In their recent letter to the Health and Social Care Secretary the Joint Committee on Vaccination and Immunisation (JCVI) advised that although prisons may be higher risk in terms of covid-19 transmission, this potential for increased exposure did not warrant prioritisation of prisoners for vaccination, given that prevention of mortality is the key aim of phase 1 vaccination.
As the risk of covid-19 mortality increases with age, the JCVI recommend a general prioritisation of vaccination by age group. However, there are several reasons why prisons may constitute an exception, warranting resident and staff vaccination amongst all ages concurrently.
First, our recent analysis of HMPPS data suggests that people in prisons in England and Wales are three times more likely to die from covid-19 than people in the general population, after accounting for age and sex differences. This is likely a result of the combination of high levels of underlying health conditions in the prison population and the higher risks of transmission and exposure to the virus in closed institutional settings.
This higher mortality rate is despite the very stringent infection prevention and control measures that have been deployed by the prison service throughout the pandemic. There is no doubt that these measures have saved many lives relative to a scenario with few restrictions, however, it is clear that these measures alone are not sufficient. There is a strong case for widespread institutional vaccination of prisoners to reduce mortality associated with institutional outbreaks.
Second, prisons remain high-risk environments for large, “explosive” outbreaks. Even as the community prevalence decreases to low levels prisons will remain at high risk, with a single case imported in able to evolve rapidly into an outbreak situation. The prison population is highly dynamic, with many movements within and between prisons, and between community settings such as courts and hospitals. These movements have been restricted during the pandemic, but will resume, to allow delivery of the rehabilitative regime. As courts return to normal levels the numbers of new receptions to prisons will increase. Visitation, paused for the most of last year, will need to resume to protect the human right to a family life for both prisoners and their families. Together, these changes will increase the likelihood of introduction of infection. Alongside a broader strategy for infection prevention and control, widespread vaccination policies will reduce this risk.
Third, covid-19 has caused wider harms. To prevent risks of transmission prisoners have been mostly isolated in their cells for up to 23 hours per day. Meaningful activities have been paused, and in-person visitations stopped. The effects of this isolation on mental health are likely to be significant. According to Her Majesty’s Inspectorate of Prisons: “The prevalence of mental health problems among the prison population before the pandemic was well-documented. The effect of covid-19 restrictions on this population had therefore been significant”.
Fourth, prisons are a potential reservoir and amplifier of infection, including new variants. The risk of infection and outbreaks in prisons has increased markedly in the second wave of covid-19—this has become particularly apparent as the B.1.1.7 variant (with substantially increased transmissibility) has become dominant across the UK. Failure to protect prisons from increased transmission levels will leave a window of opportunity for new variants to amplify, potentially leading to prisons as a reservoir of infection for the community. During the second wave there have been several instances where large prison outbreaks have meant that the local area has measured some of the overall highest infection rates in England, despite low levels of local community transmission. This demonstrates how prison infections can escalate quickly, despite far lower community prevalence.
In addition, there is a good case for concurrent widespread vaccination of prison staff. Prison staff have daily connections with communities outside of prison and as such are the most likely group to bring the infection into prison. As evidence of the effect of vaccination on transmission grows, this is an increasingly important consideration. Prison officers also hold a role similar to that of social care staff, with many having contact with clinically vulnerable prisoners under the care of their institution. Like healthcare workers, prison staff have a high risk of exposure to covid-19 as demonstrated both by numerous prison outbreaks and the finding from a recent ONS study showing those in “protective service occupations” have a higher risk of covid-19 infection than those working in health and social care.
Prisoners are held in settings determined and delivered by the Government, who hold a duty of care for their residents. By failing to offer strategies to enable prisons to lift lockdown restrictions at a similar pace to the lifting of restrictions in the community, including widespread vaccination, prisoners are, in effect, being served a second punishment in addition to the deprivation of liberty.
Homeless hostels and care homes have a similarly high risk of outbreaks and a vulnerable resident population, and as such universal vaccination is now recommended. There is now a strong argument to treat prisons with an equivalent approach, as Ireland, Austria and Latvia are doing. Vaccination of all people in prisons and staff will also be the most effective approach to reducing outbreaks and mortality, and enabling the prolonged severe restrictions on prisoners to be lifted safely, mitigating the many associated impacts on the wellbeing and mental health of prisoners and their families.
Chantal Edge, Specialty Registrar in Public Health and NIHR Clinical Doctoral Research Fellow, UCL Collaborative Centre for Inclusion Health @ChantalEdge
Dan Lewer Specialty Registrar in Public Health and NIHR Doctoral Research Fellow, UCL Collaborative Centre for Inclusion Health @danlewer
Isobel Braithwaite Specialty Registrar in Public Health and NIHR Academic Clinical Fellow, UCL Institute for Health Informatics @izzybraithwaite
Jake Hard Prison GP and Chair of the RCGP* Secure Environments Group @JakeHard1
Andrew Hayward Professor of Infectious Disease and Inclusion Health, UCL Collaborative Centre for Inclusion Health, Director of the UCL Institute of Epidemiology and Health Care @CCIH_Health
Competing interests: AH is a member of NERVTAG and the SAGE EMG transmission group. CE and JH are supporting the EMG transmission group to look at transmission in prisons. JH is the Chair of the RCGP Secure Environments group. Opinions expressed are of the authors, not the related groups.