Letter to Editor in Response to "COVID-19 and the Correctional Environment:
the American Prison as a Focal Point for Public Health"
In "COVID-19 and the Correctional Environment: The American Prison as a Focal Point for Public Health," 1 Montoya-Barthelemy et al. acknowledged that during the COVID-19 response correctional workers are "essential personnel" because of their daily contact with a high-risk population. In their opinion, careful preparation and planning are essential for containment. In a comparable paper by Irvine and colleagues, 2 modelers postulated that coronavirus 2019 (COVID-19) outbreaks in Immigration and Customs Enforcement facilities would overwhelm available intensive care unit beds. We describe how similar tools as those described by Montoya-Barthelemy et al. and Irvine and colleagues helped reduce severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduction into the largest juvenile detention center in the nation, which employs 600 staff members of whom 561 (94%) are considered essential. In March 2020, after the WHO declared COVID-19 a pandemic, 3 the organization's medical and executive teams began joint planning to develop a response to COVID-19. There were two objectives: (1) preventing visitors and staff from introducing SARS-CoV-2 to the facility and (2) early education of employees regarding hand hygiene, respiratory etiquette, social distancing, symptom identification, and appropriate use of personal protective equipment. Residents were separated into two cohorts: (1) newly arrived intakes (NAIs), and (2) the facility's general population (GP). After admission, each member of the NAI cohort was housed in two-tiered 7day phases and tested for SARS-CoV-2 using swabs to collect nasal specimens for polymerase chain reaction testing. Asymptomatic members of the NAI cohort were integrated into the GP after 14 days if the results were negative. The medical team participated in >100 meetings and 2 training sessions and helped develop approximately 75 written policies. The county's courts reduced the GP by reviewing cases and releasing residents who met certain criteria (Figure 1 ).
During the first 60 days, 14 members of the staff tested positive, a 2.8% attack rate. When someone tested positive, video surveillance technology helped identify staff members with significant close contact to ill employees. Additionally, residents identified as contacts were quarantined according to the established quarantine guidelines. 4 On April 21, because the prevalence of COVID-19 in the GP was unknown as were community transmission rates and rates of asymptomatic carriage, we conducted a point survey of the facility's residents. Of the 144 current and incoming residents tested, none of 88 GP residents (0%) tested positive for SARS-CoV-2, while five of 56 (8%) of the NAI cohort tested positive. All five positive NAI residents were medically isolated on the COVID unit following standard isolation guidelines. 4 The absolute risk difference between the NAI and GP cohorts was 7.4% (95% CI=0.80%, 