key: cord-0024665-wd52ksqn
authors: Wurcel, Alysse G; Guardado, Rubeen; Beckwith, Curt G
title: Hepatitis C Virus Is Associated With Increased Mortality Among Incarcerated Hospitalized Persons in Massachusetts
date: 2021-12-18
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofab579
sha: 2adc457f3c7dea27171dce0a6cfc086db5b39752
doc_id: 24665
cord_uid: wd52ksqn

Hepatitis C virus (HCV) is curable, but incarcerated populations face barriers to treatment. In a cohort of incarcerated hospitalized patients in Boston, Massachusetts, HCV infection was associated with increased mortality. Access to HCV treatment in carceral settings is crucial to avoid unnecessary death and to support HCV elimination efforts.

Incarcerated populations face barriers in accessing hepatitis C virus (HCV) treatment. The profound impact of curative HCV treatment in 2013 is clear, with decreased incidence of cirrhosis and hepatocellular carcinoma [1, 2] . Access to HCV treatments in carceral settings is limited [3, 4] . The prevalence of HCV is 2% in the US general population compared with estimates as high as 70% in incarcerated populations who report injection drug use [5] [6] [7] . Racial and ethnic minoritized populations, including Black and Latinx people, comprise the majority (>60%) of HCV cases in US jails and prisons [8] . The literature on HCV-related mortality among carceral populations is predominantly from inmates in Texas recruited from 1994 to 2003 and shows high rates of HCV-related mortality, especially in Black and Hispanic people [9] [10] [11] [12] [13] . The goal of this study was to examine the impact of HCV on 2-year posthospitalization mortality among incarcerated persons hospitalized at Lemuel Shattuck Hospital (LSH), a public health hospital outside of Boston, Massachusetts, that is the preferred inpatient facility for incarcerated persons in jails or prisons in Massachusetts.

We analyzed all incarcerated persons who were hospitalized at LSH from 2011 to 2016. Incarceration status was confirmed through specific insurance codes linked to the admission. We collected demographic data, length of stay, and International Classification of Diseases, 9th Revision and 10th Revision (ICD-9 and 10), codes associated with the admission. Race and ethnicity were drawn from the electronic medical record and guided by previously published research methods [14] ; missing ethnicity data were supplemented by review of notes in medical records and patient names. We excluded persons who had admissions >60 days given as likely representing rehabilitative admissions rather than acute care hospitalizations. We excluded persons with incomplete race or ethnicity data. We linked the hospital data to the Massachusetts Department of Public Health Registry of Vital Records and Statistics through December 31, 2018. The outcome of interest was death within 2 years of hospitalization.

Our study did not include identifiable data that required individual informed consent, as we used secondary data collection methods. The Massachusetts Department of Public Health Institutional Review Board approved this study.

We performed univariate and multivariable analyses using a Cox proportional hazard model. Time at risk was defined as the period between the participant's first admission during 2011-2016 at LSH and death, or the end of 2-year follow-up period (12/31/2018). Covariates found to be statistically significant (P < .05) in the univariate analysis were included in the multivariable model. The primary exposure of interest was HCV, indicated by the presence of HCV ICD-9/ICD-10 codes. Covariates included were age at admission, race (White, Black, or other), ethnicity (Hispanic or non-Hispanic), gender (male or female), Elixhauser Comorbidity [15, 16] 

Of 2238 incarcerated individuals who were hospitalized between 2011 and 2016, 372 died. Excluding people with hospitalizations >60 days (n = 30) and incomplete race/ethnicity data (n = 155), the final cohort included 2053 people. The average age was 46; the cohort was 91% male, 62% White, and 16% Hispanic; 9.5% (n = 178) died within 2 years of hospitalization (Table 1 ). In the univariate analysis, HCV, age, race, ethnicity, Elixhauser Comorbidity Index score, and increased hospitalizations were significantly associated (P < .05) with 2-year mortality and were included in our multivariable analysis. In the multivariable analysis, HCV (hazard ratio [HR], 1.61; 95% CI, 1.17-2.12), older age (HR, 1.57; 95% CI, 1.39-1.77), and increased Elixhauser Comorbidity Index score (HR, 1.10; 95% CI, 1.08-1.12) were associated with death. Black people had a decreased risk of mortality when compared with White people (HR, 0.60; 95% CI. 0.41-0.89) ( Table 1 ).

With highly effective all-oral treatment approved in 2013 for the treatment of HCV, no one should be dying of HCV-related causes. Expanding testing and treatment in incarcerated populations must be a priority for medical care in carceral settings to save lives and to bring the world closer to HCV elimination [17] . In this cohort of incarcerated persons hospitalized at LSH between 2011 and 2016, 15% of people with HCV died within 2 years after hospitalization. HCV was associated with a 61% increased risk of 2-year mortality even after controlling for severity of disease. Although there is no literature available for a direct comparison of HCV-related mortality, data collected through the Chronic Hepatitis Cohort Study (CHeCS) reported that in a cohort of people with HCV (mean age, 51 years), 9% died during the follow-up period of 5 years [18] . Our similarly aged population had a higher mortality over a shorter period of time. Also from the CHECS study, about 15% of people with HCV who did not receive HCV treatment died in the 4 years from 2014 to 2017 [19] . The population of people with HCV who were incarcerated and hospitalized had a similar mortality as people who did not receive HCV treatment.

Treatment of HCV decreases mortality in people with and without cirrhosis [20] , but there are barriers preventing HCV treatment in jails and prisons. One barrier is the cost of HCV medications, which can range from $26 000 to $32 000 per treatment course [21] . Previous work by our group found that Table 1 incarcerated people with HCV who were hospitalized were more likely to be readmitted, increasing health care costs [22] . Other barriers to HCV treatment include stigma against people with HCV and concerns about the ability to treat HCV when persons may be incarcerated for brief periods of time before returning to the community [23] . Although prisons have rolled out more comprehensive HCV treatment programs, coordination of HCV treatment in jails is problematic as detained people often have short or uncertain periods of detainment. There is increasing evidence that people who are in jail can be successfully treated with HCV medications, even when they are discharged mid-treatment course [24] . Black race was associated with decreased risk of death in both the univariate and multivariate analyses-a difference, but not in the direction we hypothesized. Racial disparities exist both with disproportionately elevated incarceration rates in Blacks and Hispanics [25] and decreased access to HCV care for Blacks and Hispanics in the community [26] . The synergy of decreased access to HCV care inside and outside of prison has precipitated high rates of HCV-related mortality in incarcerated persons, especially for Blacks, Latinx people, and other minoritized populations [13] . The explanation for our finding that Black race was associated with decreased risk of death is unclear. Postrelease mortality rates are high across races for multiple reasons, such as untreated opioid use disorder and other chronic health care conditions including hypertension and diabetes [27] . Black people have longer incarceration periods [28] , so one possible explanation for our finding is that Black people were incarcerated for longer periods of time, leading to decreased risk of death from overdose or untreated chronic illness in the community following release. Arguing against the concept of incarceration as decreasing risk of death, there are data that the stress associated with being incarcerated leads to premature aging [29] .

There were several limitations to this study. We were unable to determine from ICD-9/-10 codes whether people had active, treated, or cleared HCV infection, and further research is necessary to assess whether the presence or absence of treated HCV is directly linked to changes in mortality. We do not know if people were incarcerated when they died or their length of incarceration before death. Additionally, our cohort was limited to persons who were hospitalized at LSH, so the cohort may miss (1) people who died at the jail/prison, (2) people hospitalized at a tertiary care hospital who were released back to prison/ jail, and (3) people who were hospitalized at tertiary care hospitals who died, if any of these 3 groups were never hospitalized at the Lemuel Shattuck Hospital. Any racial differences in these 3 groups may have led to differential capturing of people in the original cohort. There is evidence from the community literature, especially with COVID-19, that Black people present to health care with more advanced illness [30] . Outside of national efforts tracking COVID-19 cases and deaths in jails and prisons [31] , there is no current system in the United States to track hospitalizations or deaths for people who are incarcerated. There are limited data on how many deaths occur per year among people in prisons and jails for comparison. The state of Massachusetts does not track jail deaths; however, the Bureau of Justice Statistics reported 306 deaths in federal and state prisons in Massachusetts between 2011 and 2018 [32] . We believe that our methods, albeit with limitations, are an approximation of the total number of people who were hospitalized while incarcerated and died within 2 years.

Despite these limitations, we accessed a unique database to investigate HCV-related mortality in a population of hospitalized and incarcerated persons, revealing that HCV was associated with death within 2 years of hospitalization. Further research and advocacy are needed to decrease barriers to HCV testing and treatment in carceral settings and move toward HCV elimination.

Reversion of disease manifestations after HCV eradication

Risk of hepatocellular cancer in HCV patients treated with direct-acting antiviral agents

Treatment of hepatitis C: a systematic review

New hepatitis C drugs are very costly and unavailable to many state prisoners

limitations of 1945-1965 birth cohort screening in correctional settings

Hepatitis C seroprevalence among prison inmates since 2001: still high but declining

Viral hepatitis in incarcerated adults: a medical and public health concern

A systematic review and meta-analysis of racial and ethnic disparities in hepatitis C antibody prevalence in United States correctional populations

End-stage liver disease in a state prison population

Psychiatric disorders, HIV infection and HIV/hepatitis co-infection in the correctional setting

Hepatocellular carcinoma prevalence and mortality in a male state prison population

Chronic liver disease mortality among male prison inmates in Texas

HCV-related mortality among male prison inmates in Texas

Using a Spanish surname match to improve identification of Hispanic women in Medicare administrative data

Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data

A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data

Prevention of hepatitis C by screening and treatment in U.S. prisons

All-cause mortality and progression risks to hepatic decompensation and hepatocellular carcinoma in patients infected with hepatitis C virus

Chronic Hepatitis Cohort Study (CHeCS) Investigators. Low uptake of direct-acting antiviral therapy among hepatitis C patients with advanced liver disease and access to care

Association of direct-acting antiviral treatment with mortality among Medicare beneficiaries with hepatitis C

The burden of untreated HCV infection in hospitalized inmates: a hospital utilization and cost analysis

I'm not gonna be able to do anything about it, then what's the point?": a broad group of stakeholders identify barriers and facilitators to HCV testing in a Massachusetts jail

Outcomes of hepatitis C virus treatment in the New York City jail population: successes and challenges facing scale up of care

Addressing racial disparities in incarceration

Racial disparities in health conditions among prisoners compared with the general population

Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from

Demographic Differences in Sentencing: An Update to the 2012 Booker Report. United States Sentencing Commission

Incarceration as exposure: the prison, infectious disease, and other stress-related illnesses

CDC COVID-19 Response Clinical Team. Characteristics associated with hospitalization among patients with COVID-19 -metropolitan

Mortality in State and Federal Prisons

Financial support. A.G.W.: 1KL2TR002545-01; K08HS026008-01A; C.G.B.: Providence/Boston Center for AIDS Research (P30AI42853); COBRE on Opioids and Overdose (P20GM125507).Potential conflicts of interest. All authors: no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.