We are entering a new phase of the COVID-19 pandemic in the United States. Efforts to prevent infection by closing all but essential businesses, staying at home, physical distancing, wearing face masks, frequent hand washing, no face touching, and disinfecting frequently touched surfaces have begun to be effective where they have been seriously implemented by states and citizens. Hospitalizations and deaths have declined substantially in hard hit states with strong prevention orders like New York, New Jersey, Massachusetts, Illinois and California.
Meanwhile, the pandemic is spreading unevenly across the nation. In some states, nursing homes, meat processing plants and prisons have had large clusters of cases. Such clusters are even occurring in regions that have not yet seen widespread community transmission.
COVID-19 disease is continuing to spread to additional urban, suburban, and rural areas across the country. It is not as aggressive as the initial outbreaks in New York and New Jersey, but geographic spread, numbers of cases, and deaths are continuing to rise. The World Health Organization is predicting that it will be with us for a long time to come.
Now that more virus testing for diagnosis is finally becoming available, there is an opportunity to get disease spread under control, especially in areas that have been little affected so far. This includes prisons and jails that have not had many cases yet. Some state agencies are beginning to take the risk of disease in their prisons very seriously. They cannot protect their staff and local communities without protecting the prisoners. Control of COVID-19 in the prisons protects the officers and staff, the community, and the prisoners themselves.
This situation presents an opportunity. Prisoners, staff, guards, corrections agency administrators, and local community leaders have common ground around controlling the spread of COVID-19 in a facility. Reducing populations by releasing those prisoners at greatest risk for severe COVID-19 disease would be one of the best ways to control the spread in prisons. So far, governors will not do this. Controlling disease transmission can be achieved through widespread virus testing, isolation of cases, contact tracing, and quarantine of close contacts. The process is well described in the Federal Centers for Disease Control (CDC) Guidance on Management of COVID-19 Disease in Correctional and Detention Facilities. (Accessible at: cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-detention.html for those with internet connectivity)
We all must continue to do the things that help prevent infection, and now we can start to expect agencies to initiate practices to control disease transmission. Here is how it is supposed to work, in the community as well as in prisons:
1. Case Finding: There may be no telltale symptoms of disease. Even apparently healthy people may already be infected, and actively spreading the disease to others. This means it is not good enough to only test people who are sick or people who have a fever. Those people with symptoms are just the tip of the iceberg. Widespread testing of people who have no symptoms is needed, especially in higher risk institutions like prisons and nursing homes. For example, in New York one third of current deaths are occurring among people who live in nursing homes. To control COVID-19 in nursing homes, New York is now going to test all nursing home staff for infection twice a week. This will identify people who are infected but have no symptoms of disease before they have much time to spread the disease to others. Diagnosis must be followed by isolation of cases, contact tracing and quarantine of close contacts (see below).
The CDC guidance for correctional facilities and jails only recommends screening for fever and symptoms to find cases and exclude the virus. This is clearly inadequate and is the most significant gap in the CDC guidance. They excuse their omission of more widespread testing and case finding by explaining that when more tests are available they will issue new guidelines for testing in prisons and jails.
Some prison systems are beginning to take a better approach in spite of the CDC’s inadequate testing recommendations. Tennessee is testing all staff and prisoners in its correctional system. Remarkably, the vast majority of their positives, more than 80%, were without symptoms. Another important step would be to test all incoming prisoners and quarantine them for two weeks prior to placing them in the general population. Periodic retesting of staff and the population is also needed. One time is not enough to gain control of the virus.
2. Isolate the cases and “suspect cases”: People with positive virus tests are infected cases. They should be isolated so they don’t spread the disease to others while they are infectious. People with symptoms are “suspect cases” and should also be isolated while waiting for the results of their virus tests. According to CDC, the best form of isolation is single cell with a solid door kept closed. This is not always possible. The CDC guidance also suggests placing cases together (in “cohorts”) as an acceptable alternative. In fact, it gives seven different options for housing cases, listed from most effective to least effective. This allows for agencies to adapt to their specific facility architecture and space limitations.
3. Contact tracing: The idea is to identify all the people who had close contact with an infected person during the two weeks before their positive test. These are people who were likely exposed to the virus and may be infected or incubating infection.
Close contact means close enough and for a long enough period of time to get infected OR contact with infectious secretions. Sharing closed indoor space for a long time is close contact whether it be a double or quadruple cell or a dormitory or a workplace. Touching surfaces that an infected person touched can be close contact. Contact with a person who is coughing or sneezing is definitely close contact. Caring for a person with COVID-19 disease is close contact. Close contact can be more narrowly or loosely defined depending on circumstances. In some situations, such as overcrowded housing with poor air circulation, everyone living on the same unit could be considered a close contact.
4. Quarantine close contacts: Close contacts need to be tested for the virus and quarantined for 14 days so they do not infect others if they turn out to be infected. Quarantining close contacts is a critical step needed to interrupt transmission of the virus in the population. Close contacts can be housed together (cohorted) but if one of them tests positive for the virus the 14-day clock restarts for the rest of the group. This is because they have all had a new close contact with the new positive case. The new positive from among the close contacts must be moved to isolation.
CDC has also developed a tool for assessing the adequacy of a jail or prison’s implementation of their Guidance for Management in Correctional and Detention Facilities. That tool is available at https://stacks.cdc.gov/view/cdc/87561.
Additional symptoms: CDC has expanded the list of symptoms used to characterize a case of COVID-19. In addition to fever, cough and shortness of breath, they now include chills, repeated shaking chills, muscle pain, sore throat, headache, and loss of sense of taste or smell.
“COVID Toe” Clinicians caring for COVID-19 patients have noticed another new symptom: purple, painful toes.
No cutting, No sewing T-shirt mask: Pull a T-shirt over your head, do not put your arms through the sleeves, stop when the neck hole is at the bridge of the nose so that the nose and mouth are still covered, pull the sleeves back around to the back of your head and tie off. Easy. The only problem is that T-shirt material is very porous and doesn’t block droplets very well. Improve the filtering performance by adding layers of material in front of the nose and mouth. This can be done by folding up some of the rest of the T-shirt and tucking it into the neck hole; inserting folded up boxer shorts; insert a handkerchief, or any other material. Anything added is held in place by the tied sleeves.
Types of Tests: There are now two types of tests being discussed in the news: virus tests and antibody tests.
Virus tests are used to diagnose infection by finding evidence of virus particles in a specimen from the back of the nose. Spit tests for virus are being used in a few locations now, too.
Antibody tests are used to determine if a person was previously infected with the virus by finding specific proteins in the blood that the body produced to fight this virus. These tests are not readily available yet and many of the commercial antibody test products appear to give inaccurate results. The New York State Department of Health is using a reliable antibody test to try to determine how widespread coronavirus infection has been in different regions of the state and among different demographic groups: by age, gender, race/ethnicity, and geographical location for example. These studies have shown that up to 20% of New York City residents have been infected, whereas so far only around 3% of upstate New York populations outside the New York City metropolitan region have been infected.
Re-Opening the States: The White House issued guidance for a phased re-opening. A more detailed guidance from the CDC has so far been suppressed by the Trump administration, but may be released before this article goes to print.
According to the White House guidance, disease criteria to be achieved before states begin to re-open include downward trends for 14 days for symptomatic illnesses and positive tests. Some states are re-opening without achieving such downward trends.
Recommended state preparedness criteria to be achieved before states begin to re-open include various aspects of their capacity for diagnostic virus testing and contact tracing. Some states are re-opening without such capacity in place.
The White House guideline included a phased approach to reopening that starts slowly and expands only when no significant rebound in case numbers is found to be occurring. Some states are re-opening widely without a closely monitored phased approach.
There is every indication that re-opening without meeting the disease criteria, preparedness criteria, phased approach and close monitoring of new cases is going to cause a significant increase in new cases, hospitalizations, and deaths. We can expect to see such unfortunate results by mid-June, about four weeks after the impulsive re-opening of some states. In early reopening states, the only protection against a surge in new cases will be the unwillingness of citizens and businesses to participate. To protect their families and communities, citizens and businesses may choose to stay in and stay closed. We can only hope that such common sense will prevail.
Michael Cohen was the Medical Director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie NY. For 10 years he participated in a support group for people with diabetes at Great Meadow CF in Comstock NY. With the group, he co-authored the Prisoner Diabetes Handbook published by Southern Poverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.
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