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Association Between Prison Crowding and COVID-19 Incidence Rates in Massachusetts Prisons, April 2020-January 2021

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is prison crowding associated with the risk of COVID-19 among incarcerated persons?

Findings  In this longitudinal ecological study including all incarcerated persons in 14 Massachusetts state prisons from April 2020 to January 2021, on average 6876 persons, COVID-19 incidence was significantly higher in prisons operating at a higher percentage of their design capacity and was significantly lower in prisons where a higher proportion of incarcerated people were housed in single-cell units.

Meaning  Prison crowding was associated with increased COVID-19 incidence rates; strategies that reduce crowding and increase single-cell occupancy should be explored to mitigate COVID-19 risk in prisons.

Abstract

Importance  COVID-19 incidence and mortality are higher among incarcerated persons than in the general US population, but the extent to which prison crowding contributes to their COVID-19 risk is unknown.

Objective  To estimate the associations between prison crowding, community COVID-19 transmission, and prison incidence rates of COVID-19.

Design, Setting, and Participants  This was a longitudinal ecological study among all incarcerated persons in 14 Massachusetts state prisons between April 21, 2020, and January 11, 2021.

Exposures  The primary exposure of interest was prison crowding, measured by (1) the size of the incarcerated population as a percentage of the prison’s design capacity and (2) the percentage of incarcerated persons housed in single-cell units. The analysis included the weekly COVID-19 incidence in the county where each prison is located as a covariate.

Main Outcomes and Measures  The primary outcome was the weekly COVID-19 incidence rate as determined by positive SARS-CoV-2 tests among incarcerated persons at each prison over discrete 1-week increments.

Results  There was on average 6876 people incarcerated in 14 prisons during the study period. The median level of crowding during the observation period ranged from 25% to 155% of design capacity. COVID-19 incidence was significantly higher in prisons where the incarcerated population was a larger percentage of the prison’s design capacity (incidence rate ratio [IRR] per 10-percentage-point difference, 1.14; 95% CI, 1.03-1.27). COVID-19 incidence was lower in prisons where a higher proportion of incarcerated people were housed in single-cell units (IRR for each 10-percentage-point increase in single-cell units, 0.82; 95% CI, 0.73-0.93). COVID-19 transmission in the surrounding county was consistently associated with COVID-19 incidence in prisons (IRR [for each increase of 10 cases per 100 000 person-weeks in the community], 1.06; 95% CI, 1.05-1.08).

Conclusions and Relevance  This longitudinal ecological study found that within 14 Massachusetts state prisons, increased crowding was associated with increased incidence rates of COVID-19. Researchers and policy makers should explore strategies that reduce prison crowding, such as decarceration, as potential ways to mitigate COVID-19 morbidity and mortality among incarcerated persons.

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Article Information

Accepted for Publication: May 28, 2021.

Published Online: August 9, 2021. doi:10.1001/jamainternmed.2021.4392

Corresponding Author: Amir M. Mohareb, MD, Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (amohareb@mgh.harvard.edu).

Author Contributions: Ms Leibowitz and Dr Mohareb had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Leibowitz, Mohareb.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: Mohareb.

Supervision: Tsai, Mohareb.

Conflict of Interest Disclosures: Ms Leibowitz reported provision of pro bono advising in support of Prisoners’ Legal Services of Massachusetts in litigation against the Massachusetts Department of Correction regarding the agency’s response to COVID-19. Dr Tsai reported receiving grants from the Sullivan Family Foundation during the conduct of the study; other from Public Library of Science (stipend for work as specialty consulting editor for PLOS Medicine) and other from Elsevier (stipend for work as editor in chief of SSM-Mental Health) outside the submitted work. Dr Mohareb reported receiving grants from the National Institutes of Health (T32AI007433) outside the submitted work; and provision of pro bono advising and written expert declarations in the following litigation regarding COVID-19 and incarcerated persons: Mays v Dart (Ill 2020), Foster v Mici (Mass 2020, 2021), and Savino v Hodgson (Mass 2020). No other disclosures were reported.

Funding/Support: This work was supported by the National Institutes of Health (grant No. T32 AI007433 to Dr Mohareb). Dr Tsai acknowledges funding support from the Sullivan Family Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or of the Sullivan Family Foundation.

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