published_or_final_version / Community Medicine / Master / Master of Public Health

Community-associated methicillin-resistant Staphylococcus aureus has been an increasing public health problem since its emergence in the 1990s and incarcerated populations are at disproportionately high-risk for colonization and infection. However, few studies have investigated why levels of S. aureus remain endemic in correctional settings in the absence of an outbreak. The overall objective of this dissertation was to evaluate S. aureus transmission in two maximum-security prisons using a molecular epidemiologic approach and data collected on over 2,700 inmates from 2009 – 2013. The objective of this dissertation was met using three aims. First, a systematic literature review was conducted to identify studies that used social network analysis (SNA) to evaluate infectious disease transmission via non-sexual/non-injection drug use contact pathways to detect influences of social networks on disease risk. Results of the review demonstrated that SNA approaches in infectious disease epidemiology are flexible and can be used to enhance traditional contact investigations, reveal granular patterns of transmission, evaluate influences of high-risk behaviors and activities, and identify both protective and causal effects resulting from context-specific social interactions. Second, changes in the distribution and diversity of S. aureus isolates with increasing length of incarceration were assessed. The results revealed some evidence for S. aureus transmission based on greater representation of certain strains; however, the genetic diversity of S. aureus was high regardless of length of time served. Third, the influence of social interactions among prison inmates on S. aureus colonization status was examined using SNA. The results showed that S. aureus colonized inmates were more likely to spend time in social groups and that the mechanisms of transmission differed for men and women. For women, the association was driven by being centrally located in the social network and for men it was driven by higher proportions of colonized inmates in close proximity. Overall, the results of this dissertation support the hypothesis that S. aureus is transmitted within prisons as a result of direct skin-to-skin contact and/or exposure to contaminated environmental surfaces. However, the results also demonstrate that, in the absence of an outbreak, S. aureus transmission within prisons is low indicating that endemic levels of S. aureus are primarily maintained by the constant introduction of clones into prisons from jails and the community.

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Thesis (D.P.H.)--University of Hawaii at Manoa, 1995. / Includes bibliographical references (leaves 176-183). / Microfiche. / xv, 183 leaves, bound ill. 29 cm

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Background: Cardiovascular disease (CVD) is an important health concern in prison populations as they have an increased risk of the disease compared to the general population. However, there is a lack of interventions to reduce prisoners’ cardiovascular risk, and little is known about the knowledge and risk perceptions of the disease in prison. This study aims to explore the knowledge and risk perceptions of CVD from the perspectives of prisoners and staff to guide the development of a cardiovascular risk reduction intervention for prisoners. Methods: This was a qualitative, exploratory study. Semi-structured interviews were conducted with 16 prisoners and 11 staff, who were purposively recruited from a private prison in Scotland. Framework analysis was used to analyse the data. Findings: The prisoners and staff had limited, non-expert knowledge of CVD. Common behavioural risk factors and cardiovascular events were identified, but gaps in knowledge were evidenced. There were similarities and differences in perceptions of prisoners’ risk of the disease; risk was primarily assessed by judgements about the prisoners’ current health status rather than their risk factor status. Prisoners’ risk of CVD was attributed to negative health behaviours such as smoking and physical inactivity, and these were influenced by multiple factors that interacted across three levels of influence. Individual factors included self-efficacy and mental health problems, social factors included the prison culture and social interactions, and institutional factors included the prison regime and healthcare barriers. An ecological framework was designed to guide a cardiovascular risk reduction intervention that focuses on the multi-level influences of prisoners’ cardiovascular risk. Conclusion: Prisoners have limited knowledge and misconceptions of CVD, and engage in several risky behaviours. There are multi-level influences on prisoners’ CVD risk and cardiovascular health. An ecological approach is recommended to address these influences to reduce the prisoners’ risk of CVD.

This thesis aimed to describe the epidemiology of HCV in South Australian prisons - prevalence, transmission and risk factors. This thesis also aimed to determine the impact of incarceration on reported risk behaviours. A related objective was to evaluate the epidemiological effectiveness of the ELISA - 3 HCV antibody test using PCR as the gold standard. Finally, this thesis aimed to explore the potential for minimising HCV risk in the South Australian prison population. Methods: Two case note audits were conducted at each of eight publicly operated SA prisons ( in summer and winter ) to identify any documented HCV - antibody test results. Prisoners recruited at entry to prison were offered tests for HCV - antibody and completed a pre - entry risk factor survey. Participants completed additional risk factor surveys and ( if HCV - negative at last test ) underwent further antibody tests at three - monthly intervals for up to 15 months. A sample of participants also provided blood specimens for HCV - RNA testing. Limited stakeholder consultations with prison officers and nurses were also conducted. Quantitative data were analysed using univariate and multivariate techniques. Results: 1347 case notes were audited in summer, and 1347 in winter and an overall HCV prevalence of 42 % was estimated. In both univariate and multivariate analyses, HCV prevalence was significantly higher in female prisoners ( 65 % ), those aged above 28 years ( 48 % ), and in Indigenous prisoners originating from metropolitan areas ( 56 % ). Indigenous prisoners originating from remote areas had significantly lower HCV prevalence ( 20 % ). 666 prisoners were recruited at entry, and 42 % were estimated to be HCV - antibody positive. Three seroconversions were noted in 151 initially HCV - seronegative negative individuals followed up for a median time of 121 days - a rate 4.6 per 100 person years - but community exposure could not be ruled out. Overall agreement between HCV - antibody and HCV - RNA assays was 86 % ( 100% in the HCV negative samples ) - kappa = 0.71. Injecting history was highly prevalent in prison entrants ( 70 % ) and both community and prison injecting ( but not tattooing ) were independent predictors of entry HCV status. Prison history was also independently associated with entry HCV status. Injecting in prison during the study was infrequently reported, but significantly more likely in those testing HCV - antibody positive at prison entry ( risk ratio = 2.48, P = 0.046 ). Stakeholders were most supportive of strategies to increase education and to minimise risks associated with hair clippers, but did not support most other suggested preventive strategies. Other issues related to communicable diseases and infection control were explored in the stakeholder interviews. Conclusions: HCV prevalence in South Australian prisoners is extremely high and may have contributed to a ' ceiling effect ' , minimising the seroconversion rate observed in this population. Injecting is relatively infrequently reported in prison, but more likely in those already infected with HCV. Thus, contaminated injecting equipment represents a significant threat to other prisoners and prison staff. Strategies aimed at reducing HCV risk in prisons, which address the concerns of those expected to implement them, are proposed in this thesis. / Thesis (Ph.D.)--School of Population Health and Clinical Practice, 2006.

This thesis aimed to describe the epidemiology of HCV in South Australian prisons - prevalence, transmission and risk factors. This thesis also aimed to determine the impact of incarceration on reported risk behaviours. A related objective was to evaluate the epidemiological effectiveness of the ELISA - 3 HCV antibody test using PCR as the gold standard. Finally, this thesis aimed to explore the potential for minimising HCV risk in the South Australian prison population. Methods: Two case note audits were conducted at each of eight publicly operated SA prisons ( in summer and winter ) to identify any documented HCV - antibody test results. Prisoners recruited at entry to prison were offered tests for HCV - antibody and completed a pre - entry risk factor survey. Participants completed additional risk factor surveys and ( if HCV - negative at last test ) underwent further antibody tests at three - monthly intervals for up to 15 months. A sample of participants also provided blood specimens for HCV - RNA testing. Limited stakeholder consultations with prison officers and nurses were also conducted. Quantitative data were analysed using univariate and multivariate techniques. Results: 1347 case notes were audited in summer, and 1347 in winter and an overall HCV prevalence of 42 % was estimated. In both univariate and multivariate analyses, HCV prevalence was significantly higher in female prisoners ( 65 % ), those aged above 28 years ( 48 % ), and in Indigenous prisoners originating from metropolitan areas ( 56 % ). Indigenous prisoners originating from remote areas had significantly lower HCV prevalence ( 20 % ). 666 prisoners were recruited at entry, and 42 % were estimated to be HCV - antibody positive. Three seroconversions were noted in 151 initially HCV - seronegative negative individuals followed up for a median time of 121 days - a rate 4.6 per 100 person years - but community exposure could not be ruled out. Overall agreement between HCV - antibody and HCV - RNA assays was 86 % ( 100% in the HCV negative samples ) - kappa = 0.71. Injecting history was highly prevalent in prison entrants ( 70 % ) and both community and prison injecting ( but not tattooing ) were independent predictors of entry HCV status. Prison history was also independently associated with entry HCV status. Injecting in prison during the study was infrequently reported, but significantly more likely in those testing HCV - antibody positive at prison entry ( risk ratio = 2.48, P = 0.046 ). Stakeholders were most supportive of strategies to increase education and to minimise risks associated with hair clippers, but did not support most other suggested preventive strategies. Other issues related to communicable diseases and infection control were explored in the stakeholder interviews. Conclusions: HCV prevalence in South Australian prisoners is extremely high and may have contributed to a ' ceiling effect ' , minimising the seroconversion rate observed in this population. Injecting is relatively infrequently reported in prison, but more likely in those already infected with HCV. Thus, contaminated injecting equipment represents a significant threat to other prisoners and prison staff. Strategies aimed at reducing HCV risk in prisons, which address the concerns of those expected to implement them, are proposed in this thesis. / Thesis (Ph.D.)--School of Population Health and Clinical Practice, 2006.

This thesis aimed to describe the epidemiology of HCV in South Australian prisons - prevalence, transmission and risk factors. This thesis also aimed to determine the impact of incarceration on reported risk behaviours. A related objective was to evaluate the epidemiological effectiveness of the ELISA - 3 HCV antibody test using PCR as the gold standard. Finally, this thesis aimed to explore the potential for minimising HCV risk in the South Australian prison population. Methods: Two case note audits were conducted at each of eight publicly operated SA prisons ( in summer and winter ) to identify any documented HCV - antibody test results. Prisoners recruited at entry to prison were offered tests for HCV - antibody and completed a pre - entry risk factor survey. Participants completed additional risk factor surveys and ( if HCV - negative at last test ) underwent further antibody tests at three - monthly intervals for up to 15 months. A sample of participants also provided blood specimens for HCV - RNA testing. Limited stakeholder consultations with prison officers and nurses were also conducted. Quantitative data were analysed using univariate and multivariate techniques. Results: 1347 case notes were audited in summer, and 1347 in winter and an overall HCV prevalence of 42 % was estimated. In both univariate and multivariate analyses, HCV prevalence was significantly higher in female prisoners ( 65 % ), those aged above 28 years ( 48 % ), and in Indigenous prisoners originating from metropolitan areas ( 56 % ). Indigenous prisoners originating from remote areas had significantly lower HCV prevalence ( 20 % ). 666 prisoners were recruited at entry, and 42 % were estimated to be HCV - antibody positive. Three seroconversions were noted in 151 initially HCV - seronegative negative individuals followed up for a median time of 121 days - a rate 4.6 per 100 person years - but community exposure could not be ruled out. Overall agreement between HCV - antibody and HCV - RNA assays was 86 % ( 100% in the HCV negative samples ) - kappa = 0.71. Injecting history was highly prevalent in prison entrants ( 70 % ) and both community and prison injecting ( but not tattooing ) were independent predictors of entry HCV status. Prison history was also independently associated with entry HCV status. Injecting in prison during the study was infrequently reported, but significantly more likely in those testing HCV - antibody positive at prison entry ( risk ratio = 2.48, P = 0.046 ). Stakeholders were most supportive of strategies to increase education and to minimise risks associated with hair clippers, but did not support most other suggested preventive strategies. Other issues related to communicable diseases and infection control were explored in the stakeholder interviews. Conclusions: HCV prevalence in South Australian prisoners is extremely high and may have contributed to a ' ceiling effect ' , minimising the seroconversion rate observed in this population. Injecting is relatively infrequently reported in prison, but more likely in those already infected with HCV. Thus, contaminated injecting equipment represents a significant threat to other prisoners and prison staff. Strategies aimed at reducing HCV risk in prisons, which address the concerns of those expected to implement them, are proposed in this thesis. / Thesis (Ph.D.)--School of Population Health and Clinical Practice, 2006.

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