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INTRODUCTION
According to the World Health Organisation1, vaccination is an essential component in primary health care, an unquestionable human right and one of the best financial investments in public health. Vaccines are also essential for preventing and controlling outbreaks of infectious diseases, underpinning security in world healthcare and acting as a vital instrument in the fight against antimicrobial resistance.
Despite all the achievements brought about by vaccination initiatives, many challenges still remain: these include administering vaccines to all vulnerable populations regardless of their location and protecting national vaccination programmes against the growing threat of misinformation about vaccines and vaccination2.
The population of prison inmates is a an especially vulnerable group that can be easily accessed3,4. Factors that play a part in making inmates such a vulnerable group are the low socioeconomic and cultural level of over 50% of the prison population5, the high prevalence of mental disorders (34.3% in men and 42.3% amongst women)5 and of infectious diseases (3.5% HIV6 and 9.7% hepatitis C in prisons managed by the Public Administration6, 3.9% HIV and 2.8% de hepatitis C in Catalonian prisons7), high levels of drug use (75.1% of inmates have consumed illegal substance at some point in their lives)5, high-risk behaviours amongst the prison population, such as not using condoms while being positive for diseases such as HIV (37.2%), hepatitis B (21.8%) or hepatitis C (56.4%)5 and intravenous drug use (15.3%)5
The Organic General Prison Law 1/1979, of 26 September8, regulates healthcare in Spanish prisons. Royal Decree 734/2020 of 4 August9 develops the basic structure of the Spanish Ministry of Home Affairs and the competences of the General Subdirectorate of Prison Health, which is responsible for managing healthcare in prisons governed by the Spanish Public Administration
Two Autonomous Communities have taken on the competences relating to prison management: Catalonia in 198410 and the Basque Country in 202111 while the prison healthcare competences were transferred to one Community, Navarra, in 202112. Prison healthcare in Catalonia has been managed by the Catalan Health Institute (ICS) since 2014.
Major efforts have been made by medical teams to develop vaccination as part of the primary prevention practices ever since they were established in Spanish prisons
The vaccines with traditionally high coverages in the adult prison population are tetanus-diphtheria, hepatitis B and influenza. Other vaccines were subsequently included, in line with the official recommendations of the Ministry of Health, such as vaccines against pneumococcal disease, hepatitis A, MMR, herpes zoster, meningococcal ACWY, COVID-19 and the human papilloma virus (HPV), amongst others.
VACCINATION AND THE COVID-19 PANDEMIC
The World Health Organisation (WHO) has recognised that vaccination coverage has stagnated in recent years despite the enormous advances that have been made, and that vaccination went down for the first time in a decade in 20201. The pandemic and disruptions caused by COVID-19 in recent years imposed major challenges on health systems1, and prison health is no exception in this regard.
Thanks to the efforts of professionals working in this field, SARS-CoV2 vaccination programmes have been carried out amongst prison inmates, professionals and volunteers who work in prisons. Considerable efforts were also made to control the disease, despite the lack of medical personnel in all the prisons managed by the Public Administration, which has created an excessive workload for the remaining workforce. However, all this work was completed at the cost of a loss in the above-mentioned vaccination coverage, both in prisons managed by the Public Administration (Table 1)6, and in those managed by the ICS (Table 2). This data, which has not yet been published, was provided by the ICS Prison Health Programme of the Regional Government of Catalonia for this article.
Table 1. Doses of vaccine administered in Spanish prisons managed by the Public Administration.
| 2019 | 2020 | 2021 | 2022 | |
|---|---|---|---|---|
| COVID-19 | 0 | 0 | NA | 30321 |
| Hepatitis B | 20012 | 5101 | 5338 | 6780 |
| Tetanus | 19464 | 3153 | 2915 | 2764 |
| Influenza* | 10684 | 12104 | 14720 | 14180 |
| Other vaccines† | 10266 | 10406 | 70054 | 1346 |
*Doses administered according to the digital clinical history.
†Doses administered according to the statistics issued by prisons that included all vaccines that were different from hepatitis B and tetanus in other vaccines in 2019, 2020 and 2021. In 2022 the statistics gave details of the doses administered for each vaccine, therefore the influenza and COVID vaccines were not included in the other vaccines section.
COVID-19: coronavirus disease 2019; NA: Not available.
Table 2. Vaccination coverage of prisons in Catalonia (%).
| Year | Influenza ≥60 years | Influenza <60 years with RF* | Tetanus | Pneumococcus ≥ 65 years | MMR | Hepatitis A + B in HCV+† | COVID-19 ≥60 years |
|---|---|---|---|---|---|---|---|
| 2019 | 60.7 | 53.48 | 91.62 | 83.8 | 76.6 | NA | 0 |
| 2020 | 76.1 | 65.05 | 90.17 | 86.09 | 66.15 | 79.07 | 0 |
| 2021 | 67.68 | 57.27 | 88.41 | 81.82 | 66.16 | 78.4 | NA |
| 2022 | 66.08 | 56.32 | 86.92 | 76.92 | 67.26 | 77.4 | 64.68 |
*RF: Risk factor;
†HCV: Hepatitis C virus; COVID-19: coronavirus disease 2019; NA: Information not available.
As regards the figures published by the Public Administration on administered vaccines (Table 1)6, some data can be found in the clinical histories, as is the case with influenza vaccines, while other information was sent by prison administrations as monthly statistics, which mention three categories for 2019, 2020 and 2021 (tetanus, hepatitis B and other vaccines), the latter of which also includes the doses administered for influenza and COVID. The vaccines administered are broken down into individual items in the statistics for 2022. A comparative analysis of both sources of data indicate that the information sent by the centres is incomplete, and that the data taken from the clinical history is more reliable.
Now that the epidemiological situation of COVID-19 has stabilised, we face the challenge of recovering the vaccination coverages established prior to the pandemic.
The figures for influenza vaccinations are worth considering, given that they have seen an increase in Spanish prisons after SARS CoV 2 began to appear. The coverage of influenza vaccines improved globally by 21% in 2019, 26% in 2020 and 32% in 2021, although it dropped to 30.4% in 2022 in prisons managed by the Public Administration6
A similar situation was seen in prisons managed by the ICS, where influenza vaccination likewise improved in 2020 (15,4% in the ≥60 years age group and 11.6% in the <60s with some kind of risk factor). A progressive decrease can be seen in the figures for 2021 and 2022 without reaching the figures for 2019. In the case of the Basque Country, Royal Decree 474/2021 of 21 June, transferring services and functions to the Autonomous Community, came into effect on 1/10/2111; meaning that the data about vaccination coverage for 2021 and 2022 in the Basque Country is not included in the relevant general reports published by the General Secretary of Prisons, and so the information could not be gathered for inclusion in this article
NOTIFIABLE DISEASES AND VACCINATION
According to data published by the WHO13, the number of cases of measles in the European Region reported in the first half of 2023 (n=9282) shows an increase of 22 times in comparison to the number reported in the same period for 2022 (n=405). The coverage of the first dose with a vaccine that contains measles and rubella dropped by 2% to 94% in 2020 compared to 2019. It went down once again by 1% to 93% in 2022. The deduction drawn from these figures that closing the gaps in immunity for all age groups is a crucial factor in eliminating measles and rubella. The optimal vaccination coverage with two doses of vaccine against measles and rubella is equal to or more than 95% at all levels inside a country (provinces, regions and districts)13.
If we review the cases of vaccine-preventable diseases declared by Spanish prisons in recent years, we find cases of chickenpox, hepatitis B, hepatitis A, mumps, measles and whooping cough (Table 3) in prisons managed by the Public Administration6 and in those managed by the Regional Government of Catalonia. The data for the latter institution has not been published, but it was released by the Prison Health Programme of the Catalan Health Institute for publication in this article. The data should offer a stimulus for reviewing the vaccination status of the persons we care for. All the doses of vaccines that do not appear in the records should be regarded as unadministered14. This is a fairly common event in daily practice, bearing in mind the profile of vulnerability of inmates in the prison setting, to which should be added the high percentage of foreigners, who make 30.6%15 of the prison population and do not usually provide any information about the dosages of vaccination they have received.
Table 3. Enfermedades de declaración obligatoria en instituciones penitenciarias (nº de casos).
| Año | 2019 | 2020 | 2021 | 2022 | ||||
|---|---|---|---|---|---|---|---|---|
| Administración | NPA* | Catalonia | NPA* | Catalonia | NPA* | Catalonia | NPA* | Catalonia |
| COVID-19 | 0 | 0 | 815 | 410 | 3486 | 1320 | 5044 | 452† |
| Influenza | 2935 | 137 | 1551 | 63 | 139 | 7 | 639 | 0 |
| Hepatitis A | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
| Hepatitis B | 7 | 20 | 1 | 19 | 4 | 17 | 7 | 41 |
| Meningococcal meningitis | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Mumps | 3 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Measles | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Chickenpox | 2 | 0 | 2 | 0 | 4 | 1 | 0 | 0 |
| Pertussis | 4 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
*NPA National Public Administration †Cases recorded up to March 2022.
†Cases recorded up to March 2022.
COVID-19: coronavirus disease 2019.
Given that the administration of live vaccines in previously immune persons is not associated with a larger number of adverse reactions and additional doses of inactivated vaccines produce high titres of antibodies, although they may be associated with higher reactogenicity14; the recommendation is to initiate vaccination in line with official instructions when there is no information about previous doses14.
Access by all prisons to the vaccination information systems of the autonomous communities would be desirable, enabling access to more information about a patient’s vaccination history and to report all the doses administered during a person’s period of imprisonment
This would help in any decision-making process when initiating or completing courses of vaccination. Improvements to the transmission of healthcare information between prisons managed by the Public Administration and those managed by the Autonomous Communities of Catalonia, the Basque Country and Navarra would also be a great help
LESS COMMONLY ADMINISTERED VACCINES IN PRISONS
Another challenge facing health professionals working in prisons is that of increasing the coverage of vaccines that are less frequently administered in this setting, as is the case with the HPV vaccine, the administration of which is strongly recommended for persons up to 26 years who are HIV positive, for men who have sex with other men and for sex workers. Such groups are over-represented in prisons. It is also recommended for women of any age who have undergone excisional cervical treatment and for persons with WHIM syndrome16. A similar situation occurs with the monkey pox virus vaccine (Mpox), recommended for anyone who engages in high-risk sexual practices, especially gays, bisexuals and men who have sex with other men. It is also recommended as a post-contact prophylaxis in cases of close contact with a case of this nature17.
Although herpes zoster presents low levels of mortality, the potential complications caused by having this disease are a major public health problem in Spain due to the ageing population and the growing number of persons with comorbidities and immunosuppression. Therefore, the recommendation is that herpes zoster vaccines should be administered to persons of 65 years and over and to younger persons with high-risk conditions such as HIV, solid organ transplants and hematopoietic progenitors, people receiving anti-Jak drugs, those suffering from solid tumours who are receiving treatment with chemotherapy or who suffer from malignant blood diseases. Patients who have had two or more episodes of herpes zoster should also be vaccinated, as should persons over 50 years of age who are receiving treatment with immunosuppressant or immunomodulating drugs18.
VACCINATION FOR HIGH-RISK GROUPS
Persons with immunodeficiencies are very much at risk of catching vaccine-preventable diseases. These include persons with HIV, whose prevalence in 2022 stood at 3.5% in prisons managed by the Public Administration6 and 3.9% in those managed by the Regional Government of Catalonia7
Other high-risk groups are those made up of persons suffering from chronic diseases. Such groups are growing in number because of increased life expectancy and the general ageing of Spanish society16, which is also reflected in prisons.
Another factor to be borne in mind is the specific recommendations for vaccination of institutionalised persons, including minors and adults, the recommendations for persons with high-risk behaviours or other life situations that increase vulnerability, such as pregnancy, infancy and old age16. All these factors need to be borne in mind when making decisions about administering vaccines to each patient.
VACCINATION AT CHILDBEARING AGE, DURING PREGNACY AND BREASTFEEDING
The vaccination status of women of childbearing age should be reviewed and they should be offered attenuated vaccines (MMR and chickenpox), which are contraindicated in pregnancy, before it takes place, bearing in mind that vaccination should be avoided in the month prior to the administration of each dose16
There is no evidence of adverse effects on gestation or the foetus as a result of inadvertent administration of such vaccines, and so any interruption of gestation would not be justified in this case.
Inactivated vaccines can be administered, preferably in the second and third quarter of pregnancy, given the lack of studies on the first quarter and to avoid any association with a spontaneous abortion, which is more frequent in the early stages.
It should not be forgotten that there are specific recommendations for vaccination during gestation, which have the threefold objective of protecting the expectant mother, the foetus and the newly born infant: vaccines against influenza and COVID-19, which are indicated in any quarter, and vaccines against whooping cough, which should preferably be administered between week 27 and 36 of gestation16.
Breastfeeding mothers can be administered all inactivated and attenuated vaccines with one exception, that of yellow fever, due to the risk of the breastfed infant catching the disease through the virus16.
CHILD VACCINATION
It is important to take into consideration the infant’s age when vaccinating, without considering the weight at birth or the gestational age19. The same vaccination procedure as the one administered to full-term infants should be used, and it is very important to start vaccination on the day the infant reaches two years of age or as soon as possible after this date. Vaccination against rotavirus is also recommended for this group.
Vaccination of other full-term infants is equally important, as is correcting the schedule of children who have been inadequately vaccinated
For the 2023-24 period, vaccination against respiratory syncytial virus (RSV) is recommended for minors under 6 months of age with the nirsevimab monoclonal antibody, the administration of which is compatible with the vaccination routine20.
The recommended scope of administration of the influenza vaccine, which was previously recommended for high-risk groups and institutionalised minors, has been extended to include all minors of between 6 and 59 months of age21
Another vaccine Another vaccine that has also been extended to include other groups is the meningococcus B vaccine, the administration of which is recommended for all minors of 2, 4 and 12 months of age, as well as for members of high-risk groups who have not been previously vaccinated22.
VACCINATION OF THE ELDERLY
The term immunosenescence23,24 refers to the progressive degeneration of the immune system as a result of innate and adaptive changes that take place during ageing. This progressive alteration of the functioning of the immune system leads to increased sensitivity to and severity of infections, to reactivity of infections by latent viruses and decreased efficacy of vaccination, amongst other factors25.
All these processes effectively justify the vaccination of individuals from 65 years of age onwards against tetanus, pneumococcus, herpes zoster, influenza and COVID26. Some Autonomous Communities have gone so far as to administer some of these vaccines to persons of 60 years of age27.
HEALTHCARE PROFESSIONALS AND VACCINATION
Vaccination coverage for Spanish health professionals is below desirable levels. According to data from the European Centre for Disease Prevention and Control (ECDC)28, the vaccination coverage for Spanish health professionals was below 40% until 2021, when the COVID pandemic led to a major increase in coverage that reached 62%. This figure is below the 75% recommended by the European Commission29 and the WHO for high-risk groups. We have no data on Spanish prisons in this regard.
The determining factors in the low vaccination coverages for health workers include a low perception of risk amongst professionals who work in close contact with patients and their surroundings, and the lack of knowledge about the benefits and safety of vaccination30.
It is essential for professionals to be adequately vaccinated in line with recommendations30, given the great importance that this has in preventing the transmission of diseases to vulnerable individuals who we come into contact with. Ongoing training of healthcare is an essential factor in this regard. Such courses would entail continuous updates in vaccination issues, along with scientific evidence to enable us to combat the false myths regarding the side effects of vaccine administration.
Providing our users with high quality information is essential for ensuring that they make the right decisions and for preventing the possibilities of persons being inadequately vaccinated, which can be very dangerous for highly vulnerable groups such as pregnant women, children, the elderly and persons belonging to high-risk groups, who may develop potentially serious complications.
CONCLUSIONS
Vaccination programmes have been one of the most successful initiatives in the penitentiary setting and we should be aware of the importance of establishing ongoing measures to improve and extend vaccination coverage, which would directly contribute not only to the health of the prison population, but also to that of the general public.
One possible measure would be to include vaccination coverage data for high-risk groups in healthcare statistics published by the General Secretary for Prisons. Another highly desirable measure would be for the Autonomous Communities of Catalonia, the Basque Country and Navarra to publish their vaccination statistics, which would enable the impact of the activities taking place there to be evaluated.
Improving vaccination coverage is an aim that should serve as a stimulus for healthcare professionals and act as a counterpoint to the demoralisation that can now be seen and experienced as a result of the current difficult working conditions in prisons managed by the Public Administration as a result of the lack of medical staff.
