SITUATION WITH TUBERCULOSIS AND OTHER INFECTIOUS DISEASES IN LATVIAN PRISONS PROGNOSIS AND CHALLENGES Riga, 29 – 30 May 2008

TB incidence in Latvia 1971 - 2006 per 100 000 inhabitants

Prisons are the mirror of the society. All problems of the society exist also in prisons; however, in prisons the problem level is 10 to 100 times higher. It refers also to the health problems of prisoners. It refers also to the prevalence rate of diseases in prison population because most part of prisoners come from lower socio-economic strata of society, (unemployed, homeless persons, alcoholics, drug addicts) those health problem level is much higher than those of other people.

Situation with TB in Latvian prisons TUBERCULOSIS 1999 2000 2001 2002 2003 2004 2005 2006 2007 Tuberkuloze (TB) gada laikā/year prevalence 745 562 518 491 344 278 249 149 118 uz 31.decembri /point prevalance 361 301 265 222 168 135 112 73 47 AIDS + TB uz 31.decembri /point prevalence 5 16 24 11 19 13 9 In 1998 – 1999 TB prevalence in prison population was 25 times higher than in general population. At present, the situation has improved considerably

Prisons are not totally closed institutions. People are entering prisons from the community with their problems including health problems and after some period of time they are returning into the community. The community should be interested to receive people released from prisons in good health, without serious health problems which would endanger the community.

Medical activities on TB in the Latvian prison system Prisoners examination for TB on entry and during the detention TB patients isolation All new TB cases and relapses are treated in the Latvian Prison Hospital DOTS and DOTS plus in-patient treatment is carried out in the hospital and outpatient treatment is carried out in isolated units/cells. All new TB patients and MDR TB patients are consulted in State Agency of Tuberculosis and Lung Diseases (SATLD) All TB patients are registered in the National TB Register High level prison administration officials, guards and medical staff are educated about TB Good information exchange system is organized between Prison Medical Service and SATLD. Prison medical staff notifies the local community TB out-patient medical centres about the persons who are being released from prisons and are in need to continue the treatment Organizational and technical management (the isolated out-patient units or cells are created in 7 prisons)

Collaboration between MoJ and SATLD Since 1996 – 1997 the Medical Department of Latvian Prison Administration and the State Agency of Tuberculosis and Lung Diseases is being in the close collaboration on: - assessment of TB situation in prison system - professional training of LPA specialists: - prison administration - primary care physicians phthisiopulmonologists nurses laboratory specialists - consultation of TB cases - information exchange - providing prisons with specific medicines - ensuring prisons with specific examinations and manipulations

Due to good collaboration between LPA and SATLD that eventually was good collaboration between MoJ and MoH the TB situation in prisons considerably improved. incidence prevalence on 31 Dec year prevalence 1999 279 361 745 2007 31 47 118

In 2007 a new challenge emerged in Latvian prisons - restrictions of TB preventive measures caused by closing of X-ray rooms almost in all prisons. In 2006 in 10 prisons X-ray rooms were closed because the X-ray equipment there were old and did not meet the modern standards and the new Rules of Cabinet of Ministers. Currently MoJ and Latvian Prison Administration are working to improve the situation. MoJ alloted money for 3 x-ray in 2008.

Previous years in order to decrease and normalize TB prevalence the main WHO principles were implemented in Latvian prisons: - prisoners health care should be equivalent to that available in the outside community; - prison medicine integration into the public medicine.

This work was carried out under the guidance of WHO (Latvia). The Medical Department of the Latvian Prison Administration participated in the creation of the Draft of the National TB Control Programme 2008 – 2012. This work was carried out under the guidance of WHO (Latvia).

The example with TB incidence and prevalence in Latvian prisons demonstrates that only with joint efforts (prison medicine + public medicine) it is possible to improve and normalize the situation with infectious diseases in prisons.

In 2007, with the initiative and help of WHO Health in Prisons Project (WHO HIPP) coordinator L. Moller, the „Status Paper on Prisons and Tuberculosis” was translated and distributed in Latvia. In June, 2007, for the first time in 15 years, on WHO HIPP initiative, the meeting of two Ministries was organized. High ranke officials from Ministry of Justice and Ministry of Health, and also the leading specialists from Latvian medical centres participated in the meeting.

In prison population the proportion of HIV infected persons is higher than in the general population. Proportion of HIV infected persons: - in prisons 6%; - in society 0,17%.

The HIV positive cases are diagnosed when prisoners enter prisons, therefore the incidence: - in prisons 2%; - in society 0,2%. It means, that people from marginal groups of the society, who constitute the major part of prison population, while in freedom, did not meet the necessary medical and educational services, so many activities in prisons for providing these services and preventing the spread of drug addiction and HIV/AIDS should be done.

There is a large number of drug users in the prisons of Latvia There is a large number of drug users in the prisons of Latvia. According to the research, made by Latvian University in 2003: - 65% of prisoners had been using drugs during their lifetime; - 31% of prisoners use drugs in imprisonment; - 5% of prisoners started to use drugs in imprisonment.

90% of HIV infected prisoners used injective drugs during their lifetime 11-20% of prisoners are injective opiate users (data from MoH Public Health Agency)

INFECTIOUS DISEASES PREVALENCE IN LATVIAN PRISONS 1999 2000 2001 2002 2003 2004 2005 2006 2007 HIV inficētie gada laikā/year prevalence 290 544 766 803 700 585 613 570 uz 31.decembri /point prevalance 96 197 358 522 468 454 410 401 400 % no visiem ieslodzītajiem /point 2,15 4,32 6,15 5,7 5,9 5,88 6,12 6,1 AIDS 2 10 23 59 51 72 81 97 % from all HIV cases 2= 1% 5 19 32 30 45 59 = 14,7% 74= 18,5 AIDS + TB uz 31.decembri /point 16 24 11 13 9 Syphilis 102 56 36 38 27 20 18 Gonorhoea 6 4 7 1 VHC uz 31.decembri /point prevalence 487 503 584 629

The Medical Department of Latvian Prison Administration established good collaboration with National AIDS Prevention Centre and with Latvian Infectology Centre implementing activities on HIV/AIDS in prisons. However, inadequate financing can worsen the situation. So, actually there are no activities on VHC in prisons and it is only by cause of inadequate financing.

Goals of Latvian Prison Medical Service: - to stop increase of TB cases - to continue activities on HIV/AIDS - to begin activities on VHC and VHB - to begin activities on drug addiction

MoJ and Latvian Prison Administration will be able to reach these goals only in good collaboration with MoH

Thank you for attention