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As we enter 2021 and the Covid-19 pandemic rumbles on, optimism for the coming year relies heavily on successful vaccine rollout. Attention is now increasingly focussed on the practicalities of distribution, which will involve prioritisation and difficult policy decisions. Few argue about those groups right at the top of the list like care home residents, or healthcare staff working in high risk settings. However, an important population is less on the radar: people in prison.

There are around 11 million people in prison around the world. Most will be in environments that make social distancing and other measures to reduce transmission, now a routine part of day-to-day community life for most, much more challenging. Such conditions can make prisons vulnerable to becoming overwhelmed by rapid transmission. Many of those in prison are also in higher risk groups for severe complications of Covid-19 as the underlying health inequities surrounding ethnicity and socioeconomic status, to which the pandemic has drawn renewed attention, are mirrored in prison populations.

In addition to impacting the welfare of people in prison, these are issues for the community in which prisons sit. Prisons are not closed environments and the public health response needs to reflect this. There is high turnover, and people are often released from custody into unstable housing situations. Additionally, by virtue of the large number of prison officers and other staff, there are frequent indirect and direct points of contact with the world outside the prison gates.

We became interested in Covid-19 in prisons at the start of the pandemic and brought together mental health and infectious diseases researchers in the US, UK and China to collaborate on a review of previous disease outbreak strategies within prisons. Our systematic review, which synthesises the evidence from 28 studies of outbreak investigations, was published in BMJ Global Health in November 2020 and aims to inform evidence-based practices by identifying common themes and challenges.

Screening, contact tracing and isolation appeared to be the most effective infection control strategies albeit with various challenges inherent to the specific living conditions of different prisons. For instance, screening can be an ineffective tool when it requires incarcerated individuals to divulge sensitive information regarding symptoms, especially where the fear of stigma and prolonged medical isolation is salient. Moreover, the benefits of infection control strategies such as restricting visitations or medical isolation need to be considered in light of their potentially dire consequences for the mental health of people in prison. Such consideration is crucial as this population has disproportionately higher levels of pre-existing psychiatric morbidity, self-harm and suicide than the general population.

Interestingly, strategies that would reduce the prison population directly (e.g. releasing individuals nearing the end of their sentences) constitute a considerable research gap though this idea has now been widely debated, and even implemented in some jurisdictions. Authorities should use scalable risk prediction models, such as OxRec, to assist decarceration efforts by identifying people at low risk of violent reoffending in an evidence-based and transparent way. Failing this, our research showed that clear and effective health communication and infection control measures are needed for both staff and people in prison. Accordingly, any comprehensive public health response to prison outbreaks will necessitate extensive collaboration between public health and prison authorities.

In December, the Independent Advisory Panel on Deaths in Custody wrote to the Joint Committee on Vaccination and Immunisation to call for the vulnerability of people in prison in England and Wales to be recognised during the vaccine roll-out. However, people in prison were not mentioned in the subsequent advice issued on priority groups. The American Medical Association similarly issued advice for vaccine prioritisation in a recent press release, further stressing the importance of Covid-19 policies that address correctional staff and incarcerated individuals. Some US states such as Massachusetts have responded to this call for action. However, the contentious ethical and political debate surrounding priority allocation of coronavirus vaccines to people in prison endures. Our research of past measures shows that such prioritisation may be key to stopping the spread of disease given the unique vulnerabilities and underlying risk factors of people in prison along with the challenges of traditional infection control measures in such an environment.

For our systematic review on outbreaks of highly contagious diseases in prisons see BMJ Global Health 2020; 5: e003201.

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