key: cord-279645-gwxu6dz2 authors: Montoya-Barthelemy, Andre; Lee, Charles D.; Cundiff, Dave; Smith, Eric title: COVID-19 and the Correctional Environment: The American Prison as a Focal Point for Public Health date: 2020-04-17 journal: Am J Prev Med DOI: 10.1016/j.amepre.2020.04.001 sha: doc_id: 279645 cord_uid: gwxu6dz2 nan The COVID-19 pandemic has proven to be deadly, rapidly developing, and resource depleting for all sectors of society. Within this space, prisoners and correctional staff share an environment known to amplify, accelerate, and act as a reservoir for outbreaks of respiratory disease. Correctional administrators have extraordinary power over an institution's disease response, and guidance and collaboration from the wider health system will be essential. 1 The initial outbreak of coronavirus disease 2019 , caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in December 2019 in Hubei Province, China. It has since been declared a pandemic by the WHO, with an increasing velocity of deaths and diagnoses in the U.S. As a respiratory-borne illness, the rate of transmission is largely dependent upon the extent of respiratory contact between individuals. Detention settings are extremely susceptible to rapid and disastrous spread of infectious disease, owing to both environmental and host factors-a point extensively documented by the historical spread of influenza, tuberculosis, and other respiratory pathogens. 1, 2 The U.S. holds almost 2.3 million people, exceeding 0.7% of its total population, in state and federal prisons, local jails, immigration detention centers, juvenile correctional facilities, military prisons, and state hospitals. 3 These settings are extremely diverse in terms of size and organization, but they are congregate settings where prisoners cannot leave and are generally 3 unable to maintain "social distancing." Prison staff enter and exit on a daily basis, and prisoners are regularly transferred between facilities. There is also a "jail churn" of admissions and releases from local jails, acting as a powerful "transmission multiplier" among the 7.3 million total (3.2% of adults) who are incarcerated each year. 2 Prisoners have a high prevalence of chronic disease and mental health illness, and prisons house an increasingly aging population, which will contribute directly to higher rates of severe viral illness and death. 4 Educational attainment and health literacy tend to be low and information transfer is tightly controlled, creating fertile ground for misinformation and fear. 5 Essential interventions, such as isolation and quarantine, will likely worsen pre-existing mental health diagnoses. 6 The correctional environment imposes additional risk. 1, 7 Overcrowding, poor ventilation, close habitation, or dormitory-style housing will increase COVID-19 transmission. Also, institutions strictly control everyday items such as soap, cleaning supplies, and hand sanitizer, and rarely provide spare clothing or bedding. These practices can lead to poor personal hygiene and may also contribute to virus spread. Women and minorities face particular hazards. Both women and minorities have higher rates of chronic disease than the wider prisoner population, and women are the fastest growing segment of the U.S. incarcerated population, having increased 742% between 1980 and 2016. 3 The full implications of COVID-19 infection during pregnancy have not yet been established, warranting special consideration for protection. Inadequate information technology and information sharing between facilities, chronically underfunded health systems, and medical copays that demand a substantial portion of a prisoner's income may prevent the timely identification, isolation, treatment, and referral of cases. Finally, security obligations may impede transfer of seriously ill prisoners to hospitals, and smaller facilities may have only off-site, on-call medical coverage. 1, 2 Finally, about 870,000 prisoners perform some type of work while incarcerated, earning an average of $0.93 per hour, and are effectively uncovered by the Occupational Safety and Health Administration oversight or any other federal workplace protections. 8, 9 During this outbreak, stories have emerged of inmates producing hand sanitizer and personal protective equipment, while they themselves are barred from possessing it. They are washing potentially infected laundry from the institution, local schools and hospitals, and even digging graves for COVID-19 victims in preparation for the anticipated wave of deaths. 10 Systematic investigation and information sharing are generally necessary steps to establish best practices and facilitate public health functions. Historical abuses in research, however, have led to very tight control over the performance of medical investigation among incarcerated populations. Prisoners have been viewed as an opportune population for research of many types given high prevalence of disease and exposure, susceptibility to coercion by relatively small incentives, and the assurance of reliable follow-up, all owing to the enormous power disparities that characterize their incarceration. 11 IRBs must make every effort to facilitate investigation 5 beneficial to these highly underserved populations, while still protecting prisoners from exploitation. Their protection should be closely overseen by the relevant legal authorities at every level. More than 500,000 correctional officers and correctional medical staff work in this environment. 12 They are "essential personnel" during the COVID-19 response, 1 and their professions bring them into direct contact with a high-risk population daily. They share all of the risks of the physical environment as listed above, but are additionally exposed through uncontrolled physical contact as correctional officers move prisoners or engage in altercations, and as medical staff perform physical examinations and medical procedures. Prisoners may be unable or unwilling to maintain personal hygiene, and may intentionally expose staff to body fluids in an attempt to transmit disease. 13 Correctional staff mental health is also highly vulnerable during this outbreak. Independent of COVID-19, work-related stress, anxiety, and frustration are high among correctional officers, correlating with high rates of depression, anxiety, post-traumatic stress disorder, and rates of suicide that are 40%-100% higher than police officers. 14 Recognizing this increased risk, correctional employees at both the state and federal level have filed complaints to demand hazard pay during the outbreak. 15 Correctional medical personnel work in chronically underfunded systems, where they may lack adequate guidance, personal protective equipment, testing supplies, and access to referral. During the 2003 SARS outbreak, healthcare workers reported reluctance to work, consideration of resignation, fear of infection, and transmission to colleagues and loved ones. 16 More recently during the COVID-19 outbreak, they report high rates of anxiety, depression, insomnia, somatization, and symptoms of post-traumatic stress disorder. 17 Correctional institutions are also chronically understaffed, already leading to long hours and high rates of burnout. 14 Shortages will worsen as staff are quarantined or must stay home to care for loved ones, and as officers are detailed to guard prisoners in community hospitals. Their colleagues will work longer hours, under increasing demand, guarding and caring for a population who, already deprived of their liberty, may become increasingly agitated by necessary quarantine procedures and their legitimate fear of illness or death. Treating physicians in the community should ask all patients about where they live and work, maintaining an elevated level of suspicion for COVID-19 and for stress-related disorders if the patient works in a correctional environment or has been recently incarcerated. As mentioned previously, detention settings and the outside community experience frequent contact as individuals are arrested and admitted to jails, released from jails on bail, transferred between facilities, transported to court dates and medical visits, or released from prison into the community. Corrections staff arrive and depart the facility daily after contact with their own families. Each of these contacts acts as a potential route of transmission. Because introduction of COVID-19 via asymptomatic carriers is nearly inevitable, and because conditions strongly favor 7 contagion inside the institution, most correctional facilities will amplify the COVID-19 pandemic and act as a reservoir of illness to the wider community. As of April 4, 2020, there was an estimated infection rate of 5.1% in Rikers Island, five times higher than the general population rate in New York, the state with the most cases in the country. 18 Initial studies demonstrate that 20% of COVID-19 positive patients in a community sample developed severe disease requiring oxygen supplementation. 19 Because of prisoners' underlying health conditions, a high proportion of prisoners will likely develop severe disease and require transfer for hospitalization, further burdening a community health care system already likely to be overwhelmed. As recommended by current guidelines, many jurisdictions are releasing low-risk prisoners, but without the proper support they face enormous barriers to healthy reintegration to the community. Homeless shelters are communal settings, many of which have been closed to reduce transmission. Landlords may refuse housing to recently released prisoners on concerns of contagion, and much-needed social services and medical management are heavily burdened. Already facing discrimination in hiring, released prisoners will be seeking work at a time when the unemployment rates are hitting historic levels. 18 At the time of this writing, it is not clear what, if any, social support programs may be available to the prisoners whose release is now a public health imperative. Though the correctional environment is often considered distinct or isolated from the wider society and health system, the well-being of correctional workers and prisoners is inexorably 10 linked to the health of the country as a whole. They constitute millions of family members and neighbors, and as such, their safety is inherently a matter of public health. Today, correctional workers and prisoners are under severe threat, but when correctional institutions and the outside community collaborate for the safety of their workers and residents, all will be better protected against COVID-19 illness and death. COVID-19) in Correctional and Detention Facilities Pandemic influenza and jail facilities and populations Mass Incarceration: The Whole Pie 2020. 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The American Prospect Analysis of Employment Protections and Occupational Health of Inmate Workers Paul Wright quoted in article about use of prison labor Ethical and social issues in health research involving incarcerated people Infection control in jails and prisons Correctional Officer Safety and Wellness Literature Synthesis Psychological distress of nurses in Taiwan who worked during the outbreak of SARS Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 Nowhere to go: Some inmates freed because of coronavirus are 'scared to leave The epidemiological characteristics of 2019 novel coronavirus diseases (COVID-19 Preparedness, prevention and control of COVID-19 in prisons and other places of detention: Interim guidance Preparedness-prevention-andcontrol-of-COVID-19-in-prisons.pdf?ua=1 No financial disclosures were reported by the authors of this paper.