Data: definition of core indicators to monitor elimination efforts in prisons
In order to have an effective system able to monitor progress in the elimination of hepatitis in prison, prisons should have a functioning health information system, including a surveillance system for infectious diseases to generate routine baseline data.
Following a discussion between ECDC, EUDA and WHO for the purpose of this toolkit, a set of core indicators to monitor progress towards hepatitis elimination in prisons. These indicators cover burden and transmission as well as the key areas along the continuum of care: prevention; testing and treatment, as well as linkage to care (Table 1).
| Area | Indicator | Numerator | Denominator | Method |
|---|---|---|---|---|
| Burden | Proportion of people in prison with LTP of drug injecting | Number of people living in prison who have experience of drug injection | Number of people living in prison | Cross-sectional survey using the EQDP |
| Proportion of people in prison with LTP of drug injecting inside prison | Number of people living in prison who have experience of drug injection inside prison | Number of people living in prison | Cross-sectional survey using the EQDP | |
| Proportion of people in prison with chronic HBV infection (HBsAg positive) | Number of persons in prison who tested positive for chronic HBV infection (HBsAg) during the reporting period (or at a given point in time) | Number of persons in prison who were tested for chronic HBV infection (HBsAg) during the reporting period (or at a given point in time) | Routinely collected administrative data or ad hoc survey (Bah, 2024) | |
| Proportion of people in prison with chronic HCV infection (HCV RNA or HCV-Ag positive) | Number of persons in prison who tested positive for chronic HCV infection (HCV RNA or HCV-Ag positive) during the reporting period (or at a given point in time) | Number of persons in prison who were tested for HCV infection (anti-HCV, HCV RNA or HCV-Ag) during the reporting period (or at a given point in time) | Routinely collected administrative data or ad hoc survey | |
| Proportion of people in prison with past exposure to HCV (anti-HCV positive) | Number of persons in prison who tested positive for past exposure to HCV (anti-HCV positive) during the reporting period (or at a given point in time) | Number of persons in prison who were tested for past exposure to HCV (anti-HCV positive) during the reporting period (or at a given point in time) | Routinely collected administrative data or ad hoc survey | |
| Transmission | New HBV infections (proxy for incidence) | Number of new HBV infections occurring in prison during the reporting period (negative test followed by positive test; e.g. documented seroconversion) | To get incidence rate, the number of new infections should be divided by the prison population during the reported period | Routinely collected administrative data |
| New HCV infections (proxy for incidence) | Number of new HCV infections occurring in prison during the reporting period (negative test followed by positive test e.g. documented seroconversion) | To get incidence rate, the number of new infections should be divided by the prison population during the reported period | Routinely collected administrative data | |
| Prevention | HBV vaccine coverage | Number of persons in prison with complete hepatitis B vaccination (or evidence of immunity)* at a given point in time | Number of persons in prison at a given point in time | Routinely collected administrative data or ad hoc survey |
| Harm reduction for people who inject drugs: coverage of needles–syringes*** Alternative indicator in absence of data: availability of NSP in prison |
Number of sterile needles–syringes distributed during the reporting period | Number of persons who inject drugs in prison during the reporting period Alternative denominator: number of persons in prison |
Routinely collected administrative data or ad hoc survey | |
| Harm reduction for people who use drugs: coverage of opioid agonist therapy**** Alternative indicator in absence of data: availability of OAT in prison |
Number of persons in prison receiving opioid agonist therapy during the reporting period (or at a given point in time) | Number of persons who use opioids during the reporting period (or at a given point in time) Alternative denominators: number of persons who inject opioids or number of persons who use NSP programmes or number of persons in prison |
Routinely collected administrative data or ad hoc survey | |
| Continuum of care | Hepatitis B screening coverage | Number of new arrivals to prison who were tested for hepatitis B during the reporting period (e.g. 1 year) using HBsAg testing | Number of new arrivals to the prison over the course of the reporting period *** | Routinely collected administrative data or ad hoc survey |
| Hepatitis C screening coverage | Number of new arrivals in prisons who were tested for past exposure to hepatitis C during the reporting period (e.g. 1 year) using anti-HCV testing | Number of new arrivals to the prison over the course of the reporting period*** | Routinely collected administrative data or ad hoc survey | |
| Hepatitis C diagnostic test coverage | Number of persons in prison who were tested for chronic hepatitis C infection during the reporting period using HCV RNA testing or HCV-antigen | Number of persons in prison who tested positive for anti-HCV during the reporting period | Routinely collected administrative data or ad hoc survey | |
| Test positivity hepatitis B | Number of persons in prison who tested positive for hepatitis B during the reporting period using HBsAg testing | Number of persons who were tested for hepatitis B during the reporting period using HBsAg testing | Routinely collected administrative data or ad hoc survey | |
| Test positivity hepatitis C | Number of persons in prison who tested positive for HCV RNA (active infection) during the reporting period | Number of persons who were tested for HCV RNA during the reporting period | Routinely collected administrative data or ad hoc survey | |
| HBV treatment coverage | Number of persons in prison initiated on treatment for chronic HBV infection during the reporting period | Number of persons in prison who tested positive for hepatitis B during the reporting period using HBsAg testing | Routinely collected administrative data or ad hoc survey | |
| Proportion of people diagnosed with HCV initiated on treatment | Number of persons in prison with chronic HCV infection who initiated treatment during a specified time frame | Number people living in prison diagnosed with chronic HCV infection (HCV RNA) during the reporting period | Routinely collected administrative data or ad hoc survey | |
| Proportion of people in prison with chronic HBV infection on treatment with suppressed HBV viral load | Number of persons in prison with chronic HBV infection on treatment who have a suppressed viral load, based on HBV viral load measurement during the reporting period | Number of patients with chronic HBV infection on treatment and assessed for HBV viral load during the reporting period whilst in prison | Routinely collected administrative data or ad hoc survey | |
| Proportion of people in prison who completed treatment for hepatitis C who were cured | Number of people who completed HCV treatment whilst in prison, during the reporting period, and achieved a sustained virologic response based on viral load measurement at 12 or 24 weeks after the end of treatment. | Number of people who completed antiviral treatment for HCV whilst in prison, during the reporting period, and were assessed for sustained viral response at 12 or 24 weeks after the end of treatment | Routinely collected administrative data or ad hoc survey | |
| Linkage to care for cases of hepatitis B on treatment | Is there a strategy in place to guarantee treatment continuity after release from prison? (yes/no) Are patients treated for HBV in the prison provided with a letter or other communication to their normal care provider in the community concerning their diagnostic or therapeutic information to support continuity of care? |
Routinely collected administrative data or ad hoc survey | ||
| Linkage to care for cases of hepatitis C on treatment | Is there a strategy in place to guarantee treatment continuity after release from prison (if needed)? (yes/no) Are patients treated for HCV in the prison provided with a letter or other communication to their normal care provider in the community concerning their diagnostic or therapeutic information to support continuity of care? |
Routinely collected administrative data or ad hoc survey | ||
* Either given full course of HBV vaccination in prison or with documentation that previously fully vaccinated against HBV or not susceptible to infection.
** Alternative is policy information on whether needles and syringes or opioid agonist treatment is available.
*** Where possible, denominator should exclude all those with documentation of a recent hepatitis test (i.e. within last year).
Methodological note for collecting the core indicators
Section titled “Methodological note for collecting the core indicators ”Compiling each of the indicators requires the collection and collation of different types of data from a range of sources, including from periodic surveys (Table 1). For most of the indicators it is necessary to compile the relevant numerator and denominator data and put this together to calculate the indicator.
When compiling the data there needs to be careful consideration given to whether a snapshot of data is to be collected at a particular point in time through a cross-sectional survey or whether data are collated over a period of time e.g. over the past year.
It is important when compiling the indicator that the timeframe for the numerator and denominator match i.e. for calculating hepatitis test positivity, the number testing positive for a particular timeframe (e.g. individuals testing positive during 2023) should only be matched to the same timeframe used for the denominator of numbers tested (i.e. individuals tested during 2023).
It is also important to understand how the data are generated (i.e. the testing strategy in a given prison might influence the representativeness of those individuals who are routinely tested).