Hepatitis B transmission event in an English prison and the
importance of immunization
Uma Viswanathan1, Amanda Beaumont1, E´amonn O’Moore2, Mary Ramsay3,
Richard Tedder3, Samreen Ijaz3, Koye Balogun3, Patrick Kirwan3
1Public Health, NHS, Walsall WS2 7JL, UK
2Offender Health, Department of Health, London, UK
3Centre for Infections, Health Protection Agency, London, UK
Address correspondence to Patrick Kirwan, E-mail: email@example.com
Immunization against hepatitis B virus (HBV) is recommended for all sentenced prisoners and all new entrants to prison in the UK. In November
2008, acute hepatitis B was confirmed serologically in a 27-year-old man (Case 1) who had been incarcerated since February 2007. The cell
mate of Case 1, a 26-year-old man was an established HBV carrier. A home-made tattoo gun was confiscated from their prison cell. In the
absence of other clearly identifiable risk behaviours, tattooing was deemed to be a possible route of HBV transmission. Transmission of
hepatitis B in a prison setting is a real concern and this report highlights the importance of immunizing prisoners against hepatitis B and
should encourage health professionals to communicate the benefits of immunization to inmates to increase vaccine uptake.
Keywords communicable diseases, epidemiology, prisons
Prisons were constructed to maximize public safety and not
to minimize the transmission of disease or to effectively
deliver health care. The risks of infectious disease trans-
mission are higher in prisons than in the community1owing
to a combination of factors including large dynamic popu-
lations living in close proximity in relatively overcrowded
conditions; high degrees of social mixing during activities
and engagement in high-risk behaviours2,3among a popu-
lation with an elevated prevalence of infectious disease.4
There are currently approximately 85 000 people in 140
prisons in England and Wales with an annual population
turnover of approximately 200 000.5
In prison, hepatitis B virus (HBV) can be potentially
transmitted through injecting drug use,6unprotected sexual
intercourse and body piercing and tattooing.1An outbreak
of acute symptomatic hepatitis B infection that affected
eight male prisoners of HMP Glenochil (central Scotland) in
1993 alerted the authorities to random needle sharing
among large numbers of injector inmates.6Prisons present a
window of opportunity to provide health services and
implement infectious disease preventative measures to a
population that otherwise may have poor or disrupted
contact with health services.7The transient nature of prison
populations means the benefits of hepatitis B vaccination
extends beyond the prisoners themselves, and into the wider
Immunization against HBV is recommended for all sen-
tenced prisoners and all new inmates entering prison in the
UK.8Prison staff are also at risk of acquiring Hepatitis B
and immunization is recommended for all prison service
staff who are in regular contact with prisoners.8
In 1996, a HBV vaccination policy was implemented in
England recommending that all new prisoners should be
UmaViswanathan, Consultant in Public Health Medicine
AmandaBeaumont, Head of Infection Prevention and Control
E´amonnO’Moore, Consultant in Public Health (Health Protection)
MaryRamsay, Consultant Epidemiologist
RichardTedder, Consultant Medical Virologist
SamreenIjaz, Clinical Scientist
KoyeBalogun, Clinical Scientist
PatrickKirwan, Scientific Co-ordinator
# The Author 2010, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
Journal of Public Health | Vol. 33, No. 2, pp. 193–196 | doi:10.1093/pubmed/fdq083 | Advance Access Publication 21 October 2010
by guest on November 2, 2015
offered the hepatitis B vaccine.9A prison health perform-
ance and quality indicator for all prisons in England and
Wales states that at least 80% of all prisoners should be
immunized against Hepatitis B within 1 month of reception
to prison.10In 2008, 41% of all prisoners in England and
Wales were vaccinated against Hepatitis B within 1 month of
reception (87 000 doses).11However, in the West Midlands
the reported uptake of Hepatitis B for the same period was
19.7%. This report documents HBV transmission in a
prison in the West Midlands where tattooing was a possible
source of HBV infection. It summarizes the results of the
subsequent investigation, which identified an additional case
of HBV infection and underscores the need to strengthen
harm reduction measures and implement hepatitis B immu-
nization in prisons and correctional facilities.
In November 2008, a 27-year-old man (Case 1) who had
been incarcerated since February 2007 presented to the
prison healthcare with jaundice and abnormal liver enzymes.
Acute hepatitis B was confirmed serologically by the detec-
tion of levels of antibody to hepatitis B core antigen IgM
sub-class (anti-HBc IgM) .200 mg/ml. An incident team
consisting of the prison governor and healthcare team, the
local Health Protection Unit (HPU) and the Primary Care
Trust (PCT) was convened to investigate and manage the
situation. The patient did not report any risk factors for
infection during the 6 months preceding his illness.
The team decided to use a social network model of
contact tracing to identify close contacts and determine risk
factors for HBV infection, where the index case was asked
to name people he spent a lot of time within the prison.
This is in contradistinction to naming people he engaged in
high-risk activities with as this information could be seen as
stigmatizing and potentially incriminating in a prison
Five contacts were identified by Case 1 and they were
offered immunization against HBV and serologic testing for
HBV infection. This demonstrated that three of the contacts
were susceptible to HBV, one was immune, and the remain-
ing contact, a 26-year-old man (Case 2) was also currently
infected with HBV. Further serological testing confirmed his
infection but showed that he was an established carrier
whose serum contained hepatitis B e antigen and a high
level of HBV DNA (.106IU/ml). The incident team was
stepped up to an outbreak control team involving existing
partners and the centre of infections was invited to support
the management of the investigation.
In February 2008, Case 1 had moved from a local prison
to a closed prison. The team established that Case 2 had
been incarcerated in the same local prison as Case 1 since
June 2007 and transferred to his current prison in June
2008. Cases 1 and 2 shared a cell in both prisons. Case 2
reported no history of symptoms compatible with acute
hepatitis and was previously unaware of his chronic infec-
tion. A detailed interview of this case did not yield any
further contacts. He reported no high-risk behaviour within
prison, but disclosed a history of injecting drug use and
multiple sexual partners before incarceration. Investigation
of the HBV DNA from Cases 1 and 2 indicated that both
were infected by genotype D viruses. Sequences of both
hepatitis B surface antigen (HBsAg) and pre-core/core
genes were identical at the nucleotide level making it very
likely that transmission had occurred between the two
Both offenders denied having any sexual contact with
each other. Tests for signs of drug use during the incarcera-
tion period were negative for both cases; these cell mates
did not admit to having shared toothbrushes or razors.
However, a tattoo gun was confiscated by prison staff in
the prison cell shared by both prisoners in September 2008.
Case 1 had received two tattoos prior to incarceration.
During a subsequent interview, he disclosed that he had
planned to apply a tattoo, using the tattoo gun, on himself
and his cellmate. In a further discussion, he admitted that
he had used the tattoo gun on his cellmate but was unwill-
ing to admit that he had used it on himself.
The tattoo gun was made from the motor of a stereo and
two diabetic needles, which were obtained by Case 1 from
an offender who had diabetes and who was located on the
same prison wing. The investigating team came to the con-
clusion that Case 2 was the likely source of infection, and
the tattoo gun was the probable route of transmission of
Both prisoners had refused hepatitis B immunization in
both prisons when it was previously offered. Other preven-
tative or harm reduction measures, such as condoms and
disinfectant tablets, were available to inmates in this category
C prison but uptake was low.
To prevent any further onward transmission, hepatitis B
vaccine, with additional information about hepatitis B trans-
mission, was offered to all inmates. The inmates infected
with HBV were notified of their infection status and
received a clinical assessment. The prison healthcare staff,
PCT and the local HPU collaborated to implement strategies
to improve the delivery of routine hepatitis B immunization
at reception for all inmates and strengthen harm reduction
measures in the category C prison. Since this investigation
JOURNAL OF PUBLIC HEALTH
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began, vaccine uptake has improved in this prison establish-
ment. Vaccine uptake for this prison was 68% in quarter 2
of 2009 (Prison Hepatitis B Vaccination Monitoring
Programme). There was no formal immunization pro-
gramme for prison staff at the time of the incident; however
an immunization programme for staff was introduced in
2009 following the incident.
Transmission of hepatitis B in a prison setting is a real
concern as evidenced by the transmission event cited in this
case report. The report highlights the importance of immu-
nizing prisoners against hepatitis B and should encourage
health professionals to contemplate the way in which we
communicate the benefits of immunization to inmates to
increase vaccine uptake.
Circumstantial evidence has identified tattooing as a poss-
ible route of HBV transmission, although other trans-
mission routes cannot be ruled out. Obtaining full
disclosure of risk behaviours from prisoners is difficult as
inmates may be apprehensive that they will be disciplined or
closely monitored by the prison establishment. Uncertainty
about honest disclosure of past illicit injecting drug use can
confound interpretation of epidemiological data.12Case 2
had engaged in ‘risky’ behaviours prior to imprisonment,
having multiple sex partners and injecting drug use, which
are associated with HBV infection.13Besides the fact that
both individuals denied injecting while in prison, no inject-
ing equipment was found in their cell. In addition to this,
Case 1 did not report a history of injecting drug usage even
prior to his incarceration. Sex between men is also a risk
factor for HBV infection14but both individuals denied such
behaviour. In his initial interview, Case 1 was hesitant to dis-
close any risk behaviours. However, he later disclosed his
intentions to tattoo himself and his cell mate, and finally
admitted to tattooing his inmate but not himself. It is poss-
ible that Case 1 had tattooed himself but did not want to
disclose this information. The tattoo gun was confiscated
within the window period when transmission may have
occurred. In addition to this, the tattooing equipment used,
i.e. the diabetic needle, is hollow and may facilitate the trans-
mission of hepatitis B. We therefore feel that tattooing is the
likely transmission route. This suggests that tattooing activity
in prison could have serious consequences, which merit
Transmission of hepatitis B in prison has been previously
documented and attributed to injecting drug use, needle
sharing6,15and tattooing.1Tattoos and other percutaneous
exposures (e.g. bites and abrasions) are common in
correctional facilities and have the potential to expose resi-
dents and correctional staff to blood and body fluids.16,17
Tattooing in prison represents a unique combination of risk
factors for blood-borne virus (BBV) transmission because it
is illicitly performed by untrained operators with homemade,
unsterile and frequently shared equipment. It also occurs in
a setting where a high proportion of people are already
infected with hepatitis C virus and other BBVs.4A study
conducted in 1994 showed that 53% of prisoners in
England and Wales had a tattoo and 11% of prisoners
obtained their tattoos in prison.18Tattooing in prison is
likely to be an important public health problem in England
and Wales and the extent of tattooing in UK prisons and its
consequences should be investigated.
The impact of the prison HBV immunization pro-
grammes extends benefits beyond prisoners to the wider
community19and hence the Department of Health has
commissioned the Health Protection Agency to monitor
hepatitis B vaccine delivery in prisons. Prisons are recog-
nized as important venues for delivering the hepatitis B
vaccine to high-risk groups such as injecting drug users
(IDUs).8Vaccine uptake has increased among IDUs from
50% in 2003 to 72% in 200820and the incidence of acute
cases of HBV has declined among IDUs with IDU
accounting 37% of those with known risk exposures in 2003
compared with 10% in 2008.21Vaccine uptake was poor
among new prison entrants in both the local and category C
prison reported here and the category C prison was not par-
ticipating in the Hepatitis B Vaccine Monitoring Programme
at the time of the incident. This report demonstrates the sig-
nificance of immunizing offenders and security staff against
hepatitis B and it has shown that partnerships between
prison health care, PCTs and HPUs can help to promote
hepatitis B vaccine uptake in prison establishments.
Although both prisoners were offered the hepatitis B
vaccine both refused, which emphasizes the need to raise
awareness of BBVs among the prison population. The
uptake of the hepatitis B vaccine at reception in both the
local and closed prison was poor. We should therefore
explore the way in which we offer immunization to prison-
ers. Offering immunization only on reception to prison may
not be appropriate as individuals may be suffering stress
and anxiety and are less able to process and retain new
information. Prisoners may be less likely to refuse immuniz-
ation if it is offered repeatedly after their reception to prison
when they are more familiar with their environment.
Targeted resources have been developed, by the British
Liver Trust, the Department of Health and the Health
Protection Agency, to raise awareness of BBVs among pris-
oners including a DVD (Hepatitis C inside and out) and health
HEPATITIS B TRANSMISSION IN PRISON
by guest on November 2, 2015
promotion literature (get out of jail BBV free and wise up to
BBVs) to inform prisoners of risks of transmission and
harm minimization strategies in relation to BBVs.
The potential for infectious disease transmission in prisons
has been well documented.22–24Infection control practices in
prison have focused on increasing awareness of BBVs, access
to condoms and disinfectant tablets.25Irrespective of the
route of transmission, this report illustrates that inmates
engage in tattooing activity with materials that may increase
the risks of BBV transmission and therefore we need to inves-
tigate our approach to tackling tattooing in prisons.
Evidence suggests that the prison HBV vaccine pro-
gramme has had a positive impact on vaccine uptake among
IDUs. HBV immunization should be routinely offered to
prisoners and the drive to increase vaccine coverage should
not be the result of a HBV transmission event but rather an
integral component of a prison’s local immunization policy.
We would like to thank Kate Clay, the prison healthcare
manager, and her healthcare team for their help with this
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