Italian Prisons During the COVID-19 Outbreak

Prisons are known for having a high prevalence of infections because of close contact in a too often overcrowded setting. Prisoners often have many medical comorbidities, and substance use disorders are common. All these factors may be associated with poorer health and may influence personal response to infections. Influenza outbreaks in prisons have been previously reported in the United States, Canada, Australia, Taiwan, and Thailand.¹ The outbreak of COVID-19 has necessarily involved attention to special populations, including prisoners and prison guards. To warn about a possible dramatic scenario, the Guardian disseminated hypothesis by epidemiologists at the University College of London, who suggested that an uncontrolled outbreak of COVID-19 could lead to the death of up to 1% of the prison population.² This worrisome prediction is supported by the experience of Wuhan, China, where this pandemic started, because they reported that 50% of the people affected by COVID-19 were in prison and in New York City, where prisoners had an infection rate seven times higher than that of the general population.³

On March 15, the World Health Organization (WHO) published a document about the prevention and management of COVID-19 infection in prisons, suggesting that prisoners may have emotional reactions that differ from those of the general population because prisoners cannot observe physical distancing. The guidelines indicated a possible increased need for “emotional and psychological support, for transparent awareness-raising and information-sharing on the disease, and for assurances that continued contact with family and relatives will be upheld.”⁴

THE SITUATION OF ITALIAN PRISONS

Italy has 53 187 prisoners, 8000 of them confined in Lombardy region prisons, and the outbreak of COVID-19 currently plaguing Italy could have serious implications in the prison context. As of August 1, 2020, Italy has had 248 000 laboratory-confirmed cases, 96 219 of which were in Lombardy. There have been 35 146 deaths from COVID-19, including 163 doctors and 40 nurses, 2 of whom committed suicide.

On February 22, the Italian minister of justice released an order suspending prisoners’ visits to avoid external contamination. In reaction, several riots broke out, resulting in the deaths of 14 prisoners, some of drug overdose after breaking into the prison pharmacy, which reflects their lowered tolerance.^5,6 Additionally, many police and prison officers were injured. These disturbances calmed down after a government amendment allowed prisoners to make Skype calls to their relatives. On May 1, the Italian government stated that 159 inmates had laboratory-confirmed COVID-19 (0.3%) and that 7 detainees had died of COVID-19 (0.01%).

MONZA PRISON COVID-19 PROTOCOL

Since 2008, the Italian prison health service has been allocated to the Ministry of Health, and care has been provided by specialists from the main hospitals in the region where the prison is located. In accordance with that new law, the Mental Health and Addiction Department of the Azienda Socio-Sanitaria Territoriale Monza Health Trust, which is the largest University Hospital of northern Milan, offers psychiatric and psychological appointments and follow-ups with a multiprofessional team (a prison mental health team) operating in the prison context and a small inpatient psychiatric unit in the prison (five beds). A prison mental health team is provided in only two prisons in Lombardy (Monza and Pavia) and Monza is the regional representative for the Mental Health in Prison Monitoring Project. As a consequence, in addition to the evidence from the countrywide experience in Italy, we can offer testimony from our practice in the center of the COVID-19 outbreak, the Lombardy region.

The government of Lombardy distributed specific guidelines for the prevention of COVID-19 in regional prisons. Each prison’s directive team adapted regional guidelines to the specific conditions of the prison they manage. In the prison of Monza, arrangements include performing COVID-19 tests for and taking the temperature of all the new inmates the moment they enter the prison.⁷ Regardless of the results, they observe a 14-day quarantine and take an additional COVID-19 test after 24 hours and before complete admission to the prison. In cases of a positive result without acute symptoms, prisoners are isolated and monitored by clinical staff. In cases of acute symptoms, they follow ordinary procedures with hospitalization.

Prisoners’ visiting privileges were suspended per government regulations, but inmates are offered the option of Skype calls with family and for more hours than they had for visits.

Such opportunities flanked increased attention to mental health conditions, particularly adjustment disorders and addressing fears, contributing to fix some limitations, for example suspension of therapeutic groups, which are usually scheduled on a weekly basis.

Furthermore, psychological support is offered to prison staff. Of 321 prison officers working in the prison of Monza, four have tested positive for COVID-19 and two have asked for psychological support linked to the COVID-19 outbreak.

The Monza prison is overcrowded, with a population of 721 male inmates in 600 allocated places, and 49% of the prisoners had a current drug addiction when they entered prison. Both are recognized risk factors for infections, but, despite this, none of the prisoners have yet been infected. The absence of infection is probably thanks to prevention and specific mental health assistance to prisoners and staff in addition to increased social distancing. Furthermore, procedures carried out to prevent the spread of COVID-19, together with increased mental health support, permitted the prevention of riots, as suggested by the WHO.⁴

An in-depth analysis showed that the overall number of consultations in January, February, and March 2019 compared with January, February, and March 2020 are similar (n = 4222), but the diagnosis of patients who required mental health appointments changed. In fact, in the first trimester of 2019, most mental health appointments were requested by individuals with addiction and personality disorders (25% and 29%, respectively), whereas during the same period in 2020 the rate of requests by patients with anxiety or depression disorders were significantly reduced (21% vs 14%; P = .035), with similar rates by patients with addiction and personality disorders (27% and 31%, respectively). It is crucial to underline that the number of suicides, which is strictly monitored owing to mandatory surveillance because of a higher prevalence of self-threatening behaviors among prisoners, was zero in 2020 (compared with one in 2019).

National data and our experience, by contrast with the dramatic situation in the United States, highlight that infection containment in prisons can be influenced and managed, improving attention to the needs of prisoners and supporting the prisoners’ mental well-being, which increases their compliance with new directives and their ability to handle their fears.