Coping strategies for COVID-19 in prisons: a report on experience

Abstract

Objective:

to report the experience of implementing preventive measures against COVID-19 in a prison unit.

Method:

report on experience based on institutional documents and on a prison health team’s experience carried out from March to June 2020.

Results:

a broad spectrum of preventive measures were implemented for preventing and reducing the occurrence of infection and serious COVID-19 outbreaks in the penitentiary: screening procedures and care flows for new inmates who arrive and for those already in the unit who had symptoms; rules, prevention guidelines and conduct recommendations for visitors and other persons who were authorized to enter the prison unit; attention to the prison workers who had symptoms; organization of information cycles aimed at the workers; use of communication channels with prisoners’ representatives; implementation of general sanitary measures in the prison unit; convincing inmates to be vaccinated against influenza.

Discussion:

considering the precarious conditions that favor COVID-19 dissemination in prisons, the experience attested the importance of implementing both measures to prevent contamination and transmission of COVID-19 in prisons, as well as educational and normative actions aimed at this segment of the population.

Keywords:
prisons; coronavirus infections; primary prevention; prisoners; occupational health

Resumo

Objetivo:

relatar a experiência da implantação de medidas preventivas à COVID-19 em uma unidade do sistema prisional.

Método:

relato de experiência construído a partir da vivência de uma equipe de saúde de uma unidade prisional e de documentos institucionais, no período de março a junho de 2020.

Resultados:

com o intuito de evitar ou reduzir a ocorrência de infecção e de surtos graves da COVID-19 na penitenciária, foram implantadas medidas preventivas de amplo espectro: procedimentos para triagem e fluxos de atendimento para os presos ingressantes e para os detentos da unidade que apresentam sintomas; normas, orientações de prevenção e recomendações de conduta para visitas e outras pessoas autorizadas a entrar na unidade prisional; atenção ao servidor com sintomas; organização de ciclos informativos direcionados aos servidores; uso de canais de comunicação com representantes de galeria das pessoas privadas de liberdade; implantação de medidas sanitárias gerais na unidade prisional; sensibilização de presos para vacinação contra a influenza.

Discussão:

considerando as condições precárias que favorecem a disseminação da COVID-19 em unidades prisionais, a experiência mostrou a importância da implantação de medidas preventivas para evitar a contaminação e transmissão da doença nesse ambiente, e da implementação de ações educativas e normativas voltadas para esse segmento da população.

Palavras-chave:
prisões; infecções por coronavírus; prevenção primária; prisioneiros; saúde do trabalhador

Introduction

The Brazilian prison system is facing considerable difficulties during the COVID-19 pandemic¹. About 755,274 inmates, here designated as persons deprived of liberty (PDL), are under the federal government tutelage², in more vulnerable conditions to diseases than the general population. Brazilian prisons have long been exposed to structural flaws, with precarious and unhealthy conditions that characterize them as prone to the spread of serious communicable diseases³.

In this context, governmental authorities devise strategies to prevent the dissemination of SARS-COV-2 in prisons. COVID-19 is transmitted from human to human, mainly through droplets expelled by the nose and mouth of an infected person by talking, exhaling, coughing, or sneezing¹. Infection may also occur when people touch contaminated surfaces or objects and then touch their eyes, nose, or mouth¹.

Studies estimate that, in the community as a whole, an infected individual can contaminate two to three people, but in prison this number may go up to ten⁴. General population estimates suggest that 80% of infections are non-severe or asymptomatic and 20% progress to a severe condition; 6% of these require specialized medical care, including mechanical ventilation⁵. Arresting moments, inter-prison transfers, prison visits (including those of lawyers), and employee cross-distribution are considered the moments of greater risk for PDL contamination.

The COVID-19 infection is characterized by a flu-like syndrome in which infected individuals may present mild or severe symptoms, or even be asymptomatic. Some pre-existing clinical conditions place certain groups at an increased risk of death from coronavirus, such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, or cancer, as well as advanced age. According to data from the Ministry of Health on September 1, 2020, at 8.02 p.m, Brazil had 3,950,931 cumulative cases of coronavirus, 3,159,096 of which recovered, 669,239 in follow-up, and 122,596 deaths, resulting in a 3.1% fatality rate^6).

A COVID-19 outbreak within a correctional facility poses a threat to the community as a whole. The disease rapid spread boosts the epidemics, rapidly multiplying the number of infections and overloading health services, let alone its disproportionate impacts on marginalized populations⁷. In this sense, preventing and controlling COVID-19 spread within prisons poses great challenges for State authorities and the overall society, requiring a consistent approach. To avoid losing control over the situation, measures for coping with COVID-19 must immediately be implemented. This paper aims at reporting the experience of implementing preventive measures against COVID-19 in a prison unit.

Methods

This report was based on a health team’s experience at a prison unit, from March to June 2020, carried out to face the COVID-19 pandemic. The authors are the health professionals who worked in the penitentiary at that time, and academic researchers.

The COVID-19 pandemic outlined the need for implementing preventive measures related to the care flow within the unit. To standardize and coordinate preventive actions, the health team established routines for all the prison staff, PDL, and other people who had access to the penitentiary. Although unforeseen circumstances are inevitable in the daily work routine, the adopted measures enabled information gathering and the experience reported here. This report was also based on institutional documents, reports, protocols of the Superintendence of Prison Services (SUSEPE), and literature review.

The results regarding health depend on coping resources, as the COVID-19 pandemic requires each professional to fully commit to the best way to deal with situational outcomes. In face of a new and complex scenario, collecting information and establishing routines are both fundamental for a better resolution. Thus, the health team endeavored to standardize care flows to ensure greater objectivity and promptness in the PDL’s and prison staff’s health maintenance.

This study was submitted and approved by the Ethics Committee on Research of the Superintendence of Prison Services Penitentiary System, from the State of Rio Grande do Sul, on August 24, 2020.

Results

The prison unit description

This work was conducted in a penitentiary from Rio Grande do Sul that has been operating since 1999. According to the SUSEPE website, the prison capacity is of 466 inmates, but it housed 737 PDL at the study period, 41 of them were women⁸. The unit counts on the services of prison officers, correctional administrators, military police, teachers, social workers, psychologists, lawyers, doctors, nurses, dentists, pharmacists, nutritionists, dental office assistants, and nursing technicians.

The prison is a masonry building with security system fitted to the main entrance, where all vehicles entering the complex are searched. The construction consists of three prison modules, one technical administrative area, and one area for the access and search of visitors. Prison officers circulate around the modules through a floor located above the galleries, where PDL are housed.

The Health Unit operates in one of the prison modules, including a medical and dental office, nursing area, pharmacy, warehouse, and service rooms. It also includes a computerized system, whereby the electronic medical record provides information on attended people, referrals, and worked out procedures.

The work developed

According to the recommendations put forward by the technical note nº 01/2020, from the Penitentiary Administration Department (SEAPEN) and the Superintendence of Prison Services (SUSEPE), several preventive measures were adopted within the prison unit to prevent or reduce the risk of infection and severe outbreaks of COVID-19⁹.

Among these, routines related to COVID-19 were established, such as: implementing conduct recommendations and preventive strategies for people authorized to enter the prison; screening flu-like symptoms at entering the prison premises; screening PDL when they enter the penitentiary and providing care for the detected cases; defining the care flowchart for PDL suspected or confirmed cases; offering attention to prison staff exhibiting symptoms; organizing informative and guidance panels for the staff; holding meetings with gallery representatives to provide guidance on how to cope with the coronavirus; establishing rules for visits and COVID-19 prevention; and raising the community awareness toward the vaccination against influenza.

People entering the prison unit

A trained officer responsible for the entrance gate must screen any person entering the prison facility for flu-like symptoms. The person must answer a questionnaire assessing symptoms such as fever, cough, dyspnea, nasal or conjunctival congestion, sore throat, nose twitching, sputum production, difficulty swallowing, runny nose, signs of cyanosis, and intercostal retractions. Body temperature and oxygen levels are also checked during screening. Suspected cases of COVID-19 are not permitted to enter the prison for a 14-day period and are instructed to seek care at a health service near their residence.

At the entrance gate, the team also provided posters with general guidelines on prevention measures and installed a mural on which documents and measures to fight COVID-19 established by the prison and state authorities, were posted, as well as a glossary of terms related to the disease. People allowed to enter the prison premises are required to use a protective mask and alcohol gel for hand hygiene. Protective measures also included the installation of footbaths soaked in sodium hypochlorite at the main entrance, communal areas, and in the modules entrances for passers-by to clean their shoes.

New PDL admission

A prison officer responsible for the registration in the National Prison Information Survey (INFOPEN) screens new PDL for COVID-19 symptoms upon their arrival at the penitentiary. Asymptomatic entrant inmates are isolated for 14 days in one of the 16 preventive isolation cells - previously used for intimate visits. After this period, they are taken to the prison health unit, where nursing professionals carry out a clinical evaluation and a rapid test for SARS-COV-2. If the result is non-reagent, the inmates can enter the prison gallery; if it is reagent, they are kept in isolation for another 7 days. Entrants exhibiting non-severe symptoms are likewise isolated for a 14-day period, but in a preventive isolation cell at the infirmary. A health professional reevaluates the inmate every 24 hours and collect a clinical sample (nasopharyngeal and oropharyngeal swab or nasopharyngeal aspirate) between the 3rd and 5th day for reverse transcription polymerase chain reaction (RT-PCR) testing, which must be done within the first 7 days after the symptoms onset. Patients exhibiting severe symptoms are referred to the emergency care unit (UPA) of the municipality, following the security protocols of the prison service. If hospitalization is required, they are taken to hospitals considered by the prison unit as reference. Figure 1 shows the screening flowchart for entrant PDL.

Figure 1
COVID-19 screening flowchart for persons deprived of liberty (PDL) entering the prison

Cases among inmates

PDL who were already housed in the unit and require healthcare are taken for clinical evaluation in the prison health unit wearing a protective mask. Suspected cases of COVID-19 with non-severe symptoms are kept in isolation for a 14-day period in a preventive isolation cell. The prison unit has two infirmary cells with capacity for four inmates each. Inmates with severe symptoms are referred to the municipality UPA and, if hospitalization is required, to a reference hospital, always according to the health and safety protocols of the prison service (Figure 2).

Figure 2
Care flowchart for persons deprived of liberty (PDL) presenting with flu-like symptoms, according to severity

All COVID-19 detection tests carried out in the penitentiary are registered by health professionals on the notification record website of the Federal Government (e-SUS Notifica), regardless of the result. All suspected or confirmed cases are reported to the epidemiological surveillance service of the municipality where the penitentiary is located, according to the Prison Health State Program of the Rio Grande do Sul State and Department of Health and the 3rd Regional Correctional Precinct. The legal sector of the penitentiary informs positive RT-PCR results to the Magistrate who holds jurisdiction power before the respective trials court to reassess the PDL’s legal and prison condition.

To reduce burden on the healthcare system, the prison health unit prioritizes care for severe symptomatic patients, despite being confronted with other care demands.

Attention and guidance to the workers

To reduce the risk of COVID-19 exposure, prison workers were organized in rotating system and telework in an attempt to reduce the number of people in workplaces and communal areas. Pregnant women and workers with respiratory disorders, immunodeficiency, or with medical leave recommendation started working remotely.

The health team also organized events to disseminate guidelines and preventive measures among prison workers. These were important moments for exchanging information and carrying on discussions on themes related to the disease, such as: appropriate use of personal protective equipment (PPE); cleaning and disinfection of surfaces; regular handwashing with soap and water; no-touch greetings; respiratory manners teaching how to avoid the dispersion of droplets produced by talking and breathing; and the proper use of the mask. The events also addressed the importance of maintaining social distancing in the cafeteria and not sharing the chimarrão.

Workers exhibiting COVID-19 symptoms are referred to the reference health unit and, if recommended, immediately put on sick leave.

Other general measures

The health team also adopted other prevention measures related to controlling ventilation in indoor environments; cleaning and disinfecting all surfaces with 70% alcohol and sodium hypochlorite; and establishing hygiene routines in outdoor spaces, galleries, courtyard, and communal areas. Monthly, each inmate receives a bar of soap for hand hygiene and laundry, and each cell receives 1 L of sodium hypochlorite to disinfect environments and materials donated by the judiciary.

The health team, together with the administration and the security team, held meetings with gallery representatives to identify the needs of each gallery regarding prevention measures, draw up guidelines on COVID-19, clear up doubts, and offer guidance on the use of PPE for prisoners leaving the prison for healthcare and social or legal assistance.

Rio Grande do Sul state government suspended prison in-person visits on March 23, 2020. From this date on, inmates were allowed to receive bags with hygiene, food, and clothing materials four days a week upon disinfection with sodium hypochlorite. To avoid that visitors bringing supplies stayed too near each other, besides the guidelines provided at the prison entrance, floor markings were affixed every 1.5 m to ensure that social distancing was respected. Visitors could only enter the prison wearing PPE and after sanitizing their feet in the footbath. Group activities and family visits accompanied by psychologists and social workers were also temporarily suspended. Care and support for the inmates’ families are now provided by social workers, or psychologists via telephone contact. For emergency escorts, prison workers are required to wear surgical masks and gloves throughout the displacement and instructed to intensify hand hygiene and ventilation within the vehicle as well as to clean and disinfect all surfaces after transport.

Vaccination against influenza

Influenza vaccine is yet another coping strategy for COVID-19. For reducing influenza incidence, this vaccination decreases the number of people with flu-like symptoms and, consequently, of people tested for coronavirus. Although ineffective against the novel coronavirus, the flu vaccine may promote greater agility in confirming COVID-19 cases as the doctor may rule out influenza in immunized people. Influenza vaccination is the primary method for preventing influenza and its complications and it is especially important for older adults, patients in long-term care institutions, or those with chronic conditions¹⁰. As confinement conditions may potentiate the virus spread, Brazil prioritized incarcerated people for the 2012 vaccination against influenza¹¹.

The health team adopted new approaches to increase the adhesion of PDL to influenza vaccination. The Ministry of Health set the vaccine coverage goal of 90% for the prison population¹². The first time the health team vaccinated inmates within their galleries, they reached a 64.5% coverage. To improve this rate, a nurse and the head of security talked to gallery representatives to raise their awareness and ask for their support. On a second campaign, vaccination coverage reached 80.8%. Despite the increase, it did not manage to reach the goal established by the Ministry of Health. When inmates resistant to vaccination were inquired about the reason for nonadherence, they reported exhibiting flu-like symptoms and not feeling well when they were vaccinated in previous opportunities. This argument indicates the need for health teams to promote actions aimed at expanding knowledge about the importance of immunization.

All procedures and measures for preventing and minimizing the damage caused by COVID-19 are provided for in the Penitentiary Contingency Plan developed by its technical team, composed of nurse, psychologist, social worker, lawyer, dentist, doctor, and nutritionist.

Discussion

The constant interpersonal contact and overcrowded and poorly ventilated cells in the Brazilian prison system make these environments highly favorable to the spread of the COVID-19. Yet, they are virtually absent from the public debate around the pathology⁴.

Once under the State tutelage, the health of persons deprived of liberty (PDL) is likewise their responsibility. In that sense, PDL are entitled to the same preventive and assistance conditions as the general population - as established in the Federal Constitution, Law of Criminal Enforcement, National Policy for PDL Comprehensive Health, and in international provisions such as the United Nations Standard Minimum Rules for the Treatment of Prisoners⁵.

The Recommendation no. 62 of March 17, 2020¹³, issued by the National Justice Council, proposes that courts and magistrates adopt preventive measures to reduce COVID-19 spread, including decarcerating measures that allow house-arrest or the re-evaluation of prisons for people accused of nonviolent crimes or which are not serious threads to the person. For those who remain incarcerated, which corresponds to the vast majority of prison population, state prison systems implemented a series of strategies to contain the coronavirus pandemic.

On March 16, 2020, the Minister of Justice suspended family visitation on federal prisons. As for state prisons, the measures ranged from full to partial visitation suspension¹⁴. Suspending visits intensifies loneliness and insecurity feelings among inmates, increasing their concern towards family and friends⁴. To reduce feelings of anxiety and loss of control triggered by the current global scenario, PDL must be informed of the strategies adopted by the prison administration and understand that these strategies are oriented towards protection, prevention, and healthcare. They must also communicate with their families by letters, telephone, and other available means through the prison institution⁴.

As a result of the precarious prison conditions in Brazil and the lack of an appropriate structure for isolating inmates within individual cells, the Ministry of Health issued the Interministerial Ordinance no. 7, of March 18, 2020¹⁵, which postulates that correctional facilities can isolate inmates into cohort of suspected cases and that PDL presenting the same characteristics (suspects/confirmed) must be isolated within the same group, but in different locations from the other group. Similar to Rio Grande do Sul, Rio de Janeiro determined that every entrant must undergo quarantine before being allocated to prison units. Asymptomatic entrants are kept separated from symptomatic entrants, and both groups are isolated for a 14-day period⁴. Prison systems from other countries also face difficulties in dealing with COVID-19. The USA is the country with the highest incarceration rate for the past four decades¹⁶. Due to the pandemics, some North American states and municipalities suspended prison visitations, limited the access of legal representatives, and reduced the number of inter-prison transfers. Aiming to minimize the impact of these measures, especially of social isolation, some facilities allow inmates to contact their visitors by teleconference. Despite all these actions, some correctional staff from the US prison system tested positive for SARS-COV-2 on March 14, 2020, and the first case among PDL was confirmed two days later¹⁶.

In a mass testing for COVID-19 conducted with 2,500 inmates in the Marion Correctional Institution in Ohio, USA, more than 2,000 tested positive¹⁷. Inmates’ daily routine is precarious; despite constant interpersonal contact, sharing toilets, sinks, and cafeterias, they also sleep in bunk beds and, in many countries, piled up on the floor. Oftentimes solitary confinement is deemed as a punishment by inmates, so that they will omit any symptoms of a disease. This fact discourages the search for healthcare and masks even further the pandemic situation¹⁷.

If mass testing capacity for the overall population is limited, the problem is even bigger for PDL, often not prioritized for vaccination. In that sense, we will hardly know the real situation of COVID-19 in prisons around the world.

On June 22, 2020, the number of confirmed cases for COVID-19 among inmates and prison staff in Brazil increased by 241% within a month: 4,256 inmates tested positive, 58 of which resulted in death. The Midwest (29.5%), Southeast (28.8%), and Northeast (23.3%) regions showed the highest proportions of cases in the country¹⁴.

Final considerations

In response to public health, society must see prisons through different eyes during the pandemic period. The impacts of the COVID-19 pandemic within prisons walls require a redirection of the care and support offered for inmates and people who circulate through units and services integrating these spaces.

Describing and contextualizing the experiences of health and safety professionals working in the prison system and disclosing this information may play a key role in stimulating reflections and discussions among multidisciplinary teams who work in these prisons, as well as in developing further research on the topic, and in advancing and exchanging knowledge among researchers.

The experience in coping with COVID-19 reported by the prison health team highlights the need for implementing a series of measures to prevent transmission and contamination within this environment. However, these actions represented a challenge and demanded institutional efforts, including new norms and routines.

Working in a penitentiary has its peculiarities. The health team carried out a cohesive and continuous work to implement protocols and care routines, which was achieved through the unity and affinity toward a common goal. These protocols and routines assisted the decision-making process either on the care, or the management levels, besides helping controlling the various pursued activities and assessing their resoluteness. Such a daunting challenge and responsibility favored all of those involved in the prison system.

Finally, prison conditions denote the need and opportunity for implementing preventive measures and educational actions for this population segment that, in general, has limited access to health services. Advancing knowledge in this field has become increasingly important to implement strategies aimed at meeting these populations’ specific needs.

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• 5
  The authors declare that this work was not presented at any scientific events.

Publication Dates

• Publication in this collection
  12 May 2021
• Date of issue
  2021

History

• Received
  09 Sept 2020
• Reviewed
  29 Dec 2020
• Accepted
  05 Jan 2021