Transmission of Hepatitis C Virus among Prisoners, Australia, 2005–2012 - Volume 21, Number 5—May 2015 - Emerging Infectious Disease journal - CDC

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Transmission of Hepatitis C Virus among Prisoners, Australia, 2005–2012 - Volume 21, Number 5—May 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 5—May 2015

Research

Transmission of Hepatitis C Virus among Prisoners, Australia, 2005–2012

On This Page

• Methods
• Results
• Discussion
• Suggested Citation

Figures

• Figure 1
• Figure 2
• Figure 3
• Figure 4
• Video 1
• Video 2
• Video 3

Tables

• Table 1
• Table 2

Technical Appendicies

• Technical Appendix

Downloads

• PDF[3.12 MB - 10 pgs]
• RIS[TXT - 2 KB]

Neil Arvin Bretaña, Lies Boelen, Rowena Bull, Suzy Teutsch, Peter A. White, Andrew R. Lloyd, Fabio Luciani , and on behalf of the HITS-p investigators

Author affiliations: The University of New South Wales, Sydney, New South Wales, Australia (N.A. Bretaña, L. Boelen, R. Bull, S. Teutsch, P.A. White, A.R. Lloyd, F. Luciani); Imperial College London, London, UK (L. Boelen)

Suggested citation for this article

Abstract

Hepatitis C virus (HCV) is predominantly transmitted between persons who inject drugs. For this population, global prevalence of HCV infection is high and incarceration is common and an independent risk factor for HCV acquisition. To explore HCV transmission dynamics in incarcerated populations, we integrated virus sequences with risk behavior and spatiotemporal data and analyzed transmission clusters among prisoners in Australia. We detected 3 clusters of recent HCV transmission consisting of 4 likely in-custody transmission events involving source/recipient pairs located in the same prison at the same time. Of these 4 events, 3 were associated with drug injecting and equipment sharing. Despite a large population of prisoners with chronic HCV, recent transmission events were identified in the prison setting. This ongoing HCV transmission among high-risk prisoners argues for expansion of prevention programs to reduce HCV transmission in prisons.

Hepatitis C virus (HCV) is a blood-borne virus that infects 3–4 million persons each year (1). In industrialized countries, transmission of HCV is largely attributed to injection drug use (2). The association between injection drug use, HCV infection, and imprisonment is very close (3). People who inject drugs (PWID) account for a large proportion of the incarcerated population in the United States, Canada, Europe, and Australia (4–7), and injection drug use is prevalent during incarceration (8,9). Globally, the prevalence of HCV infection among prisoners is ≈30% (10,11). A meta-analysis of 30 studies conducted in different countries revealed a clear association between the prevalence of HCV infection among prisoners and a history of injection drug use (6).

A recent meta-analysis of HCV incidence studies among prisoners revealed a mean incidence of 16.4 (95% CI 0.8–32.1) cases per 100 person-years (11). We recently documented incidence of 14.1 (95% CI 10.0–19.3) cases per 100 person-years in 37 prisons in New South Wales (NSW), Australia, and identified recent injection drug use and Aboriginal and Torre Strait Islander descent as independent risk factors for HCV seroconversion (12). This analysis also identified high prevalence of injection drug use and sharing of injecting equipment in prisons (12). Furthermore, 13 incident cases were identified in a subcohort of 114 prisoners continuously imprisoned (i.e., without release to the community) during the study period (incidence 10.3 cases/100 person-years).

Prisons can be regarded as an enclosed network of facilities within which prisoners are frequently moved. In NSW, prisoners are often transferred between prisons (e.g., because of changes in prisoner security classifications) and temporarily moved for brief periods (e.g., to go to court or obtain medical treatment). In addition, prison sentences in Australia are typically short (average 7–9 months), but reincarceration rates are high (13).

The HCV genome evolves rapidly by mutations caused by highly error-prone replication mechanisms, which generate a swarm of constantly evolving variants (quasispecies) during every infection (14). HCV is classified into 7 genotypes and 67 subtypes (15). At the nucleotide level, each virus subtype differs by up to 25% and genotypes differ by up to 33% (16). The hypervariable region (HVR) of the HCV genome is the most variable; hence, this region is commonly used in molecular epidemiologic studies to detect clusters of persons infected via recent transmission events (17). We used sequences covering envelope (E) 1 and partial E2 (HVR1).

Acute HCV infection is largely asymptomatic; hence, the precise timing and source of transmission are usually unknown. Accordingly, virus sequencing and phylogenetic analysis have been used to reconstruct probable transmission chains from prevalent cases (18–20). Although broad linkages between HCV-infected persons have been demonstrated, previous efforts to identify probable transmission pairs among infected persons by using a combination of social network information and phylogenetic analysis techniques suggested that social and genetic distances were only weakly associated (21). By contrast, a recent report from a study that used this same approach among both prevalent and incident (newly infected) case-patients, identified probable clusters evidenced by proximity of social network and clustering analysis of core HCV sequences in a community-based cohort of PWID (22).

Our study used an integrated analysis of molecular, epidemiologic, and spatiotemporal data from a well-characterized cohort of longitudinally followed PWID. We used incident case detection in prisons to identify clusters of recent HCV transmission.

Mr. Bretaña is a PhD candidate in the Inflammation and Infection Research Centre, School of Medical Sciences, The University of New South Wales, Sydney, Australia. His research interests are phylogenetics, epidemiology, and computational modeling of hepatitis C virus transmission.

Acknowledgments

The HITS-p investigators include Kate Dolan, Paul Haber, William Rawlinson, Carla Treloar, Greg Dore, Lisa Maher, and authors Andrew Lloyd and Fabio Luciani.

This work was supported by grants from National Health and Medical Research Council of Australia including NSW Health, Justice Health, and Corrective Services NSW as partners (grant nos. 222887 and 1016351); and by a National Health and Medical Research Council of Australia Practitioner Fellowship (grant no. 1043067 to A.L.)

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Figures

• Figure 1. Phylogenetic trees composed of 129 sequences from 79 participants infected with hepatitis C virus genotypes (gt) 1a, 1b, or 3a, New South Wales, Australia, 2005–2012. Names on the tips...
• Figure 2. Analysis of hepatitis C virus transmission clusters identified across a range of percentile thresholds among prisoners in New South Wales, Australia, 2005–2012. Analysis shows the relationship between the number...
• Figure 3. Analysis of pairwise patristic distances between hepatitis C virus sequences from the same participant (within-participant) sampled over time, and from between participants also sampled over time, among prisoners in...
• Figure 4. Reconstruction of the likely hepatitis C virus transmission dynamics among prisoners in New South Wales, Australia, 2005–2012.Geographic representation of the transmission dynamics among 3 participants identified in cluster...
• Video 1. Hepatitis C virus transmission dynamics among prisoners in cluster A, involving participants 315, 117, and 461, New South Wales, Australia, 2005–2012.
• Video 2. Hepatitis C virus transmission dynamics among prisoners in cluster B, involving participants 304 and 357, New South Wales, Australia, 2005–2012.
• Video 3. Hepatitis C virus transmission dynamics among prisoners in cluster C, involving participants 302 and 426, New South Wales, Australia, 2005–2012.

Tables

• Table 1. Demographic characteristics and lifetime risk behavior of prisoners in New South Wales, Australia, 2005–2012
• Table 2. Probable HCV transmission events identified by using phylogenetic analysis, spatiotemporal information, and risk behavior information, New South Wales, Australia, 2005–2012

Technical Appendix

• Technical Appendix. Supplementary methods and results for study of transmission of hepatitis C virus among prisoners, Australia, 2005–2012  231 KB

Suggested citation for this article: Bretaña NA, Boelen L, Bull R, Teutsch S, White PA, Lloyd AR, et al. Transmission of hepatitis C virus among prisoners, Australia, 2005–2012. Emerg Infect Dis. 2015 May [date cited]. http://dx.doi.org/10.3201/eid2105.141832

DOI: 10.3201/eid2105.141832

1Additional HITS-p investigators are listed at the end of this article.