the case for the priority allocation of vaccines

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At the beginning of 2021 and as the Covid-19 pandemic continues to intensify, optimism for the coming year will depend heavily on the successful launch of vaccines. Increasing attention is now being drawn to the practical aspects of distribution, which include priorities and difficult policy choices. Few argue about these groups at the top of the list like nursing home residents or medical workers working in high risk environments. However, one important population is less on the radar: people in prison.

Around 11 million people are in prison worldwide. Most will find themselves in environments where social distancing and other measures to reduce transmission are a routine that for most is a routine part of daily community life and is much more difficult. Such conditions can make prisons prone to being overwhelmed by rapid transmission. Many of the prisoners are also in groups at higher risk for serious complications from Covid-19, as the underlying ethnicity and socioeconomic status health inequalities that the pandemic has again drawn attention to are reflected in the prison population.

This affects not only the well-being of the people in prison, but also the community in which the prisons are located. Prisons are not closed environments and the public health response needs to reflect this. Sales are high and people are often released from prison in unstable housing situations. In addition, due to the large number of prison officers and other staff, there are often indirect and direct points of contact with the world outside the prison gates.

At the start of the pandemic, we took an interest in Covid-19 in prisons and brought together mental health and infectious disease researchers in the US, UK and China to work together on a review of previous strategies for disease outbreaks in prisons. Our systematic review, which summarizes the evidence from 28 studies on outbreak investigations, was published in the BMJ Global Health in November 2020 and aims to inform evidence-based practices by identifying common topics and challenges.

Screening, contact tracing, and isolation appeared to be the most effective strategies for infection control, albeit with different challenges associated with the specific living conditions of different prisons. For example, screening can be an ineffective tool when detainees need to reveal sensitive information about symptoms, especially when there is great fear of stigma and prolonged medical isolation. In addition, the benefits of infection control strategies such as restricted visits or medical isolation need to be considered in view of their potentially serious consequences for the mental health of people in prison. Such consideration is critical because this population has disproportionately higher levels of pre-existing psychiatric morbidity, self-harm, and suicide than the general population.

Interestingly, strategies that would directly reduce the prison population (e.g. releasing people near the end of their prison term) represent a significant research gap, although this idea has now been widely debated and even implemented in some countries. Authorities should use scalable risk forecasting models such as OxRec to aid the detention efforts by identifying individuals at low risk for repeat violent crime in an evidence-based and transparent manner. Failure to do so, our research has shown that clear and effective health communication and infection control measures are required for both staff and people in prison. Accordingly, any comprehensive public health response to prison breakouts requires extensive cooperation between public health and prison authorities.

In December, the Independent Advisory Panel on Death in Custody wrote to the Joint Vaccination and Vaccination Committee to request that the vulnerability of people in prisons in England and Wales be recognized during the introduction of the vaccine. However, people in prison were not mentioned in the priority group recommendations below. The American Medical Association has also issued advice on prioritizing vaccines in a recent press release, which further emphasizes the importance of Covid-19 guidelines for law enforcement officers and inmates. Some US states such as Massachusetts have responded to this call to action. However, the controversial ethical and political debate surrounding the prioritization of coronavirus vaccines to people in prison continues. Our research on previous interventions shows that given the unique vulnerabilities and underlying risk factors of individuals in prison, as well as the challenges of traditional infection control interventions in such an environment, such prioritization can be key to containing the spread of disease.

For our systematic review of highly contagious disease outbreaks in prisons, see BMJ Global Health 2020; 5: e003201.

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