Preparing correctional settings for the next pandemic: a modeling study of COVID-19 outbreaks in two high-income countries.

Introduction: Correctional facilities are high-priority settings for coordinated public health responses to the COVID-19 pandemic. These facilities are at high risk of disease transmission due to close contacts between people in prison and with the wider community. People in prison are also vulnerable to severe disease given their high burden of co-morbidities. Methods: We developed a mathematical model to evaluate the effect of various public health interventions, including vaccination, on the mitigation of COVID-19 outbreaks, applying it to prisons in Australia and Canada. Results: We found that, in the absence of any intervention, an outbreak would occur and infect almost 100% of people in prison within 20 days of the index case. However, the rapid rollout of vaccines with other non-pharmaceutical interventions would almost eliminate the risk of an outbreak. Discussion: Our study highlights that high vaccination coverage is required for variants with high transmission probability to completely mitigate the outbreak risk in prisons.

Reimbursing incarcerated individuals for participation in research: A scoping review.

BACKGROUND: Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices. METHODS: We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided. RESULTS: A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9). CONCLUSIONS: The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Education increases COVID-19 vaccine uptake among people in Canadian federal prisons in a prospective randomized controlled trial: The EDUCATE study.

Education is key to behavioural adoption and acceptability of health interventions. We evaluated the impact of an educational intervention administered 1:1 to individuals incarcerated in four Canadian federal prisons on COVID-19 vaccine uptake. Eligible individuals (those who had refused all COVID-19 vaccines) were randomized 2:1 to receive the educational intervention or not (control group); those who received the intervention completed questionnaires assessing COVID-19 vaccine-related knowledge, attitudes, and beliefs pre- and post-educational intervention. The primary and secondary outcome measures were COVID-19 vaccine uptake and vaccine confidence, respectively. Between May 3 and September 9, 2022, 202 participants were randomized to receive the intervention, of whom 127 (63 %) agreed to participate. Participants who were randomized to the intervention had higher COVID-19 vaccine uptake vs. the control group (5 % vs 1 %, p = 0.046). COVID-19 vaccine-related knowledge, attitudes, and beliefs improved post-intervention. Education increases COVID-19 vaccine uptake and confidence among people in Canadian federal correctional facilities.

Factors associated with changes in illicit opioid use during the COVID-19 pandemic among incarcerated people who use drugs in Quebec, Canada.

PURPOSE: People who use drugs (PWUD) have been disproportionately affected by the COVID-19 pandemic. This study aims to examine changes in illicit opioid use and related factors among incarcerated PWUD in Quebec, Canada, during the pandemic. DESIGN/METHODOLOGY/APPROACH: The authors conducted an observational, cross-sectional study in three Quebec provincial prisons. Participants completed self-administered questionnaires. The primary outcome, "changes in illicit opioid consumption," was measured using the question "Has your consumption of opioid drugs that were not prescribed to you by a medical professional changed since March 2020?" The association of independent variables and recent changes (past six months) in opioid consumption were examined using mixed-effects Poisson regression models with robust standard errors. Crude and adjusted risk ratios with 95% confidence intervals (95% CIs) were calculated. FINDINGS: A total of 123 participants (median age 37, 76% White) were included from January 19 to September 15, 2021. The majority (72; 59%) reported decreased illicit opioid consumption since March 2020. Individuals over 40 were 11% less likely (95% CI 14-8 vs 18-39) to report a decrease, while those living with others and with a history of opioid overdose were 30% (95% CI 9-55 vs living alone) and 9% (95% CI 0-18 vs not) more likely to report decreased illicit opioid consumption since March 2020, respectively. ORIGINALITY/VALUE: The authors identified possible factors associated with changes in illicit opioid consumption among incarcerated PWUD in Quebec. Irrespective of opioid consumption patterns, increased access to opioid agonist therapy and enhanced discharge planning for incarcerated PWUD are recommended to mitigate the harms from opioids and other drugs.

Importance of occupation for SARS-CoV-2 seroprevalence and COVID-19 vaccination among correctional workers in Quebec, Canada: A cross-sectional study.

Background: Correctional workers are at increased risk of SARS-CoV-2 infection. We examined the seroprevalence of SARS-CoV-2, determined the effects of carceral and occupational exposures on seropositivity, and explored predictors of COVID-19 vaccine uptake among correctional workers in Quebec, Canada. Methods: We conducted a cross-sectional seroprevalence study in three provincial prisons. The primary and secondary outcomes were SARS-CoV-2 antibody seropositivity (Roche Elecsys® serology test) and self-reported COVID-19 vaccination status ("fully vaccinated" defined as two doses or prior infection plus one dose), respectively. Poisson regression models with robust standard error were used to examine the effect of occupational variables with SARS-CoV-2 seropositivity and predictors of COVID-19 vaccine uptake. Estimates are presented as crude and adjusted prevalence ratios (aPR) with 95% confidence intervals (95% CI). Results: From 14 July to 15 November 2021, 105/600 (18%) correctional workers tested positive across three prisons (range 11-21%); 76% were fully vaccinated. Seropositivity was affected by prison occupation (aPR 1.59, 95% CI 1.11-2.27 for correctional officers vs. all other occupations) and low perceived concern of SARS-CoV-2 acquisition (aPR 1.62, 95% CI 1.11-2.38 for not/hardly worried vs. somewhat/extremely worried). Predictors of being fully vaccinated included race/ethnicity (aPR 0.86, 95% CI 0.76-0.99 for visible minority vs. White), presence of comorbidities (aPR 1.14, 95% CI 1.02-1.28 for > 2 vs. none), and prison occupation (aPR 0.82, 95% CI 0.73-0.92 for correctional officers vs. all other occupations). Conclusions: Correctional officers were most likely to have acquired SARS-CoV-2, but least likely to be vaccinated, underscoring the importance of addressing both occupational risks and COVID-19 vaccine hesitancy to mitigate future outbreaks.

Determinants of SARS-CoV-2 vaccine willingness among people incarcerated in 3 Canadian federal prisons: a cross-sectional study.

BACKGROUND: Maximizing uptake of SARS-CoV-2 vaccines among people in prison is essential in mitigating future outbreaks. We aimed to determine factors associated with willingness to receive SARS-CoV-2 vaccination before vaccine availability. METHODS: We chose 3 Canadian federal prisons based on their low uptake of influenza vaccines in 2019-2020. Participants completed a self-administered questionnaire on knowledge, attitude and beliefs toward vaccines. The primary outcome was participant willingness to receive a SARS-CoV-2 vaccine, measured using a 5-point Likert scale to the question, "If a safe and effective COVID-19 vaccine becomes available in prison, how likely are you to get vaccinated?" We calculated the association of independent variables (age, ethnicity, chronic health conditions, 2019-2020 influenza vaccine uptake and prison security level), identified a priori, with vaccine willingness using logistic regression and crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: We recruited 240 participants from Mar. 31 to Apr. 19, 2021 (median age 46 years; 19.2% female, 25.8% Indigenous). Of these, 178 (74.2%) were very willing to receive a SARS-CoV-2 vaccine. Participants who received the 2019-2020 influenza vaccine (adjusted OR 5.20, 95% CI 2.43-12.00) had higher odds of vaccine willingness than those who did not; those who self-identified as Indigenous (adjusted OR 0.27, 95% CI 0.11-0.60) and in medium- or maximum-security prisons (adjusted OR 0.36, 95% CI 0.12-0.92) had lower odds of vaccine willingness than those who identified as white or those in minimum-security prisons, respectively. INTERPRETATION: Most participants were very willing to receive vaccination against SARS-CoV-2 before vaccine roll-out. Vaccine promotion campaigns should target groups with low vaccine willingness (i.e., those who have declined influenza vaccine, identify as Indigenous or reside in high-security prisons).

Identifying barriers and enablers to opt-out hepatitis C virus screening in provincial prisons in Quebec, Canada: A multilevel, multi-theory informed qualitative study with correctional and healthcare professional stakeholders.

BACKGROUND: Diffuse implementation of hepatitis C virus (HCV) treatment is dependent on universal screening for HCV, but screening strategies are heterogenous across prisons in the province of Quebec (Canada). We sought to identify barriers and enablers to universal opt-out HCV screening and to describe the multisectoral decision-making processes related to HCV screening in Quebec provincial prisons. METHODS: A multilevel, multi-theory informed qualitative descriptive approach was used to conduct semi-structured interviews. Interview guides and analyses with correctional stakeholders were informed by the Consolidated Framework for Implementation Research (CFIR) and those with healthcare professionals (HCPs) were based on the Theoretical Domains Framework (TDF). Directed content analysis was used to identify domains within CFIR and TDF reflecting barriers and enablers to opt-out HCV screening. RESULTS: Sixteen interviews (correctional stakeholders: n = 8; HCPs: n = 8) were conducted in April-May 2021. Twelve CFIR constructs were identified as barriers, seven as enablers, and two as neutral factors for the implementation of opt-out HCV screening. Correctional stakeholders underscored the need for political will (construct: external policy and incentives), highlighted limited resources (construct: available resources), and expressed concerns for the lack of consideration of implementation issues (constructs: trialability, planning). Six TDF domains were identified among HCPs as relevant to the implementation of opt-out HCV screening: beliefs about consequences (mixed = enablers and barriers), environmental context and resources (barrier), social influences (barrier), optimism (mixed), emotions (mixed), and behavioural regulation (barrier). The decision-making processes vis-à-vis HCV care in Quebec correctional settings were found to be hierarchical and complex. CONCLUSIONS: The use of CFIR and TDF was helpful in identifying barriers and enablers to HCV screening at multiple levels for people incarcerated in Quebec provincial prisons. Going forward, several political, structural, and organizational factors should be addressed through the engagement of stakeholders and people with lived experience of incarceration.

Seroprevalence and Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 Among Incarcerated Adult Men in Quebec, Canada, 2021.

BACKGROUND: People in prison are at increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We examined the seroprevalence of SARS-CoV-2 and associated carceral risk factors among incarcerated adult men in Quebec, Canada. METHODS: We conducted a cross-sectional seroprevalence study in 2021 across 3 provincial prisons, representing 45% of Quebec's incarcerated male provincial population. The primary outcome was SARS-CoV-2 antibody seropositivity (Roche Elecsys serology test). Participants completed self-administered questionnaires on sociodemographic, clinical, and carceral characteristics. The association of carceral variables with SARS-CoV-2 seropositivity was examined using Poisson regression models with robust standard errors. Crude and adjusted prevalence ratios (aPR) with 95% confidence intervals (95% CIs) were calculated. RESULTS: Between 19 January 2021 and 15 September 2021, 246 of 1100 (22%) recruited individuals tested positive across 3 prisons (range, 15%-27%). Seropositivity increased with time spent in prison since March 2020 (aPR, 2.17; 95% CI, 1.53-3.07 for "all" vs "little time"), employment during incarceration (aPR, 1.64; 95% CI, 1.28-2.11 vs not), shared meal consumption during incarceration ("with cellmates": aPR, 1.46; 95% CI, 1.08-1.97 vs "alone"; "with sector": aPR, 1.34; 95% CI, 1.03-1.74 vs "alone"), and incarceration post-prison outbreak (aPR, 2.32; 95% CI, 1.69-3.18 vs "pre-outbreak"). CONCLUSIONS: The seroprevalence of SARS-CoV-2 among incarcerated individuals was high and varied among prisons. Several carceral factors were associated with seropositivity, underscoring the importance of decarceration and occupational safety measures, individual meal consumption, and enhanced infection prevention and control measures including vaccination during incarceration.

Implementing opt-out hepatitis C virus (HCV) screening in Canadian provincial prisons: A model-based cost-effectiveness analysis.

BACKGROUND: Implementing opt-out hepatitis C virus (HCV) screening across Canadian provincial prisons is crucial to achieving micro-elimination. Given short incarceration lengths, the most cost-effective screening strategy remains unknown. We compared the cost-effectiveness of current standard of care (venipuncture-based HCV-antibody+HCV RNA) and 13 alternative strategies in Quebec's largest provincial prison. METHODS: A prison cohort was simulated with a Markov micro-simulation model. Strategies differed in the biomarkers, sampling methods, and number of tests used. The model considered incarceration lengths, time to linkage to care (LTC), nursing costs, and tests' costs, performances, acceptability and turnaround times. Outcomes included costs (Canadian dollars, CAD$), number of true positives linked to care, and incremental cost-effectiveness ratios (ICERs, additional $/additional TP-L). A one-year time horizon and health-payer perspective were adopted. RESULTS: Across all analyses, three strategies consistently provided the best value for money: venipuncture-based HCV-antibody+HCV-core antigen, venipuncture-based HCV-core antigen (base-case ICER=~ $720), and point-of-care HCV-antibody+HCV RNA (base-case ICER=$4,310). However, these strategies linked only 23%-29% viremic individuals to care. Main drivers of cost-effectiveness were the seroprevalence, proportion viremic, and time to LTC. CONCLUSION: Alternative strategies would be more cost-effective than standard of care for implementing opt-out screening in provincial prisons. However, interventions to maximize LTC should be explored.

Disparities in hepatitis C care across Canadian provincial prisons: Implications for hepatitis C micro-elimination.

Background: Delivery of hepatitis C virus (HCV) care to people in prison is essential to HCV elimination. We aimed to describe current HCV care practices across Canada's adult provincial prisons. Methods: One representative per provincial prison health care team (except Ontario) was invited to participate in a web-based survey from January to June 2020. The outcomes of interest were HCV screening and treatment, treatment restrictions, and harm reduction services. The government ministry responsible for health care was determined. Non-nominal data were aggregated by province and ministry; descriptive statistical analyses were used to report outcomes. Results: The survey was completed by 59/65 (91%) prisons. On-demand, risk-based, opt-in, and opt-out screening are offered by 19 (32%), 10 (17%), 18 (31%), and 9 (15%) prisons, respectively; 3 prisons offer no HCV screening. Liver fibrosis assessments are rare (8 prisons access transient elastography, and 15 use aspartate aminotransferase to platelet ratio or Fibrosis-4); 20 (34%) prisons lack linkage to care programs. Only 32 (54%) prisons have ever initiated HCV treatment on site. Incarceration length and a fibrosis staging of ≥F2 are the most common eligibility restrictions for treatment. Opioid agonist therapy is available in 83% of prisons; needle and syringe programs are not available anywhere. Systematic screening and greater access to treatment and harm reduction services are more common where the Ministry of Health is responsible. Conclusions: Tremendous variability exists in HCV screening and care practices across Canada's provincial prisons. To advance HCV care, adopting opt-out screening and removing eligibility restrictions may be important initial strategies.

A randomized pilot study assessing the acceptability of rapid point-of-care hepatitis C virus (HCV) testing among male inmates in Montreal, Canada.

BACKGROUND: The OraquickⓇ fingerprick point-of-care hepatitis C virus antibody (HCV-Ab) test is favoured to venipuncture among people who inject drugs; however, its acceptability in prison populations is unknown. We aimed to compare the acceptability of the OraquickⓇ versus standard venipuncture among people in prison. METHODS: From October to December 2019, 280 sentenced male inmates at L'Établissement de Détention de Montréal (Quebec, Canada) were screened for participation, 150 excluded due to prior HCV screening, and 52 refused participation. The remaining 78 were randomized 1:1 to opt-out HCV-Ab screening with OraQuickⓇ or venipuncture (n = 39 each). Acceptability was determined by the proportion accepting to undergo screening. RESULTS: The majority of participants (median age 33 years) reported a history of drug use (76%; 8% injection drug use); 47% perceived their HCV risk to be moderate/high. All inmates randomized to OraquickⓇ accepted testing while 87% accepted venipuncture. Among those who accepted OraquickⓇ vs. venipuncture, 100% vs. 97% were satisfied with the test, 97% vs. 94% would recommend the same test, and 100% vs. 76% would choose the same test again. CONCLUSION: Adult incarcerated men in Canada were both more likely to accept OraquickⓇ compared to venipuncture, and to choose OraquickⓇ for future HCV screening.

Using the barriers and facilitators to linkage to HIV care to inform hepatitis C virus (HCV) linkage to care strategies for people released from prison: Findings from a systematic review.

Elimination of hepatitis C virus (HCV) among short-term sentenced prison populations will require improved access to HCV care and specific strategies dedicated to linkage upon release. Prison-based HCV care has lagged behind HIV care, but much can be learned from HIV studies. We performed a systematic review to identify individual-, provider- and system-level barriers and facilitators to linkage to HCV and HIV care among released inmates. We searched MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials and Embase, and performed a grey literature search for English articles published up to November 2018. Two searches were conducted, one each for HCV and HIV; 323 and 684 unique articles were identified of which two and 27 studies were included, respectively. Facilitators to linkage to HCV care included social support, having an existing primary care provider, and receipt of methadone, whereas barriers included a perceived lack of healthcare information and a lack of specialized linkage to care programs. The principal facilitators to linkage to HIV care included social support, treatment for substance use and mental illness, the provision of education, case management, discharge planning and transportation assistance. Important barriers were unstable housing, age <30 years, HIV-related stigma, poor providers' attitudes and the lack of post-release reintegration assistance. While HCV care-specific studies are needed, much can be learned from linkage to HIV care studies. Ultimately, a multi-pronged approach, addressing several individual-level social determinants of health, and key provider- and system-level barriers may be an appropriate starting point for the development of HCV linkage to care strategies.

The hepatitis C virus cascade of care in a Quebec provincial prison: a retrospective cohort study.

BACKGROUND: Hepatitis C virus (HCV) microelimination efforts must target people in prison; however, although some inmates may qualify for treatment in provincial prisons, it may not be routinely provided. Our aim was to characterize the cascade of HCV care in Quebec's largest provincial prison. METHODS: We conducted a retrospective study of all HCV-related laboratory tests requested at the Établissement de détention de Montréal (men's prison with on-demand screening), between July 1, 2017, and June 30, 2018. We defined 8 HCV care cascade steps: 1) total sentenced inmates, 2) screened for HCV (via HCV antibody [HCV Ab]), 3) HCV Ab positive, 4) tested for HCV RNA, 5) HCV RNA positive, 6) linked to care, 7) HCV treatment initiated and 8) achieved sustained virologic response. We measured proportions of inmates at each step using denominator-numerator linkage. We also calculated the proportion screened among inmates with a sentence duration of at least 1 month, during which time screening should be feasible. RESULTS: Of the 4931 sentenced inmates, 344 (7%) were screened for HCV, of whom 38 (11%) were HCV Ab positive. Thirty-five (92%) of the 38 received HCV RNA testing, which showed positivity in 16 (46%). Ten (62%) of the 16 inmates were linked to care; treatment was initiated in 3 (30%), 2 of whom (67%) achieved a sustained virologic response. Among inmates with a sentence duration of at least 1 month (n = 1972), the proportion screened increased to 17%. INTERPRETATION: A small proportion (7%) of men at a Canadian provincial prison with on-demand HCV testing were screened, and rates of treatment initiation were low in the absence of formal HCV cure pathways. To eliminate HCV in this subpopulation, opt-out HCV testing should be considered.

Evaluating the impact of Aedes japonicus invasion on the mosquito community in the Greater Golden Horseshoe region (Ontario, Canada).

BACKGROUND: Aedes japonicus was first documented in Ontario, Canada, in 2001. The objective of this study was to determine the effect of Ae. japonicus establishment on the abundance of other mosquitoes in the Greater Golden Horseshoe (GGH) region of Ontario. METHODS: Adult mosquito data from the Ontario West Nile virus surveillance program were used. Descriptive analyses, linear trends and distribution maps of average trap count per month for six mosquito species of interest were produced. Multivariable negative binomial regression models were constructed to 1) test whether the invasion of Ae. japonicus affected the abundance of other mosquitoes by comparing the time period before Ae. japonicus was identified in an area (pre-detection), to after it was first identified (detection), and subsequently (establishment), and 2) identify the variables that explain the abundance of the various mosquito species. RESULTS: The monthly seasonal average (May-October) of Ae. japonicus per trap night increased from 2002 to 2016, peaking in September, when the average of most other mosquitoes decrease. There were increased numbers of Ae. triseriatus/hendersoni (Odds Ratio (OR): 1.40, 95% Confidence Interval (CI): 1.02-1.94) and decreased numbers of Coquillettidia perturbans (OR: 0.43, 95% CI: 0.26-0.73) in the detection period, compared to the pre-detection period. Additionally, there was a decrease in Cx. pipiens/restuans (OR: 0.87, 95% CI: 0.76-0.99) and Cq. perturbans (OR: 0.68, 95% CI: 0.49-0.94) in the establishment period, compared to the pre-detection period. None of the most parsimonious explanatory models included the period of the establishment of Ae. japonicus. CONCLUSIONS: There is no evidence that the introduction of Ae. japonicus significantly reduced populations of Ae. triseriatus/hendersoni, Cx. pipiens/restuans or An. punctipennis in the GGH. While further research is needed to understand the impact of the Ae. japonicus invasion on other mosquito species, our work indicates that, on a regional scale, little impact has been noted.