Prisons

Prisons have unique challenges when it comes to outbreak investigation and management. Some of these challenges include:

Increased disease background rates

Newly incarcerated populations tend to have a higher prevalence of certain infections than the general population, e.g., human immunodeficiency virus infection, hepatitis B virus infection, hepatitis C virus infection, syphilis, gonorrhoea, chlamydia, and tuberculosis . During their stay in prison, inmates are at an increased risk for acquiring blood-borne infections, sexually transmitted infections, MRSA infection, and infection with airborne pathogens, such as M. tuberculosis, influenza virus, and varicella-zoster virus.

Overcrowding and hygiene

Overcrowding is a common issue in prisons, which can facilitate the spread of infectious diseases. It makes implementing preventive measures, such as social distancing, more difficult. Jails and prisons often lack sufficient hand washing areas, isolation rooms, and personal protective equipment.

Challenges in standard and transmission-based precautions in prisons

	Precaution	Challenge(s)
	Hand hygiene	Many areas in which clinical care is provided lack hand washing stations. Soap and soap dispensers are valuable commodities and may be stolen by inmates. Alcohol-based hand washes burn with a clear flame and may raise concerns with custody staff.
	PPE	Custody employees routinely search inmates and conduct cell searches, increasing the risk for sharps injuries and contact with blood and other potentially infectious materials. Inmates may intentionally expose staff to blood and other potentially infectious materials by either spitting or throwing fluids. PPE is often stored in locked containers to prevent theft, limiting access.
	Sharps	To limit syringe diversion, puncture-resistant leak-proof containers may not be available at the site where sharp instruments are used. Use of sharps in nonclinical areas, such as housing units (e.g., cells and dormitories), increases the risk for injury.
	Patient care equipment	Patient care equipment (e.g., stethoscopes, blood pressure cuffs, and otoscopes) can be made into weapons or escape paraphernalia and, therefore, cannot be left in the rooms of inmates who are on contact precautions. These items can become contaminated and lead to transmission of pathogenic organisms.
	Housing	Most jails and prisons are overcrowded and have an inadequate number of single cells that can be used for isolation, facilitating the transmission of contagious illnesses. Large dormitories make it difficult to cohort inmates.
	Patient hygiene	Many inmates do not have ready access to soap and water. Shower access is often restricted. The number of toilets may be insufficient to serve the population.
	Laundry	Clothing and linen is strictly rationed. Inmates who have conditions that predispose to soiling clothing with blood and/or body fluids may not be able to secure additional clothing. Inmates often wash their own clothes in buckets, sinks, or bags to ensure that they do not lose their clothes. This may remove dirt and odors, but it does not disinfect clothing. Bleach is contraband and is not available to inmates.
	Housekeeping and sanitation	Most housecleaning is performed by inadequately trained inmates who do not have access to effective cleaning supplies. Housing areas and common areas (such as booking and bus screen areas, showers, toilets, day rooms, gymnasiums, weight equipment, and clinic waiting rooms) may be infrequently cleaned.
	Patient transport	Inmates are often moved without informing clinical services. Transportation vehicles may be inappropriate for transmission-based precautions. Vehicles may not be routinely cleaned and can be a source of transmission of contagious illnesses. Custody restraints are often reused without disinfection.
	Access to medical care	Many facilities have lengthy delays for inmates to see clinicians. Copayments discourage inmates from seeking care and may lead to further transmission of contagious conditions.

Table 1. Challenges to the implementation of standard and transmission-based precautions in jails and prisons.

Limited resources

Prisons may have limited medical facilities, staff, and resources, hindering timely diagnosis and management of outbreaks. Often, medical records of inmates are difficult to access for outbreak investigation.

High-risk populations

Prisons often house individuals with underlying health conditions, substance abuse issues, and compromised immune systems. These factors can make the prison population more susceptible to infectious diseases. For example, in an outbreak of itching in a penitentiary facility for drug couriers, it was observed that knowledge of dermatological problems in dark-skinned people was limited among the medical staff, resulting in unwarranted anxiety.

Security concerns

Security issues can create barriers to accessing external resources and limit the movement of inmates and staff, making outbreak investigation and management more challenging.

Surveillance and detection

Surveillance is a crucial part of an outbreak investigation in prisons. An effective surveillance system helps to:

1. Identify trends and patterns in disease occurrence, enabling early detection of outbreaks.
2. Monitor the effectiveness of control measures and inform adjustments as needed.
3. Provide data for long-term planning and resource allocation.

In prisons, surveillance should be adapted to the unique challenges and constraints of the setting. Data should be collected systematically and regularly analyzed, with appropriate confidentiality and privacy measures in place.

Outbreak confirmation and case definition

Upon detection of a potential outbreak in prison, the first step is to confirm the outbreak and develop a case definition. This involves:

1. Verifying the diagnosis: Confirming the outbreak by laboratory testing and clinical evaluation.
2. Developing a case definition: A case definition should be specific, sensitive, and practical for the prison setting. It should include elements such as clinical criteria, laboratory results, and exposure history.
3. Identifying and counting cases: Using the case definition, investigators should identify and count cases to determine the outbreak's scope.

Descriptive epidemiology

Descriptive epidemiology helps investigators characterize the outbreak in terms of time, place, and person. In prisons, this may involve:

1. Examining the distribution of cases by time: This can help identify trends and potential exposures, as well as the effectiveness of control measures.
2. Analyzing the distribution of cases by place: Investigating the spatial distribution of cases within the prison can help identify potential transmission sources and inform targeted interventions.
3. Describing the distribution of cases by person: Understanding affected individuals' demographic and risk factors can help tailor control measures and identify vulnerable populations.

Hypothesis generation and analytical epidemiology

Using descriptive epidemiology, investigators should generate hypotheses about the source, transmission mode, and outbreak risk factors. Analytical epidemiology can help test these hypotheses, which may involve:

1. Comparing exposures and outcomes among the prison population. The unique circumstances of a well-defined community of inmates and penitentiary personnel make it easier to set up cohort studies rather than the usual case-control studies in outbreak investigations
2. Analyzing transmission patterns: This can help determine the transmission mode and inform control measures.
3. Getting information on exposure and outcomes may face specific challenges:

• • Inmates may be reluctant to be open about particular exposures (.e.g. substance abuse or sexual practices)
  • It may be difficult to ascertain syndromic outcomes, as these are often collected via personal accounts; ascertainment bias may play a part, in particular when there are benefits of being classified as 'ill'

Control measures and evaluation

Outbreak control measures in penitentiary institutions are based on generic outbreak control measures, though certain aspects deserve attention:

1. Coordinating with prison administration: Collaborating closely with prison administrators is essential for implementing control measures effectively, as they have a deep understanding of the prison environment and can facilitate access to resources and logistical support.
2. Balancing security and public health: In a prison setting, control measures must balance ensuring the safety and security of inmates and staff and protecting public health. This might involve negotiating with prison authorities to temporarily relax certain security protocols or developing alternative strategies to maintain security and health objectives.
3. Adapting control measures to limited resources: Prisons may have limited medical and infrastructural resources, making it necessary to prioritize and adapt control measures based on resource availability. For example, infection control measures may need to be modified to account for limited PPE supplies or the lack of isolation facilities.
4. Engaging inmate populations: Involving inmates in developing and implementing control measures can help foster a sense of ownership and promote compliance. This might include providing inmates with opportunities to participate in educational programs or assigning responsibilities related to infection control, such as peer education or cleaning duties.

Evaluation of outbreak response in prisons may face particular challenges:

1. Overcoming data limitations: Accurate and timely data collection may be challenging in prisons due to factors such as limited medical staff, high inmate turnover, and concerns about privacy and confidentiality. Investigators may need to develop alternative methods for gathering data or rely on proxy measures to evaluate the effectiveness of control measures.
2. Addressing unique barriers to adherence: Evaluating adherence to control measures in prisons may involve identifying and addressing unique barriers that inmates or staff may face, such as fear of stigma or retaliation, lack of trust in authorities, or competing priorities related to security and daily operations.
3. Building capacity for future outbreaks: As part of the evaluation process, investigators should identify opportunities for building capacity within the prison system to better respond to future outbreaks. This could include training staff in outbreak detection and management, strengthening surveillance systems, or improving infrastructure to support infection control efforts.

In conclusion, outbreak investigations in prisons require special attention to the unique challenges and constraints of the setting. By adopting control measures and evaluation strategies to address these peculiarities, public health practitioners can effectively manage outbreaks and protect inmates' and staff's health and well-being.

Recommended reading

• Centers for Disease Control and Prevention. (2017). Guidelines for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings. Retrieved from https://www.cdc.gov/hai/pdfs/norovirus/229110A-NorovirusControlRecomm508A.pdf
• Hammett, T. M., Roberts, C., & Kennedy, S. (2001). Health-related issues in prisoner reentry. Crime & Delinquency, 47(3), 390-409. doi: 10.1177/0011128701047003006
• Kinner, S. A., & Young, J. T. (2018). Understanding and improving the health of people who experience incarceration: An overview and synthesis. Epidemiologic Reviews, 40(1), 4-11. doi: 10.1093/epirev/mxx015
• Maruschak, L. M., & Beavers, R. (2009). HIV in Prisons, 2007–08. Bureau of Justice Statistics Bulletin. Retrieved from https://www.bjs.gov/content/pub/pdf/hivp08.pdf
• Nellums, L. B., Rustage, K., Hargreaves, S., Friedland, J. S., & Zimmerman, C. (2018). Access to healthcare for people seeking and refused asylum in Great Britain: A review of evidence. Equality and Human Rights Commission Research report 126. Retrieved from https://www.equalityhumanrights.com/sites/default/files/research-report-126-healthcare-access-for-refused-asylum-seekers.pdf
• Spaulding, A. C., Seals, R. M., McCallum, V. A., Perez, S. D., Brzozowski, A. K., & Steenland, N. K. (2011). Prisoner survival inside and outside of the institution: Implications for health-care planning. American Journal of Epidemiology, 173(5), 479-487. doi: 10.1093/aje/kwq422