State of transition to Ministry of Health governance of prison healthcare in the Council of Europe region

OBJECTIVES

This study aimed to examine timebound prison healthcare governance amendments and current structures in Europe two decades after the World Health Organization (WHO) Declaration on Prison Health as part of Public Health adopted in Moscow on 24 October 2003 (Moscow Declaration), which recommended prison health care be closely linked with public health systems to ensure quality prison health care, connected health surveillance, and continuity of care.

STUDY DESIGN

We present here a regional evolutionary mapping of the Council of Europe Member State transfer of prison healthcare governance to the auspices of the Ministry of Health.

METHODS

The European Committee for the Prevention of Torture database and WHO Regional Office for Europe Health In Prison European Database were scrutinised for Council of Europe (CoE) Member State status regarding the Ministry responsible for prison healthcare governance and if this had changed since the adoption of the Moscow Declaration in 2003.

RESULTS

As of October 2023, completed transfer of governance to the Ministry of Health nationally is documented in 13 CoE Member States and in one CoE Member State candidate (Kosovo). Partial transfer is documented in Spain (Catalonia and Basque Autonomous Community) and Switzerland (cantons of Geneva, Valais, Vaud, Neuchatel, and Basel-Stadt). Three CoE Member States operate joint governance of prison health care between Ministries (Malta, Portugal, Türkiye). Transfer is a lengthy process (up to 10 years).

CONCLUSIONS

Successful transition requires political commitment, cooperation, needs assessment, resourcing, and evaluation. Monitoring of cost and prison healthcare standards, due process for complaints, and cooperation with independent/Committee against Torture inspections is critical.

Relapses in Illicit Drug Use Among Probationers: Results in a Risk Group of Public Health Services in Bavaria

Objective: We aimed to identify in this study time trends of relapses in the illicit consumption of narcotics in a special at-risk population of former drug users under a public health perspective. Methods: In a pooled dataset of 14 consecutive calendar years (2006-2019), the use of seven different narcotic substances was studied in 380 persons with a total of 2,928 urine samples which were analyzed using a valid marker system for narcotic residues. Results: During the entire observation period, the relapse rate for cannabinoids and opiates was the highest despite abstinence requirements. It was noticeable that the relapses across all narcotics groups occurred primarily during the first 3 years of the probation period (90%) with a decrease in illegal consumption during the following years of the observation period. Conclusion: Special attention should be paid to probationers at the beginning of the probation period to develop more effective prevention strategies for substance abstinence by all involved actors in public health services.

HIV and HCV among drug users and people living in prisons in Germany 2022: WHO elimination targets as reflected in practice

People who inject drugs (PWID) and prisoners are considered key populations at risk for human immunodeficiency virus (HIV) and/or Hepatitis C Virus (HCV). In 2016, the Joint United Nations Program on HIV/AIDS (UNAIDS) was implemented to eliminate HIV and AIDS by 2030 and the World Health Organization (WHO) presented the first strategy to eliminate viral hepatitis by 2030 as well. Following the objectives of the WHO and the United Nations, the German Federal Ministry of Health (BMG) presented the first integrated overall strategy for HIV and HCV in 2017. This article discusses the situation of PWID and prisoners in Germany with regard to HIV and HCV five years after the adoption of this strategy, on the basis of available data and against the background of the most recent practice in the field. In order to meet the elimination goals by 2030, Germany will have to improve the situation of PWID and prisoners substantially, mainly through the implementation of evidence-based harm reduction measures as well as the promotion of diagnosis and treatment in prisons and in freedom.

COVID-19 vaccination in prison settings: a model to design tailored vaccine delivery strategies

Introduction

Vaccinations are one of the most powerful preventive tools discovered by modern medicine. Although expanded programmes of immunization are well established in EU/EEA, significant immunity gaps and suboptimal coverage are registered among specific populations, including people living in prisons (PLP). PLP are also at increased risk to vaccine-preventable diseases (VPD) with potential outbreak in prison, e.g. flu, COVID-19, as well as other VPDs such as HBV. The EU-funded project RISE-Vac, aimed at collecting models of care developed during the pandemic to design tailored vaccine delivery strategies that could be extended beyond the sole COVID-19 vaccine.

Methods

Through a survey to healthcare staff working in prisons in six countries of the EU/EEA (Cyprus, France, Germany, Italy, Moldova, UK) we collected information on the implementation of COVID-19 vaccination program. The following areas were investigated: challenges & barriers encountered, workload distribution, education & training activities for prison staff and PLP, referral strategies after release, immunization information system.

Results

The respondents reported that in prisons COVID-19 programs have been implemented efficiently. Strategies for optimal management of the vaccination campaign included: week-day dedicated to vaccination services when vaccines were delivered and immediately administered to overcome cold chain challenges; new staff recruitment & task shifting; administration of booster doses within prison premises for released individuals; distribution of informational material both to PLP & prison staff.

Conclusions

Our results show that universal immunisation campaigns are feasible, acceptable and effective in places of detention when there is commitment to implementing them. Evidence from the pandemic situation may inform future provision of expanded immunization programmes.

Overview of availability of harm reduction interventions in European prisons

Introduction

Prisons are high-risk environments for the transmission of drug related infections, due to over-incarceration of people who inject drugs; often inadequate healthcare, substandard prison conditions; and others. An overview of the availability and coverage of prison-based harm reduction interventions in Europe is presented.

Methods

National Focal Points of the EMCDDA (30) collected 2019 data, which were integrated with findings from the European funded project HA-REACT (Joint Action on HIV and Co-infection Prevention and Harm Reduction).

Results

Prison based harm reduction interventions are available in European countries, but only few of them are available in most countries and often with a low coverage (e.g. less than 10% of prison population in Opioid Substitution Treatment (OST) in most countries). Interventions available in most countries (20 or more) include: HIV, HBV, HCV testing (29), OST continued from community (29), Referral to HIV treatment upon release (28), HIV treatment (27), Referral to HCV treatment upon release (25), HCV antiviral treatment (25), Testing for TB (23), HBV antiviral therapy (25), OST initiated in prison (22), Treatment for TB (21), Vaccination for HBV (20). Interventions available in 10 to 19 countries are: condom distribution (19), OST (re)initiated before release (17), prison/community guidelines for implementation of OST (13). Interventions provided in < 10 countries include: distribution of disinfectant (9), condom with lubricant (9), take-home naloxone (5), needles and syringes programs (3).

Conclusions

Compared to the community, the availability and coverage of harm reduction interventions in European prisons are limited and large information gaps exist. Scaling up harm reduction in prison can achieve important individual and public-health benefits.

Offering HCV treatment to prisoners is an important opportunity: key principles based on policy and practice assessment in Europe

Background

Prisoners have a high prevalence of hepatitis C virus (HCV) infection but may find it difficult to access healthcare services. This may be related to risk behaviour including history of injecting drugs and marginalisation related to problem drug use/ opioid use disorder (OUD). Direct-acting antiviral products with superior efficacy and safety compared to interferon-based regimens offer HCV cure. Many citizens in Europe have been treated, although few received therapy in prisons.

Methods

Analysis of prisoner HCV treatment need and policy determinants of clinical practice was completed for 5 EU countries. Evidence was collected from national statistical sources and peer-reviewed publications to describe prison populations and HCV prevalence, to map national prison/ HCV health policy or guidance. A consensus of important principles for prisoner HCV care was developed.

Results

Data from published sources describing prisoner HCV prevalence is limited. Prisoner population requiring HCV treatment is not known; estimated numbers based on analysis of evidence: England and Wales, 9000, France, 8000, Spain, 6000, Italy, 6000, Germany, 6000. Treatment access: national law defines right to equivalent care in all countries implying access to HCV therapy in prison similar to community; useful prisoner HCV guidance facilitating treatment decisions present in: 4 of 5 national/ regional HCV policy documents, 4 of 5 national prison healthcare policies. Four of five had practical prison HCV clinical guidelines. Despite existence of policy, implementation of guidance, and so HCV treatment, is suboptimal in many locations.

Conclusions

Prison is an important location to detect, address and treat HCV infection in people who may be underserved for healthcare and find it difficult to navigate community treatment pathways. This is often related to problems with OUD and resulting social inequity. HCV management in prisons must be improved. Policy and clinical practice guidance must be set to promote treatment, and practical steps to make treatment easy should be followed including education to promote engagement, set-up of optimal screening and work up processes with modern tools to reduce time needed/ achieve efficiency; programs to make it easier to get specialists’ input include remote working and nurse-led services.

Substitution treatment and HCV/HIV-infection in a sample of 31 German prisons for sentenced inmates

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners worldwide. However, little is known about the prevalence of IDUs, HCV/HIV and the availability of respective treatment options in German prisons. Data provided by prison physicians of 31 prisons, representing 14,537 inmates, were included in this analysis. The proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in three out of four prisons (74.2%). Overall, 1137 substitution treatments were provided annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and 1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment annually, 86.5% of all HIV-positive inmates in antiretroviral HIV-treatment. Generally, substitution treatment, and HCV and HIV testing and treatment are available. However, due to abstinence-orientated treatment aims, substitution treatment is rarely available as maintenance treatment, and HCV/HIV-treatment is mainly provided for patients with an existing treatment before imprisonment. The inconsistent data quality necessitates changes in prison-related policy to improve surveillance and to generate aggregated data in German prisons. The selection process in this analysis might lead to overestimating the provision of substitution and antiviral HCV-treatment.

Tobacco use among prison staff in Germany: a cross-sectional study

BACKGROUND

Studies on tobacco in the prison environment report high prevalence of use among detainees, but little data regarding staff are available. An observational study addressing tobacco control in German prisons was conducted in 2011. It involved multiple strands (quantitative and qualitative components) both among detainees and staff. This article presents quantitative results regarding staff.

METHODS

Cross-sectional study among prison employees in 16 different institutions in nine regions (Länder) in Germany. Tobacco use and second-hand smoke (SHS) exposure (primary outcomes) were assessed by a questionnaire designed specifically. Logistic regression models were used to assess the risk factors associated with each outcome.

RESULTS

Among 704 participants (60.6% male, mean age 43.9 years ± 9.33), 27.7% are smokers and 68% declared to be exposed to SHS. Independent factors associated with smoking were female gender [odds ratio (OR) 1.49,P= 0.026], an age below 45 years (OR 1.35,P= 0.08) and working in areas other than administration (ORP= 0.08). An age below 45 was associated with a higher degree of self-reported SHS exposure. The association between SHS and gender was different depending on occupational area with significantly more men exposed to SHS in administrative area and more women in health/social area (interaction between gender and occupational area,P= 0.02).

CONCLUSION

Importance of SHS exposure among prison employees and confirm the need for a comprehensive tobacco control policy including support to smoking cessation and better enforcement of the smoke-free regulation, especially where staff contributes to SHS. Particular attention has to be given to female employees.

Substitution Treatment and HCV / HIV Infection in a Sample of 31 German Prisons for Sentenced Inmates

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners worldwide. However, little is known about the prevalence of IDUs and HCV/HIV and the availability of respective treatment options in German prisons. Data, provided by prison physicians of 31 prisons, representing 14,187 inmates, were included in this analysis. The proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in three out of four prisons (74.2%). Overall, 1,137 substitution treatments were provided annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and 1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment annually, 86.5% of all HIV-positive subjects in antiretroviral HIV treatment.

Generally, substitution treatment, HCV and HIV testing and treatment are available. However, due to abstinence-oriented treatment aims substitution treatment is rarely available as maintenance treatment, and HCV/HIV treatment is mainly provided for patients with an existing treatment before imprisonment. The inconsistent data quality necessitate changes in prison related policy are needed, to improve surveillance and to generate aggregated data in German prisons. The selection process in this analysis might lead to overestimating the provision substitution - and antiviral HCV-treatment.

[Prevention of hepatitis C virus infection in drug users]

The high prevalence and incidence rates of the hepatitis C virus (HCV) infections in drug users demonstrate the urgent necessity for a coordinated national prevention strategy. In the shadow of HIV/AIDS the necessary attention to the rapid spreading of the hepatitis C in drug users was started late, without being able to reach the public attention level of HIV/AIDS. The present efforts in the primary and secondary prevention of the hepatitis C in drug users are obviously not sufficient to reduce the prevalence with long-lasting results. Substitution treatment is of central relevance in the prevention of hepatitis C in opiate-dependent subjects, but requires, as current data of the HCV incidence of substituted opiate dependents illustrate, a stronger HCV-specific accentuation. Further settings, which are relevant for the group of intravenous drug users, have to be accessed and sensitized. Furthermore structural and political efforts are necessary, in order to develop a systematic and evidence-based answer to the challenge of the HCV spreading in drug users, in particular due to the fact that a German HCV strategy is still lacking.

Evaluation of needle exchange pilot projects shows positive results

We first reported on a needle-distribution pilot project undertaken in two prisons in Lower Saxony, a state in Northern Germany, in 1997. Scientific evaluation of the project has now shown what scientific evaluation of such projects in Switzerland had also shown--that needle exchange programs can be successfully implemented in prisons.

[Transmission of infectious diseases during imprisonment--results of a study and introduction of a model project for infection prevention in Lower Saxony]

The increasing imprisonment rate of drug users is linked to a spread of infectious diseases in prisons (HIV and Hepatitis B and C). Several studies indicate a close correlation of imprisonment and transmission of infectious diseases. An analysis of international studies showed that worldwide in several cases transmissions of HIV-infection during imprisonment have been discovered. The cross-sectional examination presented here is describing the situation in the women's prison of Vechta (Lower-Saxony). Empirical data on the prevalence of infections with HIV, HBV, HCV and Lues of the years 1992 to 1994 were recorded. Moreover the scientific interest also included on the diagnosis of seroconversions. Discovered seroconversions were examinated on a possible transmission in custody. The spread of infectious diseases in prisons led to the demand for an alignment of internal drug aid services with external, tried and tested prophylaxis models. The availability of sterile syringes is included. The basic comparability of health care inside and outside prison (principle of equivalence) is not only demanded and recommended by the prison law [4] but also by international organisations [27]. As the first provencial government, the state of Lower Saxony in Germany has started to develop infection prophylaxis offers in two prisons (in the women's prison in Vechta since April 15th 1996 and in the men's prison of Lingen I, department Gross Hesepe since July 15th 1996) in 1996. These offers include the provision of sterile injection equipment to intravenous drug addicts (ivDA). Modalities of the practice and first experiences documented by the schientific evaluation are presented.

A combined silver and cholinesterase method for studying exact relations between the pre- and the postsynaptic elements at the frog neuromuscular junction

Combination of Karnovsky's cholinesterase staining with silver impregnation of axons (modified Bodian's technique) offers a new means of studying the relation between the pre- and postsynaptic elements in the frog neuromuscular junction. The method can be applied to whole muscles so that synapses of individual superficial muscle fibers which have previously been investigated by electrophysiological techniques can be identified after staining. In this way synaptic activity can be correlated with such synaptic features as number of axon branches, length of the occupied synaptic gutter, axonal sprouts, etc. The distinction between occupied and unoccupied parts of the synaptic gutters is useful when studying reinnervation, regression, or growth of a synapse.

The labelling of motor end-plates in skeletal muscle of mice with 125I tetanus toxin

Twelve hours after injection of 125I labelled tetanus toxin into the shank of one hindlimb of mice radioactivity was found in the end-plate region of soleus muscles. The ratio between the radioactivity of the end-plate and the end-plate-free region was 2.5 +/- 0.4 S.D. Autoradiographs showed intense labelling of end-plates and a slight but clear labelling of axons. When 125I tetanus toxin was injected 3 days after denervation of the soleus muscle the former end-plate region still accumulated a higher radioactivity (ratio 2.0 +/- 0.5 S.D.), however, autoradiographs showed a diffuse distribution of labelled tetanus toxin. It can be concluded that tetanus toxin binds to the presynaptic nerve terminal. This binding is not dependent on activity of the nerve terminal or transmitter release.