Memorandum by the Home Office
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
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 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,
Monitoring the extent of communicable diseases
The Public Health Laboratory Service Communicable
Disease Surveillance Centre provides a communicable disease data
collection and monitoring service for Prison Health.
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
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
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
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
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.
Measures to Reduce the Risk from the Spread of
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
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.
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
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
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
Persons Subject To Immigration ControlMEDICAL
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.
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
TB screening and referral (as appropriate).
The results of the pilot have yet to be evaluated.
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
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
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
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 serviceshospital care for
examplewill 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
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.
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.
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].