Communicable Diseases in Prisons, Threats and Opportunities © Carl Cordonnier © Carl Cordonnier © Maxim Dondiuk © Maxim Dondiuk Communicable Diseases in Prisons, Threats and Opportunities Vilnius Summit 1 July 2016 Dr Masoud Dara, Team Leader, TB and M/XDR-TB, Joint TB, HIV/AIDS and Malaria programme, WHO Regional Office for Europe

Outline of presentation A short overview of Prison population globally and in WHO European Region Prisons specifications in relation to communicable diseases TB as an example of CDs in prison Factors contributing to prison outcomes UNION Statement (Time to Act)

World Prison Population List (tenth edition), Roy Walmsley Prisons ‘Prison’ is a term used for any place of detention. On any day, it is estimated that the world’s prisons hold 8-10 million prisoners. 4-6 times this number pass through prisons each year, because of the high turnover of the population.  ‘Prison’ is a term used for any place of detention. It includes centres for pre-trial and convicted prisoners as well as centres for juvenile offenders and illegal immigrants. World Prison Population List (tenth edition), Roy Walmsley

Prison population The highest prison population rate is in USA – 716 per 100 000 of population. Prison population increased by 25-30% within 15 years, while world population about 20%. 2014 – prison population rate was about 144 per 100 000 world population, while the respective rate in 2013 was 136 per 100 000. «World Prison Population List (tenth edition) Roy Walmsley»

General prison population in Europe*: around ~770 000 2000 prisons in 30 European countries Prison Population Rate*100,000: : 130 Russia: 475; US: 716 4 % women (~ 32 000) 17 countries with overcrowding 16 % average foreigners 1/4 prisoners no final sentence Mainly short sentences High recidivism Sources: SPACE 2014 – Council of Europe * Europe: 28 EU countries, Norway and Turkey; International Centre for Prison Studies

Threats Vulnerability to communicable disease before imprisonment Stress, overcrowding, nutrition High risk behaviors in prisons: peer pressure, smoking, unprotected sex, unsafe injection Lack of/willingness to access (to) health services, psychological aspects High mobility and difficulties in integration after release

Threats (2) Health often not prioritized (versus security) Limited staff Inadequate link of prison and civilian services Insufficient funding Difficult working conditions

Opportunities Effective prevention and harm reduction Promoting healthy life style Collaboration and/or integration of health services in penitentiary and civilian sector Involving peer-educators and ex-prisoners Strengthening surveillance WHO Health in prison Project

6.5% of new TB cases in the WHO European Region are reported from prisons © Maxim Dondiuk

In 10 countries in Region TB rate in prison population exceeds 1000 cases per 100,000 Countries reporting TB notification rate in prisons in WHO European region, 2013 Notification rates of new TB cases in prisons in all reporting countries were multiple times higher than the rates found in general population and were over 1000 per 100,000 detainees in Kosovo, Kazakhstan, Moldova, Azerbaijan, Russia, Kyrgyzstan Ukraine Georgia, Tajikistan, and Latvia.

TB Relative Risk in prisons is ranging from 3 to 48 Relative Risk of TB in prison vs. general population, WHO European Region TB Relative Risk in prisons is ranging from 3 to 48 Overall, in the Region the TB rate in prisons about 24 times is higher compared to general population in 2013

Treatment outcome in prison and civilian population, WHO European region, 2013 Chance of positive treatment outcome among new and relapse TB cases among prisoners is only 62% vs.77% observed in civilian population in WHO European Region.

Factors leading to treatment failure Patients related factors Medical services related factors PS related factors

Patients related factors Food refusal HIV infection or other serious co-morbidity Drug addiction and mental disorders Retreatment

Medical services related factors Tuberculosis control in prisons: current situation and research gaps, Dara M et al, International Journal of Infectious Diseases March 2015, Volume 32, Pages 111–117 60-70% ex-prisoners don’t refer to TB facilities after release from prisons Medical services related factors Shortages in supply, quality assurance leading to delay in diagnosis and treatment Insufficiencies in medical staff Irregularities in TBD and reagents supply Poor or non-existent coordination with MoH Uncontrolled TB therapy

UNION Statement call for Action Adapt stop TB strategy in prisons Conduct screening Ensure infection control Provide access to early diagnosis and treatment Ensure early start of ARV for TB/HIV coinfected individuals Provide preventive therapy

UNION Statement call of Action (II) Ensure continuum of care Monitor the situation Encourage collaboration between civilian sector and prison services Provide psychological support Raise awareness, educate prisoners and staff Operational research

References http://www.prisonstudies.org/sites/prisonstudies.org/files/resources/downloads/wppl_10.pdf World Prison Population List (tenth edition) http://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf?ua=1 Prisons and Health, WHO, 2014 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000381 Tuberculosis Incidence in Prisons: A Systematic Review, 2010 http://pdf.usaid.gov/pdf_docs/PNADP462.pdf GUIDELINES FOR CONTROL OF TUBERCULOSIS IN PRISONS, USAID ,2009 https://www.icrc.org/eng/assets/files/other/reyes_ijph_march2007.pdf Pitfalls of TB management in prisons, revisited ICRC, 2007 http://www.ijidonline.com/article/S1201-9712(14)01747-0/fulltext Tuberculosis control in prisons: current situation and research gaps , 2015

Acknowledgement Dr Arax Hovhannesyan , Dr Andrei Dadu, Dr Elmira Gurbanova, Dr Irada Mammadova, Ms Nina Blinkenberg, Dr Lars Moller

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