Increasing Availability of COVID-19 Vaccine to Older Adults Under Community Supervision

Abstract

Design/methodology/approach.

This is a Viewpoint paper regarding mitigating the spread of COVID-19 by improving access to vaccine and boosters among community supervised adults, especially the aging population.

Purpose.

Vaccinating adults who are involved with the carceral system, particularly those aged 55 or older, is crucial to containing the COVID-19 pandemic in the United States, particularly as variants continue to emerge and spread. In this Viewpoint, we discuss the reasons why improving access to COVID-19 vaccine and boosters among community supervised adults, especially the aging population, is critical to mitigating the public health consequences of the COVID-19 pandemic. We conclude by providing recommendations to enhance vaccine and booster uptake in this population, as the pandemic continues.

Findings.

A key population that has been overlooked in vaccination efforts are older adults involved in the carceral system who are living in the community (i.e., “community supervised” or people on probation or parole). Older adults on probation and parole are at high risk for SARS-CoV-2 transmission and severe disease due to numerous factors at the individual, community, social, and structural levels.

Individuals involved in the carceral system have been at the epicenter of the COVID-19 pandemic in the United States (US). As of September 2022, there have been 622,494 COVID-19 cases among people incarcerated in prisons, resulting in the deaths of >2,900 people (The COVID Prison Project, 2022a). Despite this grim reality, efforts to improve access to vaccines and boosters for adults involved in the carceral system is limited in scale. Thirty states have reported vaccinating individuals involved in the carceral system, however, the scope of vaccine distribution efforts has waned and been limited to people incarcerated in detention settings (The COVID Prison Project, 2022b). Systematic efforts omit individuals on probation and parole; a population representing ~74% of people involved in the carceral system (Pew Charitable Trusts, 2021), totaling nearly 4.4 million (or 1 in 58) American adults (Kaeble, 2020). A growing segment of this population, those aged 55 years or older (Wildeman et al., 2019), continue to be at an increased risk of serious illness, hospitalization, and mortality due to COVID-19 and should be targeted for on-going vaccination and booster efforts. In this Viewpoint we discuss the reasons why prioritizing adults involved in the carceral system who are living in the community (i.e., “community supervised” or people on probation or parole), particularly older adults, is critical to containing the COVID-19 pandemic. We conclude by providing recommendations designed to enhance access to and uptake of vaccine booster shots in this population.

People on probation and parole are at high risk for SARS-CoV-2 transmission and severe disease. This is particularly notable for older adults who experience high rates of two or more chronic medical diseases (“medical multimorbidity”), a high prevalence of geriatric conditions (e.g., functional and cognitive impairments), mental illness, and substance use disorders, and an increased risk of complications due to COVID-19 if infected (Greene et al., 2018, Knapp et al., 2019, Winkelman et al., 2020, Dumont et al., 2012, Centers for Disease Control and Prevention, 2021a, Crouse Quinn et al., 2017). In general, older adults experience unique challenges that contribute to poor engagement in healthcare (including during periods of detention) including provider satisfaction, lack of provider responsiveness to health concerns, difficulties in coordinating care for multimorbidities, inadequate health literacy (e.g., reading, interpreting, and understanding written information), and, for community-based care, more tangible barriers like cost and transportation (MacLeod et al., 2017, Fitzpatrick et al., 2004, Janes et al., 1999). Individuals under community supervision also frequently live in profoundly disadvantaged neighborhoods, in institutional settings (e.g., transitional housing), and/or experience homelessness (Simes, 2019), all of which independently confer increased risk of COVID-19 transmission (Tobolowsky et al., 2020). People under community supervision are also predominantly from racial and ethnic minority groups; populations that are disproportionately affected by COVID-19 (Millett et al., 2020, Price-Haywood et al., 2020).

Providing older adults in community corrections with tailored public health messaging and outreach from trusted sources will work towards addressing disparities in vaccine acceptance and completion. Institutional distrust, including medical mistrust, is elevated among people involved with the carceral system due to the dehumanization and mistreatment they experience during detainment and interactions with the police or other agents of the system (e.g., probation officers) (Peterson et al., 2019, Vandergrift and Christopher, 2021). Carceral mistrust is often generalized to other societal institutions, including health care settings, which are becoming increasingly “policed”(Brayne, 2017, Lara-Millan, 2014). Among older adults, trust is also a barrier to care engagement, and importantly, vaccine uptake. In a survey of adults aged ≥ 50 years conducted by the AARP, distrust in the government was cited as a key factor among individuals who reported they were unlikely to get the COVID-19 vaccine (McSpadden, 2021). There are also racial and ethnic disparities in healthcare system trust among older adults: Black and Hispanic older adults express lower levels of trust in the healthcare system than their White counterparts (Guerrero et al., 2015). These experiences and perceptions, combined with centuries of medical abuses (Nephew, 2021) can lead to vaccine “hesitancy” among racial and ethnic minority groups and marginalized populations.

Compared with White Americans, racial and ethnic minority groups experience a higher risk for COVID-19 (The COVID-19 Health Equity Interactive Dashboard, 2022). Racial and ethnic disparities in vaccine uptake evident at the beginning of the pandemic have narrowed and even reversed for Hispanic adults (Kaiser Family Foundation, 2021, Ferdinand et al., 2020, Ndugga, 2022). While this narrowing may demonstrate more equitable vaccine coverage nationally, recent data suggest that booster and second booster coverage rates are lower among non-Hispanic Black or African American, Hispanic or Latino, and multiracial persons(Fast et al., 2022). Roughly 43% of eligible Black adults have received a first booster dose and 28.1% have received a second booster dose as compared to ~55% and ~37% of eligible White adults, respectively. First and second booster uptake is even lower for Hispanic Americans (37% uptake of the first booster and 24% receiving a second booster). As the pandemic continues, the number and type of COVID-19 vaccine booster options will expand, as will recommendations related to booster shots. Innovative strategies to address vaccine hesitancy (e.g., leveraging trusted sources of information and communication channels) and increase vaccine uptake equitably (e.g., via mobile health outreach, drive through vaccination) that were implemented early in the pandemic have been replaced with more traditional approaches to address vaccine education and access. For example, current booster dissemination strategies include leveraging pharmacies and health centers and less resources than at the start of the pandemic have been dedicated to addressing hesitancy that may persist in these groups (Centers for Disease Control and Prevention, 2022, Centers for Disease Control and Prevention, 2021d, Dada et al., 2022). To maintain equitable gains in initial vaccine uptake, there needs to be a sustained effort to funnel resources and implement dissemination strategies to disenfranchised groups, including older adults from racial and ethnic minority groups; many of whom are supervised by the carceral system.

Enhancing vaccine access for adults under community supervision can also help address logistical barriers to vaccine and booster completion for people recently released from detention settings. Accessing the second vaccine and or booster shots for individuals who have received some vaccine during their detention can be blocked through limited computer and/or internet access, and many states require a functioning e-mail account in addition to time to search for appointments, and travel to vaccine distribution centers. Moreover, people who are incarcerated may postpone vaccination until they are in the community because they do not trust the clinical operations at the prison or jail where they are incarcerated. For older adults in particular, lack access to a social support network that may be able to offer assistance to vaccine distribution sites, administrative barriers (e.g., access to recent photo identification), and reduced mobility may further complicate vaccine uptake (Centers for Disease Control and Prevention, 2021c). Vaccination initiation and completion will need to be juggled with a myriad of other competing priorities necessary during re-entry, such as finding food, medical appointments, and shelter (Dong et al., 2018b, Dong et al., 2018a). Steps taken to co-locate vaccination with other post-release services frequently accessed by the population will facilitate vaccine uptake and completion, bolstering public health-focused COVID-19 mitigation efforts.

Improving vaccine access among older adults on community supervision provides a second layer of assurance that people interacting with institutions at high risk for outbreaks are protected. Adults supervised in the community have frequent contact with jails and prisons (Alper, 2018): in 2017, 45% of prison admissions were due to violations of probation or parole (The Council of State Governments, 2019). In addition, adults involved in the carceral system have high rates of homelessness and housing insecurity (California Health Policy Strategies L.L.C., 2019, Couloute, 2018) and frequently cycle through high density emergency public services (e.g., transitional housing, substance use treatment facilities), and living settings (e.g., homeless encampments, residential communities for older adults) (Rountree, 2019). These sites are at elevated risk for outbreaks because of built environment characteristics like crowding, lack of access to hygiene supplies, or shared hygiene facilities (Rogers et al., 2020, Tsai and Wilson, 2020). The rapid spread of COVID-19 between these settings resembles a potential network of “revolving doors” of SARS-CoV-2 transmission that we should endeavor to interrupt.

Lastly, augmenting access to COVID-19 vaccines among community supervised older adults will provide an opportunity to expand protection in geographic areas that are disproportionately affected by COVID-19. Mirroring patterns evident in other health conditions (e.g., HIV, cancer) (Ransome et al., 2016, Fang and Tseng, 2018), COVID-19 cases and deaths are concentrated in geographic areas with a higher proportion of Black and Hispanic residents (Millett et al., 2020). For example, the roughly 20% of counties in the US that are disproportionately Black (i.e., have a higher proportion of Black residents compared to the national average) accounted for over half of COVID-19 diagnoses and 58% of COVID-19 related deaths (Millett et al., 2020). Individuals involved in the carceral system inhabit communities that are characterized by social, structural, and material disadvantage (e.g., low socioeconomic status, high rates of incarceration, poor access to health services) that elevate individual risk for COVID-19 (Hooks, 2020, Simes, 2019, Warner, 2016). Federal (Centers for Disease Control and Prevention, 2021b) and state-level vaccine programs (California Department of Public Health, 2021) initiated early on in the pandemic employed an equitable approach to vaccine distribution in which vaccine was strategically increased in communities disproportionately affected by COVID-19 infections, hospitalizations, and deaths (by boosting vaccine allotment to Federally Qualified Health Centers or providing vaccine sign-up assistance, for example). Extending such programs to support booster access and uptake specifically to reach older adults under community supervision is a feasible approach that has the potential to broaden the community benefit.

While individuals involved in the carceral system are not explicitly mentioned, prioritizing this population aligns with the goal’s laid out in the Biden Administration’s plan to get Americans updated COVID-19 vaccine (The White House, 2022). As such, we propose the following recommendations to improve access to COVID-19 vaccine and boosters among this population of community supervised older adults:

1. Provide information on COVID-19 vaccines, vaccination, and boosters in community supervision settings in accessible formats (e.g., meeting necessary requirements of the Plain Language Ace, Americans with Disabilities Act) that leverage a range of media channels that minimize reliance on computers and internet access (e.g., newspaper, radio).

2. Coordinate with community supervision sites to offer COVID-19 vaccine and booster service referral systematically, alongside other referrals typically offered for older adults in these settings including disability, housing, employment, and substance use treatment services.

   1. Augment referral processes with support programs to aid members of this group get to vaccine distribution centers (e.g., transportation assistance, reserved appointment slots for older adults).

3. Utilize models in community supervision settings and processes that have demonstrated efficacy in building trust and reducing discrimination-related barriers to healthcare engagement for older adults, members of racial and ethnic minority groups, and individuals involved in the carceral system, like patient navigation and community health workers (Tobias et al., 2010, Morgan et al., 2015, Myers et al., 2018, Kennedy et al., 2021), to provide COVID-19 vaccine information and distribute vaccine and boosters to this group.

4. Fund a system to notify community supervision sites about the need to orchestrate COVID-19 vaccine and booster service linkage for folks re-entering the community from detention settings, including specific alert systems noting whether individuals fit eligibility criteria for boosters based on their age.

Implementation of these recommendations will continue to mitigate COVID-19 risk among a population that has been marginalized and overlooked yet has been the epicenter of the COVID-19 pandemic.