Substance Misuse

Strep A Guidance For Prisons

On 14th May 2019, the Government published some information and guidance around Group A Streptococcal Disease (GAS). Amongst prisoners, officers and healthcare staff, this is more commonly referred to as Strep A. This guidance was jointly created by Public Health England (PHE) and HM Prison and Probation Service (HMPPS).

What is Strep A?

Strep A is a type of bacteria often found in the throat and on the skin. The most invasive GAS (iGas) infections happen when the bacteria get past the skin and other bodily defence. The less common, but more severe cases on the invasive disease could be life threatening.

Over the past 18-24 months this bacteria has caused infection with ever increasing frequency amongst the prison population and across the wider prison estate. Local prisons are the most at risk of infections, given the correlation with those who are part of the homeless community (also a high risk area) and those active within the drug sub-culture being the most common.

Strep A – Signs And Symptoms.

Signs and symptoms of invasive group A streptococcal disease include:

  • High fever
  • Severe muscle aches
  • Localised muscle tenderness
  • Redness at the site of a wound

Where any of these symptoms develop, seek medical advice immediately. If anyone you know develops these symptoms, they should also seek medical advice immediately.

Actions To Minimise Risk.

  • Prisoners should be encouraged to maintain clean cells.
  • Prisoners should have opportunities for clothing to be washed at the right temperature and dried fully.
  • Prisoner bedding should be regularly changed and washed. This should be more frequent for those who have wounds.
  • Prisoners should have opportunities to wash and shower at least daily.
  • Prisoners should be reminded of the importance of good hand hygiene – washing hands after using the toilet and before the eating or preparing of food.
  • For those prisoners who have infected wounds, the guidance is that they should not use the gym, until they have had 48 hours of antibiotics and/or the wound is covered or healed.

The concerns will rise where the this guidance is not adhered to, and the disease is allowed too become more prevalent as a consequence of denial, ignorance or complacency. In all reality, it is likely to a combination of all of these factors.

The full guidance is found here.

Photo by Brian Patrick Tagalog on Unsplash.

Hepatitis C Report – Prisons In England 2019

In this latest report (published on 9 April 2019), Hepatitis C in England 2019, Public Health England summarises the current data and the impact of action plans in England to drive down mortality from Hepatitis C Virus (HCV) and to reduce the number of new infections. Also included is an outline the actions required to make further progress. It is clear that progress is being made, but there is still much to do.

This post provides a summary of the key points relative to the levels of activity ongoing through the prison estate in England.

Latest modelled estimates suggest that around 143,000 people in England were living with chronic HCV infection in 2015. Prevalence is estimated to have fallen in recent years, and was predicted to decline to 113,000 in 2018 with the advent of new treatments. HCV affects a larger proportion of people in prison and other detention centres than the wider population, principally as a result of the relatively higher levels of injecting drug use that are observed among this population.

Partnership Working – HMPPS, NHSE and PHE.

Since 2013/14, PHE in partnership with NHS England and Her Majesty’s Prison and Probation Service (HMPPS) have overseen the rollout of BBV testing in adult prisons on an ‘opt-out’ basis. A significant milestone was reached in April 2018, when after more than 4 years of implementation, the programme was successfully rolled out across the entire adult prison estate.

Testing and Diagnosis.

Opt-out bloodborne virus (BBV) testing is now fully implemented across the prison estate, and among new receptions to English prisons, levels of testing have risen from 5% in 2010/11 to 19% in 2017/18. In the 2017/18 financial year, Health and Justice Indicators of Performance (HJIP) testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing, 26% were tested, 11% of those tested were found anti-HCV positive but less than half (46%) went on to have HCV Ribonucleic acid (RNA) testing. About 40% of those testing positive for HCV RNA received specialist referrals for their HCV infection.


Overall, these data suggest an increasing awareness of HCV in prisons with significant increases in testing, including Dried blood spot (DBS) testing. Whilst testing volumes remain sub-optimal, work is ongoing to move from the implementation of BBV testing to improving the quality of the offer and uptake of testing within prisons.

HJIP Metrics.

Prison Health Performance and Quality Indicators and HJIPs have shown a rise in HCV tests performed, from 5.3% in 2010/11 to 19.4% in 2017/18. It is likely that the recent increase in testing of people in prisons is due to the introduction of BBV opt-out testing, which was agreed in October 2013 by PHE, NHS England and HMPPS and is now fully implemented across the prison estate. While this increase in testing is welcomed, current levels are still below the lower BBV testing threshold proposed by NHS England (50-74%), and well below the target threshold of at least 75% uptake.

Performance in relation to the BBV opt-out testing programme is measured at the prison level by NHS England through the collection of data via HJIPs. These metrics include specific reports on:

  • the number of BBV tests offered within 72 hours of reception,
  • the number of tests undertaken,
  • the number of people newly diagnosed,
  • the number of patients referred for specialist treatment following diagnosis,
  • the number who received treatment.

These data are used by NHS England commissioners to performance manage healthcare providers in prisons and are important for identifying potential attrition points in the testing pathway.

In the 2017/18 financial year, HJIP testing data suggest that, after excluding previously confirmed cases, 75% of new receptions and transfers were offered HCV testing and of these 26% were tested. Of those tested, 11% were positive and 46% of these went on to have HCV RNA testing.

The image with this post illustrates the Hepatitis C testing cascade in the English prison estate (112 prisons).

World Hepatitis Day is held on 28 July 2019.

Read the full report Here

Eradicating Hepatitis C In Prisons

In March 2018, the All-Party Parliamentary Group published the report – Eliminating Hepatitis C in England. A report produced with the aim of moving towards achieving NHS England’s ambition to eliminate hepatitis C by 2025 at the latest. A target date some five years before the World Health Organization target of 2030.

One of the key risk factors was the acknowledgment that Hepatitis C disproportionately affects people who inject drugs (PWID) are the group most at risk of becoming infected with hepatitis C, with transmission occurring via shared syringes and other injecting equipment. Approximately 50% of PWID remain undiagnosed, and prevalence of hepatitis C among recent initiates in drug use was found to be 26%. PWID are a key target population for hepatitis C prevention, diagnosis, and treatment initiatives.

There is a high prevalence of hepatitis C among people in prison, due to a high population of PWID in prison, as well as unsafe injecting and tattooing taking place within prison.

Prisons, substance misuse services, and sexual health services have traditionally been the key settings to offer hepatitis C testing to high concentrations of at-risk populations. People in touch with these services are highly likely to have put themselves at risk for transmission, and the aim in these settings should be universal testing and regular re-testing of all service users. There are unique challenges and missed opportunities in each of these settings.

This report puts forward a series of desired outcomes and action-based recommendations to support objectives leading to elimination of hepatitis C, which are specific to prisons and prison healthcare providers:

Desired Outcomes:

  • Increased awareness of hepatitis C among PWID and people in prison.
  • Increased awareness of the ease and short duration of new direct acting antiviral (DAA) treatments among prisoners.
  • Increased awareness of the ease and short duration of new DAA treatments among PWID.
  • Prison staff are an effective source of information for prisoners on harm reduction and prevention.
  • Fewer new infections as a result of improved knowledge of transmission risks.
  • Increased coverage and uptake of testing in substance misuse services.
  • Increased coverage and uptake of testing in prisons.
  • Opt-out dry-blood spot testing for hepatitis C is fully implemented in substance misuse services and prisons.
  • A target of 20,000 people per year treated is set, incentivised, and monitored.

Recommendations & Actions:

  • Awareness-raising talks delivered by peers to be commissioned as an integral part of contracts for substance misuse services and in prisons.
  • Nationally-approved NHS England Health and Justice publicity highlighting the ease of new treatments to be rolled out across HM prison estate.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts in prisons.
  • Nationally-approved publicity highlighting the ease of new treatments to be rolled out across substance misuse services.
  • Hepatitis C peer programmes to be commissioned as an integral part of commissioning contracts for substance misuse services.
  • BBV training to be made compulsory for prison staff.
  • Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts for substance misuse services and in prisons.
  • Opt-out testing for hepatitis C to be commissioned by local authorities in substance misuse services.
  • Re-offer of testing to all those engaged with substance misuse services every six months to be mandated and commissioned.
  • Testing to be re-offered in prisons to those who did not receive a test at reception.
  • Opportunities to be provided for those who previously tested to re-test in prison.
  • Clear national protocol to be developed surrounding wording of opt-out test offer in prisons.
  • Commissioners to support access for prisoners to second reception screening.
  • Research to be conducted on transmission risk within prisons to determine impact of re-testing.
  • Commissioning contracts for substance misuse services and prisons to have clear mechanisms to hold services to account for failures to meet testing targets.
  • Unnecessary tests and appointments to be reduced, and the use of reflex tested dry blood spot samples, which necessitate only one sample and can be delivered in the community, to be mainstreamed.
  • Proportional prison treatment targets to be set for prisons specifically in every ODN depending on prison population.

Conclusion.

The findings of this inquiry give us much cause for optimism, and the firm belief that elimination of hepatitis C in the very near future is an achievable national ambition. Given the concentration of this at-risk population within the prison setting, these suggested actions offer real opportunities for prisons and prison healthcare providers to make a positive contribution to society for the elimination of Hepatitis C.

Links/References:

http://www.appghep.org.uk/download/reports/Eliminating%20Hep%20C%20APPG.pdf

Photo by Matthew T Rader on Unsplash.

Smoke Free Prisons: What Does A Post-Implementation Smoking Cessation Service Look Like?

Background

All prisons in England and Wales are commissioned to provide stop smoking services in partnerships with relevant health providers.

Nearly 2 years have passed since many (closed) prisons in England and Wales transitioned to becoming smoke free. In January 2019, the MOJ published the Smoke Free Policy Framework in addition to the NHS England Minimum Service Offer that was already in place.

With this in mind, what makes for an effective smoking cessation service?

Post Implemention Prisons

Access to Nicotine Replacement Therapy (NRT), with patches and lozenges being the most often provided, are all too often prone to being abused or misused. Both patches and lozenges are being traded as a form of currency, whereas the boiling and smoking of patches in not an uncommon practice. In the Post Implementation Smoke Free prison estate, those who are serving their sentences have made their choices to vape or use e-cigarettes or not smoke at all.

The challenges lie for those prisoners who arrive on remand, who are smokers. Being a new reception on remand and with some much going on in their lives, e.g pending court case, trying to maintain external relationships, or perhaps some financial worries etc. smoking (to a smoker) would be a reassuring coping mechanism for so many. Being a new reception in prison would most certainly not be the time/place to decree “I’m going to give up smoking!”

Smoking cessation becomes more a matter of something best described as a “Nicotine Maintenance Programme” for those on remand or perhaps serving very short sentences. That is until at least they are released when they can then return to tobacco smoking or vaping, if they so wish.

As prisons are now fully smoke-free, and at the post implementation stage, there will continue to be a need for ongoing stop smoking support and relapse prevention. This is at a very different level to pre-implementation.

A harm reduction option will be more suitable than a programme of cessation for patients transferring into smoke-free accommodation, who intend to return to smoking on transfer or release. All prisoners who are on sentences of less than 8 weeks should initially be offered a harm reduction intervention, to help them manage their addiction whilst in prison.

Those prisoners in a reception or local prison should be offered harm reduction interventions as a first line treatment, with full cessation being offered at the point of sentence or on transfer to another prison, whether that is to another place of detention, or to the community.

Points to consider when delivering an effective service:

  • Smokers identified as vulnerable and at risk of self-harm or suicide due to smoke free policy will have safer custody processes applied to support them whilst in custody.
  • Smokers must be seen by a stop smoking adviser within 48 hours of arrival into custody. Prisoners will be referred to a smoking cessation programme if they wish to participate.
  • Providing a prison regime that encourages and supports abstinence from smoking.
  • Provision of a range of stop smoking support, including harm minimisation approaches, to assist prisoners to abstain from smoking.
  • Developing strategies to address continued smoking seeking behaviour including misuse of Nicotine Replacement Products.
  • Recent popularity of electronic cigarettes (e-cigarettes) and more so vapes, has demonstrated that many smokers are interested in using these as less harmful sources of nicotine.

This level of ongoing need will also be dependent on prisoner movement and turnover within the establishment, whether prisoners are received from smoking or smokefree establishments and consideration should be given to what is required in a reception prison with comparatively high turnover as compared to a training prison with a more stable population.

Conclusion

All this condenses down to 3 simple actions to take when delivering an effective smoking cessation service:

  • For all new reception prisoners, provide access to e-cigarettes or vapes as part of first night reception packs.
  • For all new reception prisoners who are sentenced to more than 8 weeks, see within 48hrs and offer smoking cessation services to all those who’ve not opted to use e-cigarettes or vapes.
  • For all new reception prisoners who are on remand of sentenced to less than 8 weeks, promote harm reduction options.

References/Links:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/773041/smoke-free-policy-framework.pdf

https://www.england.nhs.uk/publication/minimum-offer-for-stop-smoking-services-and-support-in-custody/

Photo by Dev Asangbam at Unsplash

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