key: cord-0939243-v2l9e96l authors: Toblin, Robin L.; Hagan, Liesl M. title: COVID-19 Case and Mortality Rates in the Federal Bureau of Prisons date: 2021-02-25 journal: Am J Prev Med DOI: 10.1016/j.amepre.2021.01.019 sha: 06d18718f1774e05c0da346e1121c18bc52c5d5d doc_id: 939243 cord_uid: v2l9e96l Introduction People living in correctional facilities are at high risk for contracting the novel coronavirus disease 2019 (COVID-19). To characterize the burden of COVID-19 in the Federal Bureau of Prisons, inmate testing, case, and mortality rates are calculated and compared with the U.S. Methods Bureau of Prisons data were derived from its inmate management system and a Bureau of Prisons COVID-19–specific database. U.S. data were derived from the Centers for Disease Control and Prevention and the U.S. Census. Data were aggregated from February to September 2020 and accessed in September and November 2020. Testing rates were calculated for both the Bureau of Prisons and U.S. Case and infection fatality rates were calculated overall and by institution and compared with the U.S. An age- and sex-standardized mortality ratio was calculated. Results The Bureau of Prisons tested more than half of its inmates (50.3%); its crude case and mortality rates were 11,710.1 and 77.4 per 100,000, respectively. Compared with the U.S., the case ratio was 4.7 and the standardized mortality ratio was 2.6. The infection fatality rate for both the Bureau of Prisons and U.S. was 0.7%. Among institutions that tested ≥85% of inmates, the combined infection fatality rate was 0.8% and ranged from 0.0% to 3.0%. Conclusions The Bureau of Prisons COVID-19 case rates and standard mortality ratio were approximately 5 and 2.5 times those in U.S. adults, respectively, consistent with prisons nationwide. High testing rates and standardized death reporting could result in a more accurate infection fatality rate in the Bureau of Prisons than the U.S. Testing and other mitigation strategies, including reducing the population, have likely prevented further transmission and mortality in the Bureau of Prisons. People living in correctional facilities are at high risk for contracting the novel coronavirus disease 2019 (COVID-19), 1,2 but the risk for federal inmates has not been specifically examined. Prior to the pandemic, the Federal Bureau of Prisons (BOP) managed approximately 146,000 inmates in 122 institutions in 36 states, the District of Columbia, and Puerto Rico. To characterize the burden of COVID-19 in the BOP, inmate testing, case, and mortality rates are calculated and compared with the U.S. population. Data for the BOP population census, including age and sex distributions, were ascertained from the BOP's inmate management system, SENTRY, as of February 29, 2020, before BOP's first known COVID-19 cases. U.S. population data were ascertained from the U.S. Census. The COVID-19 case (laboratory-confirmed and probable) and testing data in the BOP and U.S. population (inclusive of BOP) were aggregated from February 29 through September 23, 2020 using a COVID-19-specific data set for BOP and Centers for Disease Control and Prevention (CDC) data, respectively. BOP deaths were also aggregated through September 23; CDC mortality data were aggregated through September 26 (the week including September 23). 3, 4 Data were accessed September 24, 2020 except for U.S. deaths, which were accessed November 25, 2020. BOP's IRB deemed this study as exempt. The BOP and U.S. COVID-19 testing rates were calculated to account for disease burden from asymptomatic cases and provide context for case rates. BOP testing rates were calculated overall and by institution as the proportion of inmates with a returned test. BOP tests inmates with signs and symptoms of COVID-19; close contacts of case patients; and upon intake, transfer, or release; some institutions have performed mass testing. 5 U.S. testing rates include multiple tests for some individuals; thus, the exact number of individuals tested is unknown. To compare crude case rates between BOP, which only houses adults, and the U.S., the proportion of case patients aged 0-17 years (8.4%) 3 were subtracted from U.S. case patients. The overall BOP infection fatality rate (IFR) was calculated as the number of deaths among COVID-19 case patients and was compared to a meta-analysis of the U.S. IFR that included children. 6 To account for BOP's asymptomatic cases, 5 the IFR was also calculated collectively and individually for institutions that tested >85% of inmates relative to its February 29, 2020 census. To account for substantial differences in age and sex distributions in the BOP and U.S adult populations (variables associated with differential COVID-19 mortality), an age-and sexadjusted standardized mortality ratio (SMR) was calculated by comparing BOP deaths to CDC COVID-19 mortality counts by age and sex 4 referenced against U.S. Census counts. Analyses were conducted in Excel 2016. Most BOP inmates were male (92.5%), U.S. citizens (87.5%), and young (3.7% were aged ≥65 years relative to 17.0% in the U.S.) with a greater proportion of racial/ethnic minorities compared with the U.S. ( Table 1 ). As of September 23, 50.3% of BOP inmates and 32.5% of the U.S. population (assuming 1 test per person) had been tested for COVID-19. The crude case rates for the BOP and U.S. adults were 11,710.1 and 2,484.4 cases per 100,000 people, respectively, a ratio of 4.7. The crude mortality rates were 77.4 and 80.5 per 100,000 people, a ratio of 1.0 (Appendix Table 1 ). The crude IFR for both the BOP and U.S. 6 was 0.7%. Deaths occurred in 23.8% of BOP institutions. Appendix Table 2 displays institution-specific COVID-19 cases and deaths for the 25 institutions that tested ≥85% of inmates relative to their February 29 census. These institutions represented 19.9% of the overall BOP population and had a case rate of 33,189.8 per 100,000 people, 2.8 times that of the overall BOP. For these institutions, the combined IFR was 0.8% (range=0.0%-3.0%, median=0.3%, IQR=0.0%-1.0%). Table 2 presents age-and sex-specific SMRs for BOP. BOP inmates were 2.6 times as likely to die from COVID-19 as U.S. adults (male SMR=2.5, female SMR=4.6). These findings update and augment an earlier study that presented aggregated COVID-19 cases and deaths in state and federal prisons 2 ; this study uses more recent federal data and includes testing data, IFRs, and institution-specific information. The high BOP case rate relative to U.S. adults may be attributed to close contact within congregate living environments, combined with numerous opportunities for COVID-19 introduction from staff with community-acquired infections, new intakes from other jurisdictions, and inmates with hospital-acquired infections. 1 BOP's high testing rate (>50%) may also contribute to the high case rate. 5 Testing as a mitigation strategy has allowed BOP to identify and isolate cases, and quarantine their close contacts as recommended by CDC, 7 likely preventing further transmission and mortality. At 0.7%, the overall BOP IFR is the same as in the U.S. 6 The IFR among BOP institutions with the highest testing rates (i.e., ≥85%) was 0.8%. BOP's higher testing rate overall, and especially in these institutions, may account for more asymptomatic cases than U.S. testing, potentially resulting in a more accurate estimate of total infections compared with the U.S. In addition, BOP's standardized death reporting system likely results in less under-reporting of COVID-19related deaths compared with U.S. mortality systems that are not standardized. 8 Both of these factors could result in a higher degree of accuracy in the BOP IFR compared with the U.S. IFR. After adjusting for age and sex differences, the overall BOP SMR of 2.6 is consistent with a previous study of prisons nationwide. 2 All female deaths but one occurred during an outbreak in a single institution housing female inmates with medical comorbidities, potentially contributing to the higher female-specific SMR; the small numbers make interpretation challenging. Higher age-and sex-adjusted mortality from COVID-19 in BOP likely reflects the high rates of underlying health conditions, especially at younger ages, 1 which increase the risk of severe illness from COVID-19. One way BOP addressed this was by decreasing its population by 13.4% through reduced intakes and releases to the community, residential re-entry centers, and home confinement to protect inmates at highest risk for COVID-19 if deemed to be a low risk to public safety. This study has 4 limitations. First, institution-specific testing rates relied on pre-pandemic censuses, although censuses shifted throughout the pandemic owing to releases and inmate movement to reduce institution density. Second, tests given to inmates in hospitals were excluded. Third, U.S. testing rates and the IFR include children. Taken together, these measurement biases could underestimate BOP testing rates (and overestimate BOP's IFR) and overestimate U.S. adult testing rates (and underestimate the U.S. adult IFR). Fourth, the calculation of BOP's SMR did not control for the high rates of underlying health conditions or racial and ethnic differences in correctional populations relative to the U.S., 1 which are associated with differential COVID-19 mortality. The COVID-19 case rates and SMR for federal inmates were approximately 5 and 2.5 times those in U.S. adults, respectively, consistent with prisons nationwide. 2 and Christopher Bina, Jeffery Allen, Michael Long, and TeCora Ballom, all in BOP HSD, for their comments on previous drafts. The research presented in this paper is that of the authors and does not reflect the official policy of the BOP or Department of Justice. The paper was reviewed by the BOP IRB. No conflicts of interest or financial disclosures were reported by the authors of this paper. The work was conducted as part of the authors' duties on temporary duty to BOP. Author contributions are as follows: conceptualization, methodology, data curation, writingoriginal draft preparation, writing-reviewing and editing (RLT); writing-reviewing and editing (LMH). COVID-19 and the correctional environment: the American prison as a focal point for public health COVID-19 cases and deaths in federal and state prisons CDC. Coronavirus disease 2019 (COVID-19): CDC COVID Data Tracker Provisional death counts for coronavirus disease 2019 (COVID-19): weekly updates by select demographic and geographic characteristics Mass testing for SARS-CoV-2 in 16 prisons and jails -six jurisdictions A systematic review and meta-analysis of published research data on COVID-19 infection fatality rates COVID-19) in correctional and detention facilities Excess deaths from COVID-19 and other causes Derived by dividing the total number in the -citizen, 18 and over population‖ table by the total number in the -18 years and over‖ section within the age-and sex-stratified tables of the total U.S. population. d Census data included an option for 2 or more races, whereas BOP did not, so the U.S. data do not total to 100%.BOP, Federal Bureau of Prisons.