Resources for Behavioral Health and Criminal/Legal Institutions during the COVID-19 Outbreak

Compiled by:
Brad Ray, Ph.D.; Sheryl Kubiak, Ph.D., M.S.W.; Tyler Logan, M.A.; Bianca Burch, M.A., M.S.W.; Stacey Campbell, B.A.

Detroit was impacted early by the 2019 novel coronavirus (SARS-CoV-2), which causes the disease COVID-19. In March 2020, the Wayne County Jail (WCJ) learned that numerous staff members were infected and, ultimately, three jail medical staff died from the coronavirus. As the disease spread across Michigan and social mitigation efforts began to emerge, county administrators worked with the Wayne State University School of Medicine (WSU-SOM) and the CBHJ to develop a plan to slow the spread of the virus.

Recognizing that mass testing was the right first step, emergency funding was obtained from the Michigan Justice Fund for the WSU-SOM to organize and administer mass testing of all jail inmates. This testing included both the PCR (nasal swabs) to detect current infection and serology tests (to assess antibodies). With the results of the mass testing, the jail immediately quarantined COVID-19 symptomatic and asymptomatic positive individuals. 

Following this, the CBHJ started coordinating regular meetings with key Wayne County and state government collaborators to assist in the identification and implementation of a COVID-19 mitigation strategy for the WCJ that included testing, contact tracing, quarantine, and release strategies. Since March 2020, jails across the state have taken various measures to prevent COVID-19 transmission, including verbal screening, decreasing the population, restricting movement within facilities, prohibiting visitation, and suspending internal programming. However, few have implemented testing and we felt it was important to share the lessons and strategies using to developed these procedures. 

Amidst national data showing that incarceration settings have prevalence and mortality rates five times the general population, accounting for 80 percent of the largest COVID-19 outbreaks (surpassing nursing homes and food processing plants), and the realization that asymptomatic carriers can unwittingly infect staff and detainees, a comprehensive plan for identification and mitigation is best practice. Governor Whitmer issued Executive Order 2020-170, providing guidelines for correctional facilities in Michigan (both jails and prisons), clarifying the standards jails have to meet before they can transfer individuals to the Michigan Department of Corrections (MDOC), and calling for routine risk reduction and testing for COVID-19 in county jails¹). The Executive Order was issued on August 15, 2020 and expired on September 30, 2020. This toolkit was finalized on September 15, 2020. 

With funding from the Michigan Justice Fund, the CBHJ documented the barriers and successes that Wayne County community leaders and partners faced implementing mitigation efforts in the WCJ in order to inform decision-makers across the state with practical strategies for reducing the transmission of COVID-19². 

Jail testing data combined with data regarding the surrounding community and region should be used to inform decisions related to jail operations. With this in mind, mitigation strategies will look different for each jail depending on a number of factors including the community viral spread of COVID-19. For example, when positivity rates increase, mitigation strategies need to intensify, which might include decarceration along with increasing the frequency or type of testing, contact tracing strategies, and discharge planning efforts. Appendix E provides an example of how testing data from the jail as well as the surrounding community might guide the response.

Testing for the virus that causes COVID-19 is fundamental in mitigating the spread of the virus by identifying symptomatic and asymptomatic carriers. When, where, how often and by whom tests are administered will vary based upon the jail and health personnel available and the community and jail COVID-19 positive rate. Understanding the variation in testing types, modes of administration, and what has been implemented in other jails will help you develop a strategy for your county that works for visitors, staff, and those booked into the jail. The CDC recommends that an individual should receive no more than one test in any 24-hour period. If an individual is moved between facilities within that period, it is not recommended to re-test. It is important to note that screening for symptoms without testing does not comply with EO-2020-170 (set to expire on September 30, 2020).

Diagnostic tests provide information on the presence of current COVID-19 infection and can be used to assess acute infection. These tests are administered by nasal swabs, throat swabs, or using saliva. The RT-PCR test (molecular test) is currently the most accurate and detects genetic materials using nasal swabs or saliva; this is the most widely used diagnostic test. Result times have decreased to as quickly as 15 minutes but can take up to 1-3 days, depending on the capacity and backlog of the testing lab.  A new diagnostic test has been developed to test for multiple respiratory viruses that include SARS-CoV-2, influenza A virus, and influenza B virus (check here for updates). This is due to symptoms of COVID-19 and the flu being very similar. It has also been reported as being more efficient in giving accurate results for all three viruses. The CDC may stop suggesting the use of the current RT-PCR test at the end of this year on December 31, 2021.  They may begin using the Flu-SC2 Multiplex Assay more widely beginning in January 2022, though the Flu-SC2 Multiplex Assay tests are currently FDA-approved for use and is encouraged. The CDC does highly recommend that people get the vaccination to help maximize protection against the current COVID-19 strains, and potentially any new ones, while helping decrease the spread of the virus.  It is also recommended to continue wearing masks indoors when in public areas to help prevent the spread and keep people safe, as another layer of protection, even if you are vaccinated.    

As the vaccine continues to rollout, testing efforts should shift to concentrate more on testing individuals who have not been vaccinated. However, testing should still continue to be administered to anyone (vaccinated and unvaccinated) who show signs and symptoms of the virus that causes COVID-19.  Any individual who is at high-risk for exposure to the virus, regardless of vaccination, should undergo a series of two viral tests for COVID-19 infection.  1) They should be tested immediately and 2) 5-7 days after exposure to the virus.  It is recommended that if an individual remains asymptomatic for 90 days after infection, there is likely no need for more testing. 

The antigen test (point-of-care test) detects certain proteins on the surface of the virus and is administered by nasal or throat swabs. This is a rapid test, with results generated within an hour. These tests can be less sensitive and are becoming widely available. The antigen test is highly accurate for COVID-19 positive cases; however, negative results are less accurate, and may need to be confirmed from the molecular (RT-PCR) test. Jails may also consider onsite machines that assist in analyzing tests results onsite. Contact your local health department for additional guidance on testing efforts.

The antibody test, also referred to as the IgG or IgM test, involves serology (blood draw) and requires medical personnel. This test determines past exposure to COVID-19 by assessing antibody production; however, it does not indicate a current or active infection from the virus. Additionally, an individual testing positive with the IgG may have no recollection of having the virus because they were previously an asymptomatic carrier or only had mild symptoms. Further research is underway to learn if or how long the antibodies may provide protection from COVID-19. Please, note that antibody tests may raise a different set of issues, as the CDC doesn't currently recommend using antibody testing for diagnosing of current COVID-19 infection status.³ Therefore, if not already done so, jails should consult with their local health departments if using antibody tests to create strategies for administering diagnostic testing for the virus as well. 

One strategy to help identify staff for testing is to implement symptom and temperature checks into daily standard practices. However, this would miss asymptomatic or pre-symptomatic cases, highlighting the need to have procedures in place for re-occurring and consistent diagnostic testing for all staff entering the facility (i.e., correctional, sanitation, food services, and administrative staff).

Additionally, standardizing practices among staff to minimize unnecessary contact (i.e., contact between quarantine unit staff and non-quarantined unit staff) is crucial to help minimize spread and to inform staff testing decisions based on access and proximity to detainees. Another strategy is to implement broader facility-wide testing following any COVID-19 positive case in the facility.

Jail facilities need to have a quarantine plan in place for staff members that includes the risk reduction protocols highlighted by the State of Michigan (SOM) and the CDC (See Appendix A for more information). Any jail staff member (symptomatic or asymptomatic) who learns that they have been in close contact with anyone who has tested positive for the virus that causes COVID-19 should receive a diagnostic test. At minimum, it is recommended that the staff person, even if vaccinated, be required to home quarantine for ten days, and until either no symptoms have developed or symptoms have improved with at least 24-hours post fever. It is important to note that the CDC is no longer recommending a negative test result as guidance to determine when an employee can return to work following COVID-19 positive status (additional information can be found here).

At the onset of the pandemic, every two to three weeks, more than 1,000 WCJ staff were encouraged to seek testing at one of the contracted testing sites in Wayne County; WCJ still encourage all of their staff to get tested and assure that they have access to vaccinations through jail and community resources, as needed. To continue facilitating this, county public health agencies are working to increase the number of providers administering COVID-19 testing and vaccinations, including an onsite mobile testing near the jail, allowing for more geographic and time-related flexibility for staff seeking testing or vaccination.

Contact tracing is a public health tool used to identify and notify the recent contacts of someone who has COVID-19. Recommendations include tracing all contacts from the 48-hours prior to symptoms and in the case of asymptomatic cases, 48-hours prior to testing. This includes anyone that came in contact with the detained individual and were within 6 feet of that person for at least 15 minutes, starting from 48 hours prior to showing symptoms. The objective is to identify cases or locations that can break the transmission chain.

In Michigan, contact tracing for positive COVID-19 can be conducted by the state or, when a high-risk population is involved, local health departments can coordinate contact tracing efforts. These local and state efforts can be coordinated through the MDSS via the Outbreak Management System (e.g., TraceForce), which is used by local health departments to record positive cases and their contacts. Depending upon the county system, permission can be granted for someone within the jail to enter the COVID-19 positive case information directly into MDSS. Otherwise, the information can be shared verbally or electronically within the local health department. 

Since jails, like other congregate living situations, are considered high risk, it is important to note that the local county health department will use the information obtained from the detained individual at booking to engage in contact tracing after a positive result. If this information is not collected at booking, a valuable opportunity is lost as it becomes more difficult to locate individuals post jail discharge.

Data collection and information sharing is critical to mitigate the spread of COVID-19 within jails and their surrounding communities. As processes are defined to implement testing and contact tracing, it is also necessary to implement processes to capture, record and share information. Depending upon the size and resources of a jail, including the technological tools available, each jail may have varying solutions. At a minimum, each jail will need to identify a person or people responsible for the data collection and management. Information will need to be shared within the jail, as well as with local and/or state health departments. 

Test Results. Depending on policies within the jail, testing may occur at different times. Ideally, with the guidelines provided by the CDC, as well as local and state government, testing will be implemented routinely upon admission to the jail, including routine testing of staff. Booking lists are helpful to ensure that you have accounted for the full population entering the jail. The designated staff person(s) should record the date an individual was tested, which test(s) they received, and the date test results were received. Refusals and mitigating circumstances which prevented testing should also be documented.

Vaccinations. Each jail should implement their own policies and procedures around vaccinations.  It is recommended for the safety of everyone in the jail that staff be encouraged to get the vaccine, especially because of their frequent access and exposure to the community.  This can help to reduce the spread of COVID-19 and keep individuals entering the jail, including other jail staff, and their families, safer. Also, providing information on vaccinations, and other mitigating strategies, in collaboration with your local health professionals and/or documents from your local health departments, is important. By providing this information and resources to individuals entering/exiting the jail can be helpful in providing increased safety for everyone. Vaccinations are not currently mandatory for all jail staff and detained individuals, but are strongly encouraged where possible.  Labs and/or organizations are not required to report current vaccination status.

Prevalence Rates. Aggregate booking numbers, including the number of positive cases returned from the lab, will provide the jail with their COVID-19 prevalence rate (proportion or percentage of COVID-19 cases in the population at a given time). Prevalence can be tracked on a weekly basis to account for lab processing time. Tracking prevalence over time can provide jail administration with timely warning signs of when mitigation efforts might be implemented or reduced (see Appendix E for more information). Additionally, it is suspected that changes in the community's COVID-19 prevalence rate may foreshadow changes in the jail's prevalence rate. Therefore, monitoring changes in the community can also be valuable data to inform jails of altering mitigation efforts.

Sharing Information with Public Health. Public health officials at the state and local level track positive cases in an attempt to determine community prevalence and to employ preventative efforts. A confirmation of a positive COVID-19 case is not only a cause of concern within the jailit is public health issue. If someone enters the jail with COVID-19, there are individuals in the community that have now been exposed. Because jail medical and the emerging outside labs they use for COVID-19 testing might report results only back to the jail or jail health staff, routine practices for sharing information with the health department may not have been established. Links with the local health department and protocols for sharing the information need to be implemented to connect jail COVID-19 mitigation strategies to the broader community.

Sharing Information with Detainees. Knowing test results and especially having a record of the results is important. We recommended that jails share a paper copy of the testing results with justice-involved individuals. Those who are released prior to receiving their results should receive communications (phone calls, texts, or mail) with their results, irrespective of whether they are positive or negative. Proof or knowledge of COVID-19 test results can help justice-involved individuals seeking additional support or services upon discharge. If the jail is engaged in diagnostic as well as antibody testing, the results of the antibody test are also highly valued, as those found to have antibodies may have some limited immunity to COVID-19. Effective communication of test results may decrease individual anxiety and mistrust between medical professionals and communities. 

Sharing and Receiving Information Involving Jail Staff. Jails may implement requirements for routine testing of staff. If such a requirement is issued, jail administration may require documentation of testing. A process for collecting and tracking staff testing will require resources of employee time. Because labs are required to report positive test results to the state, it is assumed that contact tracing efforts as well as disclosure of the employee will activate prevention and intervention measures within the jail. 
 

It is important to note that anyone can be at risk for contracting COVID-19 (Coronavirus). This includes justice-involved persons, law enforcement personnel such as police, first responders, custodial and food staff, and correctional officers. Similar to testing, screening and contact tracing, setting up quarantine, sanitation and social distancing procedures is imperative in helping correctional facilities decrease transmission of the virus. Implementing measures such as testing all inmates and staff upon entry, and establishing evidence-based polices for both asymptomatic and symptomatic individuals would be recommended. ^{5 6}

Addressing the needs of correctional facilities, especially as it pertains to health outcomes, is imperative. The safety of both staff and justice-involved persons is inherently a matter of public health. The following are key considerations when creating a safe environment for everyone in correctional facilities: provide proper personal protective equipment (PPE), increase healthcare infrastructure and equipment where applicable, implement policies that limit contact between the officers and inmates, and expand efforts of de-incarceration (decreasing the population of those in correctional facilities). Coordination between facilities, arranging for sharing information, and maintaining consistent contact can also help with safety. Providing soap, tissue, proper PPE, and hand sanitizer to inmates at no cost can help with sanitation.