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Spaulding AC, Chen J, Mackey CA, et al. Assessment and Comparison of Hepatitis C Viremia in the Prison Systems of New Mexico and Georgia. JAMA Netw Open. Published online September 06, 20192(9):e1910900. doi:10.1001/jamanetworkopen.2019.10900
Recently published estimates by Rosenberg et al1 of hepatitis C virus (HCV)–infected persons by state, using National Health and Nutrition Examination Survey (NHANES) data for community-dwelling persons, included an estimate of the prevalence of viremia of 10.7% among all criminal justice (CJ) populations.1,2 Although those estimates included a sensitivity analysis varying the non-NHANES prevalence rates (mostly among the CJ population, and to a lesser extent homeless individuals) to mirror statewide epidemics,1 we are concerned that failure to consider other data sources3,4 may have led to an artificial flattening of the peaks and valleys of statewide HCV estimates.
National surveys of HCV antibody prevalence (seroprevalence) in state prison systems consistently show heterogeneity, varying 5- or 6-fold by state, with New Mexico having the highest seroprevalence of HCV.4 Injection drug use, the most common risk factor for HCV, is relatively frequent there. The New Mexico Corrections Department (NMCD) has conducted universal HCV antibody screening at intake since 2009 and reflex HCV RNA testing since 2017. Georgia has less injection drug use, a higher incarceration rate, and a higher degree of disproportional minority confinement.5 This cross-sectional study assesses and compares the prevalence of HCV among CJ populations in NMCD and the Georgia Department of Corrections (GDC).
We conducted a cross-sectional study of antibody and viremia prevalence from NMCD entry testing and GDC exit testing. We followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. The Emory University institutional review board determined that each state’s surveillance constitutes public health practice rather than human subjects research. Nonetheless, GDC required specific, written informed consent for HCV testing. No such requirement exists in NMDC.
We evaluated age, HCV seroprevalence, and viremia of persons entering NMCD in 2018, compared with those tested on release from 6 GDC facilities from October 2016 through May 2018. The New Mexico Corrections Department sent specimens to BioReference Laboratories; GDC sent specimens to Quest Diagnostic Laboratories. Antibody testing was performed using Centaur (Siemens Healthineers) for specimens from NMCD and test kits from Ortho Clinical Diagnostics for specimens from GDC. Both states used COBAS AmpliPrep/COBAS TaqMan HCV Test version 2.0 (Roche) for reflex testing of seropositive specimens; the lower limit of detection of HCV is 15 IU/mL.
Logistic regression was performed to calculate odds ratios (ORs) and 95% CIs for viremia by birth cohort from 1965 and earlier vs subsequent birth cohorts for men in NMCD and for men and women in GDC. We used 2-tailed χ2 tests (α = .05) to assess statistical significance of age as a categorical variable. Analyses were performed using SAS version 9.4 statistical software (SAS Institute, Inc).
Table 1 shows HCV testing results for antibodies and viremia by birth cohort. The HCV viremia prevalence among male and female entrants in NMCD was 40.8% (95% CI, 39.3%-42.5%). In this predominantly male (89.4%) prison system, HCV prevalence among men was 42.6% (95% CI, 40.9%-44.3%). The HCV viremia prevalence among tested persons exiting GDC was 6.1% (95% CI, 4.2%-8.6%). For men in NMCD, the OR for viremia by birth cohort from 1965 and earlier vs all others was 0.50 (95% CI, 0.36-0.69; P < .001). For GDC, this OR was 3.00 (95% CI, 1.20-6.87; P = .01).
Rosenberg et al1 estimated 26 700 cases of HCV statewide for New Mexico. However, when we substituted observed NMCD values for overlapping non-NHANES populations, the statewide prevalence in New Mexico increased to 33 521 cases (Table 2). When we substituted the observed HCV prevalence from GDC, the number of cases decreased to 26 274. The absolute difference using NMCD vs GDC data was 7247 cases. The same exercise for Georgia showed that the estimate by Rosenberg et al1 of 56 800 cases of HCV decreased to 54 425 using the observed prevalence from GDC and increased to 100 092 cases using the observed prevalence from NMCD, with an absolute difference of 45 667 cases.
We found that substituting natural variations in the prevalence of HCV among CJ populations into the non-NHANES portion of the model by Rosenberg et al1 changed the overall statewide estimates of HCV cases substantially. While the increase in Georgia (by 45 667 cases) would not have doubled the number Rosenberg et al1 estimated statewide (56 800), the change was greater than the 0.4% found in their previous sensitivity analysis.1 Estimates of statewide prevalence of HCV may improve with accounting for the state’s imprisonment rate and HCV viremia prevalence in the CJ population. Our updates on state seroprevalence diversity are available online.6
Limitations in our analysis included considering only 2 states at opposite ends of the HCV prevalence spectrum within CJ populations, at a single time point. While NMCD had the highest seroprevalence in the last survey, it was not an outlier: the prevalence of HCV in the Ohio prison population was 91% that of NMCD.4 The Georgia Department of Corrections tied for seventh lowest HCV prevalence.
A revised model using state-specific, observed values of viremia in prisons may help improve the accuracy of future estimates of how many persons in all sectors statewide have HCV infection.
Accepted for Publication: July 22, 2019.
Published: September 6, 2019. doi:10.1001/jamanetworkopen.2019.10900
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Spaulding AC et al. JAMA Network Open.
Corresponding Author: Anne C. Spaulding, MD, MPH, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322 (email@example.com).
Author Contributions: Dr Spaulding and Mr Selvage had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Spaulding, Chen, Bowden, Thornton.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Spaulding, Chen, Adee, Thornton.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Spaulding, Chen.
Obtained funding: Spaulding, Mackey, Adee, Bowden.
Administrative, technical, or material support: Spaulding, Bowden, Selvage, Thornton.
Supervision: Spaulding, Bowden, Selvage.
Conflict of Interest Disclosures: Dr Spaulding reported receiving grants from Gilead Sciences during the conduct of the study; receiving personal fees from Gilead Sciences, Merck, and AbbVie outside the submitted work; and having worked recently as an infectious disease physician in a jail through NaphCare and Correct Care Solutions (Wellpath). In the past, she has worked for Medical College of Georgia as a consulting physician within the Georgia Department of Corrections. Mr Selvage reported employment by the New Mexico Corrections Department, which operates New Mexico’s prison system for state inmates. No other disclosures were reported.
Funding/Support: This work was supported by National Science Foundation award 1722906 and a Gilead Sciences/FOCUS Program grant to Emory University.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Laura Dirks, BS (Rollins School of Public Health, Emory University), provided fact checking of the manuscript before submission.
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