Select Committee on Science and Technology Written Evidence


Memorandum by the Home Office

INTRODUCTION

  Each year around 150,00 people come into prison custody. As a consequence of risky health behaviour while in the community, such as substance misuse, injecting of drugs, possible sharing of needles, homelessness, and alcoholism, they may already have been exposed to communicable diseases prevalent in the community such as blood borne viruses, HIV, Hepatitis B and C or Tuberculosis. Prisoners who are foreign nationals or held as immigration detainees are vulnerable to infection, acute or chronic, with the communicable diseases that are prevalent in their countries of origin. Tuberculosis is a particular concern in this connection. In addition, exposure to the childhood illnesses prevalent in the United Kingdom can occasionally present some problems, since people's immunity to these infections may well be low if they are uncommon in their countries of origin.

  The Prison Service adopts three main approaches to the management of common communicable diseases. First, a primary health promotion approach. This means giving individual prisoners as much information about the illness concerned and the methods of its acquisition, so that they can avoid being exposed. An example of this is giving information that Hepatitis B is blood borne and is easily acquired if someone shares a needle for injecting.

  Secondary prevention is to offer protection to an individual if he/she continues to engage in risky behaviour. One example of this would be to offer immunisation against Hepatitis B.

  Finally, tertiary prevention involves diagnosing that someone has a particular illness and treating the consequences of the infection. In circumstances where health services in the community may have experienced difficulty in providing effective treatment to people with chaotic lifestyles, such as intravenous drug users, prison offers a valuable opportunity for more successful treatment interventions eg through directly observed therapies.

  The Prison Service engages in all forms of health protection for common communicable diseases.

  The management of communicable disease and the control of infection in Prison Service establishments has benefited greatly from the development since 1 April 2000 of the partnership between the Prison and National Health Services. It is now far more common place for prisons to be considered as part of the local health community and thus simply another health setting, albeit one which poses different challenges. An example of this is the role of the prison and the local NHS Consultant in Communicable Disease Control (CCDC) in the management of prisoners who have notifiable diseases. The local CCDC will offer advice on contact tracing of prisoners, staff, family and also friends who may have been in contact with them during the incubation period. Advice is also provided on how others within the prison may be prevented from acquiring the illness in the future ie in the case of a food borne illness by washing hands when preparing food and after visiting the toilet.

PREVALENCE

  The Public Health Laboratory Service (PHLS) undertook an unlinked, anonymised survey of the prevalence of HIV, Hepatitis B (HBV) and Hepatitis C (HCV) amongst the prisoners in eight prisons in England in 1997-98. This was one of a series of surveys carried out by the PHLS to determine the prevalences of these infections in important sub-groups of the population as a whole. The study was funded jointly by the Department of Health and the Prison Service.

The results showed that, in the total sample, prevalence of anti-HIV was 0.36 per cent, of anti-HBV was 7.8 per cent and of anti-HCV was 7.5 per cent. A full report of the outcome of the study was published in "Communicable Disease and Public Health" in June 2000.

  Prison Service establishments are currently reporting around 50 new cases of tuberculosis each year. Some people will, of course, come into prison during the nine-month incubation period of the infection when they are not, however, infectious themselves.

Monitoring the extent of communicable diseases in prisons

  The Public Health Laboratory Service Communicable Disease Surveillance Centre provides a communicable disease data collection and monitoring service for Prison Health.

INFORMATION

Prison Service Standard

  The Prison Service's Performance Standard, "Health Services for Prisoners" (July 2002) requires every establishment to have in place effective arrangements for the prevention, control and management of communicable diseases. Written information on communicable disease control policy must be made available to, and understood by, staff and prisoners. This must include an action plan in the event of an outbreak of a communicable disease; arrangements for the notification of all incidents of notifiable disease to the local Consultant in Communicable Disease Control (CCDC); policy and practice for immunisation against Hepatitis B; and protocols for the provision of post-exposure prophylaxis.

Advice to Prison Service Establishments about Communicable Diseases

  The Prison Service's former Director of Healthcare issued a letter [DDL(94) five dated 22 April 1994] drawing prison doctors' attention to the need for the early detection and effective treatment of pulmonary tuberculosis. Annexed to that letter was a document, "Guidelines on Prevention and Control of Tuberculosis in Prisons".

  Prison Service Order 3845 "Blood Borne and Related Communicable Diseases" (30 April 1999) gave advice to Prison Service management and staff on the risks from communicable diseases, including tuberculosis, and the procedures that should be adopted to minimise them.

  Information on Hepatitis C was made available to all prison medical officers in a "Dear Doctor Letter (DDL, 96, 3)". This letter was prepared in consultation with the Department of Health and the Public Health Laboratory Service. It provides doctors with information on natural history, epidemiology, prevention, treatment and guidance in those areas.

  Other detailed information about Hepatitis C is included in a new booklet, "Hepatitis C: guidance for those working with drug users", (published by the Department of Health last summer). Copies of this booklet were sent to each establishment's drug strategy co-ordinator and health care manager in October 2001 under cover of a Prison Service Instruction and an Information and Practice Note. All Prison Service establishments were also more recently sent copies of "Hepatitis C-New Guidance for Professionals" produced by Health Promotion England in spring 2002.

  The need for further guidelines on Hepatitis C for Prison Service establishments will be considered once the Department of Health issues its national strategy for Hepatitis C.

PRIMARY HEALTH PROMOTION

  Information about the nature and methods of acquisition of communicable diseases such as blood borne viruses forms a key element of the work of health care and CARATs staff during detoxification, rehabilitation and preparation for release. A variety of media is used including written information, leaflets, cards, videos, group work, and one to one sessions.

  One of the targets in the Hepatitis C Strategy issued by the Department of Health issued for consultation earlier this year is that all prisoners entering an establishment for juveniles or young offenders should receive information about Hepatitis C. The rationale for this is that entry into custody presents a major health promotion opportunity. While these young people may have been using drugs in the community, they are less likely than older prisoners to be dependent on Class A drugs and also less likely yet to have injected drugs. There is therefore a good opportunity for health gain.


SECONDARY HEALTH PREVENTION

Measures to Reduce the Risk from the Spread of Blood-borne Viruses

A.  Disinfecting Tablets

  The Prison Service's drug strategy and other measures have, however, achieved considerable success in reducing drug misuse in prison. HIV and other serious communicable diseases such as Hepatitis are readily spread when drugs users share contaminated injecting equipment. Because the possession of injecting equipment is strictly prohibited in prisons, the small core of prisoners who persist in injecting are highly likely to share any such items that they manage to acquire. As a proportionate response to the risks associated with the sharing of needles, the Prison Service is re-introducing the issue of disinfecting tablets to prisoners. This is to encourage the small number of them who persist in injecting drugs in prison to clean their illicitly held injecting equipment before passing it on to others. Such an arrangement appears to have worked well in Scottish prisons for some years. The Scottish experience also suggests that where injecting equipment is not cleaned there is a risk of serious infection.

  Disinfecting tablets were initially distributed in Prison Service establishments in England and Wales in September 1995 but were withdrawn later that year after concerns had been raised about their safety. Following tests by the Health and Safety Executive, the Prison Service re-introduced disinfecting tablets on a trial basis on 11 sites in 1998-99. This pilot project was evaluated by The London School of Hygiene and Tropical Medicine, which judged it to have been successful. The Prison Service will be re-introducing disinfecting tablets at all its establishments.

B.  Needle Exchange Schemes

  The Prison Service has no present plans to introduce a needle exchange scheme. It continues to monitor developments in the field both at home and abroad, including existing practice in the community here, policy and practice in custodial settings abroad and the effectiveness of needle exchange schemes over other harm minimisation measures.

C.  Hepatitis B Immunisation

  For the last few years Prison Service policy has been to offer all prisoners an accelerated immunisation protocol against Hepatitis B on reception. This involves giving three injections, at nought, one and two months, and a booster injection at the 12-month stage to prisoners serving a sentence of sufficient length. This is intended to provide a raised prison group immunity to Hepatitis B and therefore increased protection for individuals, reduced risk of outbreaks of infection in prisons and increased protection for the community following release. Implementation of this policy has, however, become patchy across the prison estate. Funds have been made available to develop and implement a three-year Hepatitis B immunisation strategy for prisoners. The following three-year Hepatitis B vaccination strategy for prisoners has been developed and is being put in place.

    —  Hepatitis B immunisation will be offered to every prisoner on reception, with a priority for those on remand, women and young offenders, aged 15-21 years.

    —  Existing prisoners will be offered immunisation at a specific regular prison clinic.

    —  Consenting patients will be offered the rapid immunisation schedule of immunisation involving three injections at Day one, Day seven and Day 21.

  In the case of a prisoner serving a sentence of sufficient length, a booster injection should be offered at month 12.

  The vaccination programme began in 37 establishments in 2001-02 and three more have been added this financial year. The programme will be evaluated to inform the allocation of the remainder of the available resources in the third year.

TERTIARY HEALTH PREVENTION/TREATMENT

  Prisoners are highlighted in both the National Sexual Health and HIV Strategy and the National Hepatitis C strategy as one of the groups who are highly vulnerable to infection with HIV and Hepatitis C. Therefore case finding amongst prisoners is important. Both strategies highlight the need to refer prisoners who test positive for either infection to NHS specialists for further assessment, diagnosis and management. Such prisoners should be managed in the same way as all other NHS patients.

Treatment and Services for prisoners with HIV/Hepatitis

  These include pre and post-test counselling services, the provision of psycho-social support, clinical monitoring and treatment. For those who are currently well, integration into the general prison community is the aim. NHS specialist services are closely involved and patients are referred to outside NHS facilities for further assessment and treatment as clinically appropriate.

  Combination therapy should not present undue problems for prisoners or the Prison Service. This therapy can be undertaken either on the wing, or if the prisoner is frail or requires additional supervision, in the prison's health care centre. If the timing of therapy and meals creates problems, the prisoner should be able to have additional food in his/her possession to take with the tablets, as already occurs for prisoners with diabetes.

Treatment and contact tracing for Tuberculosis

  The diagnosis, care, treatment and management of prisoners with tuberculosis is undertaken, in consultation with local NHS specialists (chest physicians), in accordance with the British Thoracic Society guidelines followed in outside hospitals and the community. It is routine practice to contact-trace the prison contacts of any newly diagnosed cases of tuberculosis. This process is normally led by the consultant in communicable diseases (CCDC) for the local authority in which the establishment is situated.


Persons Subject To Immigration ControlMEDICAL SCREENING AT PORTS

    —  The Immigration Act 1971, and the Immigration Rules, provide the statutory basis for the appointment of medical inspectors at ports and for medical examination of passengers seeking leave to enter the UK.

    —  Immigration Officers have the power to refer any individual who is subject to immigration control to a doctor for a medical examination at the port of entry.

    —  Current policy is to refer for medical examination any person who intends to remain in the United Kingdom for more than six months, or who mentions health or medical treatment as a reason for his visit, or who appears not to be in good mental or physical health, or who comes from an area of the world which is high risk for tuberculosis.

    —  An Immigration Officer has discretion, which should be exercised sparingly, to refer for examination in any other case.

    —  Where a health problem is identified, the medical inspector can pass information (eg test results) to the district to which an entrant is heading, so that appropriate treatment may be offered.

INDUCTION CENTRES

  We intend that asylum applicants who go to an induction centre on arrival will undergo a basic health screening. To evaluate the specification and benefits of this new service, a pilot started at Dover Induction Centre during the summer of 2002. The pilot includes the following;

    —  Recording immunisation history.

    —  Recording full medical history to identify past illnesses, ongoing chronic conditions and communicable diseases.

    —  TB screening and referral (as appropriate).

  The results of the pilot have yet to be evaluated.

OAKINGTON

    —  Any asylum seeker who arrives at a Port and is identified as having an infectious/contagious disease would not meet the criteria for acceptance into Oakington Reception Centre.

    —  Every detainee arriving at the Centre is seen by a qualified nurse and a Health Questionnaire is completed in their own language, to ascertain whether they are taking any medication, whether they wish to speak to a doctor or nurse about a health problem and whether that health problem is urgent. If the detainee indicates that he/she does wish to see a doctor or nurse then he/she is seen the following morning or the same day if urgent along with an interpreter.

    —  During the establishment of the healthcare service at Oakington Reception Centre, clear and effective communication channels were established with the local Public Health department. There are established procedures to permit the prompt recognition, investigation and control of outbreaks of food borne/communicable diseases, to notify the relevant authorities and comply with the relevant legislation.

ACCOMMODATION CENTRES

Summary

  1.  On site primary healthcare facilities will be provided at the proposed trial accommodation centres for asylum seekers. This provision is intended to minimise the impact which asylum seekers would otherwise have on local GPs, and other primary health care services in the area. We envisage that, in the long term, accommodation centres will help relieve some of the pressures on primary care services in the areas of the country to which asylum seekers have been regularly dispersed since April 2000.

Primary Care Services

  2.  The on-site medical centre will provide accommodation centre residents with services designed to meet asylum seekers' primary healthcare needs. Facilities will include, GP services, health counselling and access to dental, ophthalmic and chiropody services. Also, health education and prevention programmes and activities. The centre operator will be required to develop and implement effective policies for the prevention, control and management of communicable diseases.

Secondary Care Services

  3.  Some services—hospital care for example—will not be deliverable on site. The Home Office is working with the Department of Health to facilitate access to such services with NHS and social service organisations local to the proposed trial centres.

Provision of Services

  4.  As in the NHS, those involved in providing the healthcare (under contract to the centre operator), may be from the public sector or under contract from the private sector. Either way, the standards of provision available will be provided to NHS standards. All staff will be appropriately trained and, where relevant, properly qualified and registered with the appropriate regulatory body.

Health Screening

  5.  When accommodation centres are established, the intention that health screening of asylum seekers will normally be conducted at the induction centre prior to arrival in the accommodation centre. Any accommodation centre residents not already screened will be offered an initial health assessment and TB screening on arrival at the accommodation centre.

Evaluation

  6.  The Home Office will evaluate the trial accommodation centres, including the provision of healthcare, and will work with colleagues in the Department of Health to appraise the effectiveness of the health services available to asylum seekers in the centres.

IMMIGRATION DETENTION CENTRES

    —  Persons detained under the Immigration Act 1971 are, subject to their consent, given a medical examination by a doctor within 24 hours of their reception into an immigration removal centre (Rule 34, Detention Centre Rules 2002 [SI 2001/238]).

    —  A person found to be suffering from an infectious disease would be treated at either the removal centre's healthcare facility or in hospital, as appropriate.

  Paragraph three of Schedule 12 to the Immigration and Asylum Act 1999 provides for detainees to be required to submit to a medical examination at a removal centre if there are reasonable grounds for believing that a person detained at the centre is suffering from a disease, specified by order of the Secretary of State, which might endanger the health of others at the centre. The relevant diseases are set out in the Detention Centre (Specified Diseases) Order 2001 [SI 2001/240].

January 2003


 
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