Letters

Health effects of prisons

Many injectors stop injecting while imprisoned

Risks of syringe exchange programmes in prisons prevail

Properly executed vaccination programme might minimise harm

Legitimacy of punishment systems should be addressed

Many injectors stop injecting while imprisoned

EDITORIn their study of bloodborne viral infection in Irish prisons, Allwright et al found that infection with hepatitis C was associated with continued drug use by injecting in that setting.¹ A study by Stark in Germany has also confirmed this finding.² The authors of both studies have highlighted the discrepancy between the existence of well developed harm reduction programmes in the community, which include needle exchange and methadone maintenance, and the absence of such services in prisons.

I support the principle that imprisonment should not deprive an individual of access to services that are proved to reduce harm. Examination of the currently available research evidence, however, indicates that provision of needle exchange could possibly cause an increase in transmission of bloodborne viral infection in prisons. The findings reported by Allwright and Stark actually support this concern as they indicate that many injectors stop injecting while imprisoned.

In the Irish prison study, 51% of injecting drug users had not injected in the month before interview.¹ In the German study, 53% of injectors had never injected while in prison.² An Australian study, examining incidence of hepatitis C among prisoners, found that longer stay in prison (with no access to needle exchange) protected injectors against infection.³ One plausible interpretation of this research evidence is the following: injectors who inject in prison tend to do so unsafely, but as so many injectors cease injecting during their sentence, the incidence of infection (and other adverse events such as accidental overdose) drops among the total population of imprisoned injectors.

There has been insufficient examination of the reasons why so many injectors cease or curtail injecting while in prison. There are many possible explanations for this finding, but the absence of available sterile injecting equipment could be an important factor. Although there is no evidence that provision of needle exchange encourages individuals to start injecting in the community, implementation of such a service could cause many more of these established injectors to opt to continue injecting while in prison. The introduction of needle exchange in prison could ultimately be shown to have a beneficial effect in reducing harm, but its introduction now would be premature while we have a poor understanding of the factors that mediate the observed reduction of injecting in this setting.

Bobby P Smyth, specialist registrar. 
Academic Unit, Young People's Centre, Chester CH2 1AW bobbypsmyth{at}hotmail.com

Risks of syringe exchange programmes in prisons prevail

EDITORSince 1998, 203 366 prisoners in Bavaria have been tested for HIV when placed under detention; 1379 prisoners were diagnosed for the first time as being infected with HIV. During the course of their detention around 35 000 inmates have been tested, predominantly drug addicts; only one serum conversion has been found.

An inquiry last year by the doctors in the largest of the 37 Bavarian prisons (12 300 inmates) did not find any case of acute clinical hepatitis C during the course of detention. A survey in four prisons containing 3710 prisoners found that between 11.9% and 22.2% of all prisoners and between 61% and 75% of intravenous drug users were positive for antibodies to hepatitis C virus on entry to prisonlower than in the Irish prison survey.¹ In two prisons 213 prisoners were systematically examined on their release, and one case of serum conversion was found. Examination of the case files on 130 inmates at Nuremberg's prison who were positive for hepatitis C virus showed that two prisoners may have been infected during the course of their detention, one of them in a "blood brother" ritual.

Many studies show that drug users are most likely to become infected with hepatitis C virus at the beginning of their addiction.² In Germany, this phenomenon may clearly be seen among young immigrants of German background from parts of the former Soviet Union. Most of them have lived in Germany for only a few years. Having begun misusing drugs intravenously, they become infected with hepatitis C virus before their first prison sentence in an alarming number of cases.

Detention protects against infection according to the results of a study of serum conversion in Maryland.³ Evaluation of a syringe exchange programme in a prison in Hamburg found that many prison inmates who had stopped misusing drugs started misusing them again. Also, many inmates went from inhaling drugs back to intravenous drug misuse while sharing needles regularly.⁴ The decisive factor in the incidence of hepatitis C in prisons has been the availability of heroin. In Bavarian prisons a strict zero tolerance policy is followed in relation to drugs. Under these circumstances a syringe exchange programme would be misunderstood as accepting drugs. Prisons would be flooded with heroin immediately. The situation would be out of control and infection rates would rise considerably.

Herbert Langkamp, Anstaltsarzt, member of working group. 
Justizvollzugsanstalt Nürnberg, Mannertstrasse 6, 90429 Nuremberg, Germany

On behalf of the Hepatitis in the Bavarian Penal System Working Group, whose members are Drs Karl-Heinz Strigl (Bernau), Ellen Döring (Aichach), Elisabeth Hartmann-Llanos (Augsburg), Hermann Braun (Munich), Anja Rieger-Kaiser (Bayreuth), and Alfred Geissler (Bayreuth).

Properly executed vaccination programme might minimise harm

EDITORAllwright et al have produced a highly commendable insight into bloodborne infections among prisoners in the Irish Republic, highlighting in particular the high prevalence of infection with hepatitis C virus in that group.¹ Data for England and Wales suggest a similarly high prevalence in the same population.²

In the United Kingdom it is recommended that prisoners be vaccinated against hepatitis B infection, particularly injecting drug users and people testing positive for hepatitis C virus.³ With this in mind, there is a paucity of information in Allwright et al's paper relating to uptake of vaccination against hepatitis B virus among Irish inmates who are positive for hepatitis C virus and HIV.

In 1999 we carried out an unselected prospective study of a proportion (132/550 patients positive for hepatitis C virus) of the Sheffield hepatitis C virus cohort (M L Schmid et al, sixth meeting of the Federation of Infection Societies, Manchester, December 1999). Most of the 132 were injecting drug users or former injecting drug users (>80%), and a significant proportion of these had previously been incarcerated in prison (over 40% admitted to prison sentence). Serological testing showed 60% had no evidence of previous exposure to hepatitis B virus. Only 20% of the 132 had protective antibody levels against hepatitis B virus. Minimisation of harm should start with a properly executed vaccination programme targeting all prisoners, thus minimising the risk of acquiring or disseminating hepatitis B virus and reducing the risk of more aggressive liver disease.⁴ Furthermore, vaccination for hepatitis A may also be worth considering for similar reasons.⁴

Matthias L Schmid, consultant physician. 
Department of Infection and Tropical Medicine, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE

Stephen T Green, consultant physician. 
Michael W McKendrick, consultant physician. 
North Trent Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF

Legitimacy of punishment systems should be addressed

EDITORAllwright et al are to be congratulated for obtaining and presenting further solid evidence of the unacceptable health effects of prisons.¹ They also emphasise in their closing statement what is well knownthat imprisonment adds to the health risks of an already disadvantaged population. This evidence from Ireland extends similar earlier findings available relating to Scotland.² The BMJ has a good record of publishing studies describing the health damage wrought by European punishment systems,^1-4 including robust editorial comment by researchers on the lack of evidence based health protection measures in British prisons. But the journal does not go further to address editorially the legitimacy of these punishment systems from a health point of view.

It is salutary to contrast our silent assent to health damage caused by of our own punishment regimens with our willingness to criticise other cultures. A well reasoned piece from Médecins Sans Frontières described the difficulties in expressing dissent against the Sharia punishment system in Afghanistan.⁵ Given findings that 21% of drug using prisoners started injecting in prison and a dose-response relation between time in prison and risk of hepatitis C infection,¹ can we really say that punishment systems in the British Isles are less barbaric than those that amputate a hand? The editor's choice article in the BMJ that accompanies the articles on Sharia punishment describes judicial amputation as a challenge to the ethics of humanitarian organisations, but the journal is silent on the ethics of judicial elevation of the risk of drug addiction and hepatitis C infection.

This highlights real challenges for the medical profession. Should the medical profession support widespread punishment by imprisonment in our society? Should the profession take the lead in conducting an assessment of the health impact of imprisonment? Also, given that many of the factors predicting poor health and other disadvantage also predict imprisonment, an assessment of the impact of health inequalities is needed. It seems safe to assume that no large political party will make this debate a priority in the near future. If the medical profession in the United Kingdom, and the BMJ as its most representative journal, has a duty to the health of the worst off in our society then they must take a lead in this area.

Noel McCarthy, specialist registrar in public health. 
Oxfordshire Health Authority, Oxford OX3 7LG noel.mccarthy{at}oxon-ha.anglox.nhs.uk

1.	Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000; 321: 78-82. (8 July.)
2.	Gore SM, Bird AG, Burns SM, Goldberg DJ, Ross AJ, Macgregor J. Drug injection and HIV prevalence in inmates of Glenochill prison. BMJ 1995; 310: 293-296[Abstract/Free Full Text].
3.	Gore SM, Bird AG. Drugs in British prisons. BMJ 1998; 316: 1256-1257[Free Full Text].
4.	Rotily M, Delorme C, Obadia Y, Escaffre N, Galinier-Pujol A. (1998). Survey of French prison found that injecting drug use and tattooing occurred. BMJ 1998; 316: 777[Free Full Text].
5.	Perrin P, Nolan H. Ethical dilemma: Sharia punishment, treatment, and speaking out. Supporting Sharia or providing treatment: the International Committee of the Red Crosslearning to express dissent: Médecins Sans Frontières. BMJ 1999; 319: 445-447[Free Full Text].