Vaccinations in prisons: A shot in the arm for community health

Figures & data

Table 1. Importance of vaccination in prisons

Access to vulnerable social groups
Groups with little normal access to the health system
Prisoners come from disadvantaged social strata (educational and socioeconomic level)
Greater history of illicit drug use before entering prison
Greater history of alcohol abuse
High prevalence of carriers of communicable diseases and other morbidities
Overrepresentation of especially-vulnerable groups: LGTB, sex workers, immigrants
Progressively greater proportion of elderly adults
High risk of acquiring infections in prison
Sexual activity, often unprotected, in prisons
High rate of starting or returning to illicit drug use (injectable and non-injectable)
Tattoos / piercings
Physical violence (injuries, rapes)
Permanent contact with the community
High rotation rates in prison (short sentences, transfers)
Visits/ staff/ temporary release
High risk of extreme behavior in the first weeks after release (drug abuse)
Prison population is known and concentrated in one place
Population identified and easily located

LGBT: gay, lesbian, transgender, bisexual.

Figure 1. Comparison of US estimates of lifetime prevalence (%) of viral hepatitis risk factors and seroprevalence of hepatitis A, B and C virus exposure in inmates vs. the overall population 2009. HBc IgG, IgG antibody to hepatitis B core antigen; HCV Ab, antibody to hepatitis C Total virus. HAV IgG, IgG antibody to hepatitis A. MSM, men who have sex with men. Figure modified from “Viral hepatitis in incarcerated adults: a medical and public health concern;” by Hunt, DR & Saab S.⁴⁴

Figure 2. Transmission of communicable diseases inside and beyond prisons. Figure modified from Guidelines for the Control of Tuberculosis in Prisons, WHO 1998.¹⁵³

Table 2. Biological Hazards Prison

Transmisson by serum

HIV

Hepatitis B

Hepatitis C

Respiratory transmission

Tuberculosis

Influenza

Measles

Mumps

Rubella

Meningococcal infection

Pneumococcal infection

Enteric transmission

Hepatitis A

Transmission by contact

Herpes simplex

Varicela Zoster

Scabies

Viral conjuntivitis

HPV

Diphtheria

Tetanus

* Vaccine available.

Table 3. Prevalence of Hepatitis B in prison

Country (reference)	City, State or Region	Survey year	Prisons	Population	Seroprevalence (%)
Australia (35)	New South Wales, Queensland, Tasmania and Western Australia	2004, 2007, 2010	29	1388 914(IDUs)	2.3% 3.1%(IDUs)
Brazil (68)	Goias (State)	2007–08	1	150	0.7% – 1.3%
Brazil (69)	Sao Pablo (State)	2003	1	333	2.4% – 1.2%
Croatia (65)	All country	2005–2007	20	3290	1.3%
England and Wales (66)	Different regions	1997 – 98	8	3930 775 (IDUs)	8% 20%(IDUs)
Ghana (70)	Different regions	2004–05	8	1366	25.5%
Hungary (41)	All country	2007–09	20	4894	1.5%
Iran (64)	Isfahan	2009	2	970 (IDUs)	3,3% (IDUs) 13,9% (IDUs)
Mexico (67)	West central Mexico	2007	1	30	20%
Nigeria (71)	Nasarawa (State)	2007	4	300	23%
Pakistan (34)	Karachi	2007–08	1	357	5.9%
Spain (31)	All country	2008	18	342	2.6%
USA (42)	Different States	Studies between 1975 and 2005	25	nd / meta-analysis 23 studies	0,9% – 8% 6,5% – 42%

EEUU: United States of America. IDUs: prevalence among injecting drug users. HbsAg=hepatitis B surface antigen; HBc IgG=IgG antibody to hepatitis B core antigen.

* = hepatitis B surface antigen (HbsAg).

** = IgG antibody to hepatitis B core antigen (HBc IgG).

*** = HbsAg plus HBc IgG positives. nd = no data.

Table 4. Summary of Strategies and Recommended Guidelines

Vaccine	Recommendations/Strategies	Schedules	Comments
Hepatitis B	All new inmates with negative or unknown serology.	Normal: 0, 1 and 6 months Accelerated: 0, 1, 2 and 12 m Rapidly-accelerated: 0, 7, 21 d and 12 m	Previous serology recommended.
	New inmates with risk factors: IDUs, chronic disease, MSM, mental illness.
Hepatitis A	All new inmates with negative or unknown serology.	HA: 0 – 6 months HAV/HAVB: 0, 1, 2 and 12m HAV/HBV: 0, 7, 21 and 12 m	Evaluate age and place of origin.
	New inmates with risk factors: IDUs (pre-serology not necessary), MSM and hepatic risk factors.
Tetanus/diphtheria	Prisoners without demonstrated history of vaccination.	0, 1 and 6–12 months (Td)	Evaluate vaccination if there are lesions.
	All new inmates with last dose > 10 y ago.	1 booster dose (Td)
PCV13 and PPSV23	Prisoners aged more than 65 y	0 (PCV13) and 6–12 months (PPSV23). If previous PPSV23, PCV13 > = 1 y	Two doses of VP23 recommended in specific risk groups
	Prisoners aged more than 18 y with baseline pathology included in recommendations	0 (PCV13), PPSV23 minimum of 8 weeks later
Seasonal influenza	All new inmates	One annual dose during influenza season.
	Risk groups: > 65 years, pregnancy, chronic medical condition or immunosuppression
Mumps, measles and rubella	All new inmates with negative or unknown serology.	History of childhood vaccination: 1 dose. No history of vaccination: 0, 1 month.
	Women of child-bearing age.
Human papilloma virus	Women with no history of vaccination or incomplete vaccination.	0, 1–2 and 6 months	Prioritize persons aged less than 26 y Upper limits vary by country
Meningococcal C	Inmates aged less than 26 y	1 doses
Varicella	Prisoners with proven history of vaccination.	0–4,8 weeks
	Prisoners who remember receiving one dose.	One booster dose

IDUs: injecting drug users. MSM: Men who have sex with men. HAV: Hepatitis A virus. HBV: Hepatitis B virus. PCV13: 13-valent pneumococcal conjugate vaccine. PPSV23: 23-valent pneumococcal polysaccharide vaccine.

* CDC 2014 recommendations.¹⁰²

** See risk groups: CDC 2012.¹⁰³

*** WHO 2014: recommends an upper age limit of age of 26 y.¹²²

Table 5. Research gaps: improving the introduction of prison vaccination programs

1	Cost-effectiveness assessments of integrated vaccine program introduction
2	Health technology assessment of prison vaccine program introduction
	Promotion of reports on prison vaccination with a focus on developing countries
4	Promotion of studies on the implementation of vaccination in female prisons
5	Gender studies on vaccination in prisons
6	Research on elderly prisoners and the impact of vaccines in this group
7	Research on the impact of vaccines on mentally-ill inmates

Table 6. Recommended steps to ensure vaccination schedules in prisons

Integration of health services with the prison system	1	The authority and responsibility for health care in prison lies with the health system
	2	Ensure the integration of prisons with other community health services
Application of a vaccination schedule	3	Ensure compliance with the vaccination schedule for healthy adults
	4	Ensure access to vaccination of persons with specific risk factors (HIV, HCV, MSM)
	5	Establish vaccination priorities for each prison according to identified epidemiological factors and local resources
	6	Evaluate strategies (coverage, adherence, follow up outside prison)

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