Brazilian pulmonology guidelines on Delphi panel for post-coronavirus disease 2019: reflections on persons deprived of liberty

A guideline on focus published in the Journal of the Brazilian Medical Association showed the need for a continuous medical education program offered by different institutions to increase the knowledge of COVID-19; nevertheless, there are institutions that were not included in the discussion of this study¹. A Delphi study¹ on COVID-19 should comprehensively discuss the subject, but the authors¹ did not address the strategies used in the health of Brazilians deprived of liberty during the COVID-19 pandemic. Therefore, as a contribution to the literature, we summarize the main findings on this topic.

In March 2020, the World Health Organization declared a pandemic due to the discovery of the respiratory disease caused by the new coronavirus (SARS-CoV-2). As a measure to prevent the disease (COVID-19), the use of masks and social isolation were decreed due to the high transmission of the virus through talking, sneezing, and coughing². People deprived of liberty suffer from numerous health problems, especially those of the respiratory system such as asthma and tuberculosis, due to the lack of structures in the penitentiary units, such as overcrowding in cells, unhealthy conditions, and climate control. Although the Brazilian penitentiary system is governed by laws that guarantee the health of those who are deprived of liberty, the execution of such laws and the preparation of health teams are flawed³.

The national policy for comprehensive health care for people deprived of liberty in the prison system of 2014 aims to guarantee the health of this population; however, in most protocols issued by the government regarding the confrontation of the pandemic, the prison population was rarely mentioned⁴. It is evidenced by the high potential for transmission of the virus in closed environments and with agglomerations, and in the conditions in which Brazilian prisons are found, the possibility of transmission of the coronavirus in penitentiary units is high. As it is already an environment of social isolation, the isolation measure results in a new term called super-isolation². Being characterized as a place of extreme social vulnerability, prisons worldwide have an overrepresentation of certain demographic groups, such as the black population, and the COVID-19 pandemic will disproportionately impact these specific communities⁵.

After a preliminary search of Medline, Cochrane, and JBI Evidence Synthesis, we noticed that there was a gap in the literature on this topic. In this sense, it becomes valid to build a discussion covering this topic, since the health of people deprived of liberty in Brazil is unassisted, and public policy aimed at this population is recent. In this view, the research question can be defined as: which are the main strategies and measures implemented in the health of the Brazilian population deprived of liberty during the COVID-19 pandemic? Therefore, we summarized and discuss the main strategies used in the health of people deprived of liberty in Brazil during the COVID-19 pandemic.

Original articles, experience reports, and case studies published in English, Portuguese, and Spanish languages that addressed the health of population deprived of liberty in the context of the COVID-19 pandemic were included. Duplicate articles that did not fit the proposed theme were excluded after reading the title/abstract and also after reading them in full text. Since it is a relatively new subject, no time limit was defined. First, the articles were selected by reading the title and abstract beforehand, and after going through this selection and fitting them into the review, the articles were read in full (Figure 1).

Figure 1
Flowchart.

IMPLEMENTATION OF COVID-19 CONTROL MEASURES

In this category, control measures against the coronavirus in prisons stand out. Considering prisons as a means of facilitating the resurgence of the pandemic, preventive measures must be dealt with rigorously, following the three main principles: the entry of the virus into penitentiary units must be postponed, it must be controlled if it is already in circulation, and it is the sole responsibility of the preparation of penitentiary units to deal with those who develop SARS-CoV-2².

In a penitentiary in Rio Grande do Sul, any individual who enters the unit will be screened for flu symptoms by a trained penitentiary agent, who will then answer a questionnaire to assess the symptoms suggestive of the disease, measuring the temperature and oxygen saturation. In cases suggestive of the coronavirus, entry to the unit would not be allowed for at least 14 days, and the individual is advised to seek out a health unit.

Regarding the entry of new people deprived of liberty, screening was adopted as mentioned above. In asymptomatic cases, they would be isolated for 14 days, and after compliance, they would be passed to the prison health team and submitted to the rapid test, if the result was non-reagent, they would be released to join other prisoners; if not, they would spend another 7 days in isolation⁶.

PRISON TEAM PREPARATION

The category addresses how prison staff were trained and prepared to deal with the virus. At the penitentiary in Rio Grande do Sul, events with servers were used as a strategy to provide the necessary guidance, such as the use of personal protective equipment, correct hand hygiene and disinfection of surfaces, and know what to do if they had symptoms of the coronavirus⁶. In the state of Bahia, government publications were prepared to face the pandemic in this population, with the training of professionals via videoconference, where a questionnaire was carried out about the distribution of hygiene materials to professionals and people deprived of liberty, and guidance on drawing up an internal protocol for coping with COVID-19⁷.

POPULATION DEPRIVED OF LIBERTY VACCINATION SCHEDULE

Category brings how the vaccination scheme for the population deprived of liberty was carried out, where the national plan for the operation of vaccination against COVID-19 brought people deprived of liberty as members of phase 4 of the vaccination, but in a new version of the plan, the prison population was no longer treated as a priority group. Finally after much discussion, the plan was revised, and it was decided that vaccination would be articulated with the state, municipal, and justice departments according to the prison system⁸. The Ministry of Health aims to vaccinate 90% of people deprived of liberty against influenza. Vaccination is one of the strategies used to reduce flu conditions, which consequently reduces the number of people tested for COVID-19⁶.

AUTHORS’ INTERPRETATION

We observed that the studies did not detail how the vaccination schedule of the people deprived of liberty would be carried out and also the great difficulty for the implementation of actions to control the contamination of the virus due to the conditions in which the prisons are found, such as the overcrowding of the cells, lack of ventilation, and unhealthy conditions, which was already a health problem for other infectious diseases but has become an aggravating factor for the coronavirus, which spreads quickly and easily.

The first case of COVID-19 registered in Brazil in the prison system was in the state of Rio de Janeiro, as soon as the pandemic was declared by the World Health Organization in March 2020. Since then, until August 2021, there were already 272 deaths among people deprived of liberty⁹. In the United States of America, the number of COVID cases in the prison system was 5.5 times higher when compared to the general population¹⁰.

Due to the poor governance of the financial resources of Brazilian penitentiary units and the unpreparedness of health teams, it could make it difficult for the population deprived of liberty to access the health care network in cases of extreme need due to COVID-19². In Brazil, the pandemic required not only control measures against the virus but also political positioning, requiring the elaboration of government publications that served this specific population, as occurred in the state of Bahia³.

The National Council of Justice recommended extrication measures, thus aiming at reducing the overcrowding of cells, with provisional and definitive freedom, as well as house arrest for people deprived of liberty with comorbidities or elderly people, but such measures were rarely applied within units⁴. In Iran, this strategy was used, and there was the release of more than 70,000 people deprived of liberty, which did not occur in Italy and consequently generated riots within penitentiary units, reinforcing the idea that the release of those who apparently would not commit additional crimes could decrease the transmission of COVID-19¹¹.

The Brazilian Penal Execution Law has the right to ensure visits by family members and spouses of those deprived of their liberty on pre-established days, and this right is often violated, becoming an aggravation in the pandemic, given that during these visits family members also supervise the conditions¹².

Due to the measure to reduce visits by relatives of people deprived of liberty, in Spain, as a form of compensation, an increase in telephone calls and also in videoconferences was allowed, aiming to minimize the negative impacts¹³. Controlling the spread of the virus in prison environments is essential to prevent a larger outbreak of SARS-CoV-2, in view of the health of all those who live and work in this place and also of the general population¹⁴.

In conclusion, prisons favor the transmission and proliferation of the coronavirus, and the main strategies for minimizing the pandemic issued by the World Health Organization were not designed for people deprived of liberty (who already live in a situation of social isolation and vulnerability). Thus, the neglect of the health of this population during the COVID-19 pandemic was evident.

• Funding: This study was partially supported by Higher Education Personnel Improvement Coordination (CAPES, BR, finance code: 001). However, the funding source had no involvement in the study design, collection, analysis, interpretation of data, writing of the report, or in the decision to submit the article for publication.

ACKNOWLEDGMENTS

We thank all study participants, the Dean of Postgraduate Research and Innovation (PROPESQ) of the Federal University of the Tocantins (UFT), as well as the Dean of Extension, Culture, and Community Subjects (Proex).

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Publication Dates

• Publication in this collection
  27 Oct 2023
• Date of issue
  2023

History

• Received
  27 July 2023
• Accepted
  31 July 2023