Research Article :
Background: The purpose of this project was to determine the
prevalence of Hepatitis C among the inmates of Her Majesty s Prison in
Anguilla, British West Indies, as well as the rate of transmission whilst
incarcerated. Participation was voluntarily by 24 participants and
confidentiality was maintained by replacing the inmate s names with numbers. Methods: A validated questionnaire was given and guided
towards lifestyle, behaviors while incarcerated and knowledge of the disease
and safety precautions. Following the survey, Hepatitis C testing was performed
via an immunoassay for the presence of antibodies in the samples serum. Findings: There was one inmate who tested positive for
Hepatitis C as a part of his initial work up upon incarceration, and the same
inmate was found to be positive for HCV after our testing concluding, there was no increase in the
number of affected inmates. Conclusion: This research was beneficial in educating the
inmates of Anguilla about hepatitis C and its associated risk factors however, language barriers, and small population
size were some of the limitations the researchers came across. Results for Hepatitis
C in this Anguillan prison population are significantly lower than results seen
in the United States, and Canada. Hepatitis C virus is often referred to as
a silent epidemic since it may be asymptomatic for years [1,2]. Hepatitis C
virus (HCV) is a blood-borne viral infection spread through bodily fluids it causes inflammation of the liver, affecting
its ability to properly function that can lead to cirrhosis and end-stage liver
disease [3-5]. HCV infection represents the leading indication for liver
transplantation in the United States and has caused more deaths annually than
human immunodeficiency virus (HIV) since 2007 [2,6]. HCV is disproportionately
concentrated among the most marginalized groups in society, including people
who are drug users, homeless or incarcerated [7]. There are 2.2 million people
in jail in the United States, being the most common hepatitis in prisons [4,8].
About 1 in 3 people have HCV [4,8]. The most common way HCV is spread among
inmates is by sharing equipment used for injecting drugs, tattooing, and piercings
with other people who are already infected [4]. Screening for the
Hepatitis C virus is highly recommended in populations who have or currently do
inject drugs, long-term hemodialysis patients, and children born to infected
mothers, HIV-infected patients and persons with known exposures to the virus,
such as inmates in prison [4,9]. Adult correctional facilities are at a high
risk for the transmission of Hepatitis C because many people in jails already
have Hepatitis C [10]. Another high risk behavior that predisposes inmates to
transmitting HCV is by having unprotected sex with other inmates. Research
shows that gay and bisexual men are at a higher risk for the Hepatitis C virus,
especially if they are HIV-positive, have multiple sex partners and have
unprotected sex [4, 11]. The purpose of this study
is to assess the prevalence of HCV in the incarcerated male population of Her
Majesty s prison in Anguilla, as well as the rate of transmission whilst
incarcerated. This paper will help future researchers evaluate if HCV is also higher
among the incarcerated population in the Caribbean. Inmates
voluntarily participated in this research project and the ones who consented
were given a survey to aid in assessing their health status focusing on HCV.
The questions were guided towards lifestyle, behaviors while incarcerated,
knowledge of the disease and safety precautions (Index B). In order to prevent inconsistencies
when responding to the questionnaire, it was first reviewed by research
coordinators. The questions were then asked to students as a pilot to see what
their responses would be. We refined our questions based on the responses
received by these subjects so as to be more direct. The guards brought the
inmates to the outside open area and then the questionnaires were read to the
inmates privately in a one on one setting distant from the guards. Each survey
and correspondent test was privately assigned a number to ensure inmate
confidentiality. Following the survey, each inmate was brought into the nursing
station alone without the guards (they stood outside) for safety precautions.
The senior laboratory technician from the Anguilla s Princess Alexandra
Hospital then performed the Hepatitis testing with us present. Inmates are
tested for Hepatitis C upon incarceration, as per the prison regulations therefore, the same testing methods were used
to re-verify the serum levels. Serum analysis was done via immunoassay testing
for the presence of hepatitis C antibodies. The screening immunoassay
process involved taking a blood sample from every consenting inmate at the
prison. These samples were taken by the laboratory technician from the Princess
Alexandra Hospital in Anguilla. The method of testing used was a qualitative
determination of the human antibody directed against Hepatitis C virus
(anti-HCV) present in the serum. The detection of this antibody in the inmate s
serum was analyzed using a direct solid-phase enzyme immunoassay [12]. In the hospital
laboratory, the samples were then diluted and incubated on a microwell coated
with recombinant Hepatitis C virus antigen. A peroxidase-conjugated antibody
directed against human Immunoglobulin G (IgG) was added to each well on the
micro well plate. After incubation, the wells were washed to remove particles
and a substrate solution consisting of hydrogen peroxide and o-phenylenediamine
(OPD) in a citrate buffer. After incubation, Sulfuric acid is added to stop the
reaction. Anti-HCV antibodies bind to the HCV antigen and the conjugate then
binds to that antibody. This reaction will result in an orange color absence of orange color indicates no reaction
and therefore no anti-HCV in the serum [12]. Non-reactive samples can be
considered negative for the HCV antibody, meaning the virus is not present in
the tested serum [13]. An active sample is consistent with a positive HCV
infection. This could indicate one of two things either a current HCV infection or a past HCV
infection that has resolved [14]. A positive sample will need to be tested for
HCV RNA to assess for current infection. Detection of HCV RNA indicates a current
infection and the patient should be guided toward proper care [14]. Out of 56 inmates, 24
participated in this study. 1 out of the 24 participants who were tested with
the immunoassay tested positive for Hepatitis C however, this participant also tested positive
for hepatitis C upon his incarceration at Her Majesty s prison. With the help
of the qualitative questionnaire, the average age of the consenting inmates
were 27 years old. The length of stay is evidently dependent on the crime however, of the participants, the least amount
of incarceration time is 1 month and the longest time is 8 years. There were no
new inmates who tested positive for HCV after our testing therefore, there was not an increase in number
of affected inmates. Out of the 24 inmates, 18 people are from Anguilla, 2
people are from Santo Domingo, 2 people from St. Kitts and 2 people from St.
Martin. Of the 24 inmates, 16 have been incarcerated at least once in the past,
besides their current stay, and 8/24 people is the first time they are
incarcerated. The average level of education among the inmates is high school
with the exceptions of one inmate who completed a college degree and one person
with a grade 6 level of education. All of the inmates questioned stated they
were heterosexual expect for one inmate who
expressed that he was bisexual. All 24 inmates deny ever having sexual
intercourse in prison and no one considers inmates having sex while being
incarcerated as a frequent occurrence. In the questionnaire, 8/24 people
reported they are single, 5/24 are married, 7/24 have multiple partners and
4/24 have one partner. Moreover, 12/24 people never use a condom, whereas 10/24
use condoms often. There were 14/24 inmates who have had sex with a commercial
worker and 10/24 have never had sex with a commercial worker. All inmates that
participated in the questionnaire denied ever doing intravenous (IV) drugs in
the past or while they were incarcerated. Of the 24 inmates, 16 have tattoos 9/16 obtained tattoos from a licensed
professional, 7/16 tattoos were obtained from a source other than a licensed
professional. Additionally, there were 8/24 inmates who have heard of Hepatitis
C virus and 16/24 who have never heard of HCV before. Likewise, 3/24 inmates
are aware of how HCV is transmitted. Out of the 24 inmates, 13 believe that a
person with HCV can look normal and 11/24 believes individuals with HCV would
not look normal. None of the 24 inmates believe that they have a family member with
HCV. Of the 24 inmates, 4 people have been tested for HCV in the past before
being tested upon incarceration out of
the 4 inmates, 2 say the results were negative, 1 says he was not sure and 1
was positive. Of the 3 people who stated that the results were negative, 1
person says the last test was done between 1-5 years ago and 3 people expressed
that the test was done under a year ago. No one is currently undergoing any
kind of treatment for HCV. Surprisingly, 1/24 inmates is aware of prevention
programs available to people in Anguilla to help prevent the spread of HCV. Anguilla
is a small island located in the Lesser Antilles it has a population of 13 500 people. Her
Majesty s prison is the only male prison on the island. The prisoners in Her
Majesty s prison are kept in individual cells and even separate buildings based
on which they belong to or what their crime was.
The prison is not a maximum
security prison and the inmates do have the opportunity to have social contact
with each other at certain times of the day. The population of Anguilla is very
religious and practices their faith strictly they do not condone the use of injection
drugs, as well as homosexual behaviors. We suspect that the rate of
transmission and spread of viruses such as Hepatitis C are low due to the population
s beliefs. Our results demonstrated, there were no prisoners that admitted to
using injection drugs. This comes as no surprise since the most common illicit
drugs in Anguilla are cannabis and cocaine. Homosexuality in Anguilla is not
highly regarded upon and an admission of any male sexual preference could lead
to fights and threats amongst the inmates. The only inmate who admitted to
being bisexual was placed in a separate building from the rest of the inmates
for safety precautions. Of the 16 inmates who have tattoos, over half of them
admitted to obtaining them from unlicensed professionals. This is a high risk of
transmission, especially if the tattoos or scarring are being done in the
prison. The
individual who tested positive admitted to having unprotected sex with multiple
partners, as well as commercial sexual workers during his questionnaire. At 19
years of age, this was his first incarceration. The inmate who tested positive
was covered in tattoos and stated that his tattoos are from an unlicensed professional,
having them all done by his cousin. These factors are key at determining what
put this inmate at risk for transmission. Not only did the inmate admit to not
knowing he has Hepatitis C, but he also admitted to not knowing what the
disease was or how it is transmitted. This indicates that once he tested
positive in the past he was either not informed or was not properly educated as
to the seriousness of this illness. This is a serious health hazard for the other
inmates, and workers of Her Majesty s prison that are being put at risk by a
person who does not know his HCV status. During
the course of this research project, the biggest strength was reaching out to
the inmates and educating them while performing the questionnaires. Most of the
inmates that were questioned have heard about hepatitis C but did not know anything
about the virus. We were able to educate the inmates about different risk
factors and ways to contract the virus. The majority of the inmates had tattoos
and virtually all of them have obtained them from a source other than a
licensed professional. It is unknown the amount of people who get HCV from
tattooing, though people who have tattoos are four times more likely to have
HCV [15]. Moreover, throughout this research study there were a few limitations
in our methodology. The population of the Anguillan inmates is small and only
48% of the inmates consented to participate. Out of the inmates who consented
almost half of them did not have initial work up. Luckily, the inmate who
tested positive had initial work up therefore, it is possible that there are other
inmates in the prison who are affected. This
study was beneficial in assessing the prevalence of HCV and the inmate s
knowledge about the virus. Throughout our research we discovered various areas
that require improvement to ensure the prevalence of HCV remains low at Her
Majesty s Prison. The prison s regulations are to assess inmate s health conditions
upon incarceration. Though, in the 24 people that were tested, there were 11
people who had no initial work up. This could become detrimental to the other
inmates, guards and workers at the prison. Moreover, it would also be
beneficial for the inmates to be tested for HCV when they are released from
prison. This will assess
if there is an increase HCV in the prison. This
study was beneficial in raising awareness with the inmates at Her Majesty s
prison. There was 1 positive result obtained within this prison population of
the 24 consenting inmates. This value is the same as the number of inmates who
tested positive at the start of their incarceration. Although the population is
small, results for Hepatitis C in this Anguillan prison population is
significantly lower than results seen in the United States and Canada. This
study was independently conducted by the authors of this article. Dr. Hammoudi
gave the students unrestricted rights. The other articles involved in this
study were independently prepared by the authors, with no input from Dr.
Hammoudi. The research committee at St. James Anguilla Campus funded this
research. We would
like to thank Her Majesty prison of Anguilla for allowing us to work with their
staff and inmates to conduct this research. We would also like to thank the
senior laboratory technician from Anguilla s Princess Alexandra Hospital for
sampling the inmates blood for us. Lastly, we would like to acknowledge Dr.
Hammoudi, the research committee of St. James School of Medicine for allowing
us to do this research, and the students who participated in our pilot
questionnaire. To our knowledge, both the research conducted and information gathered
by this team, at Her Majesty s Prison and Princess Alexandra Hospital, were
conducted without bias and with the highest scientific and ethical standards. 1.
Trueland J. Action stations against the silent
epidemic (2014) Nursing Standard 29:
22-23. Hepatitis C Virus, Anguilla, Prison, Prevalence, Risk Factors
The Prevalence and Incidence of Hepatitis C in the Anguillan Prison Population
Alexia Kamel*, Kristina Candido, David Frias, Henry Sioufi and D. Hammoudi
Abstract
Full-Text
Introduction
Methods
Results
Discussion
Strengths and Limitations
Recommendations
Conclusion
Declarations
Acknowledgments
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