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Assessing the Mortality Impact of the COVID-19 Pandemic in Florida State Prisons, 2020

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Assessing the Mortality Impact of the COVID-19 Pandemic in Florida State
Neal Marcos Marquez, MPH1,3
Aaron Littman, MPHIL JD 2,3
Victoria Rossi, MS MPAFF3
Michael Everett, BA3
Erika Tyagi, MS3
Hope Johnson, BA3
Sharon Dolovich, JD PHD2,3
1. University of Washington Sociology
2. University of California Los Angeles School of Law
3. UCLA Law COVID-19 Behind Bars Data Project, Los Angeles

The increased risk of COVID-19 infection among incarcerated individuals due to environmental hazards is
well known and recent studies have highlighted the higher rates of infection and mortality prisoners in the
United States face due to COVID-19. However, the impact of COVID-19 on all-cause mortality rates in
incarcerated populations has not been studied.
Using data reported by the Florida Department of Corrections on prison populations and mortality events
we conducted a retrospective cohort study of all individuals incarcerated in Florida state prisons between
2015 and 2020. We calculated excess deaths by estimating age-specific expected deaths from mortality
trends in 2015 through 2019 and taking the difference between observed and expected deaths during the
pandemic period. We calculated life table measures using standard demographic techniques and
assessed significant yearly changes using bootstrapping.
The Florida Department of Corrections reported 510 total deaths from March 1, 2020 to December 31,
2020 among the state prison population. This was 42% higher (rate ratio 1.42, 95% CI 1.15 to 1.89) than
the expected number of deaths in light of mortality rates for previous years. Reported COVID-19 deaths in
a month were positively correlated with estimated excess deaths (80.4%, p <.01). Using age-specific
mortality estimates, we found that life expectancy at age 20 declined by 4 years (95% CI 2.06-6.57)
between 2019 and 2020 for the Florida prison population.
The Florida prison population saw a significant increase in all-cause mortality during the COVID-19
pandemic period, leading to a decrease in life expectancy of more than four years. Life years lost by the
Florida prison population were likely far greater than those lost by the general United States population,
as reported by other studies. This difference in years lost highlights the need for increased interventions
to protect vulnerable incarcerated populations during pandemics.
Vital Projects Fund, Arnold Ventures, US Centers for Disease Control

The heightened risk of COVID-19 infection and related mortality among prison populations is
well documented.1–5 Previous studies have estimated that people in prison across the United
States are 5.5 times more likely to be infected with COVID-19, and that their age-standardized
COVID-19 mortality rate is 3.0 times higher than that of the general population.1 While these
differences are striking, analyzing COVID-19 infections and reported COVID-related mortality
events alone may not fully capture the health burden experienced by prison populations, as it
does not analyze the potential impact on total mortality.
Numerous studies have found that, in the general United States population, all-cause mortality
has been significantly elevated during the COVID-19 pandemic, providing evidence that
COVID-19 deaths are not simply substituting for other deaths that were likely to occur under
typical circumstances.6,7 For example, a recent study found that, in the state of Florida as a
whole, mortality rates were 15.5% higher than expected in 2020 in light of observed mortality
trends.8 As of yet, however, no research has evaluated whether prison populations have
experienced similarly heightened all-cause mortality rates.
We know that crude mortality rates in prisons increased between 2001 and 2016, although this
change appears to be largely attributable to an aging prison population, given that age-specific
mortality rates declined during this period.9 Among individuals 45 and older, leading causes of
death in prison include cardiovascular and respiratory related causes,10 with prevalence of
associated diseases exceeding that in the U.S. population more generally.11,12 Although
cardiovascular and respiratory diseases are known to lead to increased risk of
COVID-19-related morbidity and mortality,13–15 it is uncertain whether, given the heightened
prevalence of these conditions in the prison environment, deaths in prison from non-COVID-19
related causes during the pandemic would decrease (due to competing risks), increase (due to
added risk associated with COVID-19), or remain similar. To date, studies quantifying how the
overall mortality rate of incarcerated populations has changed during the COVID-19 pandemic
are extremely limited.16
Studying mortality events in incarcerated populations in the U.S. is difficult because of limited
availability of mortality and demographic information. Delays in the reporting of deaths in prisons
make timely evaluations of mortality rates difficult and, to date, comprehensive data on deaths in
U.S. prisons are reported only for years up to 2016, with little demographic detail.17 An added
complication is that data on prison population demographics are sparse, making it difficult to
construct appropriate demographic denominators to evaluate mortality rates. This challenge is
especially consequential during the COVID-19 pandemic, when prison systems saw striking
declines in total population. A recent study found that, between June 2019 and June 2020,
prisons across the United States saw a nearly 10% decrease in total population.18 Given the
politics surrounding prison releases, population declines are likely to be differentially distributed

across age and sex. However, demographic compositional shifts in prisons during this time have
not yet been studied; as a consequence, age-specific mortality denominators among prison
populations are not up to date.
To overcome this knowledge gap, we leveraged access to unique datasets about the Florida
prison population to better understand the impact of the COVID-19 pandemic on all-cause
mortality. We focused on the state of Florida for two reasons. First, the Florida state prison
system was the third-largest state prison system in the United States as of late 2020.18 With
over 80,000 people incarcerated in Florida prisons at a given time, the population is sufficiently
large to understand with some precision the historical dynamics of mortality rates and how they
may have been impacted by the COVID-19 pandemic. Second, assessment of all-cause
mortality rates in a quickly changing population--as exists in U.S. prisons--requires temporally
detailed data on mortality events and population structure. Florida is one of the few state prison
systems for which available data allow us to evaluate mortality rates in the pandemic period and
compare these rates to those observed in previous years.
Our main goals for this analysis were to 1) document demographic changes that occurred in the
Florida state prison population during the COVID-19 pandemic, 2) assess excess deaths that
occurred during the months of the COVID-19 pandemic in 2020 and their temporal relationship
to reported COVID-19 deaths, and 3) quantify changes in the overall mortality rate of the Florida
state prison population in 2020.

Study Population
As this study did not meet the definition of Human Subjects research and all data is publicly
available, IRB approval was not sought. The population analyzed for this study consists of those
individuals incarcerated from 2015 through 2020 in Florida state prisons. The Florida state
prison system, administered by the Florida Department of Corrections (FLDOC), comprises over
50 main institutions with a current aggregate daily population of over 80,000 individuals.18 While
FLDOC has produced mid-year population reports through 2019 with varying levels of
demographic detail, those reports provide only a snapshot of the population on a single day and
do not capture the changes in the population which occur over the course of the year. Proper
assessment of the person-time risk of mortality requires more temporally-detailed demographic
To construct precise, time-specific demographic profiles of the Florida prison population, we
reconstructed monthly population counts back to January 2015 using publicly available FLDOC
inmate population records. Because the intended use of the inmate population records is not to
create a point-in-time population estimate, we compared our estimates of the population to the
figures reported by FLDOC in its yearly mid-year report by age-groups and sex. We found that
our total population estimates for those dates did not differ from reported figures by more than
1.5%, while our estimates of the percentage of the population share by age-groups and sex do
not differ by more than 1 percentage point.

Our population dataset consists of age- and sex-specific monthly population data for all
individuals in the Florida state prison system age 20 and above between January 2015 and
December 2020. In total, we analyzed 6,830,581 person-months of data. Yearly breakdowns of
population counts may be found in Table 1.
Mortality Reporting
All-cause mortality of the Florida state prison population is reported by FLDOC. FLDOC publicly
releases a range of information concerning all mortality events in the Florida state prison
population, including decedents’ sex, date of birth, and date of death. Information on the manner
of death is also sometimes provided; however, these indicators are not standardized to uniform
causes of death (such as those provided by the International Classification of Diseases), so they
are not suitable for use in statistical analysis. FLDOC updates these data retrospectively and, in
order to avoid undercounting of deaths due to reporting delay, we use death data only for dates
through the end of 2020.
COVID-19 Deaths
Although FLDOC reports the cumulative number of deaths attributable to COVID-19 within the
state prison population to date, it does not report historical trends or monthly breakdowns
pinpointing when these deaths occurred. To create such a time series, we leveraged data we
collected at the UCLA Law COVID-19 Behind Bars Data Project, where we catalog and publish
officially reported cumulative COVID-19-related infections and deaths in prison populations
across the United States. We calculated monthly COVID-19 related deaths back to the
beginning of the pandemic by taking the difference in cumulative counts between the last
observed value of each month. FLDOC does not release demographic data about the
individuals who died from COVID-19.
Annual crude mortality rates were calculated by dividing the number of deaths by person-years
observed in a given year. To assess the need to adjust for changing population structure, we
calculated the proportion of the population that was female and the median age of the
population in each month. Across all months, the proportion of the population that was female
stayed within a range of 6.6% to 7.4%. Because of this minimal fluctuation (<1%), we did not
adjust in our analyses for changes in the sex composition of the population over time. However,
the median age of the population increased substantially and consistently over time, moving
from 36.9 to 40.2 years. Yearly data summaries of the Florida prison population are presented in
Table 1 and age-specific changes between 2019 and 2020 are presented in Table 2.
To account for the changing age structure of the population, we divided our analysis into age
groups similar to those used in the Florida Department of Health’s vital statistics reporting.19 We
omitted people below age 20 due to their small numbers and limited number of deaths (<5) in

Florida state prisons from 2015 through 2020. We combined the age groups of 75-84 and 85+,
in which mortality rates were high, because of the relatively small population in the latter group.
To assess excess mortality in the pandemic period and the relationship to COVID-19 deaths, we
used age-specific monthly mortality data from 2015-2019 to build a baseline measure of the
expected mortality rate. We modeled our process on a recent analysis of excess mortality for
the Florida population more generally.8 We first examined the monthly crude mortality rate using
auto-correlation functions to evaluate the need to account for either monthly or seasonal
auto-correlation. We found significant evidence of monthly auto-correlation but no evidence of
seasonal auto-correlation. We modeled age-specific monthly mortality probabilities
independently for each age group using Bayesian hierarchical logistic regression models where,
for each month, persons present at the beginning of the month represent the number of trials,
and deaths occurring among those individuals represent events. We adjust for monthly
auto-correlation in the observed mortality rates by including a latent variable following a random
walk structure of order 1. In addition, we include an unstructured independent and identically
distributed normal latent variable to account for unstructured overdispersion of monthly
probabilities. A full specification of the model including hyper-prior specification is included in the
Expected mortality for each month was calculated by taking predicted probabilities of mortality
for each month and age group in 2020 from the aforementioned models, multiplying the
probabilities by the observed monthly populations for the age groups, and summing across all
age groups. Excess mortality in the pandemic period was then calculated by taking the
difference between observed and predicted deaths for each pandemic month (March 2020 and
thereafter) and aggregating across all months to get total excess deaths during the COVID-19
pandemic period. The excess death rate is then simply the excess deaths divided by the
expected deaths. This process was repeated for the median, 97.5 quantile, and 2.5 quantile of
the posterior of predicted probabilities to generate uncertainty measures. To assess the
accuracy of our expected mortality forecast, we evaluate this model-building procedure using
data from 2015 to 2018 to calculate excess deaths in 2019, given that it is a year not expected
to have a significant percentage of excess deaths.
We calculated the correlation of reported monthly COVID-19 deaths with monthly median
estimates of excess deaths in Florida state prisons and evaluated the significance of the
correlation using a simple linear bivariate regression test. Estimates of monthly excess mortality
and reported COVID-19 deaths are shown in Figure 2.
Life table values for each year of analysis were calculated using life table methods outlined in
previous demographic work.20 Given the low number of deaths that occur in some age groups,
we used bootstrapping to obtain measures of uncertainty for life table metrics, taking 10,000
bootstrap samples. Utilizing bootstrapping allows a better understanding of whether the
differences in yearly observed calculations of life table measures are simply due to random
chance or whether they represent a meaningful change. Our primary measures of interest are

age-specific estimates of mortality rate and period life expectancy at age 20—henceforth
referred to as life expectancy—as well as the annual change in these values.
Bayesian hierarchical models were fitted with Laplace approximation of posteriors using the
INLA package 20.03.17 and all analyses were done in R version 4.04.
Role of the funding source
The funders of the study had no role in the study design, data collection, data analysis, data
interpretation, or writing of the report.

During the study period (i.e., 2015-2020), we observed a total of 2,567 deaths among the
Florida state prison population. Comparing crude mortality rates, we found that 2020 saw the
highest rate of mortality across all years, with 654 deaths per 100,000 person-years.
Furthermore, crude mortality for 2020 was significantly higher than 2019’s crude mortality rate
when using bootstrapping to compare crude rates (RR 1.56, 95% CI 1.39-1.76).
Our model for excess deaths found that using data from 2015-2018, there was—consistent with
expectations—not a significant presence of excess deaths in 2019. When repeating this process
for training years of 2015-2019 and evaluating only the 10 months of the COVID-19 pandemic in
2020, we found that there was a significant number of excess deaths, totaling 42% of expected
deaths (95% CI 15.0% - 89.4%). Monthly median posterior estimates of excess mortality were
found to be strongly and significantly correlated with monthly reported deaths related to
COVID-19 (80.4%, p <.01).
Age-specific mortality rate estimates calculated from life tables were found to be significantly
higher for four age groups between 2019 and 2020. The age groups of 35-44, 55-64, 65-74, and
75+ saw significant increases in their mortality rates year over year, with rate increases of 77%
(RR 1.77, 95% CI 1.13 to 2.72), 49% (RR 1.49, 95% CI 1.13 to 1.92), 67% (RR 1.65, 95% CI
1.28 to 2.16), and 61% (RR 1.61, 95% CI 1.18 to 2.23), respectively. The age group of 45-54
also saw a year-to-year increase, but the change was not significant. Life expectancy did not
significantly differ across any two-year periods from 2015 through 2019. Life expectancy in
2020, however, was significantly lower than in all other years recorded in the study period
(Figure 2). A substantial decrease in life expectancy—4.12 years (95% CI 2.06-6.57)—was
observed between 2019 and 2020.

The impact of the COVID-19 pandemic on mortality in prison populations has not yet been well
studied. To our knowledge, our study is the first to analyze how all-cause mortality rates, and
thus life expectancy, changed in incarcerated populations in 2020, as well as the relationship
between excess deaths and reported COVID-19 deaths. While the study population is limited to

people confined in Florida state prisons, FLDOC has not reported exceptionally high rates of
COVID-19-related infection or death as compared to other state prison systems.21,22 Similarly,
Florida prisons’ population structure, in terms of age and sex distribution, is typical of other state
prisons.17 As such, we anticipate that other prison systems are likely experiencing mortality
patterns similar to those found in this study. At a minimum, similar investigation into other state
prison systems is warranted.
Despite a population decline of more than 10,000 people between January and December
2020, FLDOC recorded more deaths among the prison population in 2020--590 individuals in
total—than in any of the previous five years. During the 10 months of the COVID-19 pandemic
in 2020, mortality rates were not only frequently much higher than would have been expected
given previous years’ mortality trends, but the estimated excess mortality rate (~42%) was also
much greater than that estimated in the Florida population more generally (~15%)8 or in the
overall U.S. population (~20%).6
To better contextualize the observed excess mortality in 2020, we can turn to life expectancy
measures. Transforming yearly mortality rates to period life expectancy allows us not only to
summarize the age-specific changes in mortality experienced by Florida state prisoners by way
of life years lost, but also to compare those losses to other populations with different age
structures.23 For example, in a recent publication by the CDC, it was estimated that in the U.S.
population more generally, life expectancy declined by 1.0 years between January and June
2020, with a decline of 1.2 for males and .9 for females.24 Effects of this scale are historic and
catastrophic. Yet our study found considerably greater declines in life expectancy, of 4.12 years,
in the Florida state prison population. This again highlights the inordinately harmful impact of
COVID-19 on the health of Florida’s prison population.
The staggering rate of excess deaths in FLDOC institutions raises the obvious question of what
role the 191 COVID-19 deaths played in contributing to this excess. In the absence of
COVID-19 infection, how many deaths may have been avoided? To quantify this value, detailed
cause of death data across all years of the analysis would be needed to account for potential
competing risks which may occur. Because cause of death data is unavailable to us, we are
unable to assess the exact effect COVID-19 had on total mortality rates. Nevertheless, we found
that for months with estimated high amounts of excess deaths, there was also a high reported
number of COVID-19 related deaths (Figure 1). In addition, we know from previous studies that
rates of COVID-19 infection have been substantially higher among the prison population than
among the general population.1 Given these findings, it seems extremely likely that excess
deaths would have been prevented had infection rates not been so widespread or had these
individuals not been in a prison setting where the risk of COVID-19 infection was so high.
Several other factors should be considered as a possible explanation for the substantial
increase in the Florida state prison mortality rate between previous years and 2020. First, while
not specifically documented among the Florida state prison population in 2020, it is likely that,
as in other prison populations, there is a disproportionately high prevalence of cardiovascular
and respiratory diseases among those held in FLDOC facilities. Previous studies have

documented that these conditions may increase risk of mortality for individuals with an active
COVID-19 infection,13–15 and the greater overall increase in mortality in the prison population
may be due in part to the higher prevalence of these pre-existing conditions.
Second, some of the change in the crude mortality rate can likely be attributed to a prison
population that was substantially older in 2020 than in previous years. The decline in the size of
the Florida prison population has largely been due to a drop in intakes rather than increased
releases.25 As people coming into prisons tend to be significantly younger, it is not surprising
that a drop in intake led to a decline in the number of younger prisoners, while older populations
either remained relatively stable or slightly increased in number (Table 2). Given COVID-19’s
high mortality rate for older individuals,26,27 this shift alone will have increased overall mortality
risk in the prisons. This, however, only offers a partial explanation, as it only explains changes in
the crude mortality rate and not the age specific mortality rate or life expectancy changes which
account for changes in the age structure of the population.
Our analysis has several limitations. First, COVID-19 deaths were attributed to the month in
which the deaths were reported and not necessarily to the month in which the individuals died.
As such, it is likely that, in some instances, we have attributed COVID-19-related deaths to later
months than the months in which they actually occurred. Second, because causes of death
were not included in death data provided by FLDOC, we were unable to attribute age and sex to
reported COVID-19 deaths. As a result, we cannot specifically attribute changes in age-specific
mortality rates to COVID-19. Nevertheless, the age-specific increases in overall mortality rates
are in line with changes in mortality rates due to COVID-19 found in other settings.26,27 Lastly,
mortality events among the prison population may not be observed or recorded if an individual
who is terminally ill is granted parole or compassionate release. If the pandemic occasioned a
substantial year-to-year change in the number of individuals being released through either of
these channels, our analysis might fail to accurately capture changes in the mortality risks to the
Florida prison population. To date, however, there is no evidence of such a change.28
To protect vulnerable incarcerated populations—including those held in FLDOC facilities—from
COVID-19 and future viral pandemics, we must identify effective strategies for preventing
infections in custody, for containing transmission, and providing adequate medical treatment for
those with symptoms when outbreaks occur. While prison populations and density have
declined in 2020, this study demonstrates that, in Florida at least, these declines have been
insufficient to avert catastrophic impacts on mortality rates and life expectancy. Our findings thus
offer evidence in support of calls from other experts for vaccine prioritization for the incarcerated
and for strategic decarceration.28–30 This study demonstrates that people in prison have faced a
substantially elevated total mortality risk during the COVID-19 pandemic, in addition to the
elevated risk for COVID-19 infection found in previous studies.1 We urge officials in Florida and
other states to evaluate interventions to reduce the risks associated with COVID-19 and to take

steps to minimize the observed discrepancies in negative health outcomes between the general
public and the incarcerated.

Author contributions
SD, AL, and VR conceived the study. ME, VR, NM, HJ, and ET collected the data. NM, ET, and
VR designed the study. NM conducted data analysis. NM drafted the manuscript with
contributions from SD, AL, VR, ET, ME, HJ. SD and AL revised the manuscript. All authors
reviewed the manuscript and agreed to be responsible for all aspects of the work.

Data sharing
All data concerning Florida state prison populations is made available by FLDOC. Historical
records of COVID-19 death data for the Florida prison population is publicly available at

All authors were funded in part by Vital Projects Fund, Arnold Ventures, and US Centers for
Disease Control.

Declaration of Competing Interest
All authors have nothing to disclose.

We would like to thank Sara Curran and Ben Nyblade for their insight into the analysis and to
remember all those in the Florida state prison system who lost their lives to COVID-19.

Table 1: Descriptive statistics of Florida state prison population by year


Median Age
Dec 31

% Female
Dec 31


Death Rate
Per 100K





































Table 2: Change in population and mortality rate by age
Age Group

Dec 1, 2019

Dec 1, 2019

Population %

Mortality Rate
Ratio ’20/ ’19





(CI 0.00 -- 1.96)





(CI .593 -- 1.80)





(CI 1.13 -- 2.72)





(CI .733 -- 1.48)





(CI 1.13 -- 1.92)





(CI 1.28 -- 2.16)





(CI 1.18 -- 2.23)

Figure 1: Observed and expected mortality trends in Florida state prison population
80 · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·

60 · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·







20 · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·

0 ............................................................................. ''''' ''.'




Figure 2: Bootstrapped estimates of life expectancy for Florida state prison population by year

84 · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·





80 ............................................................................................. .






76 · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·







Model formulation for excess mortality model.

t == Month
a == Age Group


Binomial(Pa,t, Populationa,t)

Pa,t == logit (/3a + c/Ja,t
/3a rv N(0, 1000)

+ (a,t)




(a ,t


N(0, aa)

T; 1


Gamma(l, 5e-05)

a; 1


Gamma(l, 5e-05)


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