key: cord-0792828-15yt9b6w authors: Nowotny, K. M.; Cloud, D.; Wurcel, A. G.; Brinkley-Rubinstein, L. title: Disparities in COVID-19 Related Mortality in U.S. Prisons and the General Population date: 2020-09-18 journal: nan DOI: 10.1101/2020.09.17.20183392 sha: 1e4d2cdf41157702bdc3c87066b1536594371941 doc_id: 792828 cord_uid: 15yt9b6w We provide an analysis of COVID-19 mortality data to assess the potential magnitude of COVID-19 among prison residents. Data were pooled from Covid Prison Project and multiple publicly available national and state level sources. Data analyses consisted of standard epidemiologic and demographic estimates. A single case study was included to generate a more in-depth and multi-faceted understanding of COVID-19 mortality in prisons. The increase in crude COVID-19 mortality rates for the prison population has outpaced the rates for the general population. People in prison experienced a significantly higher mortality burden compared to the general population (standardized mortality ratio (SMR) = 2.75; 95% confidence interval = 2.54, 2.96). For a handful of states (n = 5), these disparities were more extreme, with SMRs ranging from 5.55 to 10.56. Four states reported COVID-19 related death counts that are more than 50% of expected deaths from all-causes in a calendar year. The case study suggested there was also variation in mortality among units within prison systems, with geriatric facilities potentially at highest risk. Understanding the dynamic trends in COVID-19 mortality in prisons as they move in and out of hotspot status is critical. in-depth and multi-faceted understanding of COVID-19 mortality in prisons. The increase in crude COVID-19 mortality rates for the prison population has outpaced the rates for the general population. People in prison experienced a significantly higher mortality burden compared to the general population (standardized mortality ratio (SMR) = 2.75; 95% confidence interval = 2.54, 2.96). For a handful of states (n = 5), these disparities were more extreme, with SMRs ranging . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint from 5.55 to 10.56 . Four states reported COVID-19 related death counts that are more than 50% of expected deaths from all-causes in a calendar year. The case study suggested there was also variation in mortality among units within prison systems, with geriatric facilities potentially at highest risk. Understanding the dynamic trends in COVID-19 mortality in prisons as they move in and out of "hotspot" status is critical. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020 In response to these outbreaks and calls for increased transparency, many correctional systems, federal and state prisons in particular, are now publicly reporting data on COVID-19 testing, confirmed cases, and deaths among incarcerated people and staff. As prisons represent the epicenter for continued outbreaks, an understanding of the disproportionate impact of mortality in prisons is crucial to improving public health and preventing deaths. We provide an analysis of COVID-19 mortality data to assess the potential magnitude of COVID-19 among prison residents and to contextualize COVID-19 deaths in prisons. The primary data for this study are from the COVID Prison Project (CPP) (www.covidprisonproject.com). The CPP publishes an aggregate dataset examining COVID-19 in correctional facilities, including data on the number of tests, the number of confirmed positive cases, and mortality due to COVID-19 among correctional staff and incarcerated individuals. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. week. Figure 1 shows the growth in crude COVID-19 mortality rates for the prison and general population. Beginning in early May, the COVID-19 death rate in prisons began to outpace the general population rate. This is reflected in the weekly standardized mortality ratios (SMR), following the CDC data reporting schedule 6 . Adjusting for age and sex, the SMR was not significant on April 25. Beginning the week of May 2, the SMR was 1.59, meaning that adjusting for age and sex the prison population had a COVID-19 mortality rate 159% higher than the general population. By July 11, the SMR was 2.75. On July 15, the latest date that daily data . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint were available, the crude prison COVID-19 mortality rate exceeded the rate for the general population: 50 per 100,000 compared to 40 per 100,000, respectively. Figure 2 shows that there was variation in the relationship between prison and general population mortality across states. Thirty-two out of 50 state departments of correction had reported at least one COVID-19 related death. Among those states, 10 reported little to no difference in mortality between the prison and general population (WA to FL), six states reported a slightly higher mortality rate in the general population (MA to CO), and six states reported a substantively higher mortality rate in the general population (NY to LA). Conversely, three states reported a slightly higher mortality rate in the prison population (CA to AL), and seven states reported a substantively higher mortality rate in the prison population (KS to OH). The SMRs for states with a greater than 50 per 100,000 increase in the prison mortality rate compared to the general population mortality rate were TX 5.55 (95% confidence interval (95CI) 4 The COVID-19 crude mortality rate for prison residents is 79.4 per 100,000, and the corresponding rates for prison staff and the general population are 24.2 and 11.8, respectively. The Texas Department of Criminal Justice (TDCJ) reports information about residents who died in their custody through updates on their website 12 when an investigation has been completed and COVID-19 has been confirmed to be a contributing cause. As of July 15, investigations for 75 deaths were completed out of 120 total COVID-19 deaths (one case is missing age). Of the 75 completed cases, 45 deaths were among residents aged 65 and older (60.8%), 27 deaths were of residents aged 50 to 64 years (36.5%), and two were of residents below the age of 50 (4.7%). The rates for comparable age groups in the general population of Texas were 73.2%, 20.8%, and 6.0%, respectively. Underlying health conditions were noted in 36 cases. For those cases with reported information (n=41), 10 tested positive for COVID-19 after being hospitalized, 17 were tested the day of hospitalization, and 14 were tested prior to hospitalization. All but three people died in a hospital and the mean length of hospitalization was 9.38 days with a range of less than one day to 30 days. Most deaths that occurred within the custody of TDCJ happened at the Galveston Hospital Unit. Texas, and was located in a rural county with a population of less than 100,000. This facility had an average age of 65.68 years (SD = 7.91; range 30 to 88 years), a case rate of 66.5%, a case fatality rate of 4.3%, and a crude mortality rate of 29 per 1,000. The case rate among employees at this unit was 36.7%. For comparison, the case fatality rate for the county in which the prison was located was 1.2%, and the case rate was 1.2%. The county had reported 12 COVID-related . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint deaths to date (crude mortality rate was 0.14 per 1,000). A second, larger, geriatric facility, which housed three times as many people and was also located in a small rural county, reported a case rate of 34.5%, a case fatality rate of 2.8%, and a crude mortality rate of 9.7 per 1,000. The average age at this facility was 56.85 years (SD = 12.86, range 23 to 88 years). The case rate among staff was 15.0%. The county in which this prison was located had a case rate of 0.8% and had reported two deaths related to COVID-19 (a case fatality rate of 0.2%, crude mortality rate was 0.02 per 1,000). This study provides insight into the magnitude of excess deaths in prison settings due to COVID-19 in the U.S. There has been a steady increase in the COVID-19 mortality rate for the prison population overall; however, mortality rates varied by state. Overall, people in prison were experiencing a significantly higher mortality burden compared to the general population (SMR = 2.75). For a handful of states (n = 5), these disparities were more extreme, with SMRs ranging from 5.55 to 10.56. Similarly, four states reported COVID-19 related death counts that are more than 50% of expected deaths from all-causes in a calendar year. The Texas case study found that there was also variation in mortality among units within prison systems, with geriatric facilities potentially at highest risk. Prison facilities are often located in rural counties, and may contribute to the spread of COVID-19 in these areas as staff move in and out of the facility. Indeed, there was some evidence from Texas that COVID-19 case rates were higher among both prison residents and staff compared to the local county. It is important to note that this analysis does not include deaths that have occurred in other correctional spaces, such as local county jails (e.g., Cook County Jail, IL, Rikers Island, NY), city "lockups" or holding facilities, regional jails, U.S. Marshall facilities, military operated . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint facilities, tribal facilities, or ICE operated facilities. While these are all important correctional spaces that make up the "whole pie" of incarceration 26 , each of these contexts pose unique risks for the transmission of COVID-19. For example, state prisons and BOP house the largest share of people under correctional confinement on any given day (~1.3 million); although, over 10 million people cycle through jails in a given year. Large urban jails such as LA County Jail and Cook County Jail house more people than most single-site prisons. Preliminary analysis from Cook County Jail, IL 27 shows that jail cycling was associated with 15.7 percent of documented cases in IL, exceeding other known predictors (e.g., population density and public transit utilization). Another important correctional space that is absent from this analysis is community supervision (e.g., probation or parole), which is actually responsible for the largest number of people under correctional supervision (whether in the community or confined to a facility). Our study is the first to characterize COVID-19 deaths in U.S. prisons, and highlight disparities in mortality between prison residents and people living in the community. Understanding the dynamic trends in COVID-19 mortality in prisons as they move in and out of "hotspot" status 28 requires a comprehensive understanding of public health, corrections, and justice health 29 . This study also serves as a call to action. We cannot ignore the urgent need to have a focused approach to COVID-19 mitigation in prisons. This will require nuanced analyses of higher quality data both within and across systems. Finally, we would be remiss if we did not mention that, on average, prison systems have only released 5% of their population. Our findings underscore the need for more drastic release efforts such as wider use of compassionate release for geriatric and other vulnerable people 30 that includes emergency planning for release 31 . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.17.20183392 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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