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31 Weild AR, Gill ON, Bennett D, Livingstone SJ, etal. Prevalence of HIV, hepatitis B, and hepatitisC antibodies in prisoners in England and Wales:a national survey. Commun Dis Public Health.2000;3(2):121-6.32 Gore SM, Bird AG, Cameron SO, Hutchinson SJ,et al. Prevalence of hepatitis C in prisons: WASH-Csurveillance linked to self-reported risk behaviours. QJ Med. 1999;92(1):25-32.33 Long J, Allwright S, Barry J, Reynolds SR, et al.Prevalence of antibodies to hepatitis B, hepatitisC, and HIV and risk factors in entrants to Irishprisons: a national cross sectional survey. Br Med J.2001;323(7323):1209-13.34 Richie BE, Freudenberg N, Page J. Reintegratingwomen leaving jail into urban communities: adescription of a model program. J Urban Health.2001;78(2):290-303.35 Gore SM, Bird AG, Burns S, Ross AJ, et al.Anonymous HIV surveillance with risk-factorelicitation: at Perth (for men) and Cornton Vale(for women) prisons in Scotland. 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Reflections on JohnSnow’s Pump Handle:Is there a need foran infection controlprogram in SouthAustralian prisons?Doreen RaeProject CoordinatorPrimary Health Care Services - Prisoner Health &Strategic ProjectsCentral Northern Adelaide Health ServicesOne hundred and fifty years ago John Snow (1813-1858),an icon in epidemiology, provided one of the earliestexamples of using epidemiologic methods to identifydisease risk and to recommend preventative actions.Snow was intent on cholera prevention and supportedthe unpopular view that cholera was transmitted bycontaminated water and not via bad air vapours. Hisstudies, and subsequent removal of a contaminatedwell’s pump handle, highlighted public health action,guided by epidemiological data, as a proven strategy tocontrol infectious diseases, stop epidemics and correctenvironmental causes of ill health. 1Reflections on past successes in controlling epidemicsin history may be useful in developing convincinganalogies for change in non-healthcare agencies. Indeed,this would highlight the value of systemic structuralinterventions as a catalyst. The pump handle analogy, forexample, could be instructive to prisons. Historical andcontemporary prison settings are recognised as sitesof disease transmission 4 and, globally there is an overrepresentationof blood-borne viruses among peopletemporarily accommodated in prisons. 2,3The high prevalence of blood-borne viruses amongprisoners is a risk to the health of correctional staff,uninfected prisoners and to the general community. 5,6Additionally, Australian and international studies revealthat:• The health status of people living in custody isgenerally lower than that of the rest of the population;• There are high rates of physical and mental disorderamong custodial populations; and• Social and economic disadvantage is identified as themajor causative or contributing factor to the ill healthof prisoners. 7Addressing infection control issues in prison settings ischallenging for both justice and public health, due to theincreasing complexities of managing growing numbersof transient, repeat offenders who present with trimorbiditiesassociated with unresolved drug issues and21significant chronic physical and mental problems. 8,7,9Traditionally, infection preventative strategies inprisons have emphasised changing individual prisonerbehaviours through infection control education andawareness campaigns. But although prisoner-targetededucational programs are essential, they are inadequateas a prevention strategy if the means of prevention arenot available to prisoners living with multiple medicaland psychosocial challenges in prison environments. 10Effective health-promoting strategies includeintersectoral partnerships, the development oforganisational health policies, and the acknowledgementthat all agents, not only health service providers, areresponsible for the health of the prison community. 11Due to community-supported sentencing practicesprison managers have exceeded the recommendedprison utilisation rates in the past decade. In mostdeveloped countries, similar sentencing trends havealso led to prison over-crowding. 12 In 2004, the SouthAustralian Department for Correctional Servicesdescribed the current high utilisation rate of prisons as‘problematic’. 13 As a result, more people, who wouldnot normally come together, mix and mingle in prison,as accommodation pressures necessitate frequentrelocations from prison-to-prison. Greater numbersof socially disadvantaged and unwell people move inand out of prison on a regular basis. 14 Overcrowdedconditions, accommodating transient populations inperpetual flux create ideal environmental conditions forthe transmission of infectious diseases. 15,16,17Providing leadership towards healthy environments forpeople in prisons is the responsibility of each state andterritory government and it is not a federal responsibilityas are some other national infection control initiatives.There are no national infection control guidelines forprisons as there are for other high-risk settings such ashealth care facilities and children’s day care centres.So who is responsible? Justice policy-makers in SouthAustralia are primarily directed to manage the separationof offenders from the general community, and areneither accountable nor suitably resourced to be activeparticipants in health promotion. Existing infectioncontrol programs are specific to other high-infectionrisksettings such as health care facilities and aged andchild-care centres, as these are essential for the nation’swelfare. To promote the health and safety of those livingand working in prisons, the need for an audited infectioncontrol program for both public and private prisonsin South Australia seems self-evident. Developing,implementing and monitoring an infection controlprogram for prison environments, with intersectoralcollaboration between the justice system and public,environmental and occupational health would be a steptowards a safer South Australian community.South Australia is a society with health policies that aimto improve the health of the most vulnerable groupsby implementing preventative measures and hospital-
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