Experience of health professionals, police staff and prisoners in Italy informs WHO COVID-19 guidelines for prisons

The experience of doctors in Italy has contributed to the preparation of WHO’s guidance on preparedness, prevention and control of COVID-19 in prisons and other places of detention. Health professionals in Italy were among the first in Europe to face the threat of COVID-19. From the first days of the epidemic, there were concerns about prisons, as infection outbreaks in such closed settings can have an amplifying effect on the spread of the virus throughout the country.

“At the end of January 2020 Italy reported its first imported cases of COVID-19. On the heels of these developments, we began preparing for potential disease outbreaks in prisons”, said infectologist Dr Ruggero Giuliani, who has been coordinating COVID-19 control measures in the San Vittore prison, located in Italy’s Lombardy region. “We assessed our supplies, medicines and the capacity of prisons to isolate suspected cases not only among prisoners, but also among police officers, health care workers and other staff”.

“Prevention rules work in any part of the world”

From the early stages, Italian health professionals have been collaborating with WHO to prepare guidance that would contain best practices for the prevention and control of COVID-19 in places of detention. The guidance is built on concrete needs and challenges experienced by people working and living in prison.

“In this situation of uncertainty, we explored all the ideas we had to tackle the potential outbreak. We amended checklists almost every day to find the right ways to operate”, said Dr Giuliani, who also worked in Monrovia when the Ebola outbreak occurred in 2004.

“It was surprising to see how similarly people react in different epidemics and settings. As during Liberia’s Ebola outbreak, also in my home country the lockdown and fear disoriented people, we encountered similar difficulties in explaining protective measures to staff”, Dr Giuliani said. “And that is a good example of how prevention works in any part of the world. When you follow the recommendations not only at work but everywhere, you will be safe. This is the mantra I preached before and I am preaching still”.

“The Italian health system was another factor that contributed to the effectiveness of penitentiary infection control measures”, added Dr Roberto Ranieri, who also devotes his work to infection control in the San Vittore prison.

Unlike in many other countries, in Italy, health professionals working in prisons fall under the Ministry of Health rather than the Ministry of Justice. Therefore, their status is the same as that of any other doctors working in public hospitals and medical centres. This system allows prison health workers to freely exchange information about outbreaks with their colleagues. “In our case we were in close contact with specialists from Milan hospitals and we really benefited from their expertise”, explained Dr Ranieri.

The experience of Italian health professionals contributed to the creation of the WHO guidance on Preparedness, prevention and control of COVID-19 in prisons and other places of detention. Dr Giuliani and Dr Ranieri were involved in reviewing the document before it was published.

Preparation period: keep calm and isolate

The second phase of COVID-19 prevention measures came rather quickly with the beginning of the virus outbreak in Italy’s Lombardy in late February. Consequently, the likelihood of police officers and health care workers carrying the virus into prisons rose dramatically. The highest risk was among the staff working with detainees in hospitals.

“The virus spreads easily in social groups: police officers are more likely to infect other police officers, health care workers – to infect other health care workers and so on. Therefore, we have minimized opportunities for social gatherings. For example, guards were asked to stop having coffee breaks together and told to operate only in a strictly delimited area of the facility”, said Dr Giuliani.

By that time, the Italian Ministry of Justice had issued an order to minimize the number of people who could access prisons. Admission of volunteers and supporting staff into the facilities was restricted. Personal visits to prisoners were also suspended until further notice.

“Before the first COVID-19 cases emerged, we prepared different isolation facilities: for suspected cases and for new arrivals”, added Dr Giuliani. “We set up screening and temperature checking equipment at the prison entrance. Masks and gloves were distributed to all the staff working in the facility”.

Fighting COVID-19 in prisons: time to be united

March brought the third phase of infection control measures in Lombardy prisons, when the first cases of COVID-19 transmission in detention facilities were detected. On 9 March the news led to riots in numerous prisons all over Italy.

“The riots calmed down really quickly, in a couple of days. It became evident that there was huge stress and concern among detainees, as well as among prison staff, so we set up compulsory psychological consultations for people to help them cope with stress”, Dr Giuliani recalls.

Dr Roberto Ranieri points out that, overall, the measures would not have been a success without the detainees’ help.

“They have responded well to our campaign. Prisoners’ committees in each prison helped to spread important health information among the detainees”, added Dr Ranieri. This has also resulted in behavioural change.

“We have disseminated infection screening checklists aimed especially at detainees. Following the recommendation to stop exchanging cigarettes and other goods was very difficult, but eventually prisoners understood the importance of this and other measures. It was really encouraging to see that prisoners of different cultural and ethnic backgrounds were consistently complying with the measures”, said Dr Giuliani.

There was also a change in the psychology of the staff. Before the COVID-19 outbreak, police officers and health care workers had a different approach to prison inmates. Police officers were preoccupied mainly with security issues, while health care workers viewed prisoners as regular patients. However, after the first cases were confirmed in prisons, this perception began to change.

Security officers and health care workers created united work groups in every prison. “Issues such as supply shortages, alternative incarceration measures or transfers between prisons are now discussed together by the police and health staff with one common approach. This has never happened before. However, with COVID-19, everything and everyone in prisons became interconnected”, said Dr Giuliani.