Prison Breakout ... of the Delta Variant

The headline comes from a report based upon the latest CDC Morbidity and Mortality Weekly Report, specifically on an outbreak of the Delta variant in a federal prison in Texas in August. There was an initial outbreak of 18 cases in two interconnected prison units, which houses 233 people. Once recognized, direct contacts were quarantined and the infected isolated. When all was said and done, 74% of the inmates were infected (based upon rapid and PCR testing). Here are the most reported facts:

• 93% of the unvaccinated (39 of 42) were infected. 70% of the vaccinated (129 of 185). "Vaccinated" was defined as 14 days or more since being completely vaccinated.
• In the 58 cases that underwent genomic sequencing, all were from the same Delta variant.
• The protection provided by the vaccine waned over time. Infections were found in 89% of those vaccinated more than four months previously and 61% in those vaccinated in the last two months.
• Consistent with the recent Israeli data, vaccination after initial COVID infection (5% infected) was more protective than vaccination alone (57% infected).
• Four individuals were hospitalized, 3 of whom were unvaccinated. One unvaccinated inmate died.

Given this information, it is relatively easy to establish the narrative. The vaccination is not fully protective against the Delta variant, and its protection wanes with time. Vaccination continues to protect us from hospitalization and death. Vaccination after a COVID infection is more robust.

The rest of the story

For me, the elephantine question in the room is, what was the source of infection, and how did it spread so rapidly through this very controlled environment. I ask this because, as I have written previously, nursing homes, prisons, and to a lesser degree, schools share many environmental factors in common. So here are some other facts from the same CDC report to consider.

The interconnected units co-mingled until the outbreak was identified and then separated into the infected and well. Before that time, the following protocol was in place for the inmates:

• Mandatory masks in common areas
• Voluntary vaccination
• Prompt medical isolation and quarantine of test-positive individuals
• Head-to-toe sleeping arrangements, with 2 to 10 prisoners per cell.
• Hard plastic barriers to prevent physical contact of prisoners with visitors
• Free soap and encouragement to wash hands as well as individual bottles of disinfectant for prisoner’s use in their “personal space.”
• Regular disinfection of common areas and high-touch surfaces

For the staff, the protocols included;

• Voluntary vaccination
• Completion of temperature checks and COVID questions upon beginning their work shift
• Use of masks

Voluntary vaccinations

There are several interesting nuggets here. First, the Bureau of Prisons (BOP), in conjunction with the CDC, prioritized staff vaccinations over inmates, but it was widely and freely available to both groups. 79% of the inmates choose vaccination. A careful review of the demographics demonstrates an increasing vaccination rate with age, 93% of those over 60 and 67% between 18 to 30. Black, non-Hispanic inmates, was the lowest at 64%, while White, non-Hispanic the highest at 87%. When considering medical conditions, smokers and inmates with diabetes or obesity were more frequently vaccinated. The vaccination rate among the staff was 33%. [1] And before anyone says that is because the prison is in Texas, whose state motto is “Friendship,” not as you might expect “Remember the Alamo,” this vaccination rate among BOP staff is pretty consistent with other federal prisons in different geographies, which is nationally 51%.

Where is the weak link?

COVID-19’s Delta variant did not arise spontaneously in prison; someone brought it in. It might have been a prisoner transfer. I tried unsuccessfully to identify a number of transfers, but, it is certainly not high. It might have been from a prison visitation; again, we have no numerical information. Or the staff, like the staff at the nursing homes, might have brought the virus in from home. The positivity rate for testing in the counties surrounding this federal prison was 17.8%; nearly 1 in 5 individuals tested for COVID were confirmed. According to the CDC’s definition this is classified as high. Three percent of the staff was COVID positive on testing. But the reason that COVID spreads so easily is that it is largely transmitted by asymptomatic individuals.

Do any of you believe that checking temperature and attesting to a lack of COVID symptoms is a valuable screening tool, or do you feel, as I do, that it is a form of protection theater, like removing our belts at TSA? I believe that the low vaccination rate among the staff, coupled with the high infection rate in the community, resulted in the first of the weak links: the staff brought the Delta variant into the prison.

The “environmental factors” offer some other weak links. While our surroundings should be clean, disinfection didn’t seem to slow the spread of COVID. More and more, we understand that the disease is transmitted through the air, not from surfaces – “deep” cleaning is, in my view, more protection theater.

Masks were insufficient without social distancing. There was no requirement to maintain a 6-foot distance in prison; that is impractical, I get it. Moreover, head-to-toe sleeping is theoretically beneficial, but inmates were more crowded within their cells, and the mask requirement was not in effect. What is the efficacy of those plastic barriers? I believe that masks, social distancing, and plastic barriers can be helpful, but their value is far less than the protection conferred by vaccination. I do not believe that wearing a mask and maintaining “a perimeter” is even close to an equivalent substitution for vaccination.

Here is what I thought was new in the CDC report. Non-pharmaceutical interventions are nowhere as effective as vaccination. More importantly, for closed systems, like nursing homes or prisons, and to lesser degree schools, significant gaps in vaccination by the staff, guards, or teachers put the captive population of elderly, prisoners, or students at heightened risk. It is easier to see a cause and effect in nursing homes, where the degree of frailty and age means far more hospitalizations and deaths than we see in prisons or schools. But the moral and public health imperative, to protect those you have volunteered through your employment to care for, overweighs any objection, other than an actual medical contraindication you might have to being vaccinated. You have a right not to be vaccinated; you also can find other employment.

[1] Unions representing correctional officers are filing for relief from mandatory vaccination in Massachusetts and Pennsylvania, among other states. An earlier survey shows few interested in vaccination at all.