Vaccinations in prison settings: A systematic review to assess the situation in EU/EEA countries and in other high income countries.

INTRODUCTION: In 2016, more than 600,000 persons were being held in EU/EEA correctional facilities on a given day. People in prison may be at risk of vaccine-preventable diseases. While vaccination recommendations for people in prison exist, little is known on coverage and implementation options. METHODS: We performed a systematic review on existing evidence on vaccination in prison settings in the EU/EEA. We searched peer-reviewed and grey literature following international methodology and reporting standards, to gather records published between 1980 and 2016 in all languages. We analysed quantitative (acceptance, uptake, cost-effectiveness) and qualitative (barriers) outcomes. RESULTS: Out of 7041 identified records, 19 full-text articles were included from peer-reviewed literature and two from grey literature. Of these, 18 reported on hepatitis A and/or B virus (HAV/HBV), two on influenza and one on MMR vaccination. Two studies on HAV vaccine reported varying acceptance (5-91%) and uptake rates (62.9-70.5%). Seven studies reported on HBV vaccination. A comparative study showed a significantly higher uptake of the third HBV vaccine dose with the very rapid (63%) compared to the standard schedule (20%). HBV vaccination was generally well accepted (54-100%), whereas uptake was variable (dose 1:23-100%, dose 2:48-92%, dose 3:19-80%). One study on the combined HAV/HBV vaccine reported an acceptance rate of 34%, and declining uptake following dose 1. One study on influenza vaccine showed an uptake of 42-46%, while another reported a MMR vaccine acceptance of 80% and an uptake of 74%. Overall, main reasons for non-vaccination included release from/or transfer between prisons, and refusal. CONCLUSIONS: This systematic review highlighted important knowledge gaps and operational challenges for vaccination in prison settings. Vaccination is an effective measure that warrants comprehensive and tailored implementation to reduce the preventable disease burden, avoid risks of large outbreaks of vaccine-preventable diseases, and contribute to health equity for people in prison.

Drug consumption rooms: A systematic review of evaluation methodologies.

ISSUES: Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies. APPROACH: Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded. KEY FINDINGS: Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'. IMPLICATIONS: Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities. CONCLUSIONS: Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

Challenges and opportunities for the management of infectious diseases in Europes' prisons: evidence-based guidance.

People in prison have multiple complex health and social care needs. These are likely to be the result of a combination of overlapping, and sometimes interlinked, risk factors for infection, ill-health, and incarceration, such as problem drug use. Incarceration can represent a unique opportunity to make high-quality health care available to people in prison and to target socially deprived groups who are often medically underserved when living in the community they originate from. In recent years, international and European institutions have increasingly acknowledged the importance of treating prison health as an inseparable component of public health. However, numerous challenges hamper the successful implementation of such a concept, including the need for evidence-based decision making, intersectoral partnerships, and better monitoring systems. New initiatives are ongoing in the EU that might contribute to bring about positive changes, such as the publication of the first evidence-based public health guidance on prevention and control of communicable diseases in prison settings.

The Experience of the Treatment Demand Indicator in Europe: A Common Monitoring Tool Across 30 Countries.

OBJECTIVE: The article describes an epidemiological indicator called Treatment Demand Indicator (TDI). The TDI aims to provide professionals and researchers with a common European methodology for collecting and reporting core data on drug users in contact with treatment services. The article discusses the implementation of the TDI in the European countries and describes the main results, limitations, and future perspectives. METHOD: The TDI provides a common format for reporting data on clients entering treatment as a result of their drug use and related problems during each calendar year. Its technical protocol defines which clients should be reported at European level and represents the minimum common set of items each national monitoring system should be able to report to the European Monitoring Centre for Drugs and Drug Addiction. RESULTS: In 2015, 29 European countries reported data on 467,811 clients entering drug treatment from 6,846 drug treatment units. Most clients were men in their 30s and had problems related to heroin or cannabis use; patterns of drug use differed geographically. Over the past decade, clients' profiles and drug use patterns changed from young heroin injectors seeking treatment to drug clients with diversified drug use patterns and profiles. CONCLUSIONS: The TDI is the largest drug dataset in Europe, and its data is increasingly used in European and national data analysis. The use of a common drug-treatment-monitoring tool across a group of countries provides a useful instrument for policymakers, professionals, and managers working in the drug treatment field.

A systematic review on models of care effectiveness and barriers to Hepatitis C treatment in prison settings in the EU/EEA.

Hepatitis C prevalence in prison populations is much higher than in the community. Effective hepatitis C treatment within this population does not only have a direct individual health benefit, but may lead to substantial community dividend. We reviewed available evidence on hepatitis C treatment in prison settings, with a focus on the European Union/European Economic Area. A systematic review of the literature (PubMed, EMBASE, Cochrane library) was performed and complemented with searches for conference abstracts and grey literature. Thirty-four publications were included reporting on the effectiveness, acceptability and economic aspects of hepatitis C virus treatment models of care to achieve treatment completion and sustained viral response in prison settings. Available evidence shows that hepatitis C treatment in prison settings is feasible and the introduction of direct-acting antivirals will most likely result in increased treatment completion and better clinical outcomes for the prison population, given the caveats of affordability and the need for increased funding for prison health, with the resulting benefits accruing mostly in the community.

Active Case Finding for Communicable Diseases in Prison Settings: Increasing Testing Coverage and Uptake Among the Prison Population in the European Union/European Economic Area.

Prison populations are disproportionally affected by communicable diseases when compared with the general community because of a complex mix of socioeconomic determinants and environmental factors. Tailored and adequate health care provision in prisons has the potential to reach vulnerable and underserved groups and address their complex needs. We investigated the available evidence on modalities and effectiveness of active case-finding interventions in prisons by searching PubMed, Embase, and the Cochrane Library for records on prison and active case finding with no language limit. Conference abstracts and unpublished research reports also were retrieved. We analyzed the findings by testing modality, outcomes, and study quality. The included 90 records-63 peer-reviewed, 26 from gray literature, and 1 systematic review-reported variously on viral hepatitis, human immunodeficiency virus, sexually transmitted infections, and tuberculosis. No records were retrieved for other communicable diseases. Provider-initiated opt-in testing was the most frequently investigated modality. Testing at entry and provider-initiated testing were reported to result in comparatively higher uptake ranges. However, no comparative studies were identified that reported statistically significant differences between testing modalities. Positivity rates among tested inmates ranged broadly but were generally high for all diseases. The evidence on active case finding in correctional facilities is limited, heterogeneous, and of low quality, making it challenging to draw conclusions on the effect of different testing modalities. Scale-up of provider-initiated testing in European correctional facilities could substantially reduce the undiagnosed fraction and, hence, prevent additional disease transmission in both prison settings and the community at large.

Towards elimination of hepatitis B and C in European Union and European Economic Area countries: monitoring the World Health Organization's global health sector strategy core indicators and scaling up key interventions.

The World Health Organization 'Global Health Sector Strategy on Viral Hepatitis 2016-2021' aimed at the elimination of viral hepatitis as a public health threat provides a significant opportunity to increase efforts for tackling the epidemics of hepatitis B and hepatitis C virus infections across Europe. To support the implementation and monitoring of this strategy, core epidemiological and programmatic indicators have been proposed necessitating specific surveys, the systematic collection of programmatic data and the establishment of monitoring across the care pathway. European Union and European Economic Area countries already made progress in recent years implementing primary and secondary prevention measures. Indeed, harm reduction measures among people who inject drugs reach many of those who need them and most countries have a universal hepatitis B vaccination programme with high coverage above 95%. However, while a further scaling up of prevention interventions will impact on incidence of new infections, treating those already infected is necessary to achieve reductions in mortality. The epidemiological, demographic and socio-political situation in Europe is complex, and considerable diversity in the programmatic responses to the hepatitis epidemic exists. Comprehension of such issues alongside collaboration between key organisations and countries will underpin any chance of successfully eliminating hepatitis.

New psychoactive substances: Current health-related practices and challenges in responding to use and harms in Europe.

BACKGROUND: The availability of new psychoactive substances (NPS) in Europe has rapidly increased over the last decade. Although prevalence levels of NPS use remain low in the general European population, there are serious concerns associated with more problematic forms of use and harms in particular populations and settings. It has thus become a priority to formulate and implement effective public health responses. However, considerable knowledge gaps remain on current practices as well as on the challenges and needs of European health professionals who are responding to use and harms caused by these substances. The aim of this study was to explore current health responses to NPS, and highlight key issues in order to inform planning and implementation of adequate responses. METHODS: This scoping study was based on a targeted multi-source data collection exercise focusing on the provision of health and drug interventions associated with NPS use and harms, in selected intervention settings across Europe. RESULTS: Findings revealed that in the absence of specific evidence, health professionals across most intervention settings rely primarily on acquired expertise with traditional drugs when addressing NPS-related harms. This study also identified a gap in the availability and access to timely and reliable information on NPS to users and health professionals. Health professionals in sexual health settings and custodial settings in contact with certain risk groups reported particular challenges in responding to NPS-related harms. CONCLUSION: Immediate investments are required in expanding substance identification capabilities, competence building among professionals and dissemination of risk information among relevant stakeholders. The risks of neglecting under-served risk populations and failure to address the information needs of health professionals and users on NPS harms in a context of rapid changing drug markets in Europe may have unforeseeable consequences at societal level.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness.

BACKGROUND: Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality. METHODS: A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed. RESULTS: Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission. CONCLUSION: Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

The effectiveness of opioid maintenance treatment in prison settings: a systematic review.

AIMS: To review evidence on the effectiveness of opioid maintenance treatment (OMT) in prison and post-release. METHODS: Systematic review of experimental and observational studies of prisoners receiving OMT regarding treatment retention, opioid use, risk behaviours, human immunodeficiency virus (HIV)/hepatitis C virus (HCV) incidence, criminality, re-incarceration and mortality. We searched electronic research databases, specialist journals and the EMCDDA library for relevant studies until January 2011. Review conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Twenty-one studies were identified: six experimental and 15 observational. OMT was associated significantly with reduced heroin use, injecting and syringe-sharing in prison if doses were adequate. Pre-release OMT was associated significantly with increased treatment entry and retention after release if arrangements existed to continue treatment. For other outcomes, associations with pre-release OMT were weaker. Four of five studies found post-release reductions in heroin use. Evidence regarding crime and re-incarceration was equivocal. There was insufficient evidence concerning HIV/HCV incidence. There was limited evidence that pre-release OMT reduces post-release mortality. Disruption of OMT continuity, especially due to brief periods of imprisonment, was associated with very significant increases in HCV incidence. CONCLUSIONS: Benefits of prison OMT are similar to those in community settings. OMT presents an opportunity to recruit problem opioid users into treatment, to reduce illicit opioid use and risk behaviours in prison and potentially minimize overdose risks on release. If liaison with community-based programmes exists, prison OMT facilitates continuity of treatment and longer-term benefits can be achieved. For prisoners in OMT before imprisonment, prison OMT provides treatment continuity.

Associations between availability and coverage of HIV-prevention measures and subsequent incidence of diagnosed HIV infection among injection drug users.

HIV-prevention measures specific to injection drug users (IDUs), such as opioid substitution treatment and needle-and-syringe programs, are not provided in many countries where injection drug use is endemic. We describe the incidence of diagnosed HIV infection in IDUs and the availability and coverage of opioid substitution and needle-and-syringe programs in the European Union and 5 middle- and high-income countries. Countries with greater provision of both prevention measures in 2000 to 2004 had lower incidence of diagnosed HIV infection in 2005 and 2006.

Guidelines for the treatment of hepatitis C virus infection in injection drug users: status quo in the European Union countries.

Treatment guidelines are considered to be an important tool in steering patients to medical treatment. This study was conducted to analyze guidelines for the treatment of hepatitis C virus (HCV) infection in injection drug users (IDUs) in the European Union (EU) countries as a component of treatment access. National and international databases, expert contacts, professional societies, and health administrations were approached to acquire guidelines. According to their quality standard, guidelines were divided into expert opinions, semiofficial guidelines, official guidelines, and consensus processes. Recommendations for the treatment of HCV infection in IDUs vary substantially, from lack of recommendations and outright treatment disapproval to recommendations for treatment under specified circumstances. Recent guidelines that apply qualified process procedures that include literature research tend to be more permissive. Qualified guideline processes in each EU country and subsequently renewed pan-European guidelines are needed.