Enduring Injustice: Infectious Disease Outbreaks in Carceral Settings

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From the late 16th through the 18th century, louse-borne typhus swept through English prisons and into courtrooms, claiming the lives of judges, jurors, and constables and spilling out into the surrounding populations. These large outbreaks of “gaol fever,” which killed up to a quarter of incarcerated individuals, came to be known as the “Black Assizes” and ultimately drew attention to the overcrowded, unsanitary conditions of incarceration. In response, Parliament passed (1774) the “Act for Preserving the Health of Prisoners in Gaol,” one of the earliest public health measures to require basic sanitation, ventilation, isolation measures, and disease reporting in carceral settings. Two hundred fifty years later, infectious diseases continue to disproportionately afflict persons deprived of liberty (PDL), who number >11 million today, with many times more passing through jails and other forms of detention each year. Carceral facilities worldwide remain largely characterized by overcrowding, poor ventilation, malnutrition, and limited access to medical care—conditions under which infectious diseases thrive. Outbreaks of tuberculosis, cholera, measles, mumps, varicella, influenza and SARS-CoV-2 spread with devastating speed through prisons, jails, and immigration detention facilities [1]. Major endemic infectious diseases—including tuberculosis, human immunodeficiency virus (HIV) infection, and hepatitis C—remain many times more common among PDL in every country where data are available [2]. The failure to mitigate infectious disease transmission in carceral facilities subjects medically vulnerable and socially marginalized populations to serious health risks from which they often have little recourse to protect themselves. Furthermore, carceral facilities often serve as “institutional amplifiers” for pathogen transmission, driving disease burdens in surrounding communities. In the 1990s, large outbreaks of multidrug-resistant tuberculosis occurred in the New York State prison system, affecting dozens of PDL, spreading to prison staff, and leading to hospital outbreaks. Recent studies from multiple countries found that tuberculosis strains frequently spill out from prisons into surrounding communities, with large community clusters involving formerly incarcerated and never-incarcerated individuals [3, 4]. Similar effects of incarceration have been seen on community transmission of hepatitis C and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [5, 6]. Inadequate responses to the prevention, diagnosis, and treatment of infectious diseases in carceral settings often leads to even greater public health problems in the community. Preventing and mitigating infectious disease outbreaks in carceral settings requires multilevel strategies incorporating both biomedical and structural approaches. Given the elevated risk of communicable disease transmission and the difficulty of instituting effective distancing measures in densely populated congregate settings, PDL and prison staff should be considered priority groups for vaccination. In practice, however, policies and resource allocation for vaccines in carceral settings vary. For example, in the United States, a minority of states included incarcerated people as priority groups when rolling out SARS-CoV-2 vaccines, a trend that was replicated globally [7]. Concerns have been raised about acceptance of vaccines among PDL owing to medical mistrust; however, data suggest that uptake rates are often quite high, particularly when multiple opportunities are provided [8]. By contrast, vaccine uptake among correctional staff has been reported to be low in many settings, posing a serious obstacle to preventing introductions of new infections into carceral facilities [8]. Systematic screening for infections such as tuberculosis, HIV infection, and hepatitis C at entry into carceral facilities and at regular intervals is a critical strategy for containing transmission and is recommended in many public health guidelines. However, in countries where the burden of these diseases is greatest, PDL are rarely prioritized for screening and prevention programs, and underdetection of these diseases remains common [2]. The United Nations Standard Minimum Rules for the Treatment of Prisoners [9] outline basic standards of healthcare, including equivalence to services available in the community, that are not met in many carceral systems globally. Furthermore, data on infectious disease burden among PDL are rarely made publicly available, hindering efforts for accountability and progress. With proper investments, carceral settings can provide opportunities for diagnosis and linkage to treatment and preventive therapies for populations who are underserved in their communities. Studies indicate that adherence rates for tuberculosis treatment, preventive therapy, and antiviral therapy for HIV and hepatitis C are high, with excellent clinical outcomes. Because of the role of incarceration in amplifying community transmission of these infections, targeting active screening and treatment programs to PDL can have outsized public health impacts and in some cases may be essential to control and elimination strategies [10]. Infection prevention among PDL poses several unique challenges. Many carceral facilities, particularly those in low- and middle-income countries, have poor ventilation, which facilitates the spread of contact and respiratory transmitted infections [11]. Resource constraints and security concerns are frequently cited as obstacles to improving ventilation through installing windows or mechanical ventilation systems. Rather than viewing this as a fixed problem, improving air quality in carceral settings should be a focus for the development of innovative solutions. During outbreaks, measures to reduce in-person interactions among PDL and with their family members through restrictions on visitation and out-of-cell time are often instituted to prevent spread of infections; however, such policies may cause further social isolation, limit educational and employment opportunities, and worsen mental health, and they must be balanced against these harms [12]. Finally, as incarceration remains an intractable risk factor for many infectious diseases despite these efforts to mitigate risk, measures to reduce exposure to incarceration are increasingly part of the policy discussion [13]. During the coronavirus disease 2019 pandemic, several countries decreased their incarcerated populations by reducing incarceration for low-level offenses and decarcerating individuals deemed at high medical risk and/or low recidivism risk, without evidence of increases in crime rates or harms to public safety. In parts of the world where incarceration rates are rapidly rising, investments in biomedical interventions alone may be insufficient to contain the continued growth of infectious diseases among PDL [14]. In 1903, The New York Times published an article titled, “Hard Labor and Tuberculosis,” describing the dual sentence that incarceration conferred, wryly concluding, “if the prisoners are not properly the objects of sympathy, perhaps the people outside the prisons may be so considered” [15]. Today, outbreaks and endemic transmission of infectious diseases continue to disproportionately affect PDL throughout the world, and carceral facilities continue to amplify infection transmission in their communities. Investments in infection control, prioritizing active screening, preventive measures, and treatment of infectious diseases in carceral settings, and identifying alternatives to detention to reduce exposure to incarceration are needed to reduce the burden of infectious diseases among PDL and their communities. Financial support. This work was supported by the National Institutes of Health (grant R01 AI130058 and R01 AI149620 to J. R. A. and J. C.) and Brazil’s National Council for Scientific and Technological Development (J. C.)