Hepatitis C in Brazilian Carcerary Micropopulation

As viral hepatitis is caused by too many etiological agents of universal distribution, having knowledge of scientific production on the prevalence of hepatitis C and its associated risks in prisons is of paramount importance...


Introduction
Viral hepatitis is a disease caused by several etiological agents of universal distribution, which have the hepatotropism in common. They have many similarities from clinical and laboratorial point of view, but they present important epidemiological differences as well as their evolution in each one. Among the most significant progresses in viral hepatitis are the identification of the agents, the development of specific laboratory tests, the screening of infected individuals, and the emergence of protective vaccines [1]. They are considered a worldwide leading cause of liver diseases such as cirrhosis and hepatocellular carcinoma. Clinical follow-up lower than that required for conclusive diagnosis of infection may reflect disease progression, with hepatomegaly as the initial stage of progression of liver disease, evaluating to more severe degrees such as liver cirrhosis, esophageal varices, hepatocellular carcinoma and hepatic encephalopathy [2].

Hepatitis C virus (HCV) belongs to the family Flaviridae, genus
Hepacivirus, and its genome consists of a single strand of RNA of positive polarity. There is a great variety in the genomic sequence of the virus and its different genotypes were grouped into six main groups and several subtypes [1]. Currently, it is estimated that approximately 2.2 to 3.0% of the world's population (130-170 million people) are infected with HCV [3]. The most frequent complaints of chronic hepatitis C are fatigue and sleep disorders. Other symptoms include nausea, diarrhea, abdominal pain, anorexia, myalgia, arthralgia, weakness and weight loss; neuropsychiatric symptoms (e.g., depression and anxiety) are also common, although these symptoms of chronic HCV infection are not specific in most times. Abdominal pain, pruritus and dark urine are among the most common complaints of patients infected with HCV. The symptoms may lead to a decrease in quality of life, which can be partly explained by the awareness of the infection, and which can be improved after successful treatment. HCV infection has also been associated with cognitive impairment due to mechanisms not well understood. Extra-hepatic manifestations can also be verified, such as hematological, renal, autoimmune disorders, dermatological conditions and Diabetes Mellitus [5].
HCV antibody screenings include high sensitivity screening tests such as ELISA (using recombinant protein or synthetic peptides for anti-HCV uptake) and additional high specificity tests such as immunoblot (RIBA). The gold standard for the diagnosis of HCV infection is the qualitative determination of HCV-RNA through the polymerase chain reaction (PCR). Two techniques of molecular biology were also developed for HCV quantification: one of them uses PCR technology and the other is branched DNA. The most accurate method for determining the HCV genotype is the complete identification of the 9,500 nucleotides sequence and the construction of a phylogenetic tree, but this method can only be used in research laboratories, not in clinical ones Brandão et al. [6]. Thus, HCV routes of transmission are directly associated with the penitentiary environment, increasing the risk of some infections related to unprotected sexual practices and/or injecting drug use with shared utensils Brum et al. [7].
The occurrence of HCV/HIV coinfection has been reported because both share the same mechanisms of transmission, being frequent among illicit drug users and among hemophiliacs, in which occurs between 50% and 75% of the cases. The presence of HIV infection seems to accelerate the evolution of chronic HCV infection to cirrhosis and to hepatic decompensation and/or hepatocellular carcinoma, especially among the most immunodepressed people [1]. Brazil has the fourth largest penitentiary population in the world, leaving behind the United States (2,217,000), China (1,657,812) and Russia (644,237). Until December of 2014 in Brazil, the prison population was 622,202 individuals, from which 55% belonging to the age group between 18 and 29 years. Being a sexually active age group, HIV, HBV, HCV and Treponema pallidum infections compromise the public health of these individuals.
The probability of infection is higher in institutionalized settings, such as in penitentiaries, due to overpopulation and precarious situations of confinement (structural problems and problems with hygiene, food and health care). As related, the prevalence of HIV in prisoners varies from 1.19% to 25.0%. In relation to syphilis, this number ranges from 7.4% to 18%, HBV from 6.6% to 17.5% and HCV from 6.3% to 34%. In this way, the penal system can act as a concentrator and disseminator of these infections, being possible the transmission to the outside population in general Silva et al. [8].
Prisons generally do not have room to isolate people with contagious diseases and overcrowding is a risk factor for them.
Infection control at correctional establishments may be harmed by limited access to showers, clean clothing supplies, and bans on bleach and condoms. People in jails and prisons are expected to wash their own clothes by hand instead of using institutional laundry services, and that may be insufficient to disinfect clothes. In addition, kitchen workers and barbers in correctional establishments may have inadequate training in infection control [9]. Through a literary review on the prevalence of hepatitis C in prison populations in Brazil, the present study aimed to ratify the high rate of HCV infection present in these individuals deprived of their liberty, which may put at risk other cohabiting prisoners, as well as their close contacts from the outside environment during routine visits. and 2017 (using the keywords "hepatitis C", "prison" and "anti-HCV"). Ten (predominantly cross-sectional) studies were selected and, based on the results found, a discussion about the subject was made, addressing its real situation of hepatitis C in Brazil, especially in the carcerary micropopulation.

Results
According to this review of literature different prevalence of anti-HCV seropositivity in the prison population were showed.
Values ranged from 0% to almost 20% as shown (Table 1). In a study performed by Silva et al. [8], when a descriptive cross-sectional study was carried out with 847 re-students at the Juiz Plácido de Souza prison in the city of Caruaru, state of Pernambuco, the anti-HCV seropositivity was 0.24% (2/847), and values found in relation to other Sexually Transmitted Infections (STI) as HIV, hepatitis B (HBsAg), and syphilis (anti-Treponema pallidum) showed rates of 1.18% (10/847), 0.35% (3/847), and 8.31% (68/806), respectively [10]. in a descriptive cross-sectional study, conducted in the city of Porto Velho, capital of the state of Rondônia, found 0% and 1.5% of anti-HCV seropositivity in two institutions named ACUDA (Associação Cultural e de Desenvolvimento do Apenado) and in CRVG (Centro de Ressocialização Vale do Guaporé), respectively.
Still with such low rates, a study carried out in the twelve prisons of the state of Piauí, where 2131 inmates participated in the study, [11] described that anti-HCV was positive in 0.3% in people whom participated the research. Among all study participants, the prevalence of anti-HCV positivity was 0.4% (9 / 2.330). In the prison population, the anti-HCV positivity was 1.0% (7/730). In the non-prison population, the prevalence of anti-HCV positivity was 0.1% (2 / 1.600). [ 15]. Although presenting a low prevalence for HCV, Silva et al. [8] verified that in the prison population studied 53.3% were under 30 years old, 4.46% had already received blood transfusion or blood products, 64.3% reported endue tattoo, 6.25% have already used injectable drugs, 37.49% used intranasal drugs, and 41.96%

Hepatitis C virus infection in prisoners in
were not in the habit of using condoms in sexual intercourse (112 inmates were characterized for these profiles of the inmates, and 44% (11) reported having shared needles with another person. All detainees had had sexual intercourse at least once in their lives. When outside prision women informed having sex with men in 82% (228) of the time; with women 5% (13); with women, but occasionally with men 4% (12); and with men and women alike 3% (6). Regarding sexual intercourse within the prison they informed sex with men 11% (28) of the time; with women 24% (59); with women, but occasionally with men or with men and women also just an affirmative answer for each mode. The are also characterized as risk groups for infections transmitted primarily by the parenteral and sexual pathways [17].
According to the study by Negreiros and Vieira [10], HCV is more viable in the environment when compared to HIV. This way, HCV infection through the parenteral route is more effective, being ten times more infectious than HIV in exposure to sharps. than five sexual partners in the last five years. In the Pumpilo study [13], from 686 individuals tested for HCV 4.8% (33/686) presented anti-HCV seropositivity. In an analysis by sex, the prevalence in women (0.8%) was also lower than in men (7%). In general, of those 33 who presented seroprevalence of HCV infection, nine reported having never used a condom, 11 had HIV/AIDS, 18 reported injecting drugs, 12 received blood transfusion, 25 had tattoos, and two had piercings. Similar data on the presence of tattooing in patients who had positive anti-HCV were found in the study by Rosa et al. [15] in which the prevalence of anti-HCV antibodies was 9.7%.
As it can be seen, people inside prisons have many risk factors for HCV infection, as well as other STIs, as they live in poor hygiene conditions and overcrowding, sharing their personal tools, using illicit drugs, and having unprotected sex even with their casual partners or with their close contacts in intimate visits. In this way, the prison micropopulation becomes a group of individuals capable of perpetuating the HCV infection for many years ahead, regardless of the effective treatment used if preventive measures are not taken.

Conclusion
In conclusion, there is an urgent need for public health agencies to plan measures that will diagnose and treat individuals infected with HCV in prison populations, as well as educate about preventive measures and alert about the real forms of infection, trying to reduce the alarming rates of infected people in such environments and the spread to the general population. Not least, it must be remembered that there is a high risk of coinfection, and the same measures should be taken against other STIs.