COVID-19 in prisons: an impossible challenge for public health? COVID-19 nas prisões: um desafio impossível para a saúde pública? COVID-19 en las cárceles: ¿un desafío imposible para la salud pública?

Brazil has 748,000 prison inmates 1, 50,000 of whom in the state of Rio de Janeiro alone, who are practically absent from the public debate on COVID-19. But is it possible to imagine more favorable conditions for the spread of SARS-CoV-2, a virus with airborne and person-to-person transmission, in a population confined to overcrowded cells with poor ventilation and limited access to running water? According to estimates in the general population, one infected individual transmits the virus to two to three others. Given the conditions in Brazilian prisons, based on estimates, one case can infect 10 other inmates. Thus, in a cell holding 150 prisoners, 67% will be infected within 14 days, and 100% will be infected in 21 days. The majority of the infected individuals (80%) will either remain asymptomatic or develop mild forms of the disease, 20% will evolve to more serious forms requiring hospitalization, whose 6% will require intensive care 2. In this context, measures to confront COVID-19 should be anticipated in order not to lose control of the situation. To predict the pandemic’s evolution in Brazilian prisons, the reference should not be European prisons, where the virus’ spread has been limited, since European prison cells normally hold no more than four inmates each, and in better conditions of health and hygiene. The pandemic hit Brazil when the country’s prison health system was already weakened and overcrowded, with high mortality from potentially curable infectious diseases like tuberculosis. Futhermmore, the prison population includes elderly inmates and/or those with diseases associated with evolution to the severe and fatal forms of COVID-19 (the risk group), such as diabetes, cardiopathies, hypertension, renal failure, asthma, HIV/AIDS, and tuberculosis. Pregnant women and mothers with children are also part of this group because of their increased vulnerability. In this scenario, legal decarceration measures are urgent and necessary to reduce the system’s overcrowding, which reaches the absurd rate of 300% in some Brazilian prisons. The pandemic requires rapid responses, especially in low-income countries with inhumane conditions and high incarceration rates. Decarceration is a key measure in the response to COVID-19 3,4,5. However, there is intense debate on a false dichotomy: on the one hand, a view of public security that sees a major risk of releasing inmates, and on the other, the perceived and real risk of infection and death from COVID-19 in incarcerated persons. For example, some have opposed the decarceration measures in Recommendation n. 62/2020 of the Brazilian National Council of Justice 6, which provides for the possibility of house detention and case reviews as a protective measure during this pandemic, for individuals accused of non-violent or non-threatening crimes. 1 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.

Cad. Saúde Pública 2020; 36(5):e00083520 As the Brazilian Supreme Court has stated repeatedly, health in the country's prisons is the State's responsibility 7,8 , and inmates have the right, under the Brazilian Unified National Health System (SUS), to the same conditions for prevention and care as the rest of the population, as provided by the Federal Constitution, the Criminal Execution Act, the National Policy for Comprehensive Healthcare for the Prison Population, and various international legal provisions such as the United Nations Minimum Rules for the Treatment of Prisoners 2 . However, most of the official documents dealing with the COVID-19 pandemic in Brazil fail to mention the prison population or only mention it generically. Meanwhile, the main recommendations for prevention in the general population, such as social distancing and hand hygiene, have proven extremely difficult to enforce in the country's prisons.
The strategies for COVID-19 prevention cannot be limited, as in many states, to a ban on visits, suspension of transfers between prison facilities, and interruption of group activities like sports, work, classes, and religious meetings. A contingency plan is essential for prisons to adjust and implement the measures recommended for the general population. However, the prison population is not mentioned in either the state 9 or municipal contingency plans in Rio de Janeiro 10,11 , as in other states, which provide details on the procedures and roles of various levels and agencies for the prevention, detection, and confirmation of suspected cases of COVID-19, clinical care, and epidemiological surveillance. This omission reveals the de facto exclusion of the prison population from public policies established for the general population, thus violating the principles of the universal health system, with negative effects on healthcare and access to the necessary inputs for confronting the pandemic in the prisons, such as diagnostic tests and personal protective equipment (PPE), but also on epidemiological surveillance strategies. All of these factors favor the invisibility of COVID-19 inside the prison walls.
It is thus urgent and necessary for Rio de Janeiro to effectively include the 46 intramural primary healthcare units, the Penal Sanatorium, and the Prison Emergency Care Department in the state epidemiological surveillance system as reporting units in order for health professionals in the primary health services to promptly and electronically report cases of flu syndrome as suspected cases of COVID-19, according to the criteria established for the general population 9,10,11 and the Joint Resolution by the Rio de Janeiro State Health Department and Department of Correctional Facilities 12 . In addition, due to the prison system's characteristics and the high potential for the spread of COVID-19, the system should be included as a sentinel unit alongside the other 10 existing units, distributed across the five health program areas in the city of Rio de Janeiro, in order to monitor the evolution and dynamics of the pandemic's spread in the various prison units.
In the context of overcrowded prisons, rigorous surveillance to promptly identify COVID-19's introduction in the prison units and rapid blockade of transmission are essential to avoid mass spread of the infection. Thus, the 14-day quarantine implemented in Rio de Janeiro for all new prisoners before being assigned to the various prison units is important for controlling transmission, so long as asymptomatic incoming prisoners are maintained separately from symptomatic ones. Since Brazil's prisons lack the infrastructure to allow isolation in individual cells, in order to isolate suspected cases in the prison population, cohort isolation is recommended 13 ; that is, prisoners with the same characteristics (suspected/confirmed cases) should be isolated by groups in different areas.
Whether incoming or veteran inmates, it is extremely important for all prisoners with even mild symptoms consistent with COVID-19 to be tested as quickly as possible with RT-PCR, and to be isolated if they test positive. Influenza vaccination is a key priority, reducing the incidence of influenza and thus decreasing the number of symptomatic persons to be tested for COVID-19.
Thus, testing of prison inmates, prison guards, and health staff with flu symptoms should be a priority for dealing with the pandemic in the prisons. However, thus far, prison inmates are not considered a priority for testing suspected cases, and even those who have died with suspicion of COVID-19 have not been tested post mortem. Therefore, the purported absence of suspected or confirmed cases and deaths from COVID-19 in prisons in the state of Rio de Janeiro, as announced on April 14 by the prison system's administration, should be questioned due to the systematic failure to perform diagnostic testing 14 .
The lack of clarity on the clinical management of suspected cases is another delicate issue. For the general population, every patient with symptoms of a common cold or flu syndrome should be managed as a possible case of SARS-CoV-2, according to the Brazilian Ministry of Health guidelines.
Cad. Saúde Pública 2020; 36(5):e00083520 Cases classified as mild should remain in isolation for 14 days starting at the onset of symptoms, and serious cases should be referred to the urgency regulation system ("Vaga Zero") 9,11 . For the prison population, the procedures are currently limited to isolation, with no operational definition of patient flows 14 .
In case prisoners are not released, those belonging to the risk group should be assigned to an independent prison wing, with cells holding only a small number of inmates, reinforcing measures to prevent transmission and with regular medical care to reduce the likelihood of SARS-CoV-2 infection and to ensure treatment of the individual's underlying illness. This would guarantee adequate care, given the overload on the health system resulting from COVID-19 and the preventive work leave of healthcare staff included in this same risk group.
In prison, the perceived risk to health and life from COVID-19, the restrictions on circulation inside the prison walls, and the interruption of work, educational, and religious activities tend to aggravate tensions, with strong emotional implications 15 . The suspension of family visits exacerbates the inmates' feeling of isolation and insecurity, generating concern over the health and lives of family members (How are they? What might be happening to the them?) and their own welfare (Will I get sick? Will we receive medical care, or are we simply going to die in here?). To mitigate the feeling of loss of control and anxiety resulting from this situation, prisoners need to be informed on the strategies adopted by the prison administration for protection, prevention, and healthcare, and especially for them to maintain communication with their families, through letters, telephone calls, and other means provided by the institution for this purpose. It is also important to avoid stigmatization and violence against individuals identified as possible coronavirus carriers.
In this scenario, information for health personnel and security staff, the availability of PPE, diagnostic testing, influenza vaccination, and adjustment of COVID-19 risk prevention practices are indispensable, besides preventive work leave for those belonging to the risk group. Various countries have experienced constant difficulty in access to information on the COVID-19 situation inside prisons. There are cases of prison guards and inmates who test positive or have symptoms, which are only revealed extra-officially by the media, third sector organizations, families, or prison staff 4 . Key roles have been played by the justice system's oversight agencies (especially the Offices of the Public Prosecutor and Public Defender) and civil society (such as the Mechanism to Prevent and Combat Torture) to determine the real epidemiological situation and ensure that the recommended measures are actually enforced. Further according to the World Health Organization (WHO), clinical decisions must be made by health professionals and should not be ignored or overridden by prison staff. The COVID-19 pandemic cannot justify restrictions that constitute torture or cruel, inhumane, or degrading treatment, nor should the pandemic be used to impede independent inspections by international or national agencies 2 .
It is a mistake to believe that the total blockade of prisons, with prisoners' collective isolation and limitation of information on the situation inside prison walls, will avoid the spread of COVID-19 in the prison system. It is ethically imperative to implement totally transparent strategies to deal with the pandemic, including evidence-based care and surveillance, with measures similar to those recommended for the general population in order to avoid the risk of a humanitarian tragedy, more than ever placing prisons at the epicenter of necropolitics.

Contributors
All the authors participated in the conception of the central idea and writing and revision of the manuscript.