The European Union's Prison Infectious Disease Complex

On any given day there are 590,000 people incarcerated in prisons across the 28 member states of the European Union (EU), yet data on infectious disease burdens in these institutions is severely lacking.

As prison health care is being acknowledged more and more as an important element of public health, challenges such as poor monitoring systems, lag time on implementation of new programs, and a lack of information needed to introduce evidence-based decision-making inhibits progress considerably.

In a personal view piece published in The Lancet, Lara Tavoschi, PhD, and colleagues addressed the challenges and opportunities associated with the development of evidence-based guidance for management of infectious diseases in EU prisons.

According to the authors, the complexity of health care and social needs among incarcerated populations are likely due to a combination of risk factors for infection and poor health. Some recognized factors for disease transmission include poor infrastructure, overcrowding, inadequate facilities, and delays in diagnoses, among others.

Surprisingly in the EU, surveillance and reporting on new diagnoses in prison settings is only available for active tuberculosis (TB). Estimates included in the report indicate that the relative risk of detecting active TB in prison is 10 times higher than in a community setting, with latent TB risks also higher in the prison setting.

Moreover, available data on people who inject drugs (PWID) reveal an association between infection with HIV and hepatitis C virus (HCV) and prison history with longer incarceration linked to a higher prevalence.

With evidence-based decision-making becoming more mainstream, prison health has remained marginalized. The European Centers for Disease Prevention and Control set out to create prison health guidelines developed from evidence-based medicine and literature reviews. The guidance was commissioned by Tavoschi.

Unsurprisingly, the guidance development process was hampered by the shortage of published data.

“Prisons are probably one of the most challenging environments for conducting scientific research because of access problems for external researchers, and other discouraging factors affecting research planning and management, including ethical issues,” the authors of The Lancet report note.

Key conclusions from the guidance on prevention of infectious diseases in prison settings include:

• Prisons should actively offer testing for viral hepatitis and HIV to all individuals upon admission and throughout time in prison.
• A variety of testing approaches for sexually transmitted infections should be considered in order to create higher uptake. Potential approaches include risk-based, age-based, or universal testing.
• Universal provider-initiated testing for active TB should be available at prison intake. Latent TB infection testing can be considered depending on local epidemiology and the availability of resources.
• Institutions should strive to meet national standards for preventive measures to prevent disease transmission including offering vaccinations and opioid substitutions for PWID.
• For individuals who are diagnosed with an infectious disease in a prison setting, appropriate treatment that meets the same standards as community infections should be offered.
• Upon release back into the community, prisons should strive to provide education and support to ensure continuity of care.

“The delivery of health protection and harm reduction public health programs in prisons not only benefits the prison population but also can reduce the risk of transmission of some infectious diseases in the community,” Tavoschi and colleagues write.

The authors cite a study from Scotland, which showed that advocating for hepatitis B vaccination for incarcerated people has resulted in an increased uptake that has been mirrored in growing coverage among PWID outside of prison environments.

Additionally, recent modelling studies have consistently predicted a decline in the incidence of HCV in the general population following a scaling up of case findings and direct acting antiviral-based HCV treatment in prison settings, creating an attractive and cost-effective intervention.

As this report demonstrates, prison health is a critical portion of public health and it’s clear just how highly interdependent prison and health care services are. High quality health care in prisons cannot be offered without cooperation from the correctional system and the prisons cannot deliver prison services that meet international standards without good health care services.

Therefore, using standardized data collection tools in prisons would not only contribute to better estimates of disease burdens (both in the institutions and on a national and international level) and correlated health needs, but it would also allow for adequate resource allocation.

“Despite many remarkable improvements in equivalence of care during the 15 years between these events, much work remains to be done to ensure that prison health is truly seen as part of wider public health,” the authors conclude.