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Pricking the Bubble Around Prison NSPs

17 January 2012

Introduction

There is an unfounded fear in some sections of the general community and correction centres relating to the risk of both a needlestick attack and of contracting a blood-borne disease from such an injury. These fears have been deliberately aroused and used to block attempts to implement regulated Needle and Syringe Programs (NSPs) in the prison context despite clear evidence dispelling such fears.

This paper will focus on needlestick injuries and their associated risks, as well as the incidence of the hepatitis C virus (HCV) within the community and prison contexts as a result of shared needles. The need for both a regulated NSP and increased access to HCV treatment within prisons will be the core recommendations.

Firstly, the risks associated with needlestick injury will be explored. Then, the low risk of a needle being used as a weapon will be discussed. Thirdly, the prevalence of HCV among groups of people who inject drugs (PWID) both within and outside of prisons will be examined. It will be argued that the high prevalence of HCV within the prisoner population is primarily the result of PWIDs sharing needles. Lastly, the effectiveness of HCV treatment will be explored as well as its availability to prisoners.

Needle Stick Injury Risk

The estimated average risk of contracting hepatitis C from a needle stick injury has recently been revised down from 1.8%[1] to 0.5%.[2] Hepatitis B poses the greatest risk at 22%-31%,[3] however there is a vaccination against it, whereas HIV poses the lowest risk at 0.3%[4]. The occupations where needlestick injuries are most prevalent are in the healthcare sector, service provisions, police and corrective services.

In a study of two Australian prisons it was found that two-thirds of correction officers reported having discovered hidden needles and syringes, generally through cell searches, as a result of their daily work.[5] From the sample of 246 officers, 17 reported to have been injured by a needle for a total of 21 incidents. This suggests that 7% of correction officers have, at some stage of their careers, been accidently injured on one or more occasions by hidden needles and syringes. However as previously discussed, the risk of contracting HCV from a needlestick is very low (around 1 in 200 incidents will lead to a transmission) and a range of treatments are available to treat infection. This risk of a 0.5% transmission rate is much less than other adverse health events that are part of everyday living; for instance the risk of dying in a car accident is 1 in 83 while the lifetime risk of contracting cancer is 44% for males and 37% for females.[6]

Factors Increasing the Likelihood of HCV Transmission via Needle Stick Injuries

-       A hollow-bore needle

-       Deep penetration

-       Visible blood on or in the needle

-       A needle that penetrated a deep artery or vein

-       The amount of dead space at the end of a syringe

Highest-Risk Groups Within Australia of Contracting HCV[7]

-       People who inject drugs

-       Prisoners

Low Incidence of Attacks on Prison Officers Using a Needle

There are many potential weapons available to prisoners other than syringes, making the likelihood of prisoners using needles to attack prison guards very low. In consultations with prisoners, they have argued that they do not view needles, a 1.3 cm piece of wire, as weapons within the prison environment.

The low risk associated with attacks on officers with a needle is evident in the fact that only one fatal attack on a prison officer with an infected needle has ever been documented, worldwide. This single incident was a tragic attack on NSW prison officer Geoffrey Pearce in June 1991 with an HIV infected needle.[8] The attack occurred in a prison without a regulated NSP, using an illegal syringe, at a time prior to effective anti-retrovirals and post-exposure profilaxis, and was perpetrated by a prisoner with AIDS-related dementia. In 2012, the attack on Geoffrey Pearce would be unlikely to be fatal and less likely to have occurred altogether. In the two decades following this incident there has not been one record of another needle stick attack leading to the fatal transmission of HIV or HCV.

An argument raised by some prison officers was that the introduction of an NSP in prison would introduce needles and syringes and thereby create or increase the risk of needles being used as weapons. At first glance this concern might be understandable, however in reality all Australian prisons already have needles and syringes in circulation. In that regard, prison-based NSPs already exist – they are however being run by the wrong people and they circulate used and often infectious injecting equipment. In a Canadian study analysing interventions to reduce HIV transmissions related to injecting drug use in prison, it was found, through its examination of 50 prisons across 12 countries that had a NSP, that not one needle from a regulated NSP was ever used as a weapon.[9] It was also found that NSP programs facilitate more positive relationships between prisoners and correctional officers that, in the long run, would reduce attacks on correctional officers.[10]

In fact there is strong evidence indicating that NSPs make prison environments safer for correctional officers. Firstly, by reducing the amount of infected needles in circulation, the risk of infection due to needlestick injury falls after the introduction of an NSP. Secondly, without the need to hide needles, there is a reduced risk of infection during cell searches.[11]

Prevalence of HCV Within PWID Groups

A 2007 study examining HCV in Australia suggests that 80% of new HCV cases can be attributed to people who inject drugs.[12] The sharing of needles within PWID groups is the chief factor increasing the risk of seroconversion, through sharing infected needles and drug equipment contaminated by needle use.[13]

These conclusions are representative of the consensus in academic literature and various organisational reports regarding the relationship between the sharing of needles and the transmission of blood borne viruses. In prisons where needles are scarce, forbidden and treated as a commodity, prisoners must share, borrow or buy the use of needles in order to have a fix. In a significant piece of research it was found that a quarter of prisoners at the Alexander Machonochie Centre had injected in the previous month and a third in the previous year.[14] Alarmingly, between 23% to 47% of male prisoners and 50% to 70% of female prisoners currently have hepatitis C.[15] These facts, in combination with prisoners having to share needles, means that people who inject are 60 times more likely to contract hepatitis C than those in the general community.[16] A study conducted in Berlin supports these conclusions in their findings that the highest single causal factor of contracting HCV was injecting drugs in prison. [17]

Tattooing

An Australian report has found that the highest risk factor in prisons for HCV transmission, second to sharing needles, is tattooing.[18] 42% of male prisoners receive tattoos in prison. The tattoo equipment is makeshift and sometimes unsterile resulting in a high risk of transmitting HCV among prisoners. Without access to proper sterilisation equipment or processes, some prisoners are becoming infected with HCV through tattooing.

Treatment

Unlike hepatitis B, there is no current vaccination for HCV. Because of this, prevention strategies that target behavioural change backed by services such as a NSP are vital.[19]Current treatment for chronic HCV is effective in between 50% to 85% of cases. However, without an increase in treatment, the amount of people with HCV-related liver cirrhosis will increase to between 7,000 and 10,000 by 2025.[20] An important part of reducing the prevalence of HCV within the community is to tackle its prevalence within the Australian prison system.

The rate of prisoners testing positive to HCV antibodies is 40 times higher than the general community.[21] Furthermore, reports have estimated that one third of male and two thirds of female prisoners are or have been infected with HCV.[22] This equates to half the prisoner population,[23] Thus, with between 5,000 and 10,000 prisoners being released into the community each year and half potentially having HCV, it is essential that effective treatment and preventative measures are provided to prisoners from both corrections and public health sectors.[24] One treatment issue within the prison system that requires immediate attention is that 60% of HCV infected prisoners are refused access to treatment due to having an imminent release.[25]

Conclusion

The risk of a needle being used as a weapon by a prisoner is extremely low. A fatal needle attack has not occurred worldwide in over two decades. Furthermore, no record of an attack has ever been documented in 50 prisons across 12 countries that have regulated NSPs. Through prisoner consultations prisoners have rejected the notion of using a needle as a weapon within the prison environment. It is considered to be a poor weapon, as a sharpened toothbrush is a much more effective weapon. Furthermore, as a NSP would reduce the number of infected needles in circulation, it would reduce the risk of infection from any needlestick injuries.

The risk HCV needlestick transmission is miniscule (1 in 200). A regulated NSP would remove the incentive to hide needles making cell-searches safer and prison officers less likely to injure themselves on needles through their everyday work.

The primary cause of HCV transmission is when blood-to-blood contact is made through sharing injecting equipment. This explains why PWID groups in prisons are the most at risk of contracting HCV in Australia. This is Australia’s most significant HCV issue. Improved access to treatment and the adoption of regulated NSPs within the prison system is required in order to reduce the prevalence of HCV within prisons and the community.

Recommendations

  • Governments must implement regulated Needle and Syringe Programs within prisons immediately. This will ensure that the same health standards within the community are received by prisoners and will help counter the hepatitis C epidemic.
  • A tattooing sterilisation program must also be implemented.

References

Australian Government Department of Health and Ageing (2010) Third national hepatitis C strategy 2010-2013.

Australasian Society for HIV Medicine (2008) Correctional officers and hepatitis C.

Bailey, R (2006) Don’t be terrorized, http:// reason.com/archives/2006/08/11/don’t-be-terrorized <accessed 17 January 2012>.

Bell, D (2005) Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview, American Journal of Medicine, 102.

Boonwaat, L, et.al., (2010) Establishment of a successful assessment and treatment service for Australian prison inmates with chronic hepatitis C, Medical Journal of Australia, 192(9).

Centers for Disease Control and Prevention, http://www.cdc.gov <accessed 2nd December 2011>.

Dolan, K, et al., (2009) Presence of hepatitis C virus in syringes confiscated in prisons in Australia, Journal of Gastroenterology and Hepatology, 24.

Dolan, K, et al., (2010) Incidence and risk for hepatitis C infection during imprisonment in Australia, Eur J Epidemiol, 24.

Jagger, J, et al., (2002) Occupational transmission of hepatitis C virus, JAMA, 12.

Jones, P, (1991) HIV transmission by stabbing despite zidovudine prophylaxis.,Lancet.

Jurgens, R, Ball A, & Verster, A, (2009) Interventions to reduce HIV transmission related to injecting drug use in prison, Lancet Infect Dis, 9.

Lanphear, B, et al.,(1994) Hepatitis C virus infection in healthcare workers: risk of exposure and infection, Infect Control Hosp Epidemiol, 15.

Larney, S, & Dolan, K, (2005) Needlestick Injuries Among Prison Officers in Two Australian States, Australiasian Journal of Correctional Staff, 3(1).

Larney S, & Dolan K, (2008) An exploratory study of needlestick injuries among Australian prison officers, International Journal of Prisoner Health, 4(3).

Maher, L, et al., (2006) Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia, Addiction, 101.

Morgan Alexander Consultancy, AIDS, hepatitus and sexual health, www.aidshep.org.au <accessed 25 November 2011>.

National Cancer Institute, Lifetime Risk (Percent) of Being Diagnosed with Cancer by Site and Race/Ethnicity, http://seer.cancer.gov/csr/1975_2007/results_merged/topic_lifetime_risk_diagnosis.pdf <accessed 28 Novermber 2011>.

Prisoners Working Group of the hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and hepatitis, (2008) Hepatitis C prevention, treatment and care: guidelines for Australian custodial settings.

Public Health Association of Australia, (2011) Balancing access and safety: meeting the challenges of blood-borne viruses in prison, Report for the ACT Government into implementation of a Needle and Syringe Program at the Alexander Maconochie Centre.

Razali, K, et al., (2007) Modelling hepatitis C virus in Australia, Drug and Alcohol Dependence, 91.

Stark, et al.,(1997) History of Syringe Sharing in Prison and Risk of hepatitis B Virus, hepatitis C Virus, and Human.



[1] Lanphear, B, et al., (1994) Hepatitis C virus infection in healthcare workers: risk of exposure and infection, Infect Control Hosp Epidemiol, 15, pp. 745–750.

[2] Jagger, J, Puro, V, & DeCarli, G, (2002) Occupational transmission of hepatitis C virus, JAMA, 12, pp. 1469–1471.

[3] Centers for Disease Control and Prevention, http://www.cdc.gov <acessed 2nd December 2011>.

[4] Bell, D, 2005) Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview, American Journal of Medicine, 102, pp. 9–15.

[5] Larney, S & Dolan, K, (2008) Needlestick Injuries Among Prison Officers in Two Australian States. Australiasian Journal of Correctional Staff Development, 8.

[6] National Cancer Institute, Lifetime Risk (Percent) of Being Diagnosed with Cancer by Site and Race/Ethnicity, http://seer.cancer.gov/csr/1975_2007/results_merged/topic_lifetime_risk_diagnosis.pdf <accessed 28 November 2011>; Bailey, R, (2006) Don’t be terrorized, http://reason.com/archives/2006/08/11/dont-be-terrorized <accessed 4th August 2016>.

[7] Morgan Alexander Consultancy, AIDS, hepatitis and sexual health, www.aidshep.org.au <accessed 25 November 2011>.

[8] Jones, P, (1991) HIV transmission by stabbing despite zidovudine prophylaxis, Lancet, pp. 338-884.

[9] Jurgens, R. Ball A, & Verster, A, (2009) Interventions to reduce HIV transmission related to injecting drug use in prison, Lancet Infect Dis, 9, pp. 57-66.

[10] Ibid.

[11] Larney, S, & Dolan, K, (2008) An exploratory study of needlestick injuries among Australian prison officers, International Journal of Prisoner Health, vol. 4 (3) pp. 164-8.

[12] Razali, K, et al., (2007) Modelling Hepatitis C virus in Australia, Drug and Alcohol Dependence, 91, pp. 228-235.

[13] Maher, L, et al., (2006), Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia. Addiction, 101, pp. 1499-1508.

[14] Public Health Association of Australia, (2011) Balancing access and safety: meeting the challenges of blood-borne viruses in prison,Report for the ACT Government into implementation of a Needle and Syringe Program at the Alexander Maconochie Centre.

[15] Ibid.

[16] Ibid.

[17] Stark, et al., (1997) History of Syringe Sharing in Prison and Risk of Hepatitis B Virus, Hepatitis C Virus, and Human Immunodeficiciency Virus Infection among injecting drug users in Berlin, International Journal of Epidemiological Association, 26(6), pp. 1359-1366.

[18] Australasian Society for HIV Medicine, (2008) Correctional officers and hepatitis C.

[19] Prisoners Working Group of the Hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis, (2008) Hepatitis C prevention, treatment and care: guidelines for Australian custodial settings.

[20] Ibid.

[21] Australian Government Department of Health and Ageing, (2010) Third national hepatitis C strategy 2010-2013.

[22] Prisoners Working Group of the Hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis, (2008) Hepatitis C prevention, treatment and care: guidelines for Australian custodial settings.

[23] Ibid.

[24] ibid.

[25] Boonwaat, L, et al., (2010) Establishment of a successful assessment and treatment service for Australian prison inmates with chronic Hepatitis C, Medical Journal of Australia, 192(9), pp. 496-500.

 

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