Detained persons are a vulnerable and underserved population. Prior to imprisonment they frequently have limited access to healthcare due to educational, social and economic disadvantages.79;80 Prison has been identified as a substantial opportunity to address the health needs of vulnerable groups. In particular, prison health services aim to reduce inequalities by but most (57.6%) required treatment for common primary care problems, such as skin (27.0%), infectious disease (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory disorders (14.0%). Until recently Switzerland lacked national comparative data concerning health problems of a primary care nature for the general population. A recent publication provides data from ICPC-2 coded electronic medical records of 24 Swiss GPs concerning 29,398 doctor-patient encounters. The main reasons for the visits were musculoskeletal (21%), circulatory (19%), respiratory (9%) and endocrine, metabolic and nutritional disorders (8%).82 Prevalence data in our study were different for most health problems, with the exception of musculoskeletal disorders. This adds value to our findings by highlighting the extent to which primary care services in prison may differ from those provided to the general population. Our findings are consistent with those from Great Britain83 and Belgium84, where detainees consulted 3 to 3.8 times more frequently as compared to the age-and sex-adjusted general population. The main ICPC-2 code groups in the Belgium report were the same as we found. Nearly 70% of detainees in our study had consultations with a primary care physician. The increased demand for primary care services in prison can be explained not only by the accumulation of negative social determinants of health which contributes to a high burden of disease, but also by improved access to health care services in prison.80;84;85 For many inmates contact with the prison health service is their first opportunity to meet a healthcare professional. Addressing the health needs of detainees through well-coordinated primary care services offers an excellent opportunity to interact with this hard-to-reach vulnerable population
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in the interests of their individual health and of public health overall. Furthermore, these services provide an opportunity for future research to increase epidemiologic knowledge and evaluate preventive actions.
See: “Health problems among detainees in Switzerland: a study using the ICPC-2 classification”78
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Infectious diseases and epidemics
Infectious diseases are frequent in detention settings.80;86;87 Hammet estimated that “during 1997, 20% to 26% of all people living with HIV in the United States, 29% to 43% of all those infected with the hepatitis C virus, and 40% of all those who had tuberculosis disease in that year passed through a correctional facility”.88
Our findings highlight the vulnerability of detainees to infectious diseases. These diseases challenge modern social security systems and need to offer access to screening and treatment for all inmates, independent of cost. Effective screening, containment and therapeutic measures in prison provide not only obvious health and safety benefits for inmates, but these measures are also invaluable for prison personnel, facilities, and the community at large.
Tuberculosis, Hepatitis and HIV
In Switzerland, we identified prevalence rates for tuberculosis among detainees at more than ten times those found in the general population (0.2% vs. 0.006%).78;89 TB-notification rates are 14.9 times higher worldwide in detainees as compared to the general population, and in Western Europe they are 8.1-times higher.90 The high rates of infectious diseases, particularly tuberculosis, are related to risk factors which aggregate in prison, including low socioeconomic status, intravenous drug use, homelessness, lack of access to community-based health care, and detainee origin from high TB-incidence countries 86;90. High rates among inmates were also found for other infectious diseases such as HCV (5.7%) and HIV (1.0%) compared to the general population in Switzerland (0.7-1% for HCV and 0.3% for HIV).78;91;92.
Chlamydia trachomatis
As previously mentioned, CTI is the most frequently diagnosed STD in both men and women in the Western world. The exact burden of this infection remains unknown as a substantial percentage of CTI is neither diagnosed nor reported.42 Undiagnosed infections are a real challenge as untreated disease leaves patients at risk of developing complications such as sterility, ectopic pregnancy, inflammatory pelvic disease and orchitis. We found a CTI prevalence of 6.5 % among males and 10% among females in Switzerland’s largest prison,93 higher than in the general Swiss population (CTI prevalence of 2.8%)42 but within the range found in corresponding
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prison settings in France, the United Kingdom, and the U.S. where the prevalence varied between 3.9% and 21%.94-100
Chickenpox
Chickenpox is a highly contagious viral disease with greater complications and higher mortality in adults than in children. Secondary attack rates reach 90% for susceptible household contacts.101 Young adults who grew up in Western Europe have a high protective immunity (97%
to 100%).102-104 The high proportion of inmates coming from tropical countries, as well as overcrowding, increases the risk of chickenpox epidemics in prison. High ambient temperatures and humidity in the tropics may inactivate varicella zoster virus (VZV) which might explain a lower incidence in children and a higher susceptibility in adults in these regions.105-107 Outbreaks of chickenpox with deadly complications have been documented in prisons in the U.S., Australia, Scotland and Italy.108-111 Mass media has reported outbreaks of even greater magnitude in prisons in Asia, Africa and Latin America.
The occurrence of an outbreak in Switzerland’s largest prison provided the opportunity to identify susceptibility rates for chickenpox, and found a 6-fold higher susceptibility compared to Swiss or other Western European adults (12.7%).102;112 Furthermore, effective prevention measures were developed including post-exposure vaccination and quarantine of the contacts.
Measles
Measles is a highly contagious viral disease with an attack rate in susceptible exposed individuals of 75%.113 Complications are more frequent if the infection occurs during adulthood, leading to serious debilitation and even death.114-117 In 1998 the WHO member states adopted the goal of eradicating measles in Europe by 2010. However measles still persists on this continent despite the intensification of general vaccination campaigns. Switzerland, where the current measles epidemic shows no sign of decline, has one of the poorest immunization coverages and one of the highest annual incidence rates of measles in Europe.118;119
Both environmental and demographic characteristics in confined institutions, particularly prisons, explain the high risk of measles epidemics. Large proportions of inmates are migrants who come from countries where vaccination coverage is low and susceptibility rates are unknown.Moreover, the potential for dissemination is high in overcrowded conditions,120;121 and
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outbreaks of measles have been documented in various prisons in Western countries.122;123 It is important to identify specific groups at risk for measles and to tailor health information and preventive measures specifically for these individuals.
Our study of measles susceptibility in detention identified a rather low susceptibility level (6%).124 The study suggests that measles vaccination is most efficient if targeted specifically for adult migrants born after 1981 originating from transitional and developing countries outside sub-Saharan Africa.
See : “Chickenpox in a Swiss prison: susceptibility, post-exposure vaccination and control measures”,112 “Improvement of measles immunity among migrant populations: lessons learned from a prevalence study in a Swiss prison”124 and “Chlamydia trachomatis infection in a Swiss prison: a cross sectional study”93
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