Prisons and other places of detention pose particular risks for the transmission of infection for several reasons. We consider the most important factors for controlling and preventing infectious diseases in such settings with Sunita Sturup-Toft, Health and Justice public health specialist at Public Health England.

Practical Patient Care: What are some of the factors that make infection control and prevention in prisons so challenging?

Sunita Sturup-Toft: When you’re thinking about infection control generally, you always think about the environment, who you’re working with and the general prevalence of different diseases. And those three factors are exactly the same within a prison setting.

Many of the establishments that we’re working with vary in age and how they are designed, so healthcare facilities might be different within each of those buildings. And obviously the way people are detained varies too. Sometimes people have to share cells for example, so that would make us think about infection control differently. And then if we think about the population, the people we’re actually working with, the prisoners, you’ve got people who are moving in and out of the system quite quickly. The churn rate of people moving into prison, maybe moving into a different prison or going back out into the community depending on their sentence, is quite high. So keeping track of people is a challenge in itself and that’s something to consider.

This particular population has quite a high prevalence of infectious diseases. So if we think about blood-borne viruses (BBV) – hepatitis B and C, HIV, other sexually transmitted infections and tuberculosis – all of these are particularly high in this population and that’s for a host of reasons associated with socio-economics. So those three issues, the environment, the population and the prevalence of diseases, do make it quite a challenge within prisons, but what I would say is that you have to see the opportunity to work with people in the prison setting. They are detained, so we can work with them quite easily. So we see it as an opportunity of engaging with people who perhaps don’t often get the chance to engage with healthcare services in the community.

The one resource that’s increasing within prisons is the prisoners, and so how can we use prisoners to think about things like infection control?

What are the main pathogens you’re focusing on?
If we look at surveillance and actual data, the ones we see most commonly are hepatitis C, and of course gastrointestinal infections with diarrhoea and vomiting symptoms. TB is the other one, just because of the nature of the population. Those I would say are our kind of top three, and that’s also from an international level right down to a local level.

What measures are in place to control the infections?
We advocate for the standard principles of infection control that we would use in the community setting [outside of prisons], so we would still apply those precautions, such as usual hand hygiene, using protective equipment, thinking about how you dispose of sharps and any management of injuries around that.

We also think about teaching awareness and engaging with healthcare professionals, and also with the prisoners. From a public health perspective, looking more broadly at population intervention, we’ve got vaccination programmes for hepatitis B, and in England, we’re trying to move to an opt-out policy for all BBV testing and vaccination. So when a person comes into prison, we would offer them the hepatitis B vaccination programme.

We’ve got things such as flu campaigns as well. In terms of health promotion, we’re trying to get messages out there around seasonal flu vaccination. And we also try to use the people within the prison setting itself. So we’re really trying to take an asset approach to healthcare. One of the things we joke about, I suppose, is the one resource that’s increasing within prisons is the prisoners themselves, and so how can we use prisoners to think about things like infection control? I know in some places, prisoners are trained to be cleaners, and that’s to the same standard as we would see within any other NHS setting.

Have infection control procedures changed in the past ten years or so?
I think the biggest changes that we’ve seen have only been improvements. Nationally, we’re doing really well in terms of moving forwards with it. I think that’s due to a lot of standardisation we’re trying. We’ve got lots of national guidance about working in detained settings. We have an outbreak plan for detained settings that all prisons in the country are signed up to. We have a communicable disease manual for people working in detained settings, which covers all the infection control procedures. That kind of standardisation improves quality. We’ve also got a way of learning from each other’s experiences.

There’s quite a tight network around health protection but also generally around public health for prisons. We are able to exchange information quite quickly across the country. In fact, we have a weekly telephone conference where we exchange information.
That means you can actually have quite rapid responses on the ground, and that can go right down from a local level back up to a national level very quickly. We had a recent example in a prison where there was an outbreak of diarrhoea and vomiting. It was to do with food hygiene and food safety, and how they were looking after food that people were eating during Ramadan.

That’s quite a recent example. All that was required was some guidance as to how they should keep food that had to be eaten later on in the evening after sunset. That was a local issue. We were able to feed that to the national team, and within the space of a few days, the Ministry of Justice was able to issue a food-safety notice to all prisons. It’s that kind of rapid communication that improves standards within a local setting.

What’s the standard procedure in the case of an outbreak?
We have a national outbreak plan that goes through all the roles and responsibilities of different people, from the prison governor to local authorities, to the local health protection scheme that would lead the response. It tells you when you actually must call something an outbreak.

Then it goes through how you might contain the situation, how you might deal with the media, how you would bring together an outbreak control team, what the agenda for those meetings would be and how you would report to different systems. It’s quite a comprehensive plan. Prisons are asked to sign up to this, so it’s a partnership agreement that we have with the National Offender Management System (NOMS) and with NHS England.

What’s the view on antibiotics in prison healthcare?
In terms of antibiotic resistance, maybe we haven’t done so much on that, but we certainly are interested in general resistance to medications, especially in terms of TB. We’ve done quite a lot of work on multidrug-resistant TB. We’ll probably do further work with TB control boards as they come online as well. It’s about working with local health protection teams to make sure that we’re able keep people on medication, and think about how we might continue their care in other prisons and also when they are back in the community. I think that’s something important to remember when we think about working with people in prisons.

Actually, the majority of them are in prison for quite a short time. They spend most of their time in the community, so it’s important how we ensure that continuity of care happens, and that’s about having local links and ensuring health and justice is on the agenda for commissioners in a community setting as well as within the prison.

What more do you think needs to be done to limit infection transmission in prisons, and how can this be implemented?
We’ve had a really good start and what we’ve developed so far has been fantastic. We can only continue to improve it. We have got a real opportunity with health promotion. We are really interested in service users and their views, and how they can be part of the solution. I think that’s exactly what we need to do within prisons.

We need to continue to look at that population-level intervention. How do we improve vaccination rates, and how can we use our surveillance to the best advantage and detect those emerging trends?
We’ve also been thinking about how we can run simulation exercises to test the system. We have got some robust plans in place, but we want to test those, and we’ve got plans for that within the coming year.