Jemima Chantal D’Arcy
People living in prison are all too often left behind in social and scientific movements and advances. Vaccination is no exception to this; a large proportion of people living in prison are either unvaccinated or under-vaccinated, and are less likely to accept vaccination during incarceration1. This is despite the fact that individual, social and environmental risk factors put people living in prison at increased risk of vaccine-preventable diseases2. RISE-Vac is a three-year project co-funded by the European Commission which aims to increase vaccine access and uptake amongst prison populations across Europe.
Barriers to vaccine access in prisons
Vaccination strategies differ by country according to national policies and systems in place for providing healthcare in prisons; in a number of countries there is little or no provision of vaccination in prisons. Even in countries where vaccination services are provided in prison settings, accessing these can be convoluted, confusing or impractical for people living in prison. The logistical, or system-level, barriers to accessing vaccination services in prisons include delays in vaccine provision by the manufacturer, high turnover of people living in prison, and shortage of prison staff to facilitate vaccination campaigns.
On an individual level, the barriers to vaccination for people living in prisons are numerous, and can be related to cost of vaccines, source of vaccine information/recommendations, religious and moral convictions, and distrust in prison staff. Educational interventions to increase vaccination knowledge and uptake in prisons have been limited by low risk and severity perception of vaccine preventable diseases by people living in prisons, and a high turnover within the population. Studies assessing the effectiveness of these educational interventions for increasing vaccine uptake are limited, but cautiously optimistic3.
The importance of vaccination in prisons
And yet prison populations – including both staff and people living in prison – are amongst those who can most benefit from vaccination. Prisons are enclosed settings which can be poorly ventilated and over-crowded, making those living in them vulnerable to fast-spreading outbreaks of airborne pathogens such as COVID-19 or influenza4. Prison staff are a key link between the community and the prison; they are frequently in close contact with people living in prison, making them potential vectors of diseases such as COVID-19 and influenza – particularly if they are not vaccinated.
Prison populations are not only at risk of outbreaks of airborne viruses. An international review of studies on drug use in prison found that 10%–61% of men and 30%–69% of women prisoners were dependent on or had used illicit drugs in the month before entering prison5. This increases susceptibility to blood-borne viruses such as hepatitis B, which is more prevalent amongst prison populations than in the community6. Human Papillomavirus (HPV), a sexually transmitted virus which is the underlying cause behind the vast majority of cervical cancers, is another example of a disease with high prevalence in prison populations7.
All of the above-mentioned diseases are vaccine-preventable, meaning that outbreaks, severe forms of and even death from the illness can be prevented through vaccination. Furthermore, this knowledge and these vaccines are generally available to the community, but accessing them is far more complex for people living in prison. This is why RISE-Vac has as its mission to improve access and vaccination uptake in prison populations, in order to further global progress towards health equity.
What RISE-Vac is doing
The project is divided into a number of work packages, which all come together to contribute to the final aim of increasing vaccine access and uptake in prison populations across Europe. These work packages focus on literature reviews scoping the current vaccine strategies and research in prisons; developing educational materials for people living in prison and prison staff to increase vaccine knowledge; and rolling out vaccine delivery models in participating countries, focusing on HPV, COVID-19 and influenza, to increase vaccine access and uptake. Data collection will take place at the baseline and end of the project to ascertain vaccine perceptions amongst people living in prison and prison staff, as well as vaccination rates and coverage in participating prisons.
RISE-Vac employs a whole-prison approach, meaning both staff and people living in prison are included in the project’s interventions. This is key to the project’s mission, which centres around health equity and access to healthcare for all.
So far, data collection has begun in most partner countries. Consultations have been carried out with prison staff and people living in prisons to understand what they already know and what more they would like to know about vaccines, to inform the development of the educational materials on vaccinations. RISE-Vac is working with people with lived experience of imprisonment to help develop the materials for people living in prisons; their insight and understanding of the situation has been key in the development process. Finally, COVID-19 and influenza vaccine rollout in Moldova and Cyprus has been largely supported by RISE-Vac, and a monkeypox vaccine delivery model was piloted in Milan with the support of the project.
Through its multi-faceted approach to access to vaccination from all angles (knowledge, logistical and psychological), RISE-Vac hopes to provide key insight into the effectiveness of various interventions in increasing vaccine uptake in prison populations. We must, as ever, strive to leave no one behind as the world moves forward after the COVID-19 pandemic. After all, prison deprives people of their liberty; it should not also deprive them of their health.
To keep up-to-date with RISE-Vac’s progress and results, please follow the project on twitter or through our website. Final results will be published by November 2024.
References
1 Madeddu, G., Vroling, H., Oordt-Speets, A., Babudieri, S., O’Moore, É., Noordegraaf, M. V., … & Tavoschi, L. (2019). Vaccinations in prison settings: A systematic review to assess the situation in EU/EEA countries and in other high income countries. Vaccine, 37(35), 4906-4919.
2 Larney, S., Kopinski, H., Beckwith, C. G., Zaller, N. D., Jarlais, D. D., Hagan, H., … & Degenhardt, L. (2013). Incidence and prevalence of hepatitis C in prisons and other closed settings: results of a systematic review and meta‐analysis. Hepatology, 58(4), 1215-1224.
3 Perrodeau, F., Pillot-Debelleix, M., Vergniol, J., Lemonnier, F., Receveur, M. C., Trimoulet, P., … & Gromb-Monnoyeur, S. (2016). Optimizing hepatitis B vaccination in prison. Medecine et maladies infectieuses, 46(2), 96-99.
4 Enggist, S., Møller, L., Galea, G., & Udesen, C. (2014). Prisons and health. World Health Organization. Regional Office for Europe.
5 Fazel S, Yoon IA, Hayes AJ. Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women. Addiction. 2017;112(10):1725–1739.
6 Kamarulzaman, A., Reid, S. E., Schwitters, A., Wiessing, L., El-Bassel, N., Dolan, K., … & Altice, F. L. (2016). Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. The Lancet, 388(10049), 1115-1126.
7 Escobar N, Plugge E. Prevalence of human papillomavirus infection, cervical intraepithelial neoplasia and cervical cancer in imprisoned women worldwide: a systematic review and meta-analysis. J Epidemiol Community Health. 2020 Jan;74(1):95-102. doi: 10.1136/jech-2019-212557. Epub 2019 Oct 23. PMID: 31649041.
Jemima Chantal D’Arcy is a Project Support Manager at the UK Health Security Agency working on the RISE-Vac project. Having recently qualified from the Erasmus Mundus LIVE (Leading International Vaccinology Education) programme with a Msc in Vaccinology, she has a wide expertise in immunology, vaccine manufacturing, vaccine development and science communication. She has managed and contributed to various projects over her academic career.
