Hospitals, physicians and payers should brace for the effects of yet another disease outbreak. Not a flu pandemic or the drug-resistant HIV but the familiar hepatitis C, a disease thought to have ameliorated significantly in recent decades. The source: U.S. prisons.
If we don't act now, a vast new burden will be placed on the nation's healthcare system as millions of new cases of hepatitis C, or HCV, occur in coming years.
Although great strides have been made in detecting, containing and treating HCV in our society since the 1970s, in our burgeoning prison population the rate of the disease is soaring. Prisons have become a primary breeding ground for HCV in the general public as infected inmates are released and spread the virus to loved ones, casual sex partners and/or previously uninfected drug users.
Patients, communities and providers are still dealing with the tragic human and economic consequences of the lack of a sustained, coordinated response by state and federal government in the early years of the HIV pandemic. We must not let this happen again, especially since those in the general population most at risk for HCV are minorities who lack access to insurance and preventive care.
The statistics already are grim: Nearly 400,000 inmates, or roughly 20% of the combined federal, state and local prison population, are thought to be infected with the virus, according to a recent study by the Centers for Disease Control and Prevention. HCV is a slowly progressive disease that is undetectable without formal testing. Left untreated, it can result in cirrhosis, liver cancer and death. The disease is commonly transmitted through contaminated blood or blood-product transfusions, intravenous drug use, shared razors, tattooing or body piercing with unclean needles and unprotected sex. An infant also can inherit the virus from an infected mother.
Once on the outside, each former prisoner who is a drug user can spread the disease to dozens of others through shared needles. And with nearly 90% of prisoners being released eventually, it can be seen how quickly this silent killer can be unleashed into the outside world.
The cost of standard medical treatment for HCV with a combination of interferon and ribavirin drugs often exceeds $20,000 per individual per year. But this excludes life-saving liver transplants for those who don't respond to other therapy. A transplant adds at least an additional $400,000 per person per lifetime. The total annual cost of treating the prison population isn't published, but the figure probably is in the hundreds of millions of dollars. And those costs will rise sharply in the coming decade, as more and more people are incarcerated and released. Multiply that several times for the general population.
Such massive expenses not only place enormous pressure on an already overburdened healthcare system but also raise the ethical issue of who should receive the few available donor livers. About 5,000 transplants are performed in the U.S. per year; far more transplant candidates die before a suitable donor is found, according to the United Network for Organ Sharing. Under current transplantation policies, the scenario of, say, a convicted multiple murderer or child molester with HCV receiving preference for a new liver ahead of a law-abiding citizen may be closer to reality than we think. System reform may be necessary.
How can we get ahead of this epidemic? Prison authorities should screen each prisoner for the presence of HCV. Colorado, Indiana and a few other states already do. Infected inmates who are most likely to spread the virus to other prisoners through drug use, sexual contact or antisocial behavior should be separated from noninfected inmates to halt the spread of disease. Anyone found to be infected should get counseling, education, and early and aggressive medical intervention. With a cure rate now greater than 50%, this makes medical and financial sense, avoiding the need for more expensive treatment down the line. Cured prisoners no longer pose a threat of transmission either in prison or after re-entering society.
Healthcare organizations should cooperate with the prison system on continuing clinical HCV research. With infected inmates composing about 10% of all Americans infected with HCV, the prison system offers an ideal resource for studying treatment options. At present, most trials performed in civilian medical centers pose logistical difficulties in recruiting patients and tracking them. By volunteering, prisoners could not only benefit from the most advanced forms of treatment monitored by scientific researchers, but they would have an opportunity to repay their debt to society. The taxpayers would win, too. Rather than further straining government budgets, volunteers' treatment costs would be covered largely by drugmakers as a research expense.
Finally, the federal government must increase the National Institutes of Health research budget for HCV just as it did for HIV two decades ago. Our national research goals should include a quest for more potent and effective HCV chemotherapies as well as the development of an effective HCV vaccine. The Food and Drug Administration must put all current and future HCV trials on a fast track.
Time is running out. The gathering HCV epidemic in our prison system threatens to spill over into the general population. U.S. providers and doctors-and our communities-can't afford not to muster the political will and financial resources to check the spread of this deadly threat.
Albert Knapp is an associate professor of gastroenterology and hepatology at New York Univesity School of Medicine.