Equitable and tailored access to covid-19 vaccine for people in prison

For many reasonsincluding limited hygiene resources, overcrowding and inability to keep social distancing, poor ventilation, and lack of access to quality healthcare servicesthe risk of outbreaks of airborne infections in prisons is exceptionally high.1 Numerous outbreaks of different types of influenza have occurred in prisons in the past years, and SARS-CoV-2 has also found its way into prisons around the world during the recent pandemic.1 International guidelines have recommended vaccination as an essential intervention to control infection transmission in prisons, and prisons may even be a gateway to offer appropriate and high quality healthcare services to individuals who are hard to reach while in the community.2 Although information on the availability, accessibility, and coverage of vaccination programmes in prisons is scarce, the existing data show that people in prison are largely under-immunised against infectious diseases.3 This is a major public health concern.

As SARS-CoV-2 mass vaccination campaigns are rolled out, debate has sparked on which population groups to prioritise, with healthcare workers and vulnerable people flagged for fast tracking. Prison staff and prison residents should be included in the priority list, albeit for different reasons. Prison staff are essential workers, and absences should be minimised to enable prisons to function safely and humanely. The staff have a pivotal role in SARS-CoV-2 transmission within prisons, contributing to disease spread.4 Prison populations themselves are characterised by a high burden of underlying disease—including non-communicable diseases shown to correlate with low socioeconomic status5and embody the covid syndemic concept, i.e. the biological, economic and social interactions between non-communicable diseases and covid-19 increase a person’s susceptibility to infection and worse health outcomes.11 Furthermore, it has proved difficult to protect the prison population effectively by means of standard infection prevention and control or non-pharmaceutical measures, because of the infrastructural and logistic constraints of the prison system. 

Implementing SARS-CoV-2 vaccination programmes in prison present additional challenges. Suboptimal healthcare delivery and information systems with poor links to community systems are a major obstacle to ensuring accurate and timely monitoring of dose administration and completed vaccination schedules. Evidence on how to design and implement vaccination services in prison is extremely scarce,6 as operational research on prison health is usually not high in the national and international public health agenda.12

Nelson Mandela rules7 call for equity of care offered to prison populations, which may imply enhanced access to preventive measures such as vaccinations. This will not necessarily be politically palatable as the public may not see imprisoned people as their “future neighbours,” 8 but might see them as “other,” not worthy of healthcare.9 But prison health is public health,10 and what happens in prisons is not just a reflection of society, but has an impact on society. Prison walls are porous, and SARS-CoV-2 is transmitted from the community into prisons and from prisons into the community. Vaccinating the people who live and work in prisons protects us all.

Imprisoned people themselves might be deeply suspicious and reluctant to be vaccinated. Prison populations are highly heterogeneous in terms of age, ethnicity, level of education, and health literacy. Ensuring their meaningful engagement will be key to a high vaccine uptake. A European research project co-funded by an EU programme. “Reaching the hard-to-reach: Increasing access and vaccine uptake among prison population in Europe–RISE-Vac” will gather existing evidence and develop tailored vaccine delivery models in prison settings and so provide some of the evidence that is currently lacking. By upholding the principle that prison health is public health, the RISE-Vac project will provide tools and data driven, evidence based options to guide European countries in improving vaccination access for people in prisonand this is something that will benefit all of society.  

Lara Tavoschi, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy

Babak Moazen, Heidelberg Institute of Global Health, Heidelberg University, Germany; Department of Health and Social Work, Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt/Main, Germany

Emma Plugge, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

Kieran Lynch, Criminal Justice Programme, Public Health England, Reading, United Kingdom

Laura Baglietto, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy

Heino Stöver, Department of Health and Social Work, Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt/Main, Germany

Acknowledged members of RISE-Vac: Roberto Ranieri, Dr, ASST Santi Paolo e Carlo Presidio Ospedale San Carlo Borromeo – San Paolo Hospital (SPH), Milan, Italy, Ruggero Giuliani, Dr, ASST Santi Paolo e Carlo Presidio Ospedale San Carlo Borromeo – San Paolo Hospital (SPH), Milan, Italy, Vladislav Busmachiu, National Administration of Penitentiaries Moldova, Chișinău, Moldova, Irina Barbiros, National Administration of Penitentiaries Moldova, Chișinău, Moldova, Fadi Meroueh, Centre Hospitalier Universitaire Montpellier, Montpellier, France, Roberto Monarca, Health Without Barriers, Viterbo, Italy, Ioanna Yiasemi, Cyprus National Addictions Authority, Nicosia, Cyprus, Josefina Mavrou, Cyprus National Addictions Authority, Nicosia, Cyprus, Athena Demetriou, Ministry of Justice and Public Order, Cyprus Prison Department, Nicosia, Cyprus, Tasos Trattonikolas, Ministry of Justice and Public Order, Cyprus Prison Department, Nicosia, Cyprus. 

Competing interests: none declared


  1. Beaudry G, Zhong S, Whiting D, Javid B, Frater J, Fazel S. Managing outbreaks of highly contagious diseases in prisons: a systematic review. BMJ Glob Health. 2020 Nov;5(11):e003201. doi: 10.1136/bmjgh-2020-003201. PMID: 33199278; PMCID: PMC7670855.
  2. Tavoschi L, O’Moore É, Hedrich D. Challenges and opportunities for the management of infectious diseases in Europes’ prisons: evidence-based guidance. Lancet Infect Dis. 2019 Jul;19(7):e253-e258
  3. Vicente-Alcalde N, Ruescas-Escolano E, Harboe ZB, Tuells J. Vaccination Coverage among Prisoners: A Systematic Review. Int J Environ Res Public Health . 2020 Oct 19;17(20):7589.
  4. Kırbıyık U, Binder AM, Ghinai I, Zawitz C, Levin R, Samala U, et al. Network Characteristics and Visualization of COVID-19 Outbreak in a Large Detention Facility in the United States – Cook County, Illinois, 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1625-1630.
  5. Kivimäki M, Batty GD, Pentti J, Shipley MJ, Sipilä PN, Nyberg ST, et al. Association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study. Lancet Public Health. 2020 Mar;5(3):e140-e149. doi: 10.1016/S2468-2667(19)30248-8. Epub 2020 Jan 31. PMID: 32007134.
  6. Madeddu G, Vroling H, Oordt-Speets A, Babudieri S, O’Moore É, Noordegraaf MV, Monarca R, Lopalco PL, Hedrich D, Tavoschi L. Vaccinations in prison settings: A systematic review to assess the situation in EU/EEA countries and in other high income countries. Vaccine. 2019 Aug 14;37(35):4906-4919. doi: 10.1016/j.vaccine.2019.07.014. Epub 2019 Jul 18. PMID: 31327651.
  7. UN General Assembly United Nations standard minimum rules for the treatment of prisoners (the Nelson Mandela rules). Available from: https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf (Last access on 29 Jan 2021).
  8. Labutta E. The Prisoner as One of Us: Norwegian Wisdom for American Penal Practice. Emory International Law Review. 2017; Vol 31(2). Available from: https://law.emory.edu/eilr/content/volume-31/issue-2/comments/prisoner-norwegian-wisdom-american-penal-practice.html
  9. Hamilton M, Wooding D. Serial killer Levi Bellfield, 52, invited for Covid vaccine ahead of millions of vulnerable Brits. The Sun, 23 Jan 2021. Available from: https://www.thesun.co.uk/news/13830789/levi-bellfield-covid-vaccine-vulnerable-brits/ (Last access on 29 Jan 2021)
  10. Kinner SA, Young JT, Snow K, Southalan L, Lopez-Acuña D, Ferreira-Borges C, O’Moore É. Prisons and custodial settings are part of a comprehensive response to COVID-19. Lancet Public Health. 2020 Apr;5(4):e188-e189. doi: 10.1016/S2468-2667(20)30058-X. Epub 2020 Mar 17. PMID: 32197116; PMCID: PMC7103922.
  11. Offline: Covid-19 is not a pandemic, The Lancet, https://doi.org/10.1016/S0140-6736(20)32000-6
  12. Plugge E, Stürup-Toft S, O’Moore ÉJ, Møller L. WEPHREN: a global prison health research network. Int J Prison Health. 2017 Jun 12;13(2):65-67. doi: 10.1108/IJPH-03-2017-0014. PMID: 28581374