Participants

During July–August 2022, the Centers for Disease Control and Prevention (CDC) special populations team invited staff from criminal justice organizations and state health departments to participate in in-depth interviews related to their experiences responding to COVID-19 in correctional and detention facilities. The criminal justice organizations consisted of correctional and detention facilities, private correctional healthcare contractors, and federal agencies and professional organizations working within the US criminal justice system. Health department participants included staff assigned to respond to COVID-19 in correctional and detention facilities in their jurisdiction. We intentionally selected organizations (22) from an extensive list of governmental and nongovernmental organizations that the special populations team interacted with during the pandemic regarding COVID-19 response in correctional and detention facilities. To ensure that interviews included organizations without existing relationships with CDC, we supplemented the list with suggestions from leaders within prominent criminal justice organizations and agencies. The invited organizations were selected to maximize variation in geography, governmental level (federal, state, or local), facility size, population age, and role within the criminal justice system. Invited organizations could include <3 participants in the interview.

Data Collection and Analysis

Two CDC staff (1 facilitator and 1 notetaker) conducted 1-hour virtual interviews. Interviewers stated that participation would not influence CDC funding or partnerships, and participants provided verbal informed consent. No incentives were provided. Interviewers used a semistructured questionnaire to explore challenges and successes during COVID-19 response in correctional and detention facilities, relationships between public health and criminal justice organizations, and ways public health agencies can support correctional health in the future.

Two reviewers analyzed the data using thematic analysis (23). Reviewers developed separate codebooks with a subset of interviews by using an inductive approach, compared findings, and grouped codes to identify broad themes (24). After coding all interviews, we synthesized responses into summaries of emergent themes. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (45 C.F.R. part 46.102(l) (2), 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq).

Facility-Level Factors and Operational Innovations

Participants reported that the population density inherent in correctional settings, limited isolation and quarantine space, and frequent movement of incarcerated persons between facilities and across jurisdictions complicated outbreak prevention and control. Given these constraints, participants stated that their response to COVID-19 was most successful when introducing operational innovation and flexibility into facility policies was possible and when leadership was strong and had previous experience in emergency planning.

The urgency of the pandemic enabled some criminal justice participants to develop innovative solutions to longstanding operational challenges and to gain support to continue them in the future. For example, some participants planned to expand medical screening at intake to include other infectious diseases or to continue using dedicated intake housing to improve uptake of rehabilitative programming and medical care at the beginning of confinement. Some participants (primarily from youth facilities and jails) planned to use diversion and decarceration strategies more intensively to avoid crowding and encourage community-based rehabilitation. Participants believed continuing to offer virtual services such as telehealth, virtual programming, and virtual visitation (originally implemented to maintain services amidst social distancing requirements) can increase access to rehabilitative programs and specialized healthcare going forward.

Implementing COVID-19 Prevention Strategies in Correctional Settings

Criminal justice participants perceived testing and vaccination to be the most helpful COVID-19 prevention strategies, although they were difficult to implement. All facilities used testing to prevent introduction of COVID-19 into the population, and some used testing innovatively to maintain access to programming and education (test-to-program) during periods of the pandemic when testing supplies were sufficient. Although criminal justice participants believed masking and social distancing could prevent transmission, most felt implementation and enforcement were impractical in correctional environments, especially over long periods.

Facility Healthcare Capacity

On-site healthcare capacity varied greatly across facilities. Larger facilities usually had sufficient healthcare services to manage most COVID-19 cases internally and conduct large-scale testing and vaccination programs. However, because those facilities are often not regarded as healthcare settings, their access to personal protective equipment and test kits was limited when supplies were constrained. For smaller facilities, especially jails, access to healthcare providers was limited or intermittent, increasing reliance on community hospitals and delaying testing and vaccination.

Data Availability

Regardless of size and healthcare capacity, reliance on paper records was common and limited facilities’ ability to track population health, conduct contact tracing, access real-time data for decision-making, and comply with information requests for public health reporting, litigation, and government oversight. All health department participants expressed difficulty tracking COVID-19 cases and trends in correctional and detention facilities, particularly at the jail level, and none had systematic disease surveillance systems that included those facilities. Entering individual point-of-care test results was time-intensive for facility staff with competing responsibilities, particularly during mass testing events, limiting the data available to health departments. Most health departments relied on electronic laboratory reports, which required manual matching to addresses and provider names known to be associated with correctional and detention facilities.

Workforce Capacity

Criminal justice participants reported that the pandemic exacerbated staffing shortages because of family care needs, fear of contracting COVID-19 in a congregate setting, and strict quarantine and isolation policies. Many facilities offered additional paid leave to encourage staff to stay home when sick and to allow for family care needs, but some expressed that abuse of those policies had been a challenge.

Health department participants reported that facilities’ COVID-19 consultation requests exceeded their capacity, contributing to staff burnout. Although their health departments allocated staff to corrections-specific roles, those positions were funded through time-limited sources, such as the COVID-19 American Rescue Plan Act and health equity grants, and participants expressed concern about funding sustainability for correctional health work within their health departments.

Mental Health

All participants were concerned about mental health and low morale among incarcerated persons and staff because of COVID-related stress and trauma. In particular, participants mentioned that prolonged quarantine periods limited access to rehabilitative programming, visitation, and education for persons held in correctional and detention facilities, and they reported that this limited access sometimes led to increased suicide attempts and unrest. As mentioned, some facilities were eventually able to balance access to in-person services with disease prevention priorities through innovative testing approaches, where incarcerated persons exposed to COVID-19 were tested regularly and able to maintain in-person activities if they tested negative (test-to-program). Respondents stated that those approaches were only possible when they could consistently access rapid tests at low or no cost.

Partnerships and Communication

All participants reported that partnerships and communication were imperative for success in their pandemic response. Examples included providing frequent updates to staff and incarcerated persons about policy changes, having regular meetings with external partners (e.g., community-based organizations, courts, public health agencies), and offering one-on-one education to maximize COVID-19 vaccine uptake. Participants emphasized unprecedented cross-disciplinary collaboration between facility healthcare and custody staff, building trust and respect between 2 missions that can sometimes be perceived as conflicting. Some participants expressed concern that those relationships could weaken once COVID-19 was no longer the common enemy.

Before the pandemic, no participating health departments had staff dedicated specifically to correctional health. At the time of the interviews, however, each had assigned from 0.25 to 2 full-time employees to address COVID-19 in correctional settings or to support correctional health broadly. All health department participants felt that their relationships with facilities improved during the pandemic, noting that having corrections-specific public health staff built trust that could enable disease prevention in the future. However, public health responses to COVID-19 cases were sometimes limited by the strength of relationships with individual facilities and by concerns that providing tailored guidance could involve health departments in litigation.

Although critical to success, collaboration and communication were challenging, particularly with external groups, such as the media, families of incarcerated persons, courts, and community hospitals concerned about absorbing facility case surges. The continual evolution of COVID-19 science and policy, combined with politicization of the pandemic, made managing misinformation difficult. Participants stated that in future public health emergencies, expectations should be set early that guidance will shift as understanding of the threat improves, especially for a novel disease like COVID-19.

Participant Recommendations for Future Correctional Health Representation in Public Health

Although establishing productive collaborations and partnerships was one of the main challenges reported, most criminal justice participants also stated that their relationships with public health agencies improved during the pandemic, and some provided suggestions for actionable ways to expand and sustain them. Overall, participants believed that prioritizing and elevating correctional health within public health practice in future could reduce stigma that affects incarcerated persons and correctional staff. Specifically, criminal justice participants would like public health agencies at all levels of government to ensure that correctional health is represented within baseline strategy and operations, prioritize correctional and detention facilities when allocating resources, develop ways to track disease trends in correctional settings locally and nationally and share those data with the field, convene criminal justice partners to discuss shared health challenges, and disseminate information to the correctional health field early and consistently during public health emergencies. Participants believed that having a centralized point of contact and corrections-focused staff in public health agencies would support those needs.

In addition, participants cited corrections-specific public health guidance from CDC as a resource that supported their pandemic responses. However, many were frustrated that corrections-specific updates lagged behind guidance for other settings and that guidance was not written with front-line staff as an intended audience. Participants felt strongly that public health agencies should continue developing guidance and educational materials tailored for correctional settings and that such materials should include input from criminal justice partners and persons with lived experience of incarceration to improve their reach and relevance.