[Tabacco harm reduction: the need for a paradigm shift in German tobacco control policy]. / Tabak Harm Reduction: Die Notwendigkeit eines Paradigmenwechsels in der deutschen Tabakkontrollpolitik.

The consumption of tobacco continues to be the greatest preventable health risk in Germany. Every year, more than 127,000 people die prematurely as a result of using tobacco - one in five new cases of cancer is a consequence of smoking. Germany's current tobacco control policy, consisting of advertising bans, the promotion of smoke-free environments, and an abstinence-only paradigm, are only able to initiate slow change. Other countries have shown how the number of smokers can be reduced and deaths prevented by integrating harm reduction as a complementary measure and providing a much more active support for people who want to quit. This article first presents the current situation and current measures in Germany. Then recommendations for changes to the current tobacco control policy in Germany are derived from a look at the United Kingdom, which is considered a pioneer throughout Europe with its tobacco control policy, as well as a summary of the current state of research.

Implementation of COVID-19 vaccination services in prison in six European countries: translating emergency intervention into routine life-course vaccination.

BACKGROUND: Evidence has shown that the risk of transmission of SARS-CoV-2 is much higher in prisons than in the community. The release of the COVID-19 vaccine and the recommendation by WHO to include prisons among priority settings have led to the inclusion of prisons in national COVID-19 vaccination strategies. Evidence on prison health and healthcare services provision is limited and often focuses on a single country or institution due to the multiple challenges of conducting research in prison settings. The present study was done in the framework of the EU-founded project RISE-Vac. It aimed to analyse the best practices and challenges applied in implementing COVID-19 universal vaccination services during the pandemic to support future expansion of routine life course vaccination services for people living in prison (PLP). METHODS: Two online cross-sectional surveys were designed and piloted: survey1 on prison characteristics and (non-COVID-19) immunisation practices; survey2 on the implementation and coverage of COVID-19 vaccination with open-ended questions for thematic analysis. Each RISE-Vac project partner distributed the questionnaire to one or two prisons in their country. Answers were collected from eight European prisons' directors or medical directors between November 2021-May 2022. RESULTS: According to our findings, the implementation modalities of COVID-19 vaccination services in the surveyed prisons were effective in improving PLP vaccination coverage. Strategies for optimal management of the vaccination campaign included: periodic time slot for PLP vaccination; new staff recruitment and task shifting; distribution of informational material both to PLP and prison staff. Key challenges included continuity of care after release, immunisation information system, and vaccine hesitancy. CONCLUSIONS: To the best of our knowledge, this is the first study describing the implementation of COVID-19 vaccination services in European prisons, suggesting that the expansion of vaccination provision in prison is possible. There is no unique solution that will fit every country but commonalities likely to be important in the design and implementation of future vaccination campaigns targeting PLP emerged. Increased availability of vaccination services in prison is not only possible, but feasible and highly desirable, and can contribute to the reduction of health inequalities.

Vaccination against emerging and reemerging infectious diseases in places of detention: a global multistage scoping review.

Background: Despite the elevated risks of infection transmission, people in prisons frequently encounter significant barriers in accessing essential healthcare services in many countries. The present scoping review aimed to evaluate the state of availability and model of delivery of vaccination services within correctional facilities across the globe. Methods: Following the methodological framework for scoping reviews and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews criteria, we conducted a systematic search across four peer-reviewed literature databases (Medline via PubMed, Web of Science, the Cochrane Library, Science Direct, and EBSCO), as well as 14 sources of grey literature. Two researchers meticulously examined the identified papers independently to extract pertinent data published between 2012 and 2022. The quality of the selected publications was assessed using established quality assessment tools. Results: Of the 11,281 identified papers 52 met the inclusion criteria. With the exception of one, all the included publications presented data from high-income countries, predominantly originating from the United States. Across the world, the most prevalent vaccines available in prison settings were COVID-19 and HBV vaccines, typically distributed in response to health crises such as pandemics, epidemics, and local outbreaks. Vaccine coverage and uptake rates within correctional facilities displayed noteworthy disparities among various countries and regions. Besides, individual and organizational barriers and facilitating factors of vaccination in prison settings emerged and discussed in the text. Discussion: The lack of vaccination services combined with low rates of vaccination coverage and uptake among people living and working in correctional facilities represents a cause for concern. Prisons are not isolated from the broader community, therefore, efforts to increase vaccine uptake among people who live and work in prisons will yield broader public health benefits.

First German-speaking harm reduction conference in Vienna.

The first Harm Reduction DACH Conference [DACH = D (Germany), A (Austria), CH (Switzerland)] took place in Vienna on June 23rd, 2023, and focused on tobacco harm reduction. It is the first conference bringing together various experts of all three German-speaking countries to shed light on the subject of destigmatization and tobacco harm reduction and to share their experiences with the audience. All in all, the first German-speaking harm reduction conference has the goal to discuss and expand harm reduction in the German-speaking countries. This meeting report gives a brief overview of the conference.

[Urine Screening for Narcotics under Court-Imposed Abstinence Requirements: Comparative Validity of Forensic-Toxicological Analyses with Involvement of Public Health Services]. / Urinscreenings auf Betäubungsmittel unter gerichtlichen Abstinenzauflagen ­ Vergleichsvalidität von forensischtoxikologischen Analysen unter Mitwirkung des Öffentlichen Gesundheitsdienstes.

AIM OF THE STUDY: Assessment of the comparative validity between qualitative and quantitative analyses of urine screenings for defined narcotics residues under court-imposed abstinence restrictions. METHODS: Following the introduction of a valid marker system which, based on the application of a defined sugar substance and its detection in the urine of person under probation in 2006, urine samples were assayed in administrative cooperation by a Bavarian public health office for probationary services for evidence of narcotics. The urine samples were sent to an external laboratory in order to carry out forensic toxicological analyses for defined narcotics. The qualitative and quantitative laboratory results were reported back to the public health department so that a digital-based data set of a total of 380 persons with more than 27,000 individual analyses from a total of 14 consecutive calendar years could be established and retrospectively evaluated in an anonymised form. RESULTS: The overall prevalences of findings positive for narcotics were 2.7% (n=366 of 13,531) for the qualitative and 2.6% (n=348 of 13,525) for the subsequent quantitative result categorisations, with cannabis and opiates being detected most frequently in both test methods. Using the kappa coefficient as a quantitative measure for the comparative validity of both test methods, the test results showed the highest agreement (1.000) for buprenorphine and lowest agreement for PCP (0.880). No age- and gender-specific stratifications could be recorded for a total of ten different narcotic substances; substance-specific case numbers differed among the analyses. CONCLUSION: Based on the strong to very strong correspondences between qualitative and quantitative narcotics analysis results, it could be assumed that both analysis methods accurately recorded violations of abstinence requirements and were to be classified as sufficiently substantiating for judicial decisions under the Narcotics Act (Betäubungsmittelgesetz, BtMG). According to these results, the content of urine screenings for narcotics controlling abstinence should be discussed.

[Hepatitis C in prisons : Treatment and barriers to the elimination goals of the United Nations]. / Hepatitis C in Haftanstalten : Behandlung und Barrieren auf dem Weg zu den Eliminierungszielen der Vereinten Nationen.

BACKGROUND: Despite general advances in the treatment of people with hepatitis C in Germany, it is unclear to what extent this also applies to specific key populations, such as prisoners. METHODS: In a short survey conducted in June 2021, the ministries of justice in the federal states were asked about data collection and diagnostic methods as well as the prevalence of infections caused by the hepatitis C virus (HCV) and HCV treatment among prisoners in Germany. In addition, expert interviews were conducted regarding HCV treatment barriers and missed opportunities in prisons. RESULTS: It is evident that there is no complete and comprehensive data collection within the ministries of justice. Prevention measures, such as opiate substitution therapy in prison, are available in all participating federal states. More specific offers and measures (e.g., razor and syringe exchange) are only found in a few cases and are sometimes subject to a charge. Experts point out that although treatment in prison generally complies with the equivalence principle: it is more difficult to reach the target group. CONCLUSIONS: Comprehensive education and counselling on HCV treatment, consistent HCV testing and treatment, and preventive measures to avoid (re-)infection are important for successful HCV elimination in prisons.

[Narcotic Use under Probation and Parole Supervision - A longitudinal Study of Risk-group-specific Recidivism under Abstinence Conditions]. / Betäubungsmittelkonsum unter Bewährungs- und Führungsaufsicht ­ Eine Langzeituntersuchung zum risikogruppenspezifischen Rückfallgeschehen unter Abstinenzauflagen.

STUDY OBJECTIVE: The aim of this long-term study was to record substance-specific prevalences of illegal use of narcotics despite court-imposed abstinence requirements. METHODS: Urine assays were obtained by a public health department on the basis of administrative assistance for the probation department of a district court. The individual and valid allocation of these urine samples was ensured using a proven marker system. After postal dispatch, laboratory chemical analyses for narcotics residues were carried out in an external laboratory via enzyme immunoassay and validation by mass spectrography in the case of positive narcotics results. On the basis of all available routine data, a pooled data set covering a total of fourteen consecutive calendar years (2006-2019) was generated digitally and evaluated anonymously. RESULTS: From a total of 380 subjects (female: 13% versus male: 87%; average age: 30.4 years), 13,500 individual narcotic substance analyses from 2,941 urine samples were available. In 2.7% of all individual analyses, at least one of eight potential narcotic substances was detected, whereby the highest overall prevalences in the sense of a relapse were found for cannabis with 3.7% and for opiates with 2.4%. In contrast, there were almost no residues for barbiturates and LSD and no positive evidence for buprenorphine and PCP. As expected, most relapses in all narcotics groups were found in the age groups from 18 to 35 years. Strikingly, more women than men violated the court abstinence order with amphetamines, while relapses with the other seven narcotics groups occurred predominantly among men. In the course of the entire observation period, the most marked fluctuations in relapse rates were found for cannabis, opiates and cocaine. CONCLUSION: The use of narcotic substances during probation and parole supervision does not appear to be a rare occurrence and has received little professional attention. Increased attention to this group-specific recidivism and more studies on this topic should help reduce this deficit.

Children living in prison with a primary caregiver: a global mapping of age restrictions and duration of stay.

Women represent a growing proportion of the global prison population of 11·5 million people. No reliable estimates exist of the number of pregnant women or number of children born in or living in prison with a primary caregiver. Permitting a child to stay in prison with a primary caregiver for any duration has advantages and disadvantages for both the caregiver and the child. Global consensus on the age at which child confinement inhibits healthy development has not been reached. Human rights violations worldwide illustrate the failures of prison systems to consider the needs of children and ensure humane standards for children living in detention. In this Health Policy, we map the global variation in age restrictions and durations of stay in prison with a primary caregiver. We show a broad range of approaches and provisions for the placement of children in prison. Policy makers are advised to adopt provisions of Article 30 of the African Charter on the Rights and Welfare of the Child, as it is the only set of explicit guidelines regarding individualised qualitative judicial decision-making processes, consideration of relevant safeguarding factors, practical application of permissions to stay in prison regarding standards of paediatric care, and provisions of safety-net supports on prison exit. Training of staff and routine monitoring of paediatric standards of detention by national prison inspectorates and UN Human Rights Treaty Bodies are crucial. Future research agendas must focus on optimal child safeguarding and development during transfer and confinement, and on requisite prison-exit supports in various cultural contexts and settings.

Oral health services in prison settings: A global scoping review of availability, accessibility, and model of delivery.

This review aimed at evaluating the state of availability, accessibility and model of delivery of oral health services in prisons, globally. Five databases of peer-reviewed literature and potential sources of grey literature were systematically searched. Inclusion criteria encompassed oral health papers related to prisons globally, with exclusion of certain article types. Selection involved independent evaluations by two researchers, followed by quality assessment. Data on the availability of oral health interventions in prisons came from 18 countries, while information on the model of delivery of the services is scarce. In addition, two sets of individual and organizational barriers toward oral health service uptake in prisons were revealed and discussed in the text. Lack of oral health services in prisons affects people living in prisons and jeopardizes their reintegration. Urgent and concrete international actions are required to ensure the availability, accessibility, and quality of oral health services among people living in prisons.

Leveraging existing provider networks in Europe to eliminate barriers to accessing opioid agonist maintenance therapies for Ukrainian refugees.

Russia's invasion of Ukraine caused a major refugee crisis, particularly impacting Central and Eastern Europe. Ukraine has one of the highest prevalence rates of opioid use disorder (OUD) in Europe, which increases the risk of HIV spread due to injection drug use. Opioid agonist maintenance therapies (OAMT) are a gold standard treatment for OUD and the prevention of HIV spread. Refugees who were displaced and previously maintained on OAMT in Ukraine require reliable care continuity, but OAMT is often highly regulated making it difficult to access. Using an implementation science lens, we sought to understand the barriers and facilitators that might impede OAMT continuity. We performed 23 semi-structured interviews with displaced patients with OUD and providers of OAMT and harm reduction. Interview participants were purposively sampled to include individuals from the highest-impacted countries: Poland, Germany, Czechia, Slovakia, Romania, and Hungary. Interviews focused on existing provider networks and barriers that refugees on OAMT faced during displacement. Though networks existed, there was little collaboration between providers and key stakeholders, such as NGOs, in overcoming barriers. Moreover, existing formal networks were not leveraged for rapid problem-solving. We found that despite existing networks, providers encountered substantial barriers to successfully coordinating access and retention in OAMT for refugees. Owing to insufficiently leveraged coordination between providers, clinics frequently turned patients away due to insufficient capacity, language barriers, and financial coverage issues. The limited geographic distribution of clinics in larger countries, such as Poland and Germany, further inhibited refugees from accessing and remaining on treatment. To support countries and providers in responding to a rapidly evolving crisis, collaborative learning combined with rapid cycle change projects used by the Network for the Improvement of Addiction Treatment (NIATx) model could be deployed to promote collaboration between providers both nationally and throughout the European Union to guide continuity of OAMT.

Interventions to increase vaccine uptake among people who live and work in prisons: A global multistage scoping review.

The objective of this study is to examine interventions implemented to increase vaccine uptake among people who live and work in prisons around the world. Peer-reviewed and gray literature databases were searched systematically to identify relevant information published from 2012 to 2022. Publications were evaluated by two researchers independently and underwent quality assessment through established tools. Of the 11,281 publications identified through peer-reviewed (2607) and gray literature (8674) search, 17 met the inclusion criteria. In light of limited data, the identified interventions were categorized into two categories of educational and organizational interventions, and are discussed in the text. The lack of availability of vaccination services and interventions to increase vaccine uptake among people who live and work in prisons, worldwide, is a serious public health concern. These interventions reported in this review can be adapted and adopted to mitigate the burden of infectious diseases among people who live and work in prisons.

[Take-home naloxone: a building block of drug emergency prophylaxis in Germany]. / Take-Home Naloxon: Ein Baustein der Drogennotfallprophylaxe auch in Deutschland.

Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.

# Me Too: Global Progress in Tackling Continued Custodial Violence Against Women: The 10-Year Anniversary of the Bangkok Rules.

On any given day, almost 11 million people globally are deprived of their liberty. In 2020, the global female population was estimated to be 741,000, an increase of 105,000 since 2010. In order to investigate progress in the adoption of the Bangkok Rules since 2010, we conducted a legal realist assessment based on a global scoping exercise of empirical research and United Nations (UN) reporting, using detailed MESH terms across university and UN databases. We found evidences in 91 documents which directly relate to violations of the Bangkok Rules in 55 countries. By developing a realist account, we document the precarious situation of incarcerated women and continued evidence of systemic failures to protect them from custodial violence and other gender-sensitive human rights breaches worldwide. Despite prison violence constituting a complex and multifaceted phenomenon, very little research (from the United States, Canada, Brazil, Mexico, and Australia) has been conducted on custodial violence against women since 2010. Although standards of detention itself is a focus of UN universal periodic review, special procedures (violence against women) and concluding observations by the UN committees, very few explicitly mentioned women, and the implications of violence against them while incarcerated. We highlight three central aspects that hinder the full implementation of the Bangkok Rules; the past decade of a continued invisible nature of women as prisoners in the system; the continued legitimization, normalization, and trivialization of violence under the pretext of security within their daily lives; and the unawareness and disregard of international (Bangkok and others) rules.

[HIV/HCV Among Drug Users in Germany: Elimination Targets in the Mirror of Practice]. / HIV/HCV unter Drogengebrauchenden in Deutschland: Die Eliminierungsziele im Spiegel der Praxis.

BACKGROUND: In 2016, the World Health Organization presented the first strategy for the elimination of viral hepatitis by 2030, following the goals of the Agenda 2030. Ending Acquired Immune Deficiency Syndrome (AIDS) by 2030 was also formulated as one of the Sustainable Development Goals and subsequently included and elaborated in the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy. People who inject drugs (PWID) are among the most vulnerable groups in terms of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. Following the objectives of the WHO and the UN, the German Federal Ministry of Health (BMG) has presented the first integrated overall strategy for HIV and Hepatitis C (as well as Hepatitis B and other sexually transmitted infections). OBJECTIVES AND METHODS: Six years after the adoption of the German government's BIS 2030 strategy this article discusses the role of PWID in Germany in relation to the elimination targets on HIV and HCV based on currently available data and in light of recent responses and efforts from the field. RESULTS: Although there are multiple positive practice approaches, the WHO elimination targets have not yet been achieved with regard to HCV and HIV in PWID. CONCLUSION: In order not to fail the elimination targets 2030, Germany will have to substantially improve the situation of PWID as a key group and in particular advance the implementation of diagnostics and treatment as well as evidence-based harm reduction measures.

[Opioid Substitution Treatment in Prisons: Comparison of Cost of Buprenorphine Depot with other Medications - a Health-Economic Calculation]. / Opioidsubstitutionsbehandlung im Justizvollzug: Der Vergabeaufwand von Buprenorphin-Depot im Vergleich zu anderen Substitutionsmedikamenten ­ eine gesundheitsökonomische Modellrechnung.

In this study, adequate forms of treatment and choice of medication in the opioid substitution treatment of opioid-dependent prisoners are discussed from a health-economic perspective with a special focus on depot applications.

[Prevention of Drug-related Mortality after Release from Prison]. / Vermeidung drogeninduzierter Mortalität nach Haftentlassung.

The transition process of release from prisons into the community is associated with high risks for users of opioids. Especially in the first 10-14 days in freedom, the risk of drug-related overdoses is extremely high, in the worst case with lethal outcome. There are two main medical strategies for the target group: on the one hand, medication-assisted treatment before, during and after incarceration, and on the other hand, edcuation about and acccess to naloxone as an antidote in case of opioid-related overdose. This article gives an overview of current numbers of drug-related deaths after release from prison in Germany and of scientific knowledge regarding the efficacy of medication-assisted treatment and naloxone provision for opioid users at the interface of custody and freedom. Finally, necessary interventions to avoid drug-related overdose with lethal consequences are described. For this purpose, a selective literature review was carried out and 16 crime agencies in Germany were contacted.

Substance Use and Mental Health during the First COVID-19 Lockdown in Germany: Results of a Cross-Sectional Survey.

BACKGROUND: The measures taken to contain the COVID-19 pandemic have led to significant changes in people's daily lives. This paper examines changes in substance use during the first lockdown (March-July 2020) and investigates mental health burdens in substance users with increased consumption of alcohol, nicotine or tetrahydrocannabinol (THC) in Germany compared to users with unchanged or reduced consumption. METHOD: In a cross-sectional online survey, 2369 people were asked about their mental health and their substance use during the first lockdown in Germany. RESULTS: Of the participants, 28.5% increased their alcohol use, 28.8% their use of tobacco products, and 20.6% their use of THC-containing products during the pandemic. The groups with increased alcohol, nicotine, and THC use during the first lockdown reported more depressive symptoms and anxiety. Individuals who reported increased consumption of alcohol or nicotine were also more likely to experience loneliness and have suicidal thoughts and were more often stressed due to social distancing. CONCLUSION: Alcohol, nicotine and THC increased in a subgroup of consumers who reported to have more mental health problems compared to individuals who did not increase their consumption. This increased substance use could, therefore, be understood as a dysfunctional strategy to cope with negative emotions during the lockdown.

"Children in the prison nursery": Global progress in adopting the Convention on the Rights of the Child in alignment with United Nations minimum standards of care in prisons.

BACKGROUND: Out of the 11 million detained in prisons globally, the female prison population of 740,000 has increased by 50 % since 2000. 410,000 children are in detention. 19,000 live in prison with their mother. OBJECTIVE: To conduct a socio legal assessment of global progress in adopting the Convention on the Rights of the Child since 2010, and alignment with United Nations (UN) normative standards of care in prisons. PARTICIPANTS AND SETTING: Children detained with their mothers at the global level. METHODS: A comprehensive search of all published Concluding Observation reports of the UN Committees on the Rights of the Child (CRC), Elimination of Discrimination Against Women (CEDAW), Against Torture (CAT) and Human Rights (CCPR) since 2010 (n = 905). 316 CRC, 246 CEDAW, 173 CAT and 170 CCPR reports were scrutinised to examine the situation of children living with detained mothers against UN normative standards of care. RESULTS: 51 reports (24 CRC, 13 CEDAW, 12 CAT, 2 CCPR) representing 43 countries (majority in Africa) contained direct violations of the best interests of the child. These include the treatment of children as prisoners, difficulties in securing identity documents, poor detention conditions, exposure to violence, lack of access to child-appropriate healthcare, and lack of transparent data. Countries differed in durations of time permitting children to stay in prison (6 months to 8 years, with Eritrea observing no limit). CONCLUSIONS: Achieving a balance between protection of the child and punishment of the mother is inconsistent globally, and exacerbates the multiple vulnerabilities of the child.