People who are incarcerated in Criminal Justice Settings during the COVID-19 pandemic
Including those who are living with HIV, hepatitis B and hepatitis C.
ASHM COVID-19 Taskforce interim recommendations
Prepared by members of the Taskforce's Justice Health Cluster Group and the Taskforce Chair
UPDATED ON: 9th April 2020.
Disclaimer: This ASHM document is designed to provide current and relevant information to clinicians and other healthcare providers to optimise the health and wellbeing of people who are incarcerated in criminal justice settings during the COVID-19 pandemic, including those who are living with HIV, hepatitis B, or hepatitis C. The recommendations provided are based on the opinions of the authors and are not intended as explicit guidelines for standard of care or practice. This document does not reflect a systematic review of the evidence, but will be revised to include relevant future systematic review findings of the National COVID-19 Clinical Evidence Taskforce(1) and other relevant information.
SARS-CoV-2 is spread via airborne droplets or via contact with contaminated surfaces and causes both asymptomatic infection(2, 3) and clinical illness(4). Prevention of infection with this virus requires the capacity to maintain social distancing, perform regular hand hygiene and the opportunity for suitable quarantining of people with proven, or suspected COVID-19 illness, or those who have come in contact with someone recently diagnosed with COVID-19. Given the confined physical environment and restrictions of the movement of individuals, and in the context that many prison systems are at, or beyond capacity, prisons are highly likely to experience outbreaks of SARS-CoV-2, which has occurred already, as reported in(5). As a result there have been calls for decarceration of prison populations (6) and for optimising infection control measures in prisons to prevent and treat SARS-CoV-2 infections (5-7).
In Australia, an open letter written by academics and lawyers was sent to Australian Governments addressing COVID-19 and the criminal justice system(8). The Chief Executive Officer of ASHM is a signatory to this letter..
In particular, as a result of the endorsement of this open letter, the ASHM COVID-19 Taskforce supports the following:
1. The early release (decarceration) of prisoners, including those living with HIV, hepatitis B or hepatitis C, who:
• Are at higher risk of harm from COVID-19 because of age and/or co-morbidities or immunosuppression as a complication of HIV, hepatitis B or C (see below), or
• Are children or young people, or
• Have been detained for summary offences (e.g., unlawful driving; public disorder; fine default); property crimes; non-violent drug offences; common assault; and breach of justice procedures, or
• Are likely to be released in the next six months
The ASHM Taskforce acknowledges that the living and social circumstances of all people, including those living with HIV, hepatitis B or hepatitis C who are released from prison will be stressful and will include difficulty in adherence to social distancing guidelines. This may be particularly the case for sudden and unexpected releases that may occur during the COVID-19 pandemic. The ASHM Taskforce therefore also calls for the strengthening of prison to community reintegration services to ensure people released from custody are housed, clothed, fed and given access to medications, including HIV, hepatitis B and hepatitis C antiviral therapy, to support their ability to socially distance and maintain personal health and well-being. In addition, in light of their over-representation in Australian prisons, strategies need to be developed to ensure Aboriginal and Torres Strait Islanders who are released from prison are supported in a culturally appropriate way to achieve these outcomes. Post-release support strategies also need to consider potentially reduced capacity within not-for-profit agencies that usually offer post-release services and consult with these agencies on the best ways to enhance their response capabilities.
The ASHM Taskforce also acknowledges the over-representation of people with injecting drug use histories in Australian prisons and that these individuals are at historically greater risk of acquiring HIV, hepatitis B or hepatitis C. Interruptions to the supply of drugs in prison and the community may therefore heighten health risks (e.g., overdose) for people released from prison. The ASHM Taskforce therefore calls for enhanced capacity to initiate and maintain prisoners and those released from prison on opioid substitution therapy (OST) and to strengthen or implement prison take-home Naloxone programs and overdose prevention education programs.
2. For systems to be put in place that allow staff and all prisoners, including those living with HIV, hepatitis B or hepatitis C, to adopt best practice infection control procedures including hand sanitation, social distancing (supported by a reduction in exposure risk via decreasing prison population), and quarantine measures, for prisoners.
• Best practice information for the prevention and management of COVID-19 outbreaks in Correctional and Detention Facilities has been provided by the Australian Communicable Disease Network Australia (CDNA)(9)
• Clinicians caring for all people who are incarcerated, including those living with HIV, hepatitis B or hepatitis C, should evaluate whether the correctional facility housing their patients is adopting these National CDNA guidelines and in addition should advocate for suitable isolation for all prisoners with suspected or proven COVID-19 illness
The ASHM Taskforce also calls for careful consideration of the conditions under which affected prisoners are isolated in light of prisoners’ mental health and/or previous experiences of solitary confinement in prison. Of note, mental health issues are prevalent in populations living with HIV and hepatitis C. Social distancing and quarantine practices must take into account human rights principles and avoid, as much as possible, conditions that place prisoners in sustained isolation akin to solitary confinement. These considerations should particularly apply to prisoners, including those living with HIV, hepatitis B or hepatitis C, with histories of mental illness. Opportunities for contactless social engagement and periods spent outdoors need to be integrated into COVID-19 quarantining practices in prisons. In addition, where restrictions on visitations have been enacted, increased access to contactless communication with family and loved ones, such as free and more frequent phone calls and communication via digital platforms, need to be implemented.
3. Bail and non-custodial penalties for all defendants, including those living with HIV, hepatitis B or hepatitis C, who are not classified as very high risk or deemed as being unable to be appropriately managed in the community
In the general community, people over 60 years of age and people with co-morbidities including hypertension, cardiovascular disease, lung disease, cancer, diabetes and chronic liver disease are at greater risk of poorer outcomes with COVID-19 illness(4, 10-13). In addition, the Australian Government Department of Health has advised that Aboriginal and Torres Strait Islander people 50 years and older, with one or more chronic medical conditions, may be at greater risk of serious COVID-19 illness. Some people with HIV, hepatitis B or hepatitis C may have a greater level of immunosuppression and/or experience other related co-morbidities, making them more vulnerable to infection with SARS-CoV-2 and more severe COVID-19 illness. Hence the responses recommended above should be emphasised when responding to the needs of older prisoners and/or those with comorbidities living with HIV, hepatitis B or hepatitis C who are likely to be at greater risk of poorer outcomes from the COVID-19 illness.
Measures to optimise these patients’ health should include maintaining smoke-free environments in prison and continuing to support smoking cessation, encouraging appropriate exercise, and optimising diabetic and blood pressure control. We currently recommend not ceasing or switching away from ACE inhibitors or angiotensin receptor blocker medications: there is not enough evidence that these agents increase the risk of worse outcomes of COVID-19 illness(14) and ceasing or switching these agents may cause harm to otherwise stable patients. Implementing new and expanding existing Telehealth capacity (be that via telephone or video consultations) in prisons will be needed, alongside systems to maintain prisoner appointments and actively referring and encouraging patients to attend Telehealth appointments with medical and allied health specialists. Clinicians should encourage patients to consider Advance Care Planning, as discussed in a recent paper on the clinical presentation and management of COVID-19(15).
• The streamlining of care
• Supporting health maintenance
• Health and wellbeing issues may worsen, or emerge during the COVID-19 pandemic
• Current concerns of people living with these blood borne viruses about the COVID-19 pandemic
• The role antiretrovirals used to treat HIV, hepatitis B and hepatitis C in the treatment and prevention of SARS-CoV-2 infection
• HIV, hepatitis B and hepatitis C infection and the risk of SARS-CoV-2 infection and severe COVID-19 illness
• Defining some sub-groups of people living with HIV, hepatitis B and hepatitis C infection who may be more immunosuppressed than others living with these blood borne viruses
• COVID-19 illness, pregnancy and HIV, hepatitis B and hepatitis C
• Approach to the management of COVID-19 illness in people living with HIV, hepatitis B and hepatitis C infection
1. National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/.
2. Mizumoto, K., K. Kagaya, A. Zarebski, and G. Chowell. 2020. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill 25.
3. Nishiura, H., T. Kobayashi, A. Suzuki, S. M. Jung, K. Hayashi, R. Kinoshita, Y. Yang, B. Yuan, A. R. Akhmetzhanov, N. M. Linton, and T. Miyama. 2020. Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis.
4. Wu, Z., and J. M. McGoogan. 2020. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA.
5. Yang, H., and J. R. Thompson. 2020. Fighting covid-19 outbreaks in prisons. BMJ 369: m1362.
6. Akiyama, M. J., A. C. Spaulding, and J. D. Rich. 2020. Flattening the Curve for Incarcerated Populations - Covid-19 in Jails and Prisons. N Engl J Med.
7. Kinner, S. A., J. T. Young, K. Snow, L. Southalan, D. Lopez-Acuna, C. Ferreira-Borges, and E. O'Moore. 2020. Prisons and custodial settings are part of a comprehensive response to COVID-19. Lancet Public Health 5: e188-e189.
8. Open letter to Australian governments on COVID-19 and the criminal justice system: http://www.cclj.unsw.edu.au/article/open-letter-australian-governments-covid-19-and-criminal-justice-system.
9. CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID‐19 Outbreaks in Correctional and Detention Facilities in Australia https://www.health.gov.au/sites/default/files/documents/2020/03/cdna-guidelines-for-the-prevention-control-and-public-health-management-of-covid-19-outbreaks-in-correctional-and-detention-facilities-in-australia.pdf.
10. Wang, D., B. Hu, C. Hu, F. Zhu, X. Liu, J. Zhang, B. Wang, H. Xiang, Z. Cheng, Y. Xiong, Y. Zhao, Y. Li, X. Wang, and Z. Peng. 2020. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA.
11. Zhou, F., T. Yu, R. Du, G. Fan, Y. Liu, Z. Liu, J. Xiang, Y. Wang, B. Song, X. Gu, L. Guan, Y. Wei, H. Li, X. Wu, J. Xu, S. Tu, Y. Zhang, H. Chen, and B. Cao. 2020. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 395: 1054-1062.
12. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. .
13. Porcheddu, R., C. Serra, D. Kelvin, N. Kelvin, and S. Rubino. 2020. Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries 14: 125-128.
14. Vaduganathan, M., O. Vardeny, T. Michel, J. J. V. McMurray, M. A. Pfeffer, and S. D. Solomon. 2020. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med.
15. Thevarajan, I., K. L. Buising, and B. Cowie. 2020. Clinical presentation and management of COVID-19 https://www.mja.com.au/journal/2020/clinical-presentation-and-management-covid-19.