Abstracts

INTRODUCTION

Hepatitis C virus (HCV) infection is a major worldwide health care problem. The World Health Organization estimates that approximately 150 million people are chronically infected with HCV, and more than 350,000 people die every year from hepatitis C-related liver diseases.^aa World Health Organization. Hepatitis C: updated 2014. Geneva; 2014 [cited 2014 Feb 16]. (Fact sheet, 164). Available from: http://www.who.int/mediacentre/factsheets/fs164/en/ The disease severity ranges from a mild illness lasting a few weeks to a serious lifelong condition in almost 85.0% of cases, which can lead to liver cirrhosis or liver cancer. Patients can remain symptom-free for a long time; for example, liver disease may appear up to 20 or 30 years after the initial infection.²³23 Lauer GM, Walker BD. Hepatitis C virus infection. N England J Med. 2001;345(1):41-52. DOI:10.1056/NEJM200107053450107

HCV is transmitted by contact with the blood of an infected person. Although several transmission mechanisms are known, such as injection drug use, tattooing, sexual intercourse, invasive medical or dental procedures, and perinatal transmission, other routes remain unknown.³⁷37 Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepatitis C virus infection. Lancet Infect Dis. 2005;5(9):558-67. DOI:10.1016/S1473-3099(05)70216-4

The population confined in prisons may have a higher prevalence of HCV than the general population due to its low socioeconomic level and high prevalence of injecting drug dependence. The environment in most prisons could also contribute to local transmission. People confined in prisons are more likely to engage in high-risk behaviors for HCV infection than the general population,³⁸38 Skoretz S, Zaniewski G, Goedhuis NJ. Hepatitis C virus transmission in the prison/inmate population. Can Commun Dis Rep. 2004;30(16):141-8. and the serving time in prison increases risk exposures to other prisoners, because they usually have poor access to health care and live in poverty. This exposure may include high-risk sexual practices, such as sexual intercourse with prisoners with a history of sexually transmitted diseases (STD) or with a former or current injection drug user.³⁸38 Skoretz S, Zaniewski G, Goedhuis NJ. Hepatitis C virus transmission in the prison/inmate population. Can Commun Dis Rep. 2004;30(16):141-8.^,4545 Vescio MF, Longo B, Babudieri S, Starnini G, Carbonara S, Rezza G, et al. Correlates of hepatitis C virus seropositivity in prison inmates: a meta-analysis. J Epidemiol Community Health. 2008;62(4):305-13. DOI:10.1136/jech.2006.051599 However, incarceration conditions and the high cost of conducting research hamper a prospective evaluation of the extent of HCV spread within prisons. Few studies have addressed this issue with a prospective follow-up. In 2010, a study conducted among injecting drug-using inmates from Australia evaluated the reinfection of different HCV genotypes and showed that the incidence of HCV infection was 40/100 person-years.³¹31 Pham ST, Bull RA, Bennett JM, Rawlinson WD, Dore GJ, Lloyd AR, et al. Frequent multiple hepatitis C virus infections among injection drug users in a prison setting. Hepatology. 2010;52(5):1564-72. DOI:10.1002/hep.23885 In Brazil, Gois et al¹⁵15 Gois SM, Santos Junior HPL, Silveira MFA, Gaudêncio MMP. Para além das grades e ´punições: uma revisão sistemática sobre a saúde penitenciária.Cienc Saude Coletiva. 2012;17(5):1235-46. DOI:10.1590/S1413-81232012000500017 have argued that prisoner health has become a public health problem.

The prevalence of HCV infection in prisons varies by country: 5.0% in Venezuela,²⁹29 Monsalve-Castillo F, Chacín-Bonilla L, Atencio RJA, Porto LD, Costa-León LA, Estévez JE, et al. Baja prevalencia de la infección por el virus de la hepatitis C en una población de reclusos, Maracaibo, Venezuela.Biomedica. 2009;29(4):647-52. DOI:10.7705/biomedica.v29i4.142 15.2% in Pakistan,²¹21 Kazi AM, Shah SA, Jenkins CA, Shepherd BE, Vermund SH. Risk factors and prevalence of tuberculosis, human immunodeficiency virus, syphilis, hepatitis B virus, and hepatitis C virus among prisoners in Pakistan.Int J Infect Dis. 2010;14 Suppl 3:e60-6. DOI:10.1016/j.ijid.2009.11.012 19.0% in Scotland,⁴³43 Taylor A, Munro A, Allen E, Dunleavy K, Cameron S, Miller L, et al. Low incidence of hepatitis C virus among prisoners in Scotland.Addiction. 2013;108(7):1296-304. DOI:10.1111/add.12107 12.0%-31.0% in the United States,⁴²42 Tan JA, Joseph TA, Saab S. Treating hepatitis C in the prison population is cost-saving. Hepatology. 2008;48(5):1387-95. DOI:10.1002/hep.22509 34.1% in Indonesia³⁴34 Prasetyo AA, Dirgahayu P, Sari Y, Hudiyono H, Kageyama S. Molecular epidemiology of HIV, HBV, HCV, and HTLV-1/2 in drug abuser inmates in central Javan prisons, Indonesia. J Infect Dev Ctries. 2013;7(6):453-67. DOI:10.3855/jidc.2965 and 46.0% in Norway.²⁰20 Holsen DS, Harthug S, Myrmel H. Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. Eur J Clin Microbiol Infect Dis.1993;12(9):673-6. DOI:10.1007/BF02009378 The reason for the difference in results may be variations in the design, aims and criteria of different studies. Most studies around the world are conducted among male inmate populations, probably because they are larger than female ones. In 2012, Brazil had 512,964 male inmates and only 35,039 female inmates.^bb Ministério da Justiça, Departamento Penitenciário Nacional – DEPEN. Sistema Nacional de Informação Penitenciária – InfoPen: estatística. Brasília (DF); 2012 [cited 2014 May 21]. Available from: http://portal.mj.gov.br/main.asp?View={D574E9CE-3C7D-437A-A5B6-22166AD2E896}&Team=&params=itemID={2627128E-D69E-45C6-8198-CAE6815E88D0};&UIPartUID={2868BA3C-1C72-4347-BE11-A26F70F4CB26} Furthermore, the choice of anti-HCV screening tests can also influence the variation in prevalence among countries, as well as in the general population. More accurate assays, such as molecular testing for HCV RNA detection, can be used for confirmation.⁹9 Brandão ABM, Fuchs SC, Silva MAA, Emer LF. Diagnóstico de hepatite C na prática médica: revisão de literatura. Rev Pan Am Saude Publica. 2001;9(3):161-8.DOI:10.1590/S1020-49892001000300005
https://doi.org/10.1590/S1020-4989200100... Another important factor is whether the survey was performed among inmates entering prison or among already incarcerated inmates, who may have been more exposed to STD and drug use, increasing the chance of intra-prison transmission of HCV. The proportion of inmates that are injecting drug users (IDU) is very relevant information, as well as the number of inmates with tattoos.³⁸38 Skoretz S, Zaniewski G, Goedhuis NJ. Hepatitis C virus transmission in the prison/inmate population. Can Commun Dis Rep. 2004;30(16):141-8.^,4545 Vescio MF, Longo B, Babudieri S, Starnini G, Carbonara S, Rezza G, et al. Correlates of hepatitis C virus seropositivity in prison inmates: a meta-analysis. J Epidemiol Community Health. 2008;62(4):305-13. DOI:10.1136/jech.2006.051599

The aim of this study was to estimate the prevalence of HCV infection among Brazil’s inmate population.

METHODS

This systematic review was based on the directions of Stroup et al⁴¹41 Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000;283(15):2008-12. DOI:10.1001/jama.283.15.2008 and Moher et al.²⁸28 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.Int J Surg. 2010;8(5):336-41. DOI:10.1016/j.ijsu.2010.02.007

The search included articles from January 1, 1989 until February 20, 2014, using the PubMed (Medline), Lilacs and Embase databases. No language restriction was used. The terms for the search were (hepatitis C OR HCV) AND (prisoners OR inmates) AND Brazil* in all databases. Multiple reports of the same study were identified as duplicates and counted as one study.

In an attempt to identify other relevant studies, references from articles obtained in the database searches and from review articles about the topic were manually researched.

We included studies: reporting primary data; conducted in prisons in Brazil; that conducted biological testing to detect antibodies against HCV (anti-HCV); and that evaluated prisoners aged 18 years or older. The exclusion criteria were: evidence that the study population was not in fact prisoners; studies of subpopulations within the inmates; studies with a sample size smaller than 50 individuals; case reports and case series; and studies that failed to present data clearly enough. Reviews of the literature were excluded, but the data reported were checked and compared with the results of the present study.

First, the titles and abstracts were screened for relevance independently by two of the investigators (MCM and WPP or KYI). Second, disagreements were resolved by discussion. Third, the full text of all articles deemed relevant were screened. Finally, all full articles were read by at least two investigators (MCM and WPP or FMT), and whenever there was any disagreement, it was read by a third investigator and discussed.

We extracted the following information from each study: first author, year of publication, city and state, the year in which it was conducted, sex and age of participants, laboratory methods used in anti-HCV detection, sample size and number of participants positive for anti-HCV. To assess the quality of the studies, we created a quality assessment scale (0 to 8 points) based on the criteria proposed by Boyle⁸8 Boyle M. Guidelines for evaluating prevalence studies. Evid Based Ment Health. 1998;1(2):37-40. DOI:10.1136/ebmh.1.2.37 and Fowkes and Fulton.¹⁴14 Fowkes FGR, Fulton PM. Critical appraisal of published research: introductory guidelines. BMJ. 1991;302(6785):1136-40. DOI:10.1136/bmj.302.6785.1136 The scale includes reporting study design, inclusion and exclusion criteria, compliance with established criteria, outcome definition and measurement, total number of participants, proportion of non-respondents, and number of outcome events. A higher score indicates better quality.

The methods used for anti-HCV detection were enzyme-linked immunosorbent assay (ELISA) of any generation and other immunoassay tests. They are listed in Table 1, and we consider the tests appropriate for this aim.

Data used for the analysis were extracted from the eligible studies included in this review. Chi-square tests, odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic regression and the software SPSS, version 20.0.

RESULTS

Using the initial literature search strategies, we identified 50 studies, including 25 duplicates. After reading the abstracts, 11 were excluded. Thus, the full texts of 14 articles were reviewed, all of them available in English, and three of them were excluded (Figure). The studies by Fialho et al¹³13 Fialho M, Messias M, Page-Shafer K, Farre L, Schmalb M, Pedral-Sampaio D, et al. Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention. AIDS Behav. 2008;12(4 Suppl):S17-24. DOI:10.1007/s10461-008-9409-x and Zanetta et al⁴⁸48 Zanetta DM, Strazza L, Azevedo RS, Carvalho HB, Massad E, Menezes RX, et al. HIV infection and related risk behaviours in a disadvantaged youth institution of São Paulo, Brazil. Int J STD AIDS. 1999;10(2):98-104. DOI:10.1258/0956462991913718 were excluded in full text review because they included inmates younger than 18 years of age. The study by Strazza et al³⁹39 Strazza L, Azevedo RS, Carvalho HB, Massad E. The vulnerability of Brazilian female prisoners to HIV infection. Braz J Med Biol Res. 2004;37(5):771-6. DOI:10.1590/S0100-879X2004000500020 from 2004 was excluded because it included samples from the same prison as the study by Strazza et al⁴⁰40 Strazza L, Massad E, Azevedo RS, Carvalho HB. Estudo de comportamento associado à infecção pelo HIV e HCV em detentas de um presídio de São Paulo, Brasil. Cad Saude Publica. 2007;23(1):197-205. DOI:10.1590/S0102-311X2007000100021 from 2007, which provided detailed information and therefore was included.

Finally, 11 studies were included in the present review, and their mean quality classification was 7.4 (ranging from 5 to 8) (Table 2).

The number of inmates reported in the included studies ranged from 63 to 756. Overall, these studies included 4,375 inmates from seven different Brazilian states and were conducted between 1993 and 2011. Four studies included only male prisons, three included female prisons and four included both male and female prisons. Inmates were aged 18 to 80 years.

The prevalence of HCV infection in Brazilian inmates in all the studies was determined by the presence of anti-HCV in the blood, and the mean prevalence was 13.6%, with the lowest prevalence detected in the state of Espirito Santo (1.0%) and the highest in the state of Sao Paulo (41.0%) (Table 1).

Table 3 shows the prevalence of HCV (with confidence intervals) among inmate populations grouped into the seven Brazilian states included in this systematic review. Furthermore, it presents a comparison of means between Sao Paulo (reference category) and the other states. The chances of inmates being seropositive for HCV in the states of Minas Gerais, Sergipe, Mato Grosso do Sul, Rio Grande do Sul, Goias and Espirito Santo were 84.0%, 92.0%, 88.0%, 74.0%, 84.0% and 89.0% lower, respectively, than in Sao Paulo state.

Table 4 shows the prevalence with confidence intervals from the four studies conducted in the state capital, the city of Sao Paulo, and a comparison of the means from the first and the last studies conducted there. The results indicate that the prevalence reported in later studies was lower than that in the earlier ones. The chance of inmates being seropositive for HCV in Sao Paulo State in the years of 1997 and 2000 was 72.0% and 75.0% lower, respectively, than in 1993-1994.

DISCUSSION

The mean prevalence of HCV in Brazilian inmates in the present systematic review was 13.6%, ranging from 1.0% to 41.0%, with the lowest prevalence detected in the state of Espirito Santo and the highest in the state of Sao Paulo. With at least 550,000 people detained in Brazilian prisons,^bb Ministério da Justiça, Departamento Penitenciário Nacional – DEPEN. Sistema Nacional de Informação Penitenciária – InfoPen: estatística. Brasília (DF); 2012 [cited 2014 May 21]. Available from: http://portal.mj.gov.br/main.asp?View={D574E9CE-3C7D-437A-A5B6-22166AD2E896}&Team=&params=itemID={2627128E-D69E-45C6-8198-CAE6815E88D0};&UIPartUID={2868BA3C-1C72-4347-BE11-A26F70F4CB26} we can consider that there might be 74,800 inmates with hepatitis C in Brazil. There are few studies available in Latin American countries regarding the prevalence of HCV among inmates. A study carried out in Mexico found a prevalence of 10.0%,⁴4 Alvarado-Esquivel C, Sablon E, Martinez-García S, Estrada-Martinez S. Hepatitis virus and HIV infections in inmates of a state correctional facility in Mexico. Epidemiol Infect. 2005;133(4):679-85. DOI:10.1017/S0950268805003961 and another one in Venezuela found a prevalence of 5.0%.²⁹29 Monsalve-Castillo F, Chacín-Bonilla L, Atencio RJA, Porto LD, Costa-León LA, Estévez JE, et al. Baja prevalencia de la infección por el virus de la hepatitis C en una población de reclusos, Maracaibo, Venezuela.Biomedica. 2009;29(4):647-52. DOI:10.7705/biomedica.v29i4.142 Worldwide, the prevalence rates vary significantly: 4.9% in France,⁴⁴44 Verneuil L, Vidal JS, Ze Bekolo R, Vabret A, Petitjean J, Leclercq R, et al. Prevalence and risk factors of the whole spectrum of sexually transmitted diseases in male incoming prisoners in France. Eur J Clin Microbiol Infect Dis. 2009;28(4):409-13. DOI:10.1007/s10096-008-0642-z 8.1% in Iran,⁵5 Azarkar Z, Sharifzadeh G. Evaluation of the prevalence of hepatitis B, hepatitis C, and HIV in inmates with drug-related convictions in Birjand, Iran in 2008. Hepat Mon. 2010;10(1):26-30. DOI:10.1002/jmv.20375 16.6% in Canada,³³33 Poulin C, Alary M, Lambert G, Godin G, Landry S, Gagnon H, et al. Prevalence of HIV and hepatitis C virus infections among inmates of Quebec provincial prisons. CMAJ. 2007;177(3):252-6. DOI:10.1503/cmaj.060760 19.2% in Ghana,³3 Adjei AA, Armah HB, Gbagbo F, Ampofo WK, Quaye IKE, Hesse IFA, et al. Prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus and syphilis among prison inmates and officers at Nsawam and Accra, Ghana.J Med Microbiol. 2006;55(5):593-7. DOI:10.1099/jmm.0.46414-0 21.8% in Ireland,²⁵25 Long J, Allwright S, Barry J, Reynolds SR, Thornton L, Bradley F, et al. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey.BMJ. 2001;323(7323):1209-13. DOI:10.1136/bmj.323.7323.1209 24.2% in England,²²22 Kirwan P, Evans B, Brant L. Hepatitis C and B testing in English prisons is low but increasing. J Public Health (Oxf).2011;33(2):197-204. DOI:10.1093/pubmed/fdr011 38.0% in Italy,⁶6 Babudieri S, Longo B, Sarmati L, Starnini G, Dori L, Suligoi B, et al. Correlates of HIV, HBV, and HCV infections in a prison inmate population: results from a multicentre study in Italy. J Med Virol. 2005;76(3):311-7. DOI:10.1002/jmv.20375 46.0% in Norway²⁰20 Holsen DS, Harthug S, Myrmel H. Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. Eur J Clin Microbiol Infect Dis.1993;12(9):673-6. DOI:10.1007/BF02009378 and 57.5% in Australia.¹⁹19 Hellard ME, Hocking JS, Crofts N. The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities. Epidemiol Infect. 2004;132(3):409-15. DOI:10.1017/S0950268803001882

The present review indicates that the city of Sao Paulo has reported the highest prevalence of HCV infection, with a mean prevalence of 27.6% (ranging from 16.2% to 41.0%).¹⁸18 Guimarães T, Granato CFH, Varella D, Ferraz MLG, Castelo A, Kallás EG. High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection. Braz J Infect Dis. 2001;5(3):111-8. DOI:10.1590/S1413-86702001000300002^,2626 Massad E, Rozman M, Azevedo RS, Silveira AS, Takey K, Yamamoto YI, et al. Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: preponderance of parenteral transmission. Eur J Epidemiol. 1999;15(5):439-45. DOI:10.1023/A:1007523027876^,2727 Miranda AE, Vargas PM, St Louis ME, Viana MC. Sexually transmitted diseases among female prisoners in Brazil: prevalence and risk factors.Sex Transm Dis. 2000;27(9):491-5. DOI:10.1097/00007435-200010000-00001^,4040 Strazza L, Massad E, Azevedo RS, Carvalho HB. Estudo de comportamento associado à infecção pelo HIV e HCV em detentas de um presídio de São Paulo, Brasil. Cad Saude Publica. 2007;23(1):197-205. DOI:10.1590/S0102-311X2007000100021 This may be explained by the urban diversity of the country. Sao Paulo is considered one of the most populous cities in the world and is one of the main destinations for migrants from other cities of Brazil.

The study that reported the highest prevalence, 41.0%, was conducted in Sao Paulo, in the Carandiru prison. According to the authors, it was one of the clusters of highest reported HCV infection, and it remains so in Brazil until today. The authors believed that most of the HCV infections occurred prior to imprisonment.¹⁸18 Guimarães T, Granato CFH, Varella D, Ferraz MLG, Castelo A, Kallás EG. High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection. Braz J Infect Dis. 2001;5(3):111-8. DOI:10.1590/S1413-86702001000300002 It is important to emphasize that Carandiru was huge. There were nine blocks divided into several prison cells according to the features of the crime committed. We do not know the exact election criteria for the inmates/blocks included in the study. Of note, Carandiru complex was deactivated and partially demolished in 2002.

The studies involved 4,375 inmates in the last 20 years (1993-2013). The first selected study was conducted in 1993. At that time, there was no standard mechanism for consolidating data on the Brazilian inmate population; concrete data have been available at the Brazilian Ministry of Justice website since 2000. In 2000, there were 139,188 inmates in closed regime in Brazil, whereas in December 2011, the year when the last study was performed, that number increased to 203,446.^bb Ministério da Justiça, Departamento Penitenciário Nacional – DEPEN. Sistema Nacional de Informação Penitenciária – InfoPen: estatística. Brasília (DF); 2012 [cited 2014 May 21]. Available from: http://portal.mj.gov.br/main.asp?View={D574E9CE-3C7D-437A-A5B6-22166AD2E896}&Team=&params=itemID={2627128E-D69E-45C6-8198-CAE6815E88D0};&UIPartUID={2868BA3C-1C72-4347-BE11-A26F70F4CB26} Therefore, the prevalence of HCV infection in this population may have been underestimated. Indeed, the latest (December 2012) statistics available at the Ministry of Justice website about the total inmate population regime shows 548,003 inmates, which is among the largest in the world.^bb Ministério da Justiça, Departamento Penitenciário Nacional – DEPEN. Sistema Nacional de Informação Penitenciária – InfoPen: estatística. Brasília (DF); 2012 [cited 2014 May 21]. Available from: http://portal.mj.gov.br/main.asp?View={D574E9CE-3C7D-437A-A5B6-22166AD2E896}&Team=&params=itemID={2627128E-D69E-45C6-8198-CAE6815E88D0};&UIPartUID={2868BA3C-1C72-4347-BE11-A26F70F4CB26}

The scale used to assess the quality of the studies was considered appropriate, and the mean quality classification was 7.4 (the lowest score was 5), indicating that the articles included in the analysis were of good quality.

Our study has some limitations, such as the validity of the laboratory tests. Most anti-HCV screening tests use the ELISA technique because of its high sensitivity and specificity, ease manipulation, and low cost, besides considerable improvement over the years. Second- and third-generation ELISA have acceptable accuracy and thereby can help reduce the need for polymerase chain reaction (PCR)-based laboratory screening.²⁴24 Lavanchy D, Mayerat C, Morel C, Schneider P, Zufferey C, Gonvers JJ, et al. Evaluation of third-generation assays for detection of anti-hepatitis C virus (HCV) antibodies and comparison with presence of HCV RNA in blood donors reactive to c100-3 antigen. J Clin Microbiol. 1994;32(9):2272-5. Diagnostic methods for detecting anti-HCV in the literature have shown differences among the first three generations of ELISA. They found 70.0%-80.0%, 92.0%-95.0%, and 97.0% sensitivity in first-, second- and third-generation ELISA, respectively.⁹9 Brandão ABM, Fuchs SC, Silva MAA, Emer LF. Diagnóstico de hepatite C na prática médica: revisão de literatura. Rev Pan Am Saude Publica. 2001;9(3):161-8.DOI:10.1590/S1020-49892001000300005
https://doi.org/10.1590/S1020-4989200100... A study conducted in Brazil suggested a strong correlation between second-generation anti-HCV ELISA and HCV RNA positivity by PCR.¹⁶16 Gonçales NSL, Costa FF, Vassallo J, Gonçales Jr FL. Diagnosis of hepatitis C virus in Brazilian blood donors using a reverse transcriptase nested polymerase chain reaction: comparison with enzyme immunoassay and recombinant protein immunoblot assay. Rev Inst Med Trop Sao PauLo. 2000;42(5):263-7. DOI:10.1590/S0036-46652000000500005 Another study published in the late 2000s about laboratory testing for hepatitis C reported that anti-HCV antibodies are usually detected using third- or fourth-generation immunoenzymatic assays that contain HCV core antigens and HCV nonstructural genes.¹⁷17 Gonçales NSL, Gonçales Junior FL. Laboratory testing for hepatitis C. Braz J Infect Dis. 2007:11 Suppl 1:22-4. DOI:10.1590/S1413-86702007000700008

In the present systematic review, the studies of Massad et al²⁶26 Massad E, Rozman M, Azevedo RS, Silveira AS, Takey K, Yamamoto YI, et al. Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: preponderance of parenteral transmission. Eur J Epidemiol. 1999;15(5):439-45. DOI:10.1023/A:1007523027876 and Guimarães et al¹⁸18 Guimarães T, Granato CFH, Varella D, Ferraz MLG, Castelo A, Kallás EG. High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection. Braz J Infect Dis. 2001;5(3):111-8. DOI:10.1590/S1413-86702001000300002 were conducted in 1993 and 1994. The first one used second-generation ELISA and the other, third-generation ELISA. The other studies are from later years,⁷7 Barros LAS, Pessoni GC, Teles SA, Souza SMB, Matos MA, Martins RMB, et al. Epidemiology of the viral hepatitis B and C in female prisoners of Metropolitan Regional Prison Complex in the State of Goiás, Central Brazil.Rev Soc Bras Med Trop. 2013;46(1):24-9. DOI:10.1590/0037-868216972013^,1010 Catalan-Soares BC, Almeida RT, Carneiro-Proietti ABF. Prevalence of HIV-1/2, HTLV-I/II, hepatitis B virus (HBV), hepatitis C virus (HCV),Treponema pallidum and Trypanosoma cruziamong prison inmates at Manhuaçu, Minas Gerais State, Brazil. Rev Soc Bras Med Trop. 2000;33(1):27-30. DOI:10.1590/S0037-86822000000100004

11 Coelho HC, Oliveira SAN, Miguel JC, Oliveira MLA, Figueiredo JFC, Perdoná GC, et al. Predictive markers for hepatitis C virus infection among Brazilian inmates. Rev Soc Bras Med Trop. 2009;42(4):369-72. DOI:10.1590/S0037-86822009000400002^-1212 Falquetto TC, Endringer DC, Andrade TU, Lenz D. Hepatitis C in prisoners and non-prisoners in Colatina, Espírito Santo, Brazil. Braz J Pharm Sci. 2013;49(4):737-44. DOI:10.1590/S1984-82502013000400013^,2727 Miranda AE, Vargas PM, St Louis ME, Viana MC. Sexually transmitted diseases among female prisoners in Brazil: prevalence and risk factors.Sex Transm Dis. 2000;27(9):491-5. DOI:10.1097/00007435-200010000-00001^,3232 Pompilio MA, Pontes ERJC, Castro ARCM, Andrade SMO, Stief ACF, Martins RMB, et al. Prevalence and epidemiology of chronic hepatitis C among prisoners of Mato Grosso do Sul State, Brazil. J Venom Anim Toxins Incl Trop Dis. 2011;17(2):216-22. DOI:10.1590/S1678-91992011000200013^,3535 Rosa F, Carneiro M, Duro LN, Valim ARM, Reuter CP, Burgos MS, et al. Prevalence of anti-HCV in an inmate population. Rev Assoc Med Bras. 2012;58(5):557-60. DOI:10.1590/S0104-42302012000500012^,3636 Santos BF, Santana NO, Franca AV. Prevalence, genotypes and factors associated with HCV infection among prisoners in Northeastern Brazil.World J Gastroenterol. 2011;17(25):3027-34. DOI:10.3748/wjg.v17.i25.3027^,4040 Strazza L, Massad E, Azevedo RS, Carvalho HB. Estudo de comportamento associado à infecção pelo HIV e HCV em detentas de um presídio de São Paulo, Brasil. Cad Saude Publica. 2007;23(1):197-205. DOI:10.1590/S0102-311X2007000100021 when it was possible to access second- and third-generation kits. The articles that described the generation or version of the kit and used the third-generation kit are shown in Table 1.¹²12 Falquetto TC, Endringer DC, Andrade TU, Lenz D. Hepatitis C in prisoners and non-prisoners in Colatina, Espírito Santo, Brazil. Braz J Pharm Sci. 2013;49(4):737-44. DOI:10.1590/S1984-82502013000400013^,1818 Guimarães T, Granato CFH, Varella D, Ferraz MLG, Castelo A, Kallás EG. High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection. Braz J Infect Dis. 2001;5(3):111-8. DOI:10.1590/S1413-86702001000300002^,3232 Pompilio MA, Pontes ERJC, Castro ARCM, Andrade SMO, Stief ACF, Martins RMB, et al. Prevalence and epidemiology of chronic hepatitis C among prisoners of Mato Grosso do Sul State, Brazil. J Venom Anim Toxins Incl Trop Dis. 2011;17(2):216-22. DOI:10.1590/S1678-91992011000200013^,4040 Strazza L, Massad E, Azevedo RS, Carvalho HB. Estudo de comportamento associado à infecção pelo HIV e HCV em detentas de um presídio de São Paulo, Brasil. Cad Saude Publica. 2007;23(1):197-205. DOI:10.1590/S0102-311X2007000100021 The second- and third-generation ELISA tests have a specificity of approximately 99.0%, so the chance of false-positive results is generally considered not significant. Five studies performed confirmatory tests, four of them with in-house molecular testing (presence of virus), and the percentages of confirmed positive cases were 100%,¹²12 Falquetto TC, Endringer DC, Andrade TU, Lenz D. Hepatitis C in prisoners and non-prisoners in Colatina, Espírito Santo, Brazil. Braz J Pharm Sci. 2013;49(4):737-44. DOI:10.1590/S1984-82502013000400013 94.5%,²⁶26 Massad E, Rozman M, Azevedo RS, Silveira AS, Takey K, Yamamoto YI, et al. Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: preponderance of parenteral transmission. Eur J Epidemiol. 1999;15(5):439-45. DOI:10.1023/A:1007523027876 91.7%,³⁶36 Santos BF, Santana NO, Franca AV. Prevalence, genotypes and factors associated with HCV infection among prisoners in Northeastern Brazil.World J Gastroenterol. 2011;17(25):3027-34. DOI:10.3748/wjg.v17.i25.302769.0%,³²32 Pompilio MA, Pontes ERJC, Castro ARCM, Andrade SMO, Stief ACF, Martins RMB, et al. Prevalence and epidemiology of chronic hepatitis C among prisoners of Mato Grosso do Sul State, Brazil. J Venom Anim Toxins Incl Trop Dis. 2011;17(2):216-22. DOI:10.1590/S1678-91992011000200013 and 55.5%⁷7 Barros LAS, Pessoni GC, Teles SA, Souza SMB, Matos MA, Martins RMB, et al. Epidemiology of the viral hepatitis B and C in female prisoners of Metropolitan Regional Prison Complex in the State of Goiás, Central Brazil.Rev Soc Bras Med Trop. 2013;46(1):24-9. DOI:10.1590/0037-868216972013 (Table 1). This raises questions about false-positive results in serology and possible difficulties in molecular testing, such as detecting a phase of low viremia or seroconversion, the high cost of supplemental tests for diagnosing HCV infection and the need for adequate laboratory infrastructure. This issue is still relevant and somewhat controversial; some authors believe that even a specificity of 99.0% does not provide the desired predictive value for a positive test, especially among populations with a low prevalence of HCV infection and populations without liver-related diseases³⁰30 Narciso-Schiavon JL, Schiavon LL, Carvalho-Filho RJ, Cardoso JR, Freire FC, Sampaio JP, et al. Anti-HCV reactive blood donors: clinical and epidemiological factors associated with false-reactive results. Eur J Gastroenterol Hepatol. 2008;20(11):1071-6. DOI:10.1097/MEG.0b013e328303e1d6^,4747 Wu FB, Ouyan HQ, Tang XY, Zhou ZX. Double-antigen sandwich time-resolved immunofluorometric assay for the detection of anti-hepatitis C virus total antibodies with improved specificity and sensitivity. J Med Microbiol. 2008;57(Pt 8):947-53. DOI:10.1099/jmm.0.47835-0 such as inmates. Therefore, a number of false-positives by anti-HCV detection could have been present in the analyzed data, possibly constituting a study limitation.

As a second limitation, most studies used convenience sampling of inmates at the institutions. Thus, it is possible that the relevant characteristics of this group do not represent those of the total population. We found only one article on this topic in prisons in Northeastern Brazil,³⁶36 Santos BF, Santana NO, Franca AV. Prevalence, genotypes and factors associated with HCV infection among prisoners in Northeastern Brazil.World J Gastroenterol. 2011;17(25):3027-34. DOI:10.3748/wjg.v17.i25.3027 and none in Northern region. We do not know whether the inmates of these regions have similar or different epidemiological characteristics.

Brazilian prisons are suffering from overcrowding and, worsening the situation, prisoner mobility within the prison system and contact with the external population (conjugal visits) might increase the chances of exposure to other individuals infected with HCV or other STD. In general, STD prevalence is higher among inmate populations than in the general population also because they might engage in high-risk sexual practices.³⁸38 Skoretz S, Zaniewski G, Goedhuis NJ. Hepatitis C virus transmission in the prison/inmate population. Can Commun Dis Rep. 2004;30(16):141-8. In addition, many prisoners use illicit drugs, including injectable ones. The proportion of current or former IDU is approximately 40.0% of the prison population in many countries.⁴⁶46 Vumbaca G. International prisons: the need for change. Of Substance [Internet]. 2005 [cited 2015 Feb 15];3(2):10-1. Available from: http://www.ofsubstance.org.au/images/archive/pdf/ofsubstance_2005-4.pdf
http://www.ofsubstance.org.au/images/arc... IDU have been considered the main segment infected with HCV in most of the world.²2 Aceijas C, Rhodes T. Global estimates of prevalence of HCV infection among injection drug users. Int J Drug Policy. 2007;18(5):352-8. DOI:10.1016/j.drugpo.2007.04.004 A meta-analysis of the risk factors associated with HCV prevalence in Brazilian prisons was not feasible because most studies did not analyze the risk factors for HCV infection, but we believe that the use of injectable drugs favors virus transmission through the blood of the users.

Currently the number of IDU in Brazil is apparently decreasing due to the increased number of crack cocaine users (crack cocaine is smoked),¹1 Abdalla RR, Madruga CS, Ribeiro M, Pinsky I, Caetano R, Laranjeira R. Prevalence of cocaine use in Brazil: data from the II Brazilian National Alcohol and Drugs Survey (BNADS). Addict Behav. 2014;39(1):297-301. DOI:10.1016/j.addbeh.2013.10.019^,cc United Nations Office on Drugs and Crime – UNODC. World Drug report 2012. Vienna; 2012 [cited 2015 Feb 16]. Available from: https://www.unodc.org/documents/data-and-analysis/WDR2012/WDR_2012_web_small.pdf which appears to be associated with its low cost and pleasurable effects.^dd Ministério da Saúde. Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. O crack: como lidar com este grave problema. Brasília (DF); 2009. Actions to prevent drug use within the prison system should be implemented; however, the acceptability of drugs and their availability within prisons are obstacles to these interventions. Furthermore, prevention and health training programs may also be important, for example workshops on drugs for inmates, psychological care and production of informative materials for prisoners and their families. In summary, it is important to think about the implementation of public policies and policy consistency in public health because these inmates are often confined in extremely unhealthy conditions.

Also, tattooing and body piercing, both prior to or while incarcerated, may affect HCV prevalence. In addition, blood-to-blood contact as a result of violence between inmates should also be analyzed and considered as a possible risk factor in future studies.

Although some progress has been made over the last decades, studies to date are scarce and probably do not reflect the reality of Brazilian prisons. Voluntary testing to detect HCV could be provided, along with necessary information about the infection in the case of a positive test. Specific treatment for hepatitis C should be available with the persistent aim of obtaining a sustained virologic response. Further studies to better understand inmate risks are needed to control the spread of HCV infection in Brazilian prisons and to make ideal treatment and prevention decisions.

Finally, the prevalence of hepatitis C and STD in Brazilian prisons needs to be considered a consequence not only of the limited care provided to inmates but also of the increasing incarceration rates in Brazil.

REFERENCES

Publication Dates

History