Distribution of Covid-19 vaccines should be guided by evidence and based on the principle of harm reduction. In this blog, experts from the University of Oxford consider why prison populations and staff should be prioritised in national vaccination programmes, what is happening so far and the challenges to their inclusion in some places.
Prisons have become an epicentre for Covid-19 in some countries, with outbreaks since early 2020, and many still ongoing. These often overcrowded settings are generally thought to be isolated from the outside world, but this is not the case. More than 30 million individuals experience incarceration worldwide each year, the majority of which are released within months. Despite the implementation of various outbreak control measures (e.g. suspension of prison-based activities, court hearings and visits from relatives), the spread of the virus has not stopped at prison doors. In fact, coronavirus transmission to and from surrounding communities has been widely documented, and exemplifies the porous nature of prisons. With approximately 500,000 infections and nearly 4,000 deaths to date, the pandemic has taken a considerable toll on the global prison population.
Reviewing the evidence
We worked with infectious disease experts to bring together evidence from studies of outbreaks of highly contagious diseases in prisons to see what can be learned and applied to the current crisis. We identified 28 relevant studies and compiled common themes, challenges and research gaps in the management of previous prison outbreaks. Our systematic review shows that people in prison often live in overcrowded and unsanitary conditions where social distancing and most infection mitigation strategies are largely unfeasible. Marginalised persons are disproportionately represented in this population, and this translates into high rates of underlying chronic diseases and psychiatric morbidity. Hence, prisons provide fertile ground for Covid-19 due to their environmental constraints and the health vulnerabilities of the people that populate them.
Our review offers guidance for managing infectious disease outbreaks in prisons. Extensive interagency collaboration between prison officials and public health agencies is central to leading an effective infection control response. In fact, a coordinated approach between these authorities is vital, as a cluster of cases can quickly overwhelm prisons, even if they are well-staffed. Moreover, local public health agencies can help coordinate contact tracing, as it would be expected to cast on a wider scale than the prison itself. Similarly, transparent communication to people in prison about implemented measures and health risks is also important, given their lack or very limited access to the internet. Additional mitigation strategies include screening, imposing restrictions on movement and mixing, medical isolation, and quarantine.
a coordinated approach between [prison officials and public health agencies] is vital, as a cluster of cases can quickly overwhelm prisons, even if they are well-staffed
Research gaps have also emerged from our review, the first being the potential negative consequences such restriction measures will have on the mental health of people in prison. However, the most notable research gap remains decarceration efforts to reduce overcrowding in prisons, and the implications of releasing people early has generated a wide societal debate. There are hardly any risk assessment tools developed specifically for released prisoners, although OxRec, which was developed by our group, is one validated and transparent approach to predicting serious reoffending. More recently, another matter has become the subject of much contention: coronavirus vaccine priority for people in prison.
What is happening with vaccine priority?
Worldwide, the message from public health, medical and prison welfare bodies has been consistent – people in prison should not be disadvantaged for vaccine access compared to those in the community with equivalent risk profiles, and moreover they should be considered an at-risk group. In November 2020 the American Medical Association recognised that people in prison should be prioritised for the initial phases of vaccine distribution, and in December 2020, the UK’s Independent Advisory Panel on Deaths in Custody made a similar call. As national vaccine priority lists began to be published however, concern grew that scientific consensus was not translating into people in prison featuring on priority schedules. Like much of Europe, The British Joint Committee on Vaccination and Immunisation did not specifically cite people in prison in their advice on priority groups, though did mention that in the next phase those at increased risk of exposure due to their occupation, including those involved in the justice system, could be a priority. In the US, individual states have adopted a range of strategies; correctional staff are again more frequently prioritised, but in nine states people in prison are specifically featured in Phase 1 plans. More positively, in 40 states people in prison do at least feature in some form as an addressed priority group.
What is the debate?
The notion that people in prison should be high up the priority list in the response to Covid-19 including vaccination may be regarded as controversial, but is based on evidence of risk and transmission. The physical environment, including overcrowding and poor ventilation, lends itself to rapid transmission, and makes simple transmission-prevention practices much more challenging. The social health inequalities highlighted by Covid-19 are mirrored in prison populations, and physical health vulnerabilities for severe Covid-19 are more common. What is probably less appreciated in the wider public is how important transmission in prison is to the wider community – far from being cut-off, there are staff, transfers, court attendances, visits and releases. With these factors in mind, we have argued that prisons should be central to the response. The barriers to this crossing over into vaccination schedules seem more political than scientific. Some in the general public are vocal in using “moral” standpoints, pitting the relative worthiness of “incarcerated murderers” against law-abiding citizens such as in a backlash to plans in Colorado. Media have in some cases fanned these flames by publicly singling out specific individuals, defining them by the crime for which they were convicted, and inferring that they do not deserve to be prioritised on that basis. As well as being highly problematic ethically, such stances do not account for the public health implications of the situation, and are irrelevant to the decision-making process of vaccine allocation.
What is probably less appreciated in the wider public is how important transmission in prison is to the wider community – far from being cut-off, there are staff, transfers, court attendances, visits and releases.
Achieving successful vaccine rollout to prisons is not without challenges, but these are by no means insurmountable. Findings from our review can be applied to the practicalities that are emerging for Covid-19 vaccinations. We highlighted some of the environmental constraints of prisons, and these will also apply to the cold storage requirements of Covid-19 vaccines, with additional implications for distribution to facilities in more remote areas that will need addressing. The issue of Covid-19 vaccine hesitancy has been widely discussed and increasingly studied, and vaccine refusal was also highlighted in our review. Communication of information to people in prison needs to be accessible, tailored, culturally sensitive, and aim to avoid disproportionate low uptake amongst vulnerable groups, including those with serious mental disorders. A further specific challenge, particularly with multi-dose vaccination schedules, is tracking those who have received the vaccine, and contacting them for a second dose if released from prison. Rather than a barrier however, the practicality of vaccine access and tracking is arguably another reason to prioritise people in prison. Unstable accommodation situations outside of prison may make it extremely difficult for people to be contacted for vaccination in the standard manner. For example, central to the vaccine rollout in England has been coordination by local primary care settings. People in prison often have unstable accommodation situations, and it is not uncommon for an individual to be released from prison to a temporary residence. Registration with local primary care health services in these situations often lags behind someone’s geographical location, so an invitation text message or letter from the local practice might be an unlikely route to vaccination.
Effective distribution should be guided by the evidence, with regards to the harm-reduction principle. By first allocating vaccine doses to vulnerable groups where underlying risks and transmissibility are high, such as people and staff in prison, benefits can be maximised for the general public. While vaccination is critical to stop the spread of Covid-19 in prisons, considerable structural changes are required to improve preparedness for future viral outbreaks, epidemics and pandemics. In the simplest terms, prisons need to be made safer. This includes strategies for decarceration, which will help reduce occupant density and allow for social distancing. Ventilation should be improved and access to basic hygiene products needs to be democratised. In conclusion, governments have a duty of care towards people in prison, and this should be reflected in their living conditions and access to adequate healthcare.
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