Controlling COVID-19 outbreaks in the correctional setting: A mathematical modelling study.

Correctional centres (termed here 'prisons') are at high risk of COVID-19 and have featured major outbreaks worldwide. Inevitable close contacts, frequent inmate movements, and a disproportionate burden of co-morbidities mean these environments need to be prioritised in any public health response to respiratory pathogens such as COVID-19. We developed an individual-based SARS-CoV-2 transmission model for the prison system in New South Wales, Australia - incorporating all 33 correctional centres, 13,458 inmates, 578 healthcare and 6,909 custodial staff. Potential COVID-19 disease outbreaks were assessed under various mitigation strategies, including quarantine on entry, isolation of cases, rapid antigen testing of staff, as well as immunisation.Without control measures, the model projected a peak of 472 new infections daily by day 35 across the prison system, with all inmates infected by day 120. The most effective individual mitigation strategies were high immunisation coverage and prompt lockdown of centres with infected inmates which reduced outbreak size by 62-73%. Other than immunisation, the combination of quarantine of inmates at entry, isolation of proven or suspected cases, and widespread use of personal protective equipment by staff and inmates was the most effective strategy. High immunisation coverage mitigates the spread of COVID-19 within and between correctional settings but is insufficient alone. Maintaining quarantine and isolation, along with high immunisation levels, will allow correctional systems to function with a low risk of outbreaks. These results have informed public health policy for respiratory pathogens in Australian correctional systems.

Preparing correctional settings for the next pandemic: a modeling study of COVID-19 outbreaks in two high-income countries.

Introduction: Correctional facilities are high-priority settings for coordinated public health responses to the COVID-19 pandemic. These facilities are at high risk of disease transmission due to close contacts between people in prison and with the wider community. People in prison are also vulnerable to severe disease given their high burden of co-morbidities. Methods: We developed a mathematical model to evaluate the effect of various public health interventions, including vaccination, on the mitigation of COVID-19 outbreaks, applying it to prisons in Australia and Canada. Results: We found that, in the absence of any intervention, an outbreak would occur and infect almost 100% of people in prison within 20 days of the index case. However, the rapid rollout of vaccines with other non-pharmaceutical interventions would almost eliminate the risk of an outbreak. Discussion: Our study highlights that high vaccination coverage is required for variants with high transmission probability to completely mitigate the outbreak risk in prisons.

Lessons learned from keeping NSW's prisons COVID-free.

PURPOSE: New South Wales (NSW) correctional system houses 30% of prisoners in Australia and at this time has only had a single documented case of COVID-19 amongst its prisoner population. The coordinated response by Justice Health and Forensic Mental Health Network (The Network) undertaken with the support of NSW Ministry of Health, in partnership with Corrective Services NSW (CSNSW), Youth Justice and private jails has ensured that the NSW correctional system has remained otherwise COVID-free. DESIGN/METHODOLOGY/APPROACH: A research study of how a range of partners which support the operations of NSW Correctional System developed an effective approach for the prevention a COVID-19 epidemic amongst its inmates. FINDINGS: Establishment of effective partnerships, early coordination of representatives from all aspects of the NSW correctional system, limited access to the correctional environment, reduced prison population and strict isolation of all new receptions have all contributed to maintaining this COVID-free status despite other NSW settings with similar risk profiles, such as aged care facilities and cruise ship arrivals, experiencing serious outbreaks. RESEARCH LIMITATIONS/IMPLICATIONS: Although Australia/New Zealand context of suppressed community infection rates for COVID-19 (which are approaching elimination in some jurisdictions) is in contrast to the situation in other parts of the world, the principles described in this paper will be useful to most other correctional systems. PRACTICAL IMPLICATIONS: Modelling was used to underline our approach and reinforced the veracity of following this approach. ORIGINALITY/VALUE: The Network and CSNSW has been able to mount an effective, integrated response to the COVID-19 pandemic, which has been sustainable through the first peak of COVID-19 cases. This case study catalogues the process of developing this response and details each intervention implemented with inventive use of tables to demonstrate the impact of the range of interventions used.

The health of female prisoners in Indonesia.

PURPOSE: Indonesian law provides prisoners with basic rights, including access to education, health care and nutrition. Yet, structural and institutional limitations, notably overcrowding and under-resourcing, prohibits penal institutions from fulfilling these commitments for female prisoners. The purpose of this paper is to explore their health concerns. DESIGN/METHODOLOGY/APPROACH: Six prisons and one detention centre were researched, comprising: female prisoners (n=69); clinical officers (six); clinic heads (seven); wardens (seven); heads of prisons (seven); and a Directorate representative. Data were collected through observation, focus group discussions, in-depth interviews and a semi-structured questionnaire. Raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory. FINDINGS: Both "formal" and "informal" health-coping strategies were dependent upon a range of factors which determined access to treatment, medicines and other items procured both inside and outside of the prison, as well as referral services. Informal systems of support existed for women, especially in regard to pregnancy and raising of babies born in detention. Systems that maintain harmony within cell blocks were identified as an important informal coping strategy. ORIGINALITY/VALUE: This research is important in informing policy and practice. There is a clear need for gender-sensitive legislative frameworks, penal policies and prison rules to ensure women's needs are addressed. The identified coping strategies were considered viable, but do not replace the need for a health system providing women prisoners with levels of care as available in the community, including commensurate budgeting, personnel, access and referral to more specialised external health services.

Estimating the number of the people who inject drugs in Bali, 2010.

INTRODUCTION AND AIMS: A population estimation study was performed in 2009-2010 to understand the apparent decrease in people who inject drugs (PWID) attending needle syringe programs (NSPs) and to calculate the number of PWID in Bali for service planning. DESIGN AND METHODS: The multiplier method was applied to the results of a survey of 125 PWID using data from 16 institutions to calculate benchmarks for five events. Respondents were also asked to nominate other PWID and the services they used and to name PWID who had died in the previous 3 years. RESULTS: There was consistency in the estimates calculated using the multipliers for police arrests, voluntary counselling and testing and NSP which produced estimates of 700, 723 and 769 PWID, respectively. The nominator method identified 529 PWID. The number of reported PWID deaths had decreased over the past 3 years and may reflect a shrinking in the population of PWID in Bali. Police data revealed a dramatic shift in arrests for drug possession in 2002-2003 compared with arrests during 2009. Heroin possession was recorded in 37.4% of 2002-2003 arrests but decreased to 3.1% in 2009, whereas amphetamine possession increased from 11% to 30.9% in the same period. DISCUSSION AND CONCLUSIONS: Bali appears to have experienced a decrease in the number of PWID, which is likely to be related to death and to a pronounced shift to non-injected drug use.

Advice for an adventurous career.

Prescribed career paths are not for everyone and there are other, less obvious options that can lead to an interesting and varied career. Below are some reflections on my own career aimed at helping doctors of tomorrow find their way - especially if they are prepared to work in remote or developing world settings and possibly follow a path toward working in public health.