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Overcrowded conditions and lack of access to care help make COVID-19 more dangerous inside prisons, especially for minority populations, and these outbreaks are expected to continue, Neal Marquez, MPH, said at a sponsored by Health Affairs.

"Some people have said we're in the 'post-pandemic' era, but I do want to highlight that in our continued efforts to monitor COVID-19 in carceral settings more generally, we're seeing locations that are having outbreaks that outpace any of the outbreaks that we've seen in the past," Marquez, a research associate at Portland (Oregon) State University, said during Monday's webinar. "Prison facilities, jail facilities, and ICE [Immigration and Customs Enforcement] facilities still are high-density places that are going to be susceptible to outbreaks ... And so this is far from over for many carceral settings in the United States."

Marquez discussed a which analyzed monthly demographic information pertaining to COVID in the Texas Department of Criminal Justice (TDCJ) prison population for the months spanning April 2019–March 2021. The investigators calculated age-specific sex-standardized and age- and sex-standardized COVID-19 mortality rates for the TDCJ's Hispanic, Black, and white populations, as well as for the total TDCJ population, during the pandemic period. All of these populations were "standardized to the age and sex structure of the TDCJ's prepandemic White population," the authors wrote.

The researchers found that rates of standardized COVID-19 mortality among Black and Hispanic people greatly exceeded the rate among white people during the pandemic period. "The standardized rates of COVID-19 mortality during the pandemic period were 266.7 per 100,000 person-years for the Black population (96 deaths), 352.1 for the Hispanic population (109 deaths), and 165.9 for the White population (93 deaths)," the team noted.

Meanwhile, the overall COVID-19 mortality rate for the Texas Department of Criminal Justice population as a whole was 246.3 (299 deaths). In terms of odds ratios, the investigators said, "the Black and Hispanic populations were found to have mortality rates that were 1.61 (95% CI 1.21-2.14, P<0.01) and 2.12 (95% CI 1.61-2.80, P<0.01) times higher, respectively, than those of the white population."

It's well-known that jails and prisons are at high risk of infectious disease spread, Marquez said, listing influenza, H1N1, and tuberculosis as examples of diseases that have spread quickly in prisons, with higher mortality compared with the general population.

Contributing factors that lead to quicker spread include overcrowding, limited access to healthcare, and facilities not having the appropriate equipment and staff to respond to rapid outbreaks of infectious disease. In addition, "it's pretty well established that people in prisons tend to have worse prevalence of long-standing health conditions than the general population," leaving them even more susceptible, he said.

Because of those well-known facts about infectious disease in prisons, "COVID-19 immediately raised concerns about carceral contact and how it was going to impact those who happened to be behind bars at that time," said Marquez. "This was especially true given the high reproductive and mortality rate of COVID-19 -- COVID-19 was known to have a reproductive rate that was higher than some other SARS viruses, and have a mortality rate that was above influenza. And so the combination led to a large call for action from many public health [experts] and epidemiologists who are familiar with carceral contacts to address this issue head on before the problem really started to rise."

Marquez and colleagues published studies in JAMA in and showing that COVID-19 cases and mortality were much higher in the prison population. "We were seeing infection rates in the first 3 months that were five times higher in the U.S. prison population -- and over the first year, about three times higher -- than the U.S. general population, and mortality rates which were three times higher in the first few months, and two and a half times higher over the course of the first year, in prison populations compared to the overall U.S. population," he said.

In particular, "we found that Black and Hispanic populations had significantly higher rates of COVID-19 and all-cause mortality during the first year of the pandemic," Marquez said. "And this was something that didn't exist in the year prior to the COVID-19 pandemic and needs to be highlighted."

And it wasn't just prisoners themselves who had high infection and death rates, he added. "Staff were just as susceptible -- they had higher susceptibility than the general public for infectious disease spread and mortality as well, albeit not as high as those who [were] incarcerated."

In addition, surrounding communities were impacted by the high COVID infection and death rates through a process known as "jail cycling," Marquez explained: "Individuals would become incarcerated, be susceptible to the high infection rates that were in carceral settings, and then return to home locations and spread those diseases to other people in their communities as well. So it's impacting individuals who aren't incarcerated."

Another barrier to healthcare access in prisons that isn't well publicized is medical copays, according to Marquez, who said that previous studies have found that non-white people in general were more likely to cite the existence of medical copays as a reason to avoid seeking healthcare.

In Texas prisons, medical copays are $13.50 per visit, he said. "For me and you, that probably doesn't sound very expensive. But when you think about the fact that people in prisons don't have an income -- or if they do work, they're making on the order of 12 cents an hour -- that is an outrageous fee," and actually contributes very little financially toward paying the state's cost of healthcare.

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