Amendments to the WHO Interim Guidance on Preventing COVID-19 Outbreak in Prisons: Remarks from Germany

Background: Globally, at any given time over 11 million people are held behind bars, while turnover of prisoners may reach up to 30 million. Evidence leaves no doubt that inmates are at a greater risk of acquiring influenza family viruses. This issue highlights the importance of paying extra attention to this vulnerable population.

Purpose: The World Health Organization (WHO) Regional Office for Europe responded to this issue by developing a set of guidelines on COVID-19 control in prisons. This manuscript reports some important gaps in the above-mentioned guidelines and some recommendations to bridge these gaps.

Findings: A set of important factors including: 1. Information on the special handling of drug-consuming prisoners; 2. Instructions for dealing with prisoners in opioid agonist treatment (OAT); 3. Notes on reducing the number of prisoners and reducing the number of imprisonments; 4. Indications of vaccinations; 5. Information on measures suitable to ensure continuity of care; and 6. Use of rapid tests are important points that have been overlooked by the WHO guidelines to control COVID-19 in prisons.

Conclusion: This paper suggests amendments to the guidelines on COVID-19 control in prisons, developed by the WHO. Paying attention to the recommendations of this manuscript would lead to better control of COVID-19 and similar outbreaks in prisons, and mitigate the burden attributable to such infections. Interventions to control COVID-19 in prisons should be done considering the entire ethical aspects.

Background and state of the issue

At the time of writing this manuscript the exceptionally high burden of the COVID-19, is one of the main global health concerns [1,2]. Although not much is known about the current epidemiology of COVID-19 in prisons, evidence shows that members of the family Coronaviridae (e.g. H1N1 virus) can cause rapid outbreaks in prisons and the other closed settings [3,5].

To tackle this issue, the World Health Organization (WHO) Regional Office for Europe reacted promptly by developing a set of guidelines on COVID-19 control in prisons [6]. The guidelines provide a comprehensive overview of the present state of knowledge about COVID-19; however, the demands on the prison system are currently hard to fulfill due to numerous social, financial and environmental factors. With some examples from German prison context, in this manuscript we highlight some limitations of the WHO guidelines on COVID-19 control in prisons, and suggest solutions to improve the effectiveness of interventions to mitigate the burden of this disease in prisons.

Information on the special handling of drug-consuming prisoners

People who use drugs represent a significant proportion of the number of prisoners. These patients are chronically ill, the majority is male, and almost all are smoking [7]. Suggested by the international organizations as well as the Robert-Koch-Institute (RKI) in Germany [8], people who smoke are at a greater risk of acquiring COVID-19. In Germany, for example, almost all smoking prisoners are living with chronic respiratory diseases including chronic bronchitis or chronic obstructive pulmonary disease (COPD) [9]. Lack of attention to this vulnerable group of prisoners is one of the main gaps in the WHO guidelines to deal with COVID-19 in prison.

Instructions for dealing with prisoners in Opioid Agonist Treatment (OAT)

The idea of daily supervised intake of OAT medication in all prisons in Germany causes movements for a very significant proportion of prisoners and should be avoided. It is also difficult to reduce the number of prisoners in the waiting area for supervised medication in such a way that only a limited number of prisoners are allowed to be presented there. Keeping the recommended distance of 1.5 to 2 meters is also particularly difficult in prison settings. Especially since the ‘out of cell’ time in prison typically creates enclosing among prisoners.

Both the German Society for Addiction Medicine and the Chairman of the Quality Assurance Commissions of the Associations of Statutory Health Insurance Physicians have already published recommendations for actions that should be taken into account when considering the dilemma of daily suspension and high risk of contact and transmission. In addition to the usual recommendations these include an increased use of take-home supply and, in the case of patients already on treatment with buprenorphine, increased use of already available weekly or monthly depot applications. This measure could reduce 7 contacts per week to at least 1 contact per week, or even from 30 days a month to once monthly using the now possible 30-day take-home supply and the above-mentioned monthly depot. This is certainly of interest of the measures already taken by the Federal Government and certainly reduces the transmission risk considerably.

Objections to take-home allocation even in prison should not play a role in the overriding goal of preventing infection, especially in patients who do not use illicit drugs in prison.

Notes on reducing the number of prisoners and reducing the number of imprisonments

Unfortunately, the WHO guidelines also lack specific information on reducing the number of prisoners. Such efforts are reported from many (Federal) States in Germany. The lower the number of prisoners, the fewer contacts and thus opportunities for infection transmission in prisons.

Reducing prison population is possible in at least three ways

To reduce imprisonments: All arrest warrants outstanding for execution should be suspended. This mainly affects so-called alternative custodial sentences. This measure would not only reduce the number of prisoners but also free up police resources for more important tasks. It is crucial, however, that the risk of an introduced infection would be significantly reduced, an infection that would otherwise spread at breathtaking speed in the prison setting. Despite the restrictions on imprisonments, new detentions cannot be avoided entirely. A separate area should therefore be created for newly detained prisoners, where they should be initially accommodated in the sense of quarantine for a reasonable period of time. Necessary movements in the institution (e.g. dress chamber, prison office, initial medical examination) should be completed with a face mask.

To increased releases: Where it is justifiable from a security point of view, all prisoners should be released either temporarily (as happened in North-Rhine-Westfalia State) or as part of an amnesty in as ‘safe’ environments as possible. What is common practice in the context of a Christmas amnesty should not create substantial resistance from the authorities or the judiciary in the time of SARS-CoV-2 resp. COVID-19.

To suspend enforcement of penalties that would be enforced in open prison settings

This action would reduce imprisonments significantly, at least in the Federal States providing an open prison setting. In Berlin, for example, delinquents with detention up to 3 years are currently not included as new entries.

While considering the above-mentioned options, it should be guaranteed that Juveniles are no longer enforced; no prisoner is collectively transported; and as a rule, there are no excursions or ease of detention.

Indications of vaccinations

Although the Standing Committee on Immunization (STIKO) has already drawn up relevant vaccination recommendations, particularly for prisoners, many institutions (exceptions confirm the rule) are still a long way from implementing these vaccination recommendations with the necessary commitment. Now facing a situation caused by COVID-19, a concept like “vaccine awareness” naturally arises again. A large number of our previous and sometimes massively chronically ill patients (i.e. those with liver or lung conditions) would benefit significantly from vaccination against influenza and pneumococci. Since they have not been vaccinated so far despite existing indications, it is clear the current situation leads to an increased demand. As a result, pneumococcal vaccinations, for example, are currently not available from pharmacies providing central supply.

Information on measures suitable to ensure continuity of care

Understandably, duty rosters have not yet been drawn up from the perspective of a COVID-19 pandemic. If a staff member is affected by an infection and has continued to work without knowing the infection status, he may have had contact with a large number of colleagues due to the duty roster, who are all subsequently absent from duty. The alternative is to form small teams.

As an example: if 12 employees are available in a prison clinic, teams of 4 employees are formed, each of them, is deployed for a week. If one of the staff members from one team is infected, two other complete teams are still available to serve. Of course, these considerations can be modified based on the number of medical staff members in prisons.

Use of rapid tests

So far, rapid tests are not yet available in sufficient and affordable quantities. The company Cepheid has an approval in the USA for rapid tests (result in approx. 45 minutes), but for which special devices (GeneXpert machines) are required. This procedure has the disadvantage that it is very expensive and that people can only be tested individually. In Germany, the Helmholtz Center for Infection Research is currently developing a rapid test based on a different method than the Cepheid method. As soon as the rapid tests are available in sufficient quantity and quality, they should be widely and early used as a screening tool in the prison setting, both for staff members and entrants. Even outside the prison system, there are currently considerations to improve the situation through extensive testing.

Conclusion

At the time of COVID-19, leaving prisoners behind is a violation of their right to health as human beings. These vulnerable people are deprived are their liberties, but they shouldn’t be deprived of proper healthcare services. Although helpful, we believe that the WHO guidelines on COVID-19 control in prisons are not enough to deal with the infection. The recommendation of this manuscript may bridge the gap in the WHO guidelines and save the lives of thousands of highly vulnerable people behind bars, although all suggested interventions should be applied by taking ethical considerations into account.

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