Reducing COVID-19 outbreaks in prisons through public health-centred policies
Authors: Brandy F Henry
Journal: The Lancet Public Health (2021)

People in the USA who are incarcerated have been heavily impacted by the COVID-19 pandemic, experiencing an infection rate more than five times higher than the US general population.1Saloner B Parish K Ward JA DiLaura G Dolovich S COVID-19 cases and deaths in federal and state prisons.JAMA. 2020; 324: 602-603Crossref PubMed Scopus (218) Google Scholar Prisons in the USA have also been epicentres of transmission to the community.2Oladeru OT Tran N-T Al-Rousan T Williams B Zaller N A call to protect patients, correctional staff and healthcare professionals in jails and prisons during the COVID-19 pandemic.Health Justice. 2020; 8: 1-3Crossref PubMed Scopus (26) Google Scholar Evidence-based, public health-centred policies are needed to prevent COVID-19 outbreaks in prisons and save lives. Given the disproportionate rate of incarceration among marginalised groups, such policies will also improve health equity.3Henry BF Social distancing and incarceration: policy and management strategies to reduce COVID-19 transmission and promote health equity through decarceration.Health Educ Behav. 2020; 47: 536-539Crossref PubMed Scopus (37) Google Scholar Existing studies in this area have been mostly observational or case studies. An observational study of Texas prisons described three profiles of COVID-19 outbreaks—low outbreak, high outbreak, and high death—and found that maintaining housing at 85% capacity reduced risk of COVID-19 infection and death.4Vest N Johnson O Nowotny K Brinkley-Rubinstein L Prison population reductions and COVID-19: a latent profile analysis synthesizing recent evidence from the Texas state prison system.J Urban Health. 2021; 98: 53-58Crossref PubMed Scopus (32) Google Scholar A case study of the British Columbia prison system described successful prevention of COVID-19 outbreaks before the rollout of vaccines using a combination of education, screening, testing, isolation, quarantine, physical distancing, and sanitisation.5Murdoch DJ British Columbia provincial corrections' response to the COVID-19 pandemic: a case study of correctional policy and practice.Vict Offender. 2020; 15: 1317-1336Crossref Scopus (9) Google Scholar In The Lancet Public Health, Theresa Ryckman and colleagues6Ryckman T Chin ET Prince L et al.Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies.Lancet Public Health. 2021; (published online Aug 5.)https://doi.org/10.1016/S2468-2667(21)00162-6Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar have added to this body of research by modelling COVID-19 public health policies in the California state prison system. The authors used daily resident-level data in a transmission-dynamic stochastic microsimulation to predict the impact of different policy scenarios on COVID-19 infection and hospitalisation rates. Models varied the level of COVID-19 vaccine coverage, baseline immunity, in-person activities, and use of non-pharmaceutical interventions (eg, physical distancing, masking, and surveillance testing) across five prison types that differed by residential layout and demographics. Models assumed a fixed 40% rate of staff vaccination based on the actual average rate at the time of the study. The authors reported that in-person activities could be most safely resumed in prisons with high vaccine coverage (90% of residents), low room occupancy (no more than two people per cell), and continued non-pharmaceutical interventions. Ryckman and colleagues' study has contributed to the literature in two important ways. First, it has provided point estimates for COVID-19 risk under very clear policy conditions that can guide real-world policy decisions to improve health by reducing COVID-19 infection and hospitalisation rates and social isolation. Reducing social isolation in prisons is crucial, as the mental health effects can be severe.7Cloud DH Drucker E Browne A Parsons J Public health and solitary confinement in the United States.Am J Public Health. 2015; 105: 18-26Crossref PubMed Scopus (78) Google Scholar, 8Johnson L Gutridge K Parkes J Roy A Plugge E Scoping review of mental health in prisons through the COVID-19 pandemic.BMJ Open. 2021; 11e046547Crossref PubMed Scopus (45) Google Scholar Second, Ryckman and colleagues6Ryckman T Chin ET Prince L et al.Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies.Lancet Public Health. 2021; (published online Aug 5.)https://doi.org/10.1016/S2468-2667(21)00162-6Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar provide a detailed methodological description that other researchers and practitioners can apply to replicate the microsimulation using local conditions and data sources. While somewhat outside the scope of their Article,6Ryckman T Chin ET Prince L et al.Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies.Lancet Public Health. 2021; (published online Aug 5.)https://doi.org/10.1016/S2468-2667(21)00162-6Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar more detail would be useful on the mechanisms underlying the collaboration between the researchers and the California Department of Corrections and Rehabilitation, which provided the data for the study; as such partnerships are uncommon, the processes used to develop this relationship might be useful in promoting future collaborations in other jurisdictions to enhance local government capacity for complex data-driven public health modelling, which is often beyond the capability of regional government data analysts. Another direction for future research includes how to influence correctional staff and administrator decision making. The assumptions in the study's models6Ryckman T Chin ET Prince L et al.Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies.Lancet Public Health. 2021; (published online Aug 5.)https://doi.org/10.1016/S2468-2667(21)00162-6Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar regarding the relative flexibility in vaccination rate among people who are incarcerated and relative inflexibility in staff vaccination rates is rooted in real-world data, and also practically problematic. Research on strategies to effectively improve correctional staff vaccination uptake remains a crucial and understudied area. Research is also lacking into strategies to shift correctional administrator decision making to be more public health centred. Finally, there is a substantial need to detail how to move beyond containing COVID-19 outbreaks inside of prisons and move towards community integration through decarceration. Containment is important, but insufficient to truly end COVID-19 prison-related outbreaks, as prisons are not closed systems; prison staff and residents move in and out of prisons, potentially carrying SARS-CoV-2 with them. Due to the COVID-19 pandemic, some jurisdictions dramatically reduced their population of people who are incarcerated, mostly through reductions in jail admissions. This decarceration was supported by the National Academy of Sciences,9Wang EA Western B Berwick DM COVID-19, decarceration, and the role of clinicians, health systems, and payers: a report from the National Academy of Sciences, Engineering, and Medicine.JAMA. 2020; 324: 2257-2258Crossref PubMed Scopus (22) Google Scholar and provides opportunities to model cross-system policy responses to COVID-19 to identify a more holistic package of evidence-based policies to promote public health. For example, people returning to the community from incarceration need to re-establish access to health insurance, health care, housing, employment, and other key services10Mukherjee TI El-Bassel N The perfect storm: COVID-19, mass incarceration and the opioid epidemic.Int J Drug Policy. 2020; 83102819Crossref PubMed Scopus (25) Google Scholar that act as social determinants of health. Historically, there have been vast gaps in linking this population to such services, and policies across the full spectrum of health and human services can be leveraged to improve health during and beyond the COVID-19 pandemic. I have provided aid in sentencing for the Committee for Public Counsel Services, made a presentation for the National Association of Social Workers Massachusetts, and served on the board of directors for the Massachusetts Bail Fund and New Garden Society. I am supported by the National Institute on Drug Abuse (T32DA03780). Content is the author's sole responsibility and does not necessarily represent official views of the National Institutes of Health. Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policiesBalancing benefits of resuming activities against risks of outbreaks presents challenging trade-offs. After achieving high vaccine coverage, prisons with mostly one-to-two-person cells that have higher baseline immunity from previous outbreaks can resume in-person activities with low risk of a widespread new outbreak, provided they maintain widespread NPIs, continue testing, and take measures to protect the medically vulnerable. Full-Text PDF Open Access