Faculty Bibliography

The United States incarcerates more people than any other country in the world. The scale of mass incarceration ensures that almost all practicing physicians will treat formerly incarcerated patients. Yet the majority of physicians receive little training on this topic. In this paper, we will outline the need for expanded education on the interface between incarceration and health, describe initiatives taking place within the New York City jail system and nationally, and describe future directions for curriculum development. We conclude by highlighting the important role health care workers can play in transforming our criminal justice system and ending mass incarceration.

OBJECTIVE:The objective of this study was to understand predictors of hepatitis C virus (HCV) antibody positivity in a large urban jail system in New York City. METHODS:We examined demographic characteristics, risk behaviors, and HCV antibody prevalence among 10 790 jail inmates aged 16 to 86 who were screened from June 13, 2013, to June 13, 2014, based on birth cohort or conventional high-risk criteria. We used logistic regression analysis to determine predictors of HCV antibody positivity. RESULTS:Of the 10 790 inmates screened, 2221 (20.6%) were HCV antibody positive. In the multivariate analysis, HCV antibody positivity was associated most strongly with injection drug use (IDU; adjusted odds ratio [aOR] = 35.0; 95% confidence interval [CI], 28.5-43.0). Women were more likely than men to be infected with HCV (aOR = 1.3; 95% CI, 1.1-1.5). Compared with non-Hispanic black people, Hispanic (aOR = 2.1; 95% CI, 1.8-2.4) and non-Hispanic white (aOR = 1.7; 95% CI, 1.5-2.1) people were more likely to be infected with HCV. Non-IDU, recidivism, HIV infection, homelessness, mental illness, and lower education level were all significantly associated with HCV infection. The prevalence rate of HCV infection among a subset of inmates born after 1965 who denied IDU and were not infected with HIV was 5.6% (198 of 3529). Predictors of HCV infection among this group included non-IDU as well as being non-Hispanic white, Hispanic, recidivist, and homeless. CONCLUSION:These data reveal differences in HCV infection by sex, race/ethnicity, and socioeconomics in a large jail population, suggesting that a focused public health intervention is required and that universal screening may be warranted. Further sensitivity and cost-benefit analyses are needed to make this determination.

The period immediately after release from prison or jail carries increased mortality risk. This study sought to better understand postrelease death by matching electronic health records from those incarcerated in New York City jails between 2011 and 2012 with vital statistics records. The in-jail and 6-week postrelease mortality rates were estimated to be 1.39 and 5.89 per 1,000 person-years, respectively. Of 59 deaths occurring within 6 weeks of release from jail, the causes included opioid overdose (37.3%), other drugs (8.5%), chronic disease (25.4%), assaultive trauma (20.3%), and other trauma (8.5%). These data confirm that overdose death accounts for the most frequent cause of postrelease death. Matching between correctional health systems and vital statistics can inform quality improvement efforts in jail health care delivery.

A cohort of frequently incarcerated individuals in the New York City jail system was identified through "hot spotting" analysis. This group demonstrated higher levels of substance use, mental illness, and homelessness than the general jail population, and was typically incarcerated on minor criminal charges. To understand this population better, in-depth interviews (n = 20) were conducted at three Rikers Island correctional facilities with people who had entered the jail system at least 18 times in a six-year period. Findings showed that life circumstances, chronic homelessness, mental illness, and substance use resulted in repeated institutionalization across multiple settings. Participants described an "institutional circuit" that promoted a state of permanent instability characterized by rotating involvement with custodial institutions. Exiting the institutional circuit requires the ability to navigate complex bureaucratic systems; however, without structural reorganization in social service delivery and an emphasis on permanent housing, participants in this group are unlikely to break the cycle.

Because there is no standard reporting of injuries in jails and prisons, the national burden of head trauma during incarceration is unclear. We report on a case of repeated head trauma in the New York City (NYC) jail system, data on the incidence of head trauma and mild traumatic brain injury (mTBI), and compare those findings with national estimates. The case report revealed 64 injurious events over two years, 44% resulting in a head injury and 25% resulting in emergency hospitalization. During the 42 months of this analysis, 10,286 incidents of head trauma occurred in the NYC jail system. Mild TBI occurred in 1,507 of these instances. The rate of head trauma and mTBI was 269.0 and 39.4 per 1,000 person-years, respectively. The lack of reporting head trauma in correctional settings means that national prevalence estimates of these critical health outcomes miss the vulnerable cohort of incarcerated individuals.

Jails represent a critical component of the public health response to HCV elimination. We report on outcomes of 104 patients receiving HCV treatment from January 1, 2014 to June 30, 2016 in a large urban jail setting. Our data demonstrate that treatment in jails is feasible, but many barriers remain.

This article reviewed a program evaluation conducted among correctional health care staff in New York City (NYC) using a 68-question electronic survey to assess satisfaction, attitudes, and beliefs in relation to ethics and burnout of health care employees in NYC jails. Descriptive statistics were tabulated and reviewed, and further assessment of burnout and ethics was performed through group sessions with participants. This evaluation has led to changes in agency policies and procedures and an emphasis on the human rights issue of the dual loyalty challenges that the security setting places on the overall mission to care for patients.

Background. High volumes of hepatitis C (HCV)-infected detainees pass through US jails. However, short lengths of stay and competing priorities upon release complicate linkage to HCV care. We investigated linkage rates for patients with HCV following release from New York City (NYC) jails and describe a care coordination program (CCP) we initiated in June 2015 to improve linkage rates. Methods. We conducted a pre- and post-intervention study to assess rates of linkage related to the CCP. We used NYC Department of Health surveillance data to assess pre-intervention linkage rates for patients with chronic HCV seen in a correctional health clinic at Bellevue Hospital Center from January 2014 to June 2015. Linkage was defined as an HCV viral load or genotype <90 days in the community after release from an index incarceration. The CCP consists of a needs assessment, HCV education, and appointment scheduling for detainees, followed by reminder calls and appointment escort by a community patient navigator after re-entry. Statistical significance was determined using x2 tests. Results. Of 52 patients in the pre-intervention group, 24 (46.2%) were released from their index jail stay. Of those released, 10 of 24 (42%) were reincarcerated within a median of 247 days (IQR 129-318). The remaining 28 individuals were not released from their index incarceration and transferred to state prison. Of the 26 enrolled in the CCP as of April 2016, 13 (50%) have been released (6 linked, 4 pending linkage, and 3 not linked), 9 (34.6%) have not yet been released, and 4 (15.4%) have been transferred to state prison. Criteria for linkage to care within <90 days in the pre-intervention and intervention groups, respectively, were met by 3 of 24 (12.5%) versus 5 of 9 thus far (55.6%) (p = 0.01) and overall by 11 of 24 (45.8%) versus 6 of 9 thus far (66.7%) (p = 0.29). Conclusion. Pre-intervention linkage rates were low among HCV-infected detainees. While this study is ongoing, linkage in <90 days was significantly higher in the intervention group though not overall. These data provide early evidence that an integrated community-based CCP with jail-based transitional care coordinators may be effective in improving timely linkage to HCV care following release from jail

OBJECTIVES: To examine uptake of screening for all individuals born between 1945 and 1965 (referred to by the Centers for Disease Control and Prevention as the "birth cohort") and outline preliminary HCV prevalence data in the New York City jail system. METHODS: Data were extracted from electronic health records for all individuals screened for HCV between June 13, 2013, and June 13, 2014, in New York City jails. We used the Abbott EIA 2.0 HCV antibody assay for testing. RESULTS: In the year of study, 56 590 individuals were incarcerated; 15.1% were born between 1945 and 1965, and 84.6% were born after 1965. HCV screening was completed for 64.1% of the birth cohort and for 11.1% born after 1965, with 55.1% and 43.8% of cases found in these groups, respectively. The overall seropositivity rate was 20.6%. CONCLUSIONS: Birth cohort screening in a large jail system identified many HCV cases, but HCV infection was common among younger age groups. Public Health Implications. Universal screening may be warranted pending further study including cost-effectiveness analyses. (Am J Public Health. Published online ahead of print May 19, 2016: e1-e2. doi:10.2105/AJPH.2016.303163).