People in carceral settings have been disproportionately affected by COVID-19 in terms of the sheer volume of cases, hospitalizations, and deaths.1,2 Evidence-based strategies to mitigate the risk of viral transmission, including masking, testing, and disinfecting, were slowly and unevenly implemented across prisons, compounding inherent risks associated with overcrowded conditions in congregate settings. In the absence of well-deployed infection prevention measures, the COVID-19 pandemic revealed a pressing need for vaccinating prison staff to: (1) reduce staff morbidity and mortality; (2) reduce staff absenteeism because of isolation/quarantine that can disrupt facility operations; and (3) reduce onward transmission to the vulnerable residents of facilities and the communities where staff live. To date, few carceral systems have provided transparent comprehensive data on staff vaccination that would answer the following question: how successfully has vaccination rolled out among prison staff who interface with residents? This type of data is needed to identify gaps and inform the next stages of vaccine implementation.
In this issue of JAMA Health Forum, Prince et al3 address these challenging questions, using data on staff vaccination from across the California prison system, which is one of the largest state prison populations in the country. This cohort study included 31 089 custody and health care staff across 33 prisons run by the California Department of Corrections and Rehabilitation (CDCR). Using daily data extracts from December 22, 2020 (the first day vaccination was offered and recorded), through June 30, 2021, the analysis evaluated trends in vaccination uptake over time; individual-level, shift-level, and home zip code–level characteristics associated with remaining unvaccinated by the end of observation; and potential association with incident COVID-19 cases among residents during the subsequent 3 months (through September 25, 2021). The comprehensive nature of the data set, transparency of the CDCR in sharing it, and in-depth analysis are uncommon and representative of the types of partnerships and data-driven information needed to make effective policy decisions for carceral settings.
Among the key findings, 61% of custody staff and 37% of health care staff remained unvaccinated at the end of the observation period despite an initial surge of early adopters, leading to a plateau, which has been observed elsewhere.4 In CDCR prisons, staff who remained unvaccinated were younger than their vaccinated peers and were more likely to have had a prior COVID-19 infection, perhaps because of beliefs that “natural” immunity was sufficiently protective. They were also more likely to be surrounded by other people who were unvaccinated at work and home; therefore, they were at higher risk of being exposed to and potentially transmitting the virus onwards. The authors indicate demographic, community, and peer factors toward vaccine hesitancy, although other unmeasured factors may have affected vaccination decisions, including experiencing a COVID-19 death in one’s social/professional network and vaccine stigma. The authors describe 2 types of interventions to promote vaccinations: mandates and delivery of staff vaccination in the workplace that acknowledges peer influence. In this article, we discuss challenges to these approaches and our support for facility-level and structural interventions that better integrate prisons into statewide public health infrastructure.
Even the best-informed individual-level interventions to improve vaccination uptake are likely to have a modest effect across a large statewide system. It may then be tempting to solve the problem of the vaccination gap in prisons by imposing system-wide mandates for staff. Certainly, vaccine mandates effectively increase vaccination rates in other settings, but few prison staff qualify for the national vaccine requirements included in the Biden administration’s “Path Out of the Pandemic” COVID-19 Action Plan, which were just blocked by the US Supreme Court.5 Since Prince et al3 conducted their analysis, vaccine mandates have been issued for health care staff in CDCR prisons,6 but those for custody staff were appealed after workers threatened a massive walkout.7 Thus, vaccine mandates for non–health care workers are subject to red tape, bureaucracy, and litigation that often make them difficult to implement and enforce.
In lieu of legally enforceable staff vaccine mandates, facility-level interventions are important for increasing vaccination uptake among staff. Prince et al3 noted important variations among the 33 prisons they studied, with the proportion of unvaccinated custody staff ranging from 34% to 86%. Although organizational-level data were not available in the analysis, this wide variation likely reflects heterogeneity in how rapidly and effectively the pandemic preparedness plans of facilities were updated and implemented to address the surge of the COVID-19 pandemic (and accompanying “infodemic” of misinformation about COVID-19 vaccines). Differences in COVID-19 vaccination rates are, in turn, likely associated with differences in facility management and culture.
To meet the moment presented by the COVID-19 public health crisis and vaccinate prison staff, prisons need policies that are not only based on scientific evidence, but also are meaningful to the culture of the place, respond to emerging data, and are fully implemented. Correctional leadership often rely on top-down management systems that fail to incorporate user perspectives, but vaccination campaigns for carceral settings represent opportunities to include staff and incarcerated people in decision-making. Peer effects should be considered when delivering staff vaccination, but rather than encouraging staff to be vaccinated in private, as Prince et al suggest,3 elevating the perspectives of vaccinated trusted messengers within staff ranks would leverage positive peer pressure and social desirability to increase vaccination.
As part of the RADx-UP initiative,8 we are evaluating experiences of COVID-19 testing and vaccination through in-depth qualitative interviews with correctional staff and incarcerated people in prisons and jails across geographically diverse US settings. Their testimonies illuminate potential intervention strategies moving forward. Incarcerated people and correctional staff who saw themselves as in it together and dependent on others in the facility for their health and well-being were more likely to express positive attitudes toward vaccination. Instilling the perspective of unity is an important priority during and beyond this public health crisis. Some correctional leaders have implemented policies that incentivized vaccination through financial compensation or testing and sick time policies that offered advantages to those who were vaccinated. Correctional leaders must prioritize the health and safety of staff by advocating for staff vaccinations at the facility level because, as the data from Prince et al3 show, increased staff vaccinations are associated with reduced resident infections and improved health of the facility overall.
Prince et al3 demonstrate shortcomings in vaccination uptake among prison staff that were associated with negative health outcomes among a highly vulnerable population of incarcerated people. Their findings call for a multilevel campaign to increase vaccination of prison staff and correspondingly decrease the spread of COVID-19. Ultimately, organizational leadership is necessary but insufficient for vaccination rollout because prisons are often siloed from critical public health infrastructure. Departments of health and related local government offices should take a more active and intentional role about releasing guidance and updates that specifically target carceral settings and integrate prison facility administrators into related planning. Long-standing biases hold that prisons are distinct from community settings or unworthy of attention. Yet prisons, and those who live and work in them, remain a critical element of our communities and key to ending the COVID-19 public health crisis.
Published: March 11, 2022. doi:10.1001/jamahealthforum.2022.0107
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Meyer JP et al. JAMA Health Forum.
Corresponding Author: Jaimie P. Meyer, MD, MS, AIDS Program, Section of Infectious Diseases, Yale University School of Medicine, 135 College St, Ste 323, New Haven, CT 06510 (email@example.com).
Conflict of Interest Disclosures: Dr Meyer, Mr King, and Ms Rosenberg reported grants from the National Institutes of Health/National Institute on Drug Abuse (UG1 DA050072) as part of the RADx-UP initiative during the writing of this article.
Meyer JP, King J, Rosenberg A. Meeting the Moment by Vaccinating Prison Staff Against COVID-19. JAMA Health Forum. 2022;3(3):e220107. doi:10.1001/jamahealthforum.2022.0107
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