'!liPII': !RI.I"'"ty

. 3,800
23,000

ao

Uc!mawn

94

8,.503

93.4

L2
l.0

loU,9~

93.l

2..S

92
95
rJll1
94

U
10.0

100
Dla
90
94
99.9
Dla.
93.3
96
95.5

0.3

la.OOO

Di:=-:.= of Cola::bill No

9.000

~
C~

rJlll
Dii1

Ia.dI:m:l

'Y=s
No

Y=s

3,1332
11,'nS
1,31)0

No

1.2,179

~

Xansa.s
Ir..=mCtj
Mai:l.e

llW7Wld

M,sscensees
MiCig:m

Mi=esob.
Mi=o=i
~~

Nornda.
Nww 3'o-;:::sl1ire
NeW'Ya~
N~~~Oe.k=

Oi:!2llaca.
~n

P~va:\ia.
2..~ocill !sla:u:i.

64,02"35,200

P:lrtial

1.550

Y=s

2:l,3iiO

y=

lO,.S(lO

~
~Q

3S~S

Yes

20.185

9-4

No
No
No

3.180
8,300

90

5,090

2.055
6o.g34

~o

.....es

rJla
cJ~
~

No

j50

93

14.iOO

~o

a,7CO
34.000
3,2S4
2l,094

20
93
9!3

Yes
~g

23.3

3.,
3.0

1.0
fJ.S

i.a

0.3
5.0

3.5
1.0
O.l

0.3
0.7
L5
0.7
14.0
0...3
0.1
1.1
ala

3.0
3.5
1.0
1.2

~c.:m,li:u

?u:.1l

SoQDwt:.
Te=essee
'I'c:=s

¥~

Ut;:l::.

No

4,584-

v~

No
No

25~1J0

12.579
2.500

91

1.0

<LO

14,l:li'

95
95

1..300

cJ:L

W:u~..:In

Wes;'it.~3

W'1.SCn15in
W'yO:li..c:

2.15i
13.821

ala

No

~2.346

ma
No.
No

9<4.3
93

97
~5

.,
-,

95

0.4.

!l4.5

1.70

~

0.9
0.3

Not/:. da., noe ava.i!.ai:1e..

• IaIiC:cci :1umhl!n
j,

Wri:m. =~ent

~ ~

inciuded. "We

tRsC an dem<lnd or wit:1

37=lptoms.-

about 800,000 people t241. While 35 states (95%) reported seroprevalence data for mv; only 1 state ha.!
completed. a foc::W RCV seropreV'lllence study. Table 2
lists infor:nationre:ardini'e:a::tnIlt se:reeni:c.g and. treal:ment prad:ices for hepatitis C in re..e:ponding' facilities.
Only Colorado reported. "routine" hepat:il:i:s C testing'.
ThIrtypen::ent ants ami-RCV tesi:ing'retUmed posith-e
but only 1.224 tem were ran in 1 yett wh~ the total
number otinmates in. the jurisdicti.anwas 10,000. It was
lIIlclear haw ~ut:ine· testing wa:s defined. Neva.da.'s
l10nr0uC::c..e testing for RCV antibodies f'otmri a positive
nte of onl:110% by initial tes'tin& and RIBA c:omiI'med
anti-RCV positivtty af l.2~_ I:.a. Matyland. 67$ of 120
test::s pe..--!ormed were pC:sitive for :e:<JV; and. in Mi.3souri,

ET AI..

59"1& Ot 840 l:es"'..s performed were positive. In Utah., 83%
of 87 te~ wee posit:ve far HCV.
Twene-.I-seven (73%) I'eS"Ooudenb s~t!d chs.t some

RCV antibodJ'·pomive ~tes reciyed, t:reatme:::l.t.
Eidlt (22%) re?Or"'..ed chat th.eir inmates neve:' receive

~ent and 1lO ~ac:l;ties repo~ always t:eatin~.
The ~t to which a. ccuect:ional system pttrS'Ued
tNatment ofECV was not cm::::elated with whei:h~ it
was privatized. Fou: states (llS) fellow 3. 'i'r'ritten proto-col; an additional 6 (16%) are in the P~3 of developing one. The 'llw::lber ofdoses ofint:e:rfe.""On dispensed,.
if
'are s1:.cwn in Table 2. One patie!lt r ~
interi'eron t:hne tt:l:!.es weekly would rec~ve 78 doses
over 6 months a:.d 156 do:ses over 1 year.. Thera_fare,
dividing the tl~ of do:!e5 by 150 gives the appro.-ci-

mowc.,

mate'ucnber ai ~=ents !:reared. for an enti.-e year.
Data ~ the number of inmates t:re:a.ted for
hepatitis C, the n ~ not t:e:1ted, and th.e nu.mber
of liver bicp.sies pe....form.ed for the yOW' was Ilot fortb.~
c:m:ring. Responses cf sta1:e:$ "';;'b.o p-t'Q-r..ded info:c:l3.tion
are shoW'll in Tal:::.le 3. Ocly nine states (24%) repone-.:!.
numbers of in=l.atas t=aated for b.e~tic.s C: E.-,e st3.ces
reported !:hai: n.c i::.=lal:.e.s ~ ~!ltly t:e3.cad, whiie
Rhode Island. reportad t:eaCng 23 i::::l:lCu. Six sQ.tes
(16%) pr-,N [ded cab. :-egartii::lg- nw:tbe: ofliver bio~sies
perfor:ned pe:- :e~ ::me!! r2por-..ad IlOIle, tl::.a District
of Colt:::lbi.:l anC. A.:lns3S reoorted 2. and Rhode Island.
repor-...ed per:c:-::l!::lg 30 liver biopsies :per year.
Only C.ali:or-..i:J. C'Ollduc"'..ed 3. for:::13.l study of EQr
se.~cre-.ale::ce.~-is studv was cor.duc:ed in the fall or:
1594 jomtiy by :he C.ali:iorui:J. Depa...-:::::Lent ot Eeal~
Serric~, the 0 Eee ofAIDS, e:1d the Califo.rr.ia Depa::·
lne:lt of Cor=ac:ions (5J. T'c.a c::oss-seQoc.:U. blC.dee
st'..lci] 3l:.0wed Qe "CV se..""opre....ale.aee t'3.te by EIA-2
was 41% o...·e.rall. The rata for mQn was 39.4.%, with. a.
higher nte a.cor.g white5 compared with. mi..corities.
Women had an overall rata ot 54.59&, with. !:he highest
ra.te aI:l.ong La:-:-a s , fonowed by whites. A. lower tb..an
average rata was found among' Af'ricm·AmU:c::u:.
women. Of ide=.eed intravenous drug use.~. 76.1%
were ECV pcsi.t:.·,e. In. Rhode Island, avar a 4:-month
period from Septa!:lber to December 1996, 37% ofhepa.titis C Er.~ t,e!its re!:ur.c.ed positiVe. These data were
generat.d. m.:1icly from prospective kitchen workers, a
broad c::'OOS-5ec:!Or. of the in.ma.te population.

with Rev
Island pr.son syr..em, we
created. a model !:a estimal:e numbers ofinmates eligible
for sc:eeni:I.g and :ea.tment (Fig. 1). We juda~ that of
approximately 3,000 total inmates, auly 40% will meee
the length~f·sta.7 requirement of at least 15 months
(Table 4). After howtll education sessiaa.s, abem 25%
ofilia reT'"''''n;T' g 1,200 are e:cpected to ask for screeni:c.g.

In an

a~..eI:::t"l:t :0 assess costs associated

ms.n.a.gem.ent

ic. th.e Rhode

'I:ABLE2
Scree:Ungl'l"r=i:l:::1ent ~ot.oc:gls far ~ C in Sbte ~tW F~es

State
AIaUa
ArU:ana.

No

nJa

No

Ark:m.3as

No
No

TJla.
Dis

Cali!onli:&.
Ccl.or:uio

Tas:

Dist:ic:!: at Calumbi4.

No

E'lor:..d:1
C-.!O~
Id:ilio

No
No

~4

taata riana

~
~

No: 10 teac Wme

No

M:iul:

No

~
Mass:l.C:1useC:S
~
i1~at:J,

bW:sou."i
NeQ~ia

Nev:r.cb.
New H:u:1;::shi.-e
N~ Yaril:

North Dwe
O~io~

30$

s.c~c::2S

TJI"

N'e'7e'l"

'Dia.
'Dill.
nJa.

No
No

B:=tw:kr

DIs

So=ae=a
Sr.:eC::es
Ne'V'l:!"
Seoece:s

No: UO !:s=::l

acne

No
No
No
No: 2S8 ~u dc:z:.e
:Ja.
No: high rO..1k aery
No:: a.t le:ut 1 ciac.e
t-'o

Sat::.~c=~

~o

Sac:::.ci=es

67%

nia.

Socc=e5
Sace=es
s.cce,..l-...,

cia

Sac:.a':-es

59'ft.
cia.
lOS CF..I8A 1..2$)
cia.

Saca":-ps
SacaC=cs
Scce":-,.,

oJ:!

Scc:.a":- es
51Jc:.a ::::'2:1

~o
~o
~o

5oc.e::'e:s

:fa

Soc.eci.=.cs

Z'io
Cevelo,~

ala.

ria.
ala
nh.

.sOCIIC=e:I

~o:

r-."o

nla

S4ucD~a~
T~~e:s::lee

~'o

=ia

NlIVur

Ko

ch..:

Wa.s~.c11
Westv~
W"~csU:.

Wym::Ucg

~;ct~t11~

:ia.

~io

~o
~0:

37S

5

tQsts cl.aD.ll

So=c~es

Soc.ec.:er

Sv"S
ala

Soct~ci=~
N~
N~l"

Di:s
Dia
fJis.
20<;'&

Deve!c >.

nia

RhCllie Island
Soat..'1 c.rn~

VJrt.c.a

ala.
2011

Sa=!"';-e:o
N~

Nev,u"
Nlivur'

>

l....l3a
cia

nJa

Scce=e:s
Sccec=es
Scc:ce::es

37 dQtl4. if'Sx

Q

a

D~la~

No

No

No

::fa

Sac:4tC=es

NO)

~o:
~o
~o

~

Sctnce::es

Ol"elJ'CtI

Teus
Uuh

ala

No

~o
~o

2~"'1ia

507 Test:::l Done

o

Yes

S-IOS et
cia
'fJia.

cia.

No: 840 e2St: dana
No

Yo

Dev1li~

:fa

No

cia.

~o
~o

cJ:!
nh.
480
ala
236

Ye:s
D~o~

No
•
D~~

a

~a

~C1

a

Yo

c!a
lc=a
l.3"-S~

10

o

, .'Y'e::s.'
No

00
::i:l
2,53'"

a

~o

cia

a

::ora
::orQ

265

::oro

:13
:/3

N.,
~o

':Ii:!.
:13.

No
No
No

:/30

o

Nore: 013.. tlot ;lva.il:able; =to esam:1te.
• ~ut ;lOout til ~ .

• "1.995 Na. IFN dllH: t9S tFN-a23; 1.032 ~-2b.·
• -WQ CaV'l 1!:I:;lQriacced. & vfIay low pnrn1&m1:ll ofHIlP C SCI
~ "Omy i! symptoms.·

ear..-

I
'J

!;

Since 50-80% of IV dru: users acquire ECV within 6
l:lJ 12 months ofinject:i.t1g (4J, between 150 and 240 of
the 300 are likely to have positive sc:eens. However.
we estimate that at most, 100 will meet clinical exclusion and inclusion mteria tot' treatment, and only 50
will demonstrate no drug or alcohol use for a period
of at: ~t 12 months. Of these, 10% will be exclUded
secondary to liver biopsy and/or laboratory results.
Fort'J-nve Infected pr..soners may begin IFN therapy.
At. 3 months, 25~ will show ud responSe by PCR and.
therapy 'NiIl. be discontinued. Of the remaining 34
treated. 10% will drop aut aftherapy due to intolerable

side effe<:ts. T:1ir:y-<Jne HCV-posi~e prisoners may receive 12 ::nonc.s oi'IFN'. Th~ in the end. ;J.pproxi.
mately 1% of the total prison pogulacion may receive
the full COur.3e of IFN therapy. ••~
We c::aIculatad the com of scre~"
. SJ1d tres.ti.ng the

number of patients presented iJJ.,: . model (Table 5).
The total'eost for our model is to
Y $250,000. Drug
treatment, avauable to varying d~ inmost CQl:':t"eCtiou.al sysI:e.:::.s, ha:s obviaws mmq beyond allowing patients to· qualify for hepatitis ~tment. The B40da
Island Depart:-...ent of Corred::i.o~ offers both. supPort
groups and residential treab:D.qt programs for in-

96

S?'\UUHNC Zl' AI-

doses. Uncllr.l: ini'or.naticm and e:rt:imaf:e3 ma,v have
introduced observer bias, m aI:in go it diflicult to interpret
$OIl:1e of our results. For e:tSJ:1ple, many state-:! re.
~o:c.ded that they sometimes treat their HCV-positive
in.m:J.tes without providing di.saet:e value::s £cr nu:cbcr3
=Dis:"'cr:-:cc:-'-o!-:-:Cal.~l!m-:b-i:J---O--~=-===--=:'::::=-tr--.:lt-ad. Th...is r!J.Ay again ave.."estimate the cient to
~
s:'a
~
which ~tate f:](::!;~ treat. Similarly, seven of eight
ll:am:l.s
0
0
a
st:a.te=s respo:c.di:Lg t:h.:1t tb.ey neyer treat HcY ocUtted
MaiSaehlt5etb
8
TJlIl
TJla.
the nw:nl:er of S~~tests nerformed. It is not clear
Nebr:uk:1
a
1JIQ
2
~ew ~a:ilSbiro
1
w h efo!:he:.. the:3e states are notr treabg HCV-posit:i:ve
o~
2~:~:
prisoners or simply not testing fer the disease.
Rhode Island
23.
:/s
30
The iiUt'Vey did. :lot ~~ mfo:rmation on sc=ee:aiIl~
~
0
1
0
protocols. Only cn:e st::I.~ t'OUtinely tests for Rev: We
asswne that the other ~tates are oredominantly tesCnco
Nou. w~ ~C &~!&.
high.-r-=..sk
or S"'jI:lptOmatie inmateS ot' thosewb.o t'eaUes~
• 0al79~(:H%Qf~e'1r=txmcient::t)~.Iied~~
tes~_ Based an California's seropreV':Cl1ence ~es
=~~.
'..
many poten.tia.il.y t=eatable im:J.ates with heoatitis
• At the tima aI e!:a !tUdy.
may ::lot be identified by these pr.tctice:rWhile most s"'..atas are Wniliar wit:!. mv se..""Coositi....mates. Methadone !Ilainte:c.ance is provided only to tty in tlleir pr.scu SJ"S'tC!IlS, olJi.y CaIifomis. reoorted
Pl'e".an.ant fe~ Since these rehabilitative semc:es Jm.o~ HCV' seroprevalenc:e,. di:ing a rate o£ r~ugbly
would e:dst in the ~ce
helJatitis C, the cost of 39%. Tais vaiue is sigo.i:ficantly higher than the r:lca
<hug tres.t::nenc programs was not included in the fas.si- for Err, for w r.~ch. many prisoI:S rou.eely se=eo..n. It is .
TABr..E3

B:epatit!ls c: Na. af~ Trellted in. St:1te Co~ac.:U
F~cilities in One Year'
Na. or liVl!1"
Nc. treated. No. untreaUd
biap.si=

ci

or

billey moaeL

possible ~i: ~..:::ill.arrat::s would. be found in. other state
DISCUSSION

We are b Qe =idst ot an HCV epide:::::ic. Eeow:e 0:
tb.e con"elatio~ ~~!:Weo-!l. p:1r"'...nte.."'2land intr3ll.3.Sal d.rug
l.:::e and aCqOJ.Sltiotl. ofHCV, a signi:fiC3I1t pro'Po~oa of
the population in.fef:"'..ed with HCV ~es in prUoe..
~tmeo.c of an ap-p1'1)priate subgroup of this populacon may decrease their risk for ciI:rhosis and HCe and

.potentia11yprcvenl: furtherl::ra:c.smissioo.. We have initiated. a. disC".1Ssioc. of tb.is issue by assessing the currenc
stat'.1S of sC'e--..nmg fot' and treatin co chronic RCV wec.
non in state prison systems.
0
Our surrey iVas purposefully short :md directed; we
received. 3; of a potential 51 responses. Stata more
ad:Ive in the surreillance and t:reatmen.~ oCh.epatitis C
ma.y have been more likely to respond to the survey.
This selection bw. ifanything, weald overestimate the
e:::C:en1: of detection and mat!.3geme1lt of the disease in
3. correctional. se~. l'namtives such as the promise
of teclmica1 help in developing a he~titi.s C protocol
upon receipt of a completed ~e'l may have resulted
in a higher response rate.
Ma:.c.y of !:he SIlL 9 eys ~ retm:ned with partial re5pOIL6e6, estimates. and omissions of c:ritic::1l infOrm:l.
tieo.. Man OJm-plet:e re5pOIlSe9 ms..y have been elicited
h:ui the respondents bQQU talephoned. in. order to el3rify
the OmissiODS. The qnestious that appeared tD pose the
most difficulties included the numher of hepands C
tests performed ana the percentage of tests ~
positive, the a~ O£~te9 tnated mel untreated,
!:he n.umber of liver biopsies. and the: number of lFN

prisons. Despita a t3.cl:. of routi:e sc:eeo.i.tlg one state
COCI:le::.:ed, "We have expe::e.!::.ced. a very lClw prevale!:.cs of ae;! e so far."' This laclc or awar~ess of the
potentially hi~ ?nyalence of ~CV c.a1re;l~!: the pau.citoi' ofi)cillis1l.ed. ~I:a on ECV sc=e!!cing a.ad. l:reatmeA:
in the pr.sOIlS.
Most pr..scr..s soc.e";.=e~ t..-es.t HCV~ s.lthot:gh onli
£ou.: hay/! est3blished I2'l' protocols. ~I.a.n.y impor-..an.t
questions ret:!.3in to be asked.. For ~ole what era
the speC£c sc=ee.c..bg cdaria used in :aost-s~tes? What
inclt.:Sioc. c:ii:eria a.""e used. SJ:c.OI:lg the 13% of state faciIi·ties tl::tat SOIr.etimes treac Be\;"? How, s;:eciiic=illy, is
ReV t::"eatl:<1 in these fac:ilit:ies?
Issues of cost aEectivea.ess potentially limit fea.sibility of f:reatm-mt. Determined to provide standard of
care in afinar.ci.allyrestric:ive environment, Ca.I.i±"amia
. and Rhode 'Uland i:c.c:orpataf:ed a ~et of inclusion and
ezd.usiou c::i~ :nta their
pratocols (Table 4). Itt.
the yc:a:r prior to instituting these gnideIia.es, Rhode
I.Wmd. ~ 23 inmates with IFN. This number was
bi.gh CCr:1pared with. .c.u.mbexs reported in ather states
. partly because. at that time. all pro&pective kitchen
workers were sc=eaned for Rev: Some ofthe 23 mmateS
would not meet e:::rrent i:c.clusion c:rlte:r::ia.. Intetferori
prot:oeals shculd allow 1%5 to ident:ify the subset of poitient:s who will beo.efiJ: most from therapy. .
We lXlu:ri: as~ the applicability of the cm:rent HCV
tre3.tment. ~deJjn..'J t.o the prison population. A recently ~loped. fram~ prgpoees ~e:ting.:aine
factan when deciding to implement health benefits tin'
an in.t::.:lte: [25] (Table 6). In it. patient desi:re is m:L

mr

EEPAnTIS IN CORRECTIONAL S".\.CILl'l'lZS

91

Pool Excfuded from Sc:=in

imna:es with le:ngrlc
obtay > 15 montlu
2.S%
prisanen motiwrreti
to a:tlcfor HCY
l~..ening

300 prisoners

scnQu:d[or HCY

.with EIA.-2
33%

prisoner.: me!!! aLI
diJrjcaI criceria for
IFN prier fa blood
work and liver biap.ry

zoo prisoQe~

100 HCV+ prisoners
eligible for przrreatme1rt substance

1UJt

abuse ~aluar:ion

~e:: diJUcal crireria

Or

:rurrztf: dt1r.u HC/ •

EO'..;. !::Ul do 1I0f

50%
prtsonen withau:

s:UJs:anc.e cir.ue issues
de:e:rmirted by r.lbr".m-.ce
aCu.se CQoraUr.aron

90%

pr..son.e7'S willi lab

45 HCY+ prisonen
begin IFN rherapy

wo,.k and oiopsy
consistent with
~t c:ritI=:r.a

75%
pris~~Jrow

reporue to IFN ay
PCR a.r 3 momr~

34 :e:CV+ prisoners

11 HCV+ PrUQlle1'S

cont:imuf IFN at
3 montJu

lEN S'.tJpped aJ
3 mDnw

90%
31 HCV+ prisoners
3 HCV+ prisonC:n
i1t:oleahla silk
recdve 1.1 mt1'I'ltiu
lFN r".tJPfJ«l at
qru:= ta 1FN
IFN
J mon.dr:s or less
FIG. 1. EivpaCti$ C ~ =d ~ t :lOdal mBhodIt IaW:td.s=.a c:aC'llC"'....l:RW StCIiCy. ~Iadal hued
pri;:oners without

-

~ within ttlc Rbode:b1md st:l.ta c:al.~onal mt:em.

~.

;

lIStimatas

~

f:o=m

98

S?'\r.JI-OINC ET .-\I.

TABI.E4r

TaBLEs

~usi= C~.a fbr 'I'tes.t::l.ene aCRe'/'

Fs.c:ran
l.

~ =~ cri:uia.
E'ailure to IU4"'OU in ~~\aI:.l:C abuse prag::J.m ;ar 12
prior
Bisto17 ot dcc:=~ WIlt at iv drup or a1c::lhcl in

aumw

pncsclin!r 12 mGl1U:$

+

+

2.
3.
4.

+

+

~.

o.

Pa<rr c:rm~l ai a =otjer :l1Illiical iIInasJ; or
p5?ci1iarric Uh:a:a

I..eui'"lt. oi stlLy ia. priscu. <13 m=:::s :ram iniCi.atiau
of~=c

+

7_
8.

O~ ~ ncipiac:

d.!.Iieue

9.

.,.

P'.atzalac. cew::.I: <75.000

mv antibody po.s:i~ve

RCV vir:llioad <3.S00 tn' >350,000
ana ~ <20 yea:s
t..:v. lMpq: pns=o or c:i:rr'-~ :'t:y mm..-:lte
Autllimmw:.e d.i3ord.er
~onabto

SI!r"'..J:l.

Cri:u".4

ECI antibeciy posi;7e

~>18oC'<65~
Ect >30S, ~ <3..5 m.gtd1. Cr
tl:.yt'Qid l'u::.c:::Oll ':e:r~ w::hizl,

<U ~dL ~-:a <l.2
:lorm.:U liJ::::ib
Ccnsane si~ea fur :-:ndom drtz, 3I1d alcohol 3C"1le.S
dur'.ng a"e:lcnen;

Liver biopsy- ~t ".tIit::l. ciu=ic: vinl cepati:i:s

tn ~ than r:rpper lbit:J of:=-.-II!

~ ru:ode {,la:.d infar.::w:i:la. ~m Or••~e SpauI.C.Qg. ~UClc::1l Pro&:=! Cire~~ ~..h. criCerb. =eci by ==::u:-~e s:eered by
01". N'acii.m K ShDa....,. =d Dt:. JaCn R.. c.,.,;~oQ, ~~at Deputy
Di=at1, Ea1~ Ca., S ~ Di\-is:iol1.

TABLE 5
tar Sc-a~ =d.1'nlttCllll.t oCZllgible I::l:1.3tes
in Uw at ?r~ Sy~t:=:l aa.ed. on ){od.el in Fill'. I

COBt3 pel" Yaar

P:-ocedUI1!

RCVElA
Liva:- biaps1
ColTediolU1 oCi.cers! ti=1!"

Case
~,.~

n.z;a

No. oC p3tie:lt3 !oQ.l cost
300

SO

$205

50

503.900
$10,250

$309

50

tt3,4S0

~ntCC8tB

~~
Int:':ltre:ltl::1ent fDUo...-lJP'"

$2,SSO

3-mcnth.~~

~l

14-

$3.51<'

12-mcmth Cl7lU'IOlI

$74S

31

S23',095

DeC.silJ'll t:a Inl:arT1U:C'"

Ur:rem:r CJf pr.x:eil;..~
E:r;lec:ed ~~ r:lmuicu of i:s:u:arc.~tion.

Ne=l:nl:7 q£ ~t:rQ_
.
P:cb:shility ui suc::asfUl outl:':l.lne or: tre:1t:::1~ i.nc:l.~ me
rUk oJ: adverse side ~.
Pacent's desire (CCT'IISud. CIT' tmpiiC!:} S3r ~'1.e ~Ccl1.
E..-;c:"'..,ed ii::'tc:::ui impnm=m.t 1:1 :1 =It: of:he
.
ic.terYl::1tion.
W"~ Q.e i:lee.~tion ia fbr a. p~ candiCQa...
W"~..b.er the in~=an is
~1: fbr :1 ch~c

D\tn1:iau of i.afecicll >5 JI!An
CIinial sisns ar ~l:l:I3 qi liec:m:pcuated IiYtr

~ 1Jt,:~

I:mu~ ~

&

c:m:..tinuacan at ~oWi

amdia-. or is tb.e i1!i;i;lCOI1 af

a l1aw catl~ oflouf""a::I. l:1!lLCI:l!.C1t.
CJs:.

",se: R4!.2S.
imoor"'--ant criterion foI' consideration oi treatment; oth·
erS a..""e urgenq and necessity of the pT'Oceciure. likelihood of' success and improved. function with the motet'ventioc.. whether the conditiOl1 is pree."'tistb.g, whei:.her
treabe:tt was beg'.J.:I. prior to in~ciC'C.. and waat
the c~ a.nd. d::.e re?:l.sining length of t:ime witbin che
syste:n are. 10 Rhode Island, iI:m3.tes receive health'
educaticc ab:::c.t Rev: Only patiellts who $U.iJsequ~tly
request: sc=e A ... ; " g 3!:d treatment are considered for I:F'l\
ther:lpy. As I:IC~ pr.soue.."'S a..-e treated and. have ma:lageable- sicie e£fec::s, the demand by fellow inmates for
l:=eat::l.e.:1t inc:aa.ses. This pa9ulacia:1. has tolerated tr.-.
ter:arcn at: ra1.es sU:::.i1ar to !:he ge!ler.J. papulation.. Further.::ore, compliar.ce rates a:e high. bec:luse of clOSe
mediol tallow-up while i.e. pdsoc..
In=L:1tes must dec.or.stratc ~eir cici~ for creat::a.ent
by absQi.~bm inj~t:iolJ. drug OI' alcohol use for the

12 month:! pr.or to b~ treacment. Since sharing
inject::.on~g-us'l equipment puts Lnciividuals at risk
for HCV inieccion, 'He cOJlSidered includ~iumal:es wao
may bye i:a.jec::ed but [lot shared equipment in the
past 12 I:lont.;.s_ However, the patients' reliabilitywith
~gard t.a t:b.i:i m:1t"'..er would be too difficult to assess.
In addition, Cttrrellt drug USer3 lII.3.}" be at higher risk
of $~-:ng equipce:a.t if clean paraphenWia is not
aV3i!ahle.
CarrectioWll health. care practiticner.s routinely con-

sider duration. of incom:eration in their decision·
mzk::c.g. For example, emel69ncy are is not denied for
anin~.s:tawith even. the shartestsente:a.ce. On the other
U4,246
3-mouth. am.'"3e
51.D1':.5O
1+
hand, elective surgery m:J.y be justffied only if an of31
S12&.J,70
12-manth e:ae::S4.070
$259,474,
Tot:al
~ will not have ~ to outside care fer an extended
par..od at ti::::te. In the C3Se of HCV: one of the
• Cost oI 4. h of ~ fino 2 ai:ata =ec:ti0D3l ad'll:lln.
inclusion criteria. for treatment in both Rhode Island
&Includ~ CSC. LFra., -rsH, .l\NA. .U(A" ca-l ~ ccnIo:m.d Califomia is a length of prison stay of at Ie:1st 15
P1:w:liA. Rev qa:Uibtl.ve PeR.
• Costs b:Ised lJ'll ~: Rev !!ow 3heerproax:aL
mouth.s 1:0 allow for a 12-mol1th treatment course with.
.. Ba:sed
proMous studies. it i. ull'lmlAld. 25~ ol those b:e:1ted. follo";V'-o:o. While the cost or:screening and. treaQnent is
.~ lUlt ruponcl by 3 macths -.d will l'ClCeive no fiIrthel' f:l:esi:lI:I.eut.
Thcm'ore. cmly 75$ of Cu:se bqan ou tFN wU1 n!a!i.VG tha NIl U- potentiaiIy !:he limiting factOr for many pr'..son systems.
~t-benefi.t analFles in notlinc:areer:lted populations
month. coarse.

m;

=

99
[26-291 suggest ~t IFN is a COS't-eiIe<:tive treab::a.eni:
f01' an appropr..ate S"Clbse t ofpatieI:.t3. In 6e coz=ectianal.
:set::ing', the savings m.:lynoi: be.reali:.i:ed dt:ring- a.si:c.g!e
inm.:1te's prison term, but rather in the lcmg-ter.:n cost

to society.
The cost3 of sc=eening and. t:e.9.ting the patients pr~
ilented in our model totaled about a. craarter :niIlion
dollars. This ~::len~ rou,g:l-ly 39& oi~ total health.
care budget in the Rhode Wand cor=ectional system.. A
cost-benefit analyais of RCV treatme~ in !:he prisous
is Il-"'eeSS8.Ij' to e.'tP1ore potential costs sa'Ved and quality
of life pined wicb. t::o..acnent.
It is important to evaluate all sc=ee:ri:c.g and treat-

ment protocols that are im~e!llentedin a prison ~­
l:e:L. Of course. the most eff~ intervention program.
would be to dec::-ease the acqc.is:ition of hepatitis C in
the fiDt place. Correctional h.e.alth ~rvices could u:se
strategies that have been suo::essf..I1 in lowerO...::l.g the
risk ofacquir..n.g HIV-peer education. substance abuse
treatment-and apply l:.h.em to hepatitis C p~e.:::.::icn
(30].
CONCLUSION

A ~H;C3.Ilt potion of the HCV-posiCi'le population
resides m p~~:::lS. The association halc..s t4-Ji: c.oc ~t
mthe L nited States but also in otherwesta:c cou.:nt:ies.
In fact, a smd.:7 in the·Sydney, A~alia, prison s:;r..:.:
discovered an ECY seI"O!lrevaleI:.~of 37%, verJ sU::illar
::.0 I:he value r-eported by CalUcruia and Rhode Isl~d
[311. T:'e~c:' go aI:!. a-ppropr..ate subgroup ofb:u::.:1tes may
t"epr-...:sent a public hesll:b. e.xpe~dil:ux': thaI: is cost effective. In this stl:d:; we found !:!:at only Ol:.e s-..ata routinely
screens all im:1atas for Hey infection. While l:.h.e semp~o: in ClOst stata pr.soIl.3 is unk:!.ClWtl., the per·
ceu~e of infec-'..ed inmate~ is signiliC3.lltly hidler than
in the ~meral population. Multiple co.st-benefit aIUlyin nonincarce."P'3.ted populations have shown that
the be::.clits of :re3.t:I:tg hepatitis C outweigh the costs
(26-291. While a large proportion of sta.ta CQ~-cnal
facilities reported tb.at.t:reatme:lt for HCV is sometimes
coniliiered. it appean !:hat few inmaRs are actually
treated. Fu:rther.:::tore, few sta.te~ have set criteri..s. to
deterI:cinc who should be screened and treated. We advocate the development: of protocols that, while recogci%ing fin<md.:U constraints within state correctional
systems, ~ that a-pproprlate inmates with hepatitis C sre treatad ao::ording to tile current sb.I1dard of
care. Several new reltimena fiJr treat:mg hepatiti.$ C are
under development, including. combination treatment
with ribavirin. As trea.tment becomes mora e-aecdve
and less costly, addressing HCV in prisotl.5 should b'!come an e~n higher priority.

s=

~CES

I. CJ.ao Q-4 Kuo G. Weiner AJ. o.4rlly l-'t.l3r.uilq OW; E:cu;haru
M. wl.ulon at ~ e.D~ cltma derived ft'am II blood·bor::-..c non-A,
llOC1·B viral h ~ gIZI1ome. Sdma 1989~:359-62.

2.. N ab=.Il !c.stfttIUS or E:e:s1ttl Coz2s

_ee h:.eI. St:1l:~Qe:lt. ~ ,

L997;26 Sappl !:2S-1OS.
3• .All:c!r. W_ Epida=Ci.c:g)'ot1:cpuitis C.
apc.mt c:.mtare::.a:: ~ of
ai::aC'3.l::3. E~da. MD. 1991 ~ 2
.61-;0_
4. CaDr,'-Cae-;eC;l C, Va:Ula.ri= MA. Gib Ie J, Melpalder J, Sh:1k:l
AD, Viiadamill r., C': sL Roa:a:a ae' • 'em.";~ .md.li~
ciisoue Us. blcod do~ ibaz:d. :D have'
tiCs C vU-.JS ~an.
N ~ J M.ed. 159&:334:1691-6.
S. B...:i::JD.~~,j.S~l21=c:
~hepa:iCsB,hep:1tit::J
C, and. C:k ild-..rtian a=o~ inI::1:s. ' QI1r.eri:l.:r me Cali1imUa.
cocec::oc.:L1 ~..a=.. S:u:r.1meutD: '.: ; Oepar=8!11: at
HeaIQ S~ 199& M.Jr.
6. Altar YJ'_ '!:1:e de~ tnnsrri,liien. d OU:c:rmtl oi~t:.ti3
C virus i:.1ec:::c:. ~ ~t! D~ 1 ' 3~l.35--66.
I
7. Browe. 3S. Bes6::.er GM: H3r'iboal,; . riaL: of AIDS: :::'ject'.cn
drui ~ and. ur.wl ~er.:. Wi
t1: (CD: ~wood
~, l293:338.
8. Alta:' }fJ• .MaquEs =:S, ~-:.~k::i K. u. The a.:lt=i ~istcry
of Qm:ucity-=ui.."'=Ci ~atf:U C in.
U4ited. Sb!Us- ~ F:lgJ
J ~fed L.C92;32'i:iS99-s05.
I
9. SeeifU!, EuslteU-3ales Z. Wri¢.: =:C. a ~ Lotl8'-tar:::t =r'"':wt'"J
sP'~ c:--=tu:ioc-!nCCtad. ccn·A. llO B hepacitU. ~ ~(i J
Mec: 199"'-;327:.!SOS-U.
10. Korct: RL. ~y ~ C~l~ =:. Cil;:!' G. NQI:l-A. ccl1-a ?QSttr:1r.:I~OI:l b.a~::'-: looking
Cn-:e::\ ~.red L993:.!.l9:110-S.

bac.:C ini

.4

secol1d

dec::L2. .~"t

'

K:.:...-::ki 1'. N~ S. ·!oricot.O a T.1k.ed2 1',
Nalaji::::l.:l. S. eo; :.!. ?..:u-..dac1i.:ed. ::::i;I.! ot ec"~ or ;=ci=:~ ou
in.c::il:nC: at' hep:a.=iJilir ~ma.' C::-.ronie ~.1~ u;:ati::s
C ~c C;:.r:'~i.'l. U.:::c-e~ L295:34:6:1051 •
12. Ec:a~a JE. ~ullll:1liD.Jones 08, I

1I. ~ ~ ~ S.

no~-A,

=-a

I:a-;:;,:~ "litoi.

•.
N~J
RL. Jr. Thersp1 at h.epa:itis
I

:er:Jn; ... il~"'Y :-e~rt.

13.

Cari~

C~c.:e:::.S'.1' OC!'f1!lapc:~
Mllatic:is C. l'TC!J='3m and :Jbstnc:"~,a~

alpQ.a.~

'cO:: ~~enc of
- MD. 1997 ~ 2clr-

b: Nm
Ei;SS--i_

t986;3I.S:157S-3.

c; Ul~:eral\

!

a

14. R.::ebrd 0, C:...3.=.a=
Fryd=.J.,.
Soll:1mo~ A., itt u. '!.'wo-year !:lioQemi
logic:sl fallaw-up i:1 pa.cicna Wlth 6rani
i: a.m:s=iJ:.cd !'::sltiau co int:ar.anJIL al'
cgy 1995:2l:S18-22.
!
15. Sa= G. R.o:si::;l :. Abaca M:4
E, lit ai. Lc:r-te.--:: (ollaw...o;rp of paCa
C Lnated. with ;it:cnmc dma ol in
1993:18:1300-.1.
16. Davis G:L. B.:l.la.r.
SciIiiI'~ .

• ~ra;;icU. iIl:1ci i1i:stohellatitill C respoad:.:\g'

2b tre:lt:l1Cnt. Hll:t&tol-

us.i I.. G.1llo V,

~~

wit=l. .-.I1."llI1ic b.=p:l.titis
e:oa.~~. Rep.atlllac-

u..

Jr.P=:illoRP.~al. ~oC
.
bU:=.= ~ alp,ha: a. mw::HC:=;~1
t:i;al. ~ ~ J ~ 1989.,32~Ol~

17. Sal"SC:l3 G. ia:i:.a ?, To~~N:is .
L, GsIIa V. "t .u. A. r:mdom:iRCi. CD
lid. trioU o( fn.tInf=
al;aa·2!l as t:he~~,. cl=mc :mi.-A.. a.·B hepatitis. Jirl1patal
1990;11 SCp'plt=4:1-9;
I·
18. ~ x.. Godi::.ac, H. ~ M:,
ee:oa p. Zoulim F,
Ou= D. ec 31. Coc;larl..san of 1 or 3
q{ mteri'eroll al~-~
SXI4 piaalOQ iz:I. ;::u:ients 1rith CmmU:
-A. I1OI1-a he~
~oa lS9l:101:497-S02.
1.9. c..-omi.oSL,I~lC=a~1.3owdaa.DS.
c: e~ at al=bal au hepatic
t:I:ll 1996;25:52:'-0.

=-

x::ivityl

100
20. Poyn.:lZ'li T. Bed.osa P, Opola.a. P. N~ h.isto.ry oltivar ~
P~11 in pati=u 1I'icf:. c!1to:aic hoplUit:. C. I.a.ncet
199'T;J4S:tl2S-32.
21. ~ AI. &= Q{. ~

JD. HeJ:autb

C. Ann Intem

M.lIIi 1996;:125:1558-68.
•
22. IwU3OD. S. Nor~ G. Wesi«til:l. ~. C; uamnl b.i3taty
of a uzUq,Ut: im"edoD. Clin In5n:: Dia 1995;2Q:1.361-':'0!l3. Fwl'•.A!bIr a;J'. GmI:llbr:l:ill.ll S. WQt14' DC. Eailo R. ~ki
L~ en: al. ~ at ~tae:tm im=I:lit7 apinsl; ~ = ~t&.
Cap;ltil:is C vf:u3. Sci4mCII 1992;29:1M-lD.
24. Cam;! CG. ~ GM: 'Ihe
yurboak,'1S96. Scnnh Salem CNYI: cr.mi::W JU$cice rm=::ta. l..026.
.
2$. Anno BJ. FUnEr
E:3r:l=: JE. A preli::l1in3ry model for de'~...imng Ih:Ut:s !Dr =rncticu.:l h=lth are :ervic:=. J Corre:c:

===-

n.

Health Care 1996;3(1}:6i~.
26. DcsI:l..W:a GM. Robera JA. ~ al ~ tj:lQ B and. C

hs1Jatitis with inw::"c:on ~ha: an lICll".QmiC~Ppraisal.E!rpuoL.
olD' 1995;lllO3.7L
27. Shi2ll
B'Cc:s A. FI1l::ell
The ~ e ~ of alpha.

a.

ce.

sam hepatitia C. Mod J
Au.st 1994::68-272.
.
28. &=.ett WG. P:l.uk.et' Sa., Davis GL. WaDS' J'B. Yodeli..: thIlr:tpeul:ic be:1d tn. Qe:1idst: oi~ ch2rapy !lr hc~t:tis
C. Dtr Dts Sci ~:4(l: Suppl)~6S-82S.
23. BRit BS. ~TlI:.8SI malysis. In: NIH Ccm5en5U$ D~­
~ C~ ~ o( I:.e~l\til::fs C. ptopm =d
interferon in the

l::'211=e:1~ oi cilraaic

=

~ Be~)[I), Ul97 ~

24-fi;U;-9.

=

30. SlI:lllcick A. !Aoit ~
fi7r kat amt:rU1 S'rDs. JXM..4,.
1998;27'9(:}):97-.9.
•
31. Butler TG. DoLm KA. :mcl1 W. :!4cGa:i:mas1l U(. Braw: PRo.
~~ ?W F.e;::l.t!ti" B
C in N'_ South Wa.l6 ~
prev:Ue11Cl:'mtl r.sic:~. ~ J'~ 1997;16&127-1.30.

=

C=:?,J,RTI,I:;:N,

Dc
C:::RPECT:G.'IS

~

~

POLICY
570.0~O

,,, . 0

Pa;e101i

;;PC"EC71V; 0'>'7E. July Ii.
,>.UTHCi'lI1"Y:
G~r1eral

aWhc."lty cI ,o1e

i~S~

S~c:a:a"l

01

COr1'~~C"S

to

:;.a~as~

a,-,c c:'ec: ',~e Depalt.T1en:. 72.0S.J50.

PU;lPOSE:

A PPLICA'; ILrn,

C'\tis:cn 01 P"sons ar.d O,·,is:o" 01 Com.."nity Co..-..c-Jcns,
C;;P i ~ ITI C.'! S,

I

G"i"elire5 Oe\telcpr-:em Cc.. mirtee . A tar..,,,I'y es;~e"ls~ec eomm,r.e~ of Oe::a'"':'''en: "ed':al
eons"lti!.J"",lS al'c ;lhys:e:ens re;:'esen:lr,g all ~~e r1".aja' iac::'t:es. am:! ~he HeM,~ SeMees Utli;:a;;cn !'1C
ReuT.::ursemer.~ .'.larage, e' desl~"ee. Tbs commlnee is resocnsde ~cr wn:,I';. develec·,,;. l.,·0
i..c'e"'en:;r,'1 '1"iceli;es 10' "e:erm,n".; acc,c?r1ateness 01 ;l1ecical ::eatment
Review ?enel - A s,-tse~ ;'cup of '.re ;:h'ls;e;a.~s partictca:h~; cn the GuiJeliM <:),<,,='<;o,,",e"l
COmmLf:ee ~o disouss indicanons fc' t,aatrr;er,l .,.r,en tre >::q:cse<: :reat;':lent C:oo<s r.ct meat 1.1e
es:a:: ished \;uicelines
~O!.ICY:

1

Tne Oel:a~"ert 'NIIl ral aUIl'X)n:~, p,es~::te, or ,.ir::~u,-,;e ler 1.-.tarie'cn·Alona trer.;.~y to traa: :re
e::"Cl(lon et !-,epal:IIS C, exc<,pt ."ner, app,o',ec :r.rcu;n ~"e prie, a~mori:a:le!l ~:Ce~"5
deso"teC: talow

2.

?~c· ac.c'orl::alic" :or aC:mi..istannG th,s :,eat,"T'.enl tS 'eq,,"ed. T:'e ;::,e'J;ew ~"ni,1 NiH eele"",lra
the aoprocnaleneSS ct ~~e prcccsed :rea:;;:e::t a,~o ",c~e 1 :eo:::o"".menda:lon:o :re Healt~ Ca .. ~
;',C.l.~Crit'l al :~e lac:li"l. ,,..e ;:,e'"ew r'ar.el ."ill C:iscuss :.~e propesed (rea:;ner.t aM aiin'cal
inc:catlons p,s;;,acad ::y th,e cc"s~llin; ;as:rcer,1ar:la\;;S1 ""th ~:;e ,pi1ys:o:ap raO,a5~nl,ng t1"e
faa':;ry ..... ~ere :ne o~ender IS hoc.sed. To assure cOlec~vlty. t'\e "-<,'new ?alle! mem:oi!rs ..... ,11 riot
I':a"g a.~ a~ihalion ""m the lacili~! ·"nere :he or.ar,cer is nOllsa-e. Tne ~nysico1ns ~art<;:catr; cn
mis :anel .,.111 =e ,clated. T,~e nevie." ?anel's c;S':;"S~LO'" 'N,il ~e a:e'dinale<:: t'rcu;h :he He:al~h
Ser;joes U:,Ii:a~:cn and '='eimo~,seme"l Managar or deslg:-:ee, Th,s dsc~ssio'1 r:-:ay :~
Cct1du(::e~ ::>'1 a :elechcne ccn!erence ca.!.

2,

T~e

gr;e'/anoe orccess sho~ld be
reccr:'mend"tior, at tr:e F.e\/le,., Panel.

\.:H[(:e~

4

A[I $:~~alions rec;c.I~t1g either clar.ticatl<;r1 01 the ;;cliC'l cr e "'\/lew c1 the pa... el's ~roce-=L;'es NlII::e
ci rec.:ed to Ihe Heal\.' 'Oer,ices L:~ii:ltlcn er,c: ?Et::lOlirsemerl; 1-.lar,ao;er or cesi\;...ee.

b't any

o~ence'

'Nho w,shes

~o

a;::;;eal t.",e

'H:''1I''W,

The P-:lic'l Re',;ew Co""'''''.'tee ,rail oocreir.a:e the re',;ew 01
y~ars and ucdal€: as reecEd.
R"PC:i=lENCE5.
None.
SUP "RS ,,5 51 ON,

CE::ar.T.en~

?olicES at jeast a',e'y

~NC (2)

Clinical situations in which further hepatic eyalp.ation may be
indicated and in which Interferon Alpha Therapy may be
permitted in the Department of Corrections

1.

2.

Evidence of persistent or progressive hepatic synthetic function
impairment manifeSt by:

a.

Coagulopathy (prothrombin time more than 2 seconds
prolonged without other e.:r:planation)

b.

Hypoalbuminemia (albumin less than 3.0 mg/dl without other
explanation)

c.

Hyperbilirubinemia (bilirubin greater than 2.0 mg/dl without
other explanation)

Evidence of extrahepatic manifestations of Hepatitis C that may
respond to interferon alpha
a.

Essential mixed cryoglobulinemia

b.

Membranaproliferative glomerulonephritis

c.

Mooren corneal ulcer