Amendments to the WHO Interim Guidance on Preventing COVID-19 Outbreak in Prisons: Remarks from Germany

Background: Globally, at any given time over 11 million people are held behind bars, while turnover of prisoners may reach up to 30 million. Evidence leaves no doubt that inmates are at a greater risk of acquiring infl uenza family viruses. This issue highlights the importance of paying extra attention to this vulnerable population. Purpose: The World Health Organization (WHO) Regional Offi ce for Europe responded to this issue by developing a set of guidelines on COVID-19 control in prisons. This manuscript reports some important gaps in the above-mentioned guidelines and some recommendations to bridge these gaps. Findings: A set of important factors including: 1. Information on the special handling of drug-consuming prisoners; 2. Instructions for dealing with prisoners in opioid agonist treatment (OAT); 3. Notes on reducing the number of prisoners and reducing the number of imprisonments; 4. Indications of vaccinations; 5. Information on measures suitable to ensure continuity of care; and 6. Use of rapid tests are important points that have been overlooked by the WHO guidelines to control COVID-19 in prisons. Conclusion: This paper suggests amendments to the guidelines on COVID-19 control in prisons, developed by the WHO. Paying attention to the recommendations of this manuscript would lead to better control of COVID-19 and similar outbreaks in prisons, and mitigate the burden attributable to such infections. Interventions to control COVID-19 in prisons should be done considering the entire ethical aspects. Short Communication Amendments to the WHO Interim Guidance on Preventing COVID-19 Outbreak in Prisons: Remarks from Germany Karlheinz Keppler1, Babak Moazen2,3* and Heino Stöver3 1Justizvollzug, Berlin, Germany 2Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany 3Department of Health and Social Work, Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt/Main, Germany Received: 23 July, 2020 Accepted: 09 September, 2020 Published: 10 September, 2020 *Corresponding author: Babak Moazen, PhD Candidate, Heidelberg Institute of Global Health, Heidelberg University, Bergheimer Str. 20, Zimmer 317, 69115 Heidelberg, Germany, Tel: +49 (0) 6221 5636156; Fax: +49 (0) 6221 56-5948; E-mail:


Background and state of the issue
At the time of writing this manuscript the exceptionally high burden of the COVID-19, is one of the main global health concerns [1,2]. Although not much is known about the current epidemiology of COVID-19 in prisons, evidence shows that members of the family Coronaviridae (e.g. H1N1 virus) can cause rapid outbreaks in prisons and the other closed settings [3,5].
To tackle this issue, the World Health Organization (WHO) Regional Offi ce for Europe reacted promptly by developing a set of guidelines on COVID-19 control in prisons [6]. The

Information on the special handling of drug-consuming prisoners
People who use drugs represent a signifi cant proportion of the number of prisoners. These patients are chronically ill, the majority is male, and almost all are smoking [7]. Suggested by the international organizations as well as the Robert-Koch-Institute (RKI) in Germany [8], people who smoke are at a greater risk of acquiring COVID-19. In Germany, for example, almost all smoking prisoners are living with chronic respiratory diseases including chronic bronchitis or chronic obstructive pulmonary disease (COPD) [9]. Lack of attention to this vulnerable group of prisoners is one of the main gaps in the WHO guidelines to deal with COVID-19 in prison.

Instructions for dealing with prisoners in Opioid Agonist Treatment (OAT)
The idea of daily supervised intake of OAT medication in all   As an example: if 12 employees are available in a prison clinic, teams of 4 employees are formed, each of them, is deployed for a week. If one of the staff members from one team is infected, two other complete teams are still available to serve. Of course, these considerations can be modifi ed based on the number of medical staff members in prisons.

Use of rapid tests
So far, rapid tests are not yet available in suffi cient and affordable quantities. The company Cepheid has an approval in the USA for rapid tests (result in approx. 45 minutes), but for which special devices (GeneXpert machines) are required. This procedure has the disadvantage that it is very expensive and that people can only be tested individually. In Germany, the Helmholtz Center for Infection Research is currently developing a rapid test based on a different method than the Cepheid method. As soon as the rapid tests are available in suffi cient quantity and quality, they should be widely and early used as a screening tool in the prison setting, both for staff members and entrants. Even outside the prison system, there are currently considerations to improve the situation through extensive testing.

Conclusion
At the time of COVID-19, leaving prisoners behind is a violation of their right to health as human beings. These vulnerable people are deprived are their liberties, but they shouldn't be deprived of proper healthcare services. Although helpful, we believe that the WHO guidelines on COVID-19 control in prisons are not enough to deal with the infection.
The recommendation of this manuscript may bridge the gap in the WHO guidelines and save the lives of thousands of highly vulnerable people behind bars, although all suggested interventions should be applied by taking ethical considerations into account.