Modelling the hepatitis B vaccination programme in prisons

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. Over the coming years it is anticipated this vaccination programme will be extended. A model has been developed to assess the potential impact of the programme on the vaccination coverage of prisoners, ex-prisoners, and injecting drug users (IDUs). Under a range of coverage scenarios, the model predicts the change over time in the vaccination status of new entrants to prison, current prisoners and IDUs in the community. The model predicts that at baseline in 2012 57% of the IDU population will be vaccinated with up to 72% being vaccinated depending on the vaccination scenario implemented. These results are sensitive to the size of the IDU population in England and Wales and the average time served by an IDU during each prison visit. IDUs that do not receive HBV vaccine in the community are at increased risk from HBV infection. The HBV vaccination programme in prisons is an effective way of vaccinating this hard-to-reach population although vaccination coverage on prison reception must be increased to achieve this.     

Modelling the impact of prison vaccination on hepatitis B transmission within the injecting drug user population of England and Wales

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. The work here considers the impact of prison vaccination on the incidence and prevalence of hepatitis B virus (HBV) in the injecting drug user (IDU) population of England and Wales. A dynamic model of the transmission of HBV in IDUs is developed with key model assumptions and parameters being subject to sensitivity analyses. The base case model (that assumes that the vaccination coverage on prison reception is 5% in 2002, 10% in 2003 and then increases linearly up to 50% of prison receptions being vaccinated by 2006) predicts that the incidence of HBV in IDUs might be reduced by almost 80% in 12 years, and the HBV prevalence (IDUs ever infected by HBV) may be reduced from approximately 18% in 2002 to 7% in 2015. The model presented here demonstrates that HBV vaccination on prison reception can have a significant impact on the prevalence and incidence of HBV in the IDU population over time.     

Increasing hepatitis B vaccine coverage in prisons in England and Wales

The most frequently reported risk factor for hepatitis B infection in England and Wales is injecting drug use (38%). Since approximately 61% of injecting drug users (IDUs) had been imprisoned and less than 40% had received hepatitis B vaccine, a prison based hepatitis B vaccination programme was set up in 2001. At the 42 establishments participating in this study, all prisoners were offered vaccine at reception. Prisoners over 18 years were vaccinated using the 0, 7 and 21 days schedule and those under 18 years, using the 0, 1 and 2 months schedule. As far as possible a fourth dose was given to all after 12 months. In 2003, 14,163 prisoners received at least one dose of vaccine and altogether 26,265 doses were administered. A further 1111 prisoners reported they had already been vaccinated against hepatitis B. The median vaccine coverage rate was 17% (range 0-94%). Despite low coverage levels, the vaccination programme in prisons can be said to have vaccinated a sizable number of young, male prisoners, a group that have previously been shown to be at high risk of infection. The prisons which achieved vaccine coverage levels over 50% had designated nursing staff who ran the vaccination clinics.     

Hepatitis A vaccination--a prison-based solution for a community-based outbreak?

In December 2001, an increase in cases of hepatitis A was observed in South Yorkshire. Cases were predominantly young males who reported injecting drug use. A community-based vaccination programme was introduced in November 2002, but new cases continued to occur. In March 2003, a vaccination campaign was implemented in the local prison for a four-week period. One thousand two hundred and thirty-six (91%) prisoners were vaccinated. Two thirds (895/1,363) of the prisoners came from the area affected by the outbreak and 52% (465/895) reported injecting drugs. The median age of injectors was 25 years. Notifications of cases of hepatitis A from South Yorkshire ceased in August 2003. Although on this occasion the prison vaccination campaign was probably implemented too late to have had a significant impact on the local outbreak, a large number of young male injectors from the local area were successfully vaccinated. This suggests that a prison-based intervention offers a potentially effective way of immunising the IDU population and interrupting a community-based outbreak.     

Patterns of Drug Use and HIV-Related Risk Behaviors among Incarcerated People in a Prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.     

Prevalence and Correlates of HCV,HVB, and HIV Infection among Prison Inmates and Staff,Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.     

Mass vaccination response to a measles outbreak is not always possible. Lessons from a London prison

In this study, we describe a contained measles outbreak in a London prison, the second such outbreak in a custodial setting. Once vaccination commenced, just under a third of eligible prisoners were immunised due to a low uptake of the vaccine. We conducted a root-cause analysis in order to identify factors which may have prevented or altered the course of the outbreak. Our analysis revealed that many of the factors identified are those that cannot be easily changed. It is unlikely that mass vaccination at the time, even in the absence of some of the more easily rectifiable issues, could have fully avoided further cases in the event of a mass outbreak. Both measles outbreaks in a custodial setting started with a member of staff and immunisation status of the staff were largely unknown. We argue that mass vaccination following an outbreak in a prison is unlikely to fully prevent a mass outbreak, and that implementing opt-out testing, empirical vaccination and insisting on full immunisation of staff are most likely to both prevent and contain outbreaks in the future.Key words: Measles, measles outbreak, prison, mass vaccination

In July 2016, a contained measles outbreak occurred in a London prison with more than 1500 inmates, of which two-thirds were sentenced and one-third constituted new influx. This was the second case of a reported measles outbreak in a custodial setting in England. The previous outbreak occurred in a Yorkshire prison in 2013 [1]. In both outbreaks, the source of infection originated from a member of staff and there was low known immunity of prisoners as well as staff at the time. However, in terms of characteristics, there were striking differences between the two prison settings: The prison in London housed about seven times as many inmates as the Yorkshire prison and their makeup was significantly different. Average custodial stay in this London male prison was around 6 weeks at the time of the outbreak. The majority of prisoners were between 18 and 39, two-thirds were Caucasian, with men from Black Caribbean origin the second largest group at just under 10%. Nearly half of the prisoners were foreign nationals, while in the Yorkshire prison outbreak 91% of inmates were of White British origin. Data on country of origin available to us was not consistent as it came from collected ethnicity data. We do, however, know that ‘Other White’ made up the largest group of inmates at around 70% of those who were foreign nationals. Almost a quarter had diagnosed mental ill health in the London prison.In July 2016, Public Health England (PHE) confirmed two cases of measles amongst prison staff and declared it an outbreak. Transfers in and out of prisons were stopped and immunity of prisoners was assessed to be unknown for about 50% of the prison population. The risk was deemed to be confined to the segregation unit (n = 30), where the two staff members with measles worked. However, by day 6 of the outbreak, a further two cases (one probable, one possible) amongst staff had been identified and four possible cases amongst prisoners. At this point, a mass vaccination programme was decided and a National Health Service England (NHSE) IMMS01 response was employed. IMMS01 is the name of the commissioning response to outbreaks of vaccination preventable diseases in London only [2]. There is a rota of the NHSE (London) immunisation commissioners, which changes weekly with first and second on-call personal. The first on call commissioner is responsible for organising the acquirement of vaccine stocks and evoking a service provider response. This is done following an agreed protocol between PHE (London) and NHSE (London). A total of 1600 vaccines (Measles Mumps Rubella (MMR)) were ordered with the intention to vaccinate on Friday, and a check of pregnancy status in female vaccinees amongst prison staff was made (day 8). Vaccine supply was delayed coming from the manufacturer and no protocol currently exists with other institutions such as PHE to release some of their stock in the meantime in the case of a supply shortage. The prison healthcare service had a high vacancy rate amongst staff and there was a shortage of prison officers to accompany prisoners to vaccination. Due to the weekend and annual leave, it was difficult to organise vaccinators from the contracted NHS immunisation task force provider to proceed with vaccinations on day 8 as planned. Logistics of getting security clearance to enable community healthcare staff to enter the prison and lack officers to escort staff/prisoners within the establishment, alongside the lack of suitable infrastructure, conspired to make delivering mass vaccination difficult. Between days 8 and 14 a total of 4 nurses (who were sourced across the local community healthcare system) vaccinated 241 prisoners out of a possible 800 with unknown immunity status (30%). This contrasts with the Yorkshire prison, where over 90% of inmates were vaccinated. No further cases occurred. There was a high refusal rate among prisoners.We conducted an evaluation of the service response to the outbreak with the purpose to share learning and to develop a protocol for future reactive responses to prison outbreaks of vaccine preventable diseases. All healthcare service participants were interviewed as part of a root-cause analysis using standard tools [3] including the nurses who delivered the vaccinations, NHSE (London) commissioners of health and justice system, the head of the prison healthcare service, heads of service at the contracted NHS immunisation task force provider, the commissioners of the National Offender Management Service (NOMS), the on-call IMMS01 commissioners and the PHE health protection team. A thematic analysis was conducted to elicit the key points of learning. These are illustrated in detail in Figure 1. There were a number of issues which delayed or prevented mass vaccination, only some of which can be easily pre-empted for future outbreaks. For example, ensuring adequate training for potential vaccination staff or creating sharing protocols to enable a swift sourcing of vaccinations in case of shortage could have helped in recruiting vaccinators and securing vaccines more quickly. However, even with adequate number of vaccinators and timely vaccine supplies it was clear that any future reactive mass vaccination response would be hindered by ongoing staff shortages in the prison workforce (health and non-health) and the design of the physical environment which was not conducive to vaccination provision (i.e. prisoners needed to be accompanied to a room for vaccination where adequate cold chain and sharps disposals could be maintained. Rooms and staff were not readily available to enable this). A further obstacle was the high refusal rate amongst prisoners, something which may be addressed with education campaigns but is less likely to be sustainable due to the rapid turnover of the prison population. The rapid turnover will also make proactive vaccination programmes suggested by the World Health Organisation Health in Prisons Programme (WHO HIPP) [4] difficult and their cost effectiveness is unknown. A short programme of for example the measles vaccine offered over a period of weeks to prisoners may be less effective when there is high prison population churn. In addition, the challenges facing London prisons [5] may prohibit such pro-active vaccination initiatives at present. Open in a separate windowFig. 1.Fishbone diagram of factors contributing to the delay in delivery and low uptake of mass vaccination.Crick et al. [1] in their analysis of the outbreak in Yorkshire concluded that the outbreak would have been unlikely to have been stalled by mass vaccination of prisoners. It was recommended to have comprehensive documentation of the immune status of staff and prisoners. We concur with the authors and go further in our recommendations. We found that mass vaccination was difficult to implement. In the Yorkshire prison, the majority of prisoners born after 1987 had a vaccination status reported in a retrospective data gathering exercise. However, 91% of inmates were White British, while the population of inmates in London was to a large extend made up of foreign nationals where vaccination cannot assume to be as consistent as in the UK. In addition, the majority of inmates in Yorkshire were vaccinated following the outbreak, while in London only a minority consented to vaccination. Language barriers, differing understanding or knowledge, lower immunisation rates in countries of origin as well as the high number of prisoners with mental health problems may have contributed to this.Going forward, we suggest that since the measles outbreak in the London and Yorkshire prisons originated with prison staff, it is first important to ensure that all staff are vaccinated with MMR and have their annual influenza vaccine. Vaccination provision by Her Majesty''s Prison and Probation Service (HMPPS) occupational health service would help avoid potential future outbreaks being brought into prisons. Whilst not uncontroversial, one could argue that the proven immunisation status of prison staff should be part of the occupational health assessment at employment similar to health workers. Had infected staff been exposed to the entire prison as in Yorkshire and not predominantly the segregation unit, a mass outbreak may well have occurred. All adults born from 1970 onwards are entitled to the two doses of MMR for free on the NHS and this can be obtained through general practice. Influenza vaccine can also be received from participating pharmacies.Second, we would also argue that the only way to avoid mass outbreaks, in the long run, is to ensure recording of vaccination status and offer of a vaccine along with education during the admissions process for prisoners. There should be a reliable secondary assessment in prison settings to establish immunity and utilising the initial health assessment at reception or comprehensive second assessment following a first reception for identification and/or provision of opportunistic vaccinations. An opt-out approach to testing was shown to be highly effective and could be adopted to test for measles immunity [6].Finally, one could also conclude that instead of testing for immunity first in the event of an outbreak, a proactive vaccine could be given, saving time and resources. Whilst the London Region advocates for opportunistic vaccines during outbreaks, particularly in schools, this is not part of the Health Protection Team (HPT) plan at present, which tends towards treating the outbreak disease. It might be worth reviewing the opportunistic approach in the light of this outbreak.In summary, this was the second outbreak of measles in a custodial setting and both times the outbreak started with a member of staff. Our root-cause analysis revealed that many of the factors identified are those that cannot be easily changed, including challenges facing prisons such as inadequate infrastructure, staff shortages and a high turnover of inmates. A low immunisation rate and low uptake during mass vaccination are also factors that do not lend themselves to rapid correction. It is unlikely that mass vaccination at the time, even in the absence of some of the more easily rectifiable issues such as staff training, vaccinator availability and vaccine supply, could have fully avoided further cases in the event of a mass outbreak. A three pronged approach of ensuring full immunisation of prison staff, detailed recording, opt-out testing and/or empirical vaccination of prisoners as well as the offer of the opportunistic vaccine in the event of an outbreak may help prevent a mass outbreak in the future.     

Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey

Prisoners in eight of the 135 prisons in England and Wales were surveyed in 1997 and 1998 to study the prevalence of and risk factors for transmission of bloodborne viruses in prison. Subjects voluntarily completed a risk factor questionnaire and provided oral fluid specimens for unlinked anonymous testing for the presence of antibodies to HIV, hepatitis C virus (HCV), and the core antigen of hepatitis B virus (HBc). Almost 8% (4778) of the total of 60,561 prisoners were eligible and four fifths (3942) of those eligible took part. Among all those tested (3930) 0.4% (14) were positive for anti-HIV, 8% (308) for anti-HBc, and 7% (293) for anti-HCV (the anti-HBc and anti-HCV prevalences were not adjusted for assay sensitivities of 82% and 80%, respectively). Twenty-four per cent (777/3176) of adult prisoners reported ever having injected drugs, 30% of whom (224/747) reported having injected in prison. Three quarters of those who injected in prison (167/224) shared needles or syringes. Among adult injecting drug users, 0.5% (4/775) had anti-HIV, 31% (240/775) anti-HCV, and 20% (158/775) anti-HBc. The presence of anti-HCV and anti-HBc was associated with injecting inside prison and number of previous times in prison. The results suggest that hepatitis viruses are probably being transmitted in prisons through sharing non-sterile injecting equipment and that a risk of HIV transmission exists. Harm minimisation measures for the 6% of prisoners who continue to inject while in prison should be strengthened.     

Health needs of prisoners in England and Wales: the implications for prison healthcare of gender, age and ethnicity

This paper aims to provide evidence of the healthcare needs of prisoners in relation to gender, age and ethnicity, drawing from a larger systematic overview of the policy and research literature concerning primary care nursing in prisons in England and Wales. The literature overview shaped the initial stages of a research project funded by the Department of Health to examine the views and perspectives of prisoners and nurses working in prisons, and to identify good primary care nursing in the prison environment. At total of 17 databases were searched using search terms related to primary healthcare in prisons (health, nurs*, primary care, healthcare, family medicine, prison*, offender*, inmate*) with terms truncated where possible in the different databases. Following this, a sifting phase was employed using inclusion/exclusion criteria to narrow and focus the literature perceived as relevant to the research questions. All papers were critically appraised for quality using standardised tools. Findings from the literature overview show that prisoners are more likely to have suffered some form of social exclusion compared to the rest of society, and there are significantly greater degrees of mental health problems, substance abuse and worse physical health in prisoners than in the general population. Women, young offenders, older prisoners and those from minority ethnic groups have distinct health needs compared to the prison population taken as a whole, with implications for the delivery of prison healthcare, and how these needs are met effectively and appropriately.     

A nurse‐led intervention improved blood‐borne virus testing and vaccination in Victorian prisons

Objectives: Testing is the first step in treatment and care for blood‐borne viruses (BBVs) and sexually transmitted infections (STIs). As new treatments for viral hepatitis emerge, it is important to document effective models for BBV/STI testing. A nurse‐led intervention was implemented across three prisons in Victoria to improve BBV/STI testing. We evaluated the impact of the intervention on BBV/STI testing rates and hepatitis B (HBV) vaccination for reception prisoners. Methods: BBV/STI testing and HBV vaccination data were collected from the medical files of 100 consecutive reception prisoners at three prisons (n=300) prior to and after the intervention was implemented. Results: BBV testing increased significantly from 21% of prisoners to 62% post‐intervention. Testing for some STIs increased significantly, but remained low: 5% to 17% for chlamydia and 1% to 5% for gonorrhoea. HBV vaccination increased significantly from 2% to 19%. Conclusions: The nurse‐led intervention resulted in substantially increased testing and vaccination, demonstrating the benefits of a concerted effort to improve BBV and STI management in correctional settings. Implications: The availability of new treatments for hepatitis C has precipitated expansion of treatment in prisons. Improving the testing rate of prisoners, the first step in the treatment cascade, will maximise the benefits.     

HIV in prison: what are the risks and what can be done?

Prisons are recognised worldwide as important sites for transmission of blood-borne viruses (BBVs). There are two reasons why transmission risks in prison are higher than in the community. First, in most western countries, many prison entrants have histories of injecting drug use, and thus already have high prevalences of BBVs. Second, the lack or under-supply of preventive measures (such as clean needle and syringes or condoms) in most prisons, combined with extreme social conditions, creates extra opportunities for BBV transmission. HIV prevalence in prisoners in more developed countries ranges from 0.2% in Australia to over 10% in some European nations. There are case reports of HIV being transmitted by sharing injecting equipment and sexual activity. Tattooing has been reported as a risk factor for the transmission of BBVs in prison. Access to condoms and needle and syringe programmes in prisons is extremely limited, despite success when they have been introduced. The vast majority of prison inmates are incarcerated for only a few months before returning to the community--thus they are, over the long term, more appropriately regarded as 'citizens' than 'prisoners'. Public health policy must involve all sections of the community, including prison inmates, if we are to reduce transmission of HIV and other BBVs.     

Hepatitis B vaccine coverage in short and long stay prisons in Wales,UK 2013–2017 and the impact of the global vaccine shortage

Data on hepatitis B vaccination coverage across prisons in Wales 2013–2017 were analysed to describe coverage of one dose, and the full hepatitis B vaccine course for men in prison. Whilst vaccination coverage increased in both short and long stay prisons, annual coverage was consistently lower in short stay prisons compared to long-stay prisons, despite short-stay prisons delivering a higher numbers of vaccine doses. The exception of this pattern was in 2017, at a time of global vaccine shortage. The data demonstrate the need for all prisons to work together to ensure men in prison can receive the full hepatitis B vaccine course. Collaborative working will be required to recover from the vaccine shortage and to achieve higher coverage than the plateau in 2016.     

Transmission of Hepatitis C Virus among Prisoners,Australia, 2005–2012

Hepatitis C virus (HCV) is predominantly transmitted between persons who inject drugs. For this population, global prevalence of HCV infection is high and incarceration is common and an independent risk factor for HCV acquisition. To explore HCV transmission dynamics in incarcerated populations, we integrated virus sequences with risk behavior and spatiotemporal data and analyzed transmission clusters among prisoners in Australia. We detected 3 clusters of recent HCV transmission consisting of 4 likely in-custody transmission events involving source/recipient pairs located in the same prison at the same time. Of these 4 events, 3 were associated with drug injecting and equipment sharing. Despite a large population of prisoners with chronic HCV, recent transmission events were identified in the prison setting. This ongoing HCV transmission among high-risk prisoners argues for expansion of prevention programs to reduce HCV transmission in prisons.     

The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities

This study measured the prevalence and the risk factors associated with HCV antibody-positive prisoners. A total of 630 prisoners completed a questionnaire about risk behaviours associated with HCV transmission and were tested for HCV antibody from a blood test. Of these 362 (57.5%) prisoners were HCV antibody positive. A total of 436 (68.8%) prisoners reported ever injecting drugs and 332 reported injecting drugs in prison. HCV-positive prisoners were more likely to have injected drugs (OR 29.9) and to have injected drugs in prison during their current incarceration (OR 3.0). Tattooing was an independent risk factor for being HCV positive (OR 2.7). This is the first study conducted on prisoners that has identified having a tattoo in prison as a risk factor for HCV. Injecting drugs whilst in prison during this incarceration was also a risk factor for HCV. Our results show prisoners who injected drugs outside of prison continue to inject in prison but in a less safe manner.     

The role of socioeconomic status in the relationship between detention and self‐rated health among prison detainees in Belgium

Prisoners are known to report worse health than the general population. Research has also shown that the prison population counts disproportionally more people with a lower socioeconomic status (SES), making it difficult to determine whether the worse self‐reported health of prisoners is an effect of their detention or of their lower SES. This study assesses the influence of being in prison on self‐rated health and if (and how) this relationship is mediated by SES. Data from detainees were collected in 12 Flemish prisons. To compare with the general population, data from the Belgian national health survey 2013 were used. To estimate the direct and indirect effect of being in prison on self‐reported health, mediation analysis was carried out by means of natural effect models using nested counterfactuals. Following previous literature we find that prisoners report worse health than the general population and that SES has a significant influence on subjective health. Our results showed that the direct effect (exp(B) = 3.43; [95% CI: 2.924–4.024]) of being in prison on self‐reported health is larger than the indirect effect (through SES) (exp(B) = 1,236; [95% CI: 1.195–1.278]), thus contradicting the hypotheses in previous literature that the SES is the main explanation for variation in self‐reported health among prisoners. Lastly, the effect of SES on health is more important for the general population compared to detainees, suggesting that for prisoners the effect of being in prison seems to surpass the effect of SES on health.     

Cost-effectiveness of hepatitis B vaccination of prison inmates

The purpose of this paper is to determine the cost-effectiveness of vaccinating inmates against hepatitis B. From the prison perspective, vaccinating inmates at intake is not cost-saving. It could be economically beneficial when the cost of a vaccine dose is 1.6 and 50%, respectively. The health care system realizes net savings even when there is no incidence in prison, or there is no cost of chronic liver disease, or when only one dose of vaccine is administered. Thus, while prisons might not have economic incentives to implement hepatitis B vaccination programs, the health care system would benefit from allocating resources to them.     

Predictors of hepatitis B vaccination in women prisoners in two prisons in England

BACKGROUND: Hepatitis B is an important public health issue, especially in the female prison population. The high prevalence in this population is largely accounted for by the high rates of injecting drug use and the fact that these women are more likely to exchange sex for drugs or money and practice unprotected sex. There is a national programme in English prisons to vaccinate everyone against Hepatitis B. This study aimed to investigate whether women who had been in prison before were more likely to have been vaccinated against hepatitis B and whether contact with community services was more likely to predict hepatitis B vaccination. METHODS: A questionnaire survey of new entrants into two women's prisons in England. RESULTS: Four hundred and eighty seven out of 613 women approached completed the questionnaire and gave complete data on hepatitis B vaccination status, giving a response rate of 79.4%. One hundred and thirty three women (27.3%) had received at least three vaccinations against hepatitis B. Previous imprisonment and intravenous drug use were independent predictors of vaccination. Six months or more in prison greatly increased an individual's odds of being immunized [odds ratio 12.01 (95% confidence interval (CI) 5.53-26.10)]. Registration with a general practitioner (GP), contact with drug or alcohol services and exchanging money or goods for sex were not independently associated with vaccination status. CONCLUSION: Prisons play an important role in the delivery of hepatitis B vaccination. However, this should not prevent providers of health services making greater efforts to engage this marginalized group and to ensure that they receive an appropriate level of healthcare in the community.     

HIV epidemiology and risk behavior promoting HIV transmission in Austrian prisons

In 1989, 1990 and 1992, 19%, 15% and 10%, respectively, of all prisoners newly admitted to prisons and penitentiary institutions in Austria underwent HIV antibody tests. Based on the HIV test outcome in prisons in which more than 80% of the newly admitted inmates were tested, annual HIV prevalences among prison inmates in Austria were determined. These were 0.5% (11/2,223), 1.3% (19/1,466) and 0.9% (14/1,509) in 1989, 1990 and 1992, respectively. The prevalence rates among prison inmates in Austria are thus 5 times higher than those in the general Austrian population. About 5% of all inmates belong to the high-risk group of intravenous drug users. Inquiries into HIV risk behavior among prison inmates showed that, in Austrian prisons just like in those of many other countries, intravenous drug use and sexual contacts are common practices. As disposable needles and condoms are not available to prison inmates, these practices carry a particularly high risk of HIV transmission. The data collected can be taken as a basis for developing strategies which are designed to reduce the risk of HIV transmission in prisons and which have a major bearing on the development of the HIV pandemic.     

Imprisonment and women's health: concerns about gender sensitivity, human rights and public health

The health of prisoners is among the poorest of any population group and the apparent inequalities pose both a challenge and an opportunity for country health systems. The high rates of imprisonment in many countries, the resulting overcrowding, characteristics of prison populations and the disproportionate prevalence of health problems in prison should make prison health a matter of public health importance.Women prisoners constitute a minority within all prison systems and their special health needs are frequently neglected. The urgent need to review current services is clear from research, expert opinion and experience from countries worldwide. Current provision of health care to imprisoned women fails to meet their needs and is, in too many cases, far short of what is required by human rights and international recommendations. The evidence includes a lack of gender sensitivity in policies and practices in prisons, violations of women's human rights and failure to accept that imprisoned women have more and different health-care needs compared with male prisoners, often related to reproductive health issues, mental health problems, drug dependencies and histories of violence and abuse. Additional needs stem from their frequent status as a mother and usually the primary carer for her children.National governments, policy-makers and prison management need to address gender insensitivity and social injustice in prisons. There are immediate steps which could be taken to deal with public health neglect, abuses of human rights and failures in gender sensitivity.     

Prevalence and incidence of bloodborne viral infections among Danish prisoners

In order to determine the prevalence and incidence of bloodborne viral infections among prisoners, we conducted a prospective study in a Danish medium security prison for males. The prisoners were offered an interview and blood test for hepatitis and human immunodeficiency virus HIV at inclusion as well as at release from prison or end of study. Of 403 prisoners available 325 (79%) participated in the initial survey and for 142 (44%) a follow-up test was available. 43% (140/325) of the participants were injecting drug users (IDUs) of whom 64% were positive for hepatitis B (HBV) and 87% for hepatitis C (HCV) markers. No cases of HIV or human T lymphotropic virus (HTLV) were found. 32% of all prisoners could transmit HBV and/or HCV by blood contact. 70% of IDUs had shared injecting equipment, and 60% had injected inside prison. Only 2% of IDUs were vaccinated against HBV. Duration of injecting drug use, numbers of imprisonments, and injecting in prison were independently and positively associated with the presence of HBV antibodies among IDUs by logistic regression analysis. The HBV incidence was 16/100 PY (95% CI: 2–56/100 PY) and the HCV incidence 25/100 PY (1–140) among injecting drug users (IDUs). We conclude that IDUs in prison have an incidence of hepatitis B and C 100 times higher than reported in the general Danish population. They should be vaccinated against hepatitis B and new initiatives to stop sharing of injecting equipment in and outside prison is urgently needed.