Abstract
We report on data we collected from a 2018 survey examining jails’ human papillomavirus virus vaccine delivery capacity and on a secondary analysis we conducted to describe factors similarly associated with delivery planning for the COVID-19 vaccine. We provide recommendations for delivering the COVID-19 vaccine in jails, based on evidence from Kansas, Iowa, Nebraska, and Missouri. Our key finding is that jails have limited staff to implement vaccination and will require collaboration between jail administrators, jail medical staff, and local health departments.
With the approval of COVID-19 vaccines for emergency use and expanded availability, many Americans are now being vaccinated. As congregate living settings, jails and prisons have been prioritized for early vaccine receipt in many states, with 37 US states and territories prioritizing incarcerated persons for phases 1 and 2 vaccine distribution.1
Thirteen million people pass through jails in the United States each year.2 Jails hold the largest population of those under criminal legal supervision in the United States. These detention centers are also unique in their community embeddedness: they exist in almost every US county. Most people leave jails days or weeks after initial incarceration. Thus, “churning” from detention centers to communities exacerbates COVID-19 spread and amplifies the need for effective jail-based COVID-19 vaccine delivery.3 Indeed, 80% of the largest COVID-19 outbreaks in the United States have been linked to detention centers. Thousands of correctional employees move between their workplace and community homes daily, potentially passing COVID-19 from communities into jails and back.3
Bringing the COVID-19 vaccine to detention settings is critical, but challenges to doing so exist, including lack of local political will, resources, vaccine storage, supply, and county staffing. Detention centers are not well practiced in vaccine delivery. A recent review of domestic and international studies showed that incarcerated persons are underimmunized.4 Vaccine programs, such as those executed during influenza outbreaks, have been variable and limited in reach. Public health entities face substantial challenges when planning for COVID-19 vaccine delivery in jails.3
INTERVENTION
We provide public health planners and jails with a just-in-time snapshot of the infrastructure of, barriers to, and opportunities for COVID-19 vaccine delivery, drawing on data and our shared expertise as jail health researchers and administrators, and state and regional health planners.
PLACE AND TIME
Between November 2017 and October 2018, 192 of 347 invited administrators of local jails in Kansas, Iowa, Nebraska, and Missouri responded to a survey about correctional and public health capacity to deliver human papillomavirus virus (HPV) vaccine in local jails (55% response).
PERSON
All jails were located in a county with a geographically associated health department.5 The majority were in rural areas (70%). We designed survey items to correspond to consolidated framework for implementation research domains,6 yielding information for vaccine program implementation.
PURPOSE
Our goal was to provide recommendations for COVID-19 vaccine delivery in jails, extrapolating from data we previously collected with jail administrators to deliver HPV vaccine. We found that half of incarcerated persons report being willing to get a vaccine in jail.7
IMPLEMENTATION
Because of the COVID-19 pandemic, the rapid spread of disease in detention settings, and vaccine availability, we conducted a secondary data analysis to repurpose the parent study and offer timely recommendations for COVID-19 vaccine delivery. To provide recommendations for how jails can deliver the COVID-19 vaccine, we analyzed data on facility capacity and operational factors related to vaccine program coordination. Although capacity data are broadly applicable to COVID-19 vaccine planning, we designed operational questions specifically with an HPV vaccine program in mind.
EVALUATION
These data provide some broadly applicable challenges and opportunities pertinent to COVID-19 vaccine delivery.
Capacity for Vaccine Delivery
Administrators reported an average of 20 beds for females (range = 0–180) and 84 beds for males (range = 0–1250). Licensed practical nurses were the most common health care provider onsite (mean = 9 days), followed by registered nurses (mean = 7 days; Table 1). Clinicians were available at the jail more days in urban jails than in rural jails (P = .001; Table 2). Medical care was provided by corporations (38%), partnerships with health systems (22%), local providers hired by the jail (18%), and other arrangements (22%). When looking at state differences on selected variables, only Missouri had more jail health care run by a medical care corporation than other states (54% in Missouri, compared with 15% in Iowa, 35% in Kansas, and 33% in Nebraska; P = .004). Most jails (72%) dispensed medicines to incarcerated persons on a cart brought to each housing unit. Only 10% of jails reported providing the influenza vaccine, with urban jails more likely to offer vaccine (P < .001).
TABLE 1—
Jail Characteristics and Vaccine Challenges and Opportunities: Kansas, Iowa, Nebraska, Missouri; November 2017–October 2018
| Variable | Total (n = 192), No. (Range) or (%) | Iowa (n = 26), No. (Range) or (%) | Kansas (n = 70), No. (Range) or (%) | Missouri (n = 58), No. (range) or (%) | Nebraska (n = 38), No. (Range) or (%) |
| Providers available, d/mo | |||||
| MD and APP | 4.0 (0–30) | 2.0 | 5.0 | 3.5 | 3.5 |
| RN | 7.0 (0–30) | 6.5 | 9.0 | 5.5 | 6.0 |
| LPN | 9.0 (0–30) | 2.5 | 8.5 | 13.0 | 8.0 |
| Exam rooms available | 101 (53.4) | 10 (40.0) | 38 (55.1) | 34 (59.7) | 19 (50.0) |
| Entity providing medical care | |||||
| Medical care corporation | 71 (37.8) | 4 (15.4) | 24 (34.8) | 31 (54.4) | 12 (33.3) |
| Partnership with health system | 42 (22.3) | 9 (34.6) | 17 (24.6) | 5 (8.8) | 11 (30.6) |
| Local provider hired by jail | 33 (17.6) | 3 (11.5) | 14 (20.3) | 7 (12.3) | 9 (25.0) |
| Other | 42 (22.3) | 10 (38.5) | 14 (20.3) | 14 (24.6) | 4 (11.1) |
| Ability to bill third parties | 51 (34.2) | 4 (21.1) | 25 (47.2) | 11 (23.9) | 11 (35.5) |
| Coordination of vaccine programa | |||||
| Warden | 81 (50.6) | 14 (63.6) | 31 (52.5) | 20 (40.8) | 16 (53.3) |
| Jail medical staff | 47 (29.4) | 4 (18.2) | 18 (30.5) | 17 (34.7) | 8 (26.7) |
| No one | 14 (8.8) | 2 (9.1) | 6 (10.2) | 5 (10.2) | 1 (3.3) |
| Don’t know | 18 (11.3) | 2 (9.1) | 4 (6.8) | 7 (14.3) | 5 (16.7) |
| Challenges to providing vaccinesa | |||||
| Cost | 126 (65.6) | 16 (61.5) | 45 (64.3) | 42 (72.4) | 23 (60.5) |
| Medical staffing available | 90 (46.9) | 13 (50.0) | 29 (41.4) | 33 (56.9) | 15 (39.5) |
| Not a priority | 39 (20.3) | 7 (26.9) | 14 (20.0) | 14 (24.1) | 4 (10.5) |
| Not our responsibility | 67 (34.9) | 8 (30.8) | 25 (35.7) | 21 (36.2) | 13 (34.2) |
| Short length of stays for incarcerated persons | 118 (61.5) | 16 (61.5) | 41 (58.6) | 38 (65.5) | 23 (60.5) |
| Any security concerns about offering vaccinea | 100 (52.1) | 15 (57.7) | 40 (57.1) | 29 (50.0) | 16 (42.1) |
| Who would administer vaccinea | |||||
| Jail medical staff | 87 (45.3) | 7 (26.9) | 34 (48.6) | 32 (55.2) | 14 (36.8) |
| Local health department | 84 (43.8) | 12 (46.2) | 28 (40.0) | 27 (46.6) | 17 (44.7) |
| Don’t know | 19 (9.9) | 4 (15.4) | 6 (8.6) | 6 (10.3) | 3 (7.9) |
| Who would pay for vaccinea | |||||
| Local health department | 47 (24.5) | 8 (30.8) | 19 (27.1) | 15 (25.9) | 5 (13.2) |
| Jail health budget | 32 (16.7) | 8 (30.8) | 9 (12.9) | 8 (13.8) | 7 (18.4) |
| Incarcerated person/incarcerated person insurance | 104 (54.2) | 17 (65.4) | 33 (47.1) | 38 (65.5) | 16 (42.1) |
| Don’t know | 49 (25.5) | 5 (19.2) | 19 (27.1) | 13 (22.4) | 12 (31.6) |
| Staffing needs for vaccinea | |||||
| Correctional officers available to escort/guard health department staff | 130 (67.7) | 18 (69.2) | 49 (70.0) | 38 (65.5) | 25 (65.8) |
| Jail medical staff supervision/coordination | 72 (37.5) | 9 (34.6) | 28 (40.0) | 21 (36.2) | 14 (36.8) |
| Don’t know | 32 (16.7) | 6 (23.1) | 11 (15.7) | 9 (15.5) | 6 (15.8) |
Note. APP = advanced practice provider (general nurse practitioner and physician assistant); LPN = licensed practical nurse; MD = medical doctor; RN = registered nurse.
Specifically asked for human papillomavirus vaccine.
TABLE 2—
Comparing Selected Variables by Rural Versus Urban Jails: Kansas, Iowa, Nebraska, Missouri; November 2017–October 2018
| Variable (n = 185) | Rural (n = 130), No. (range) or (%) | Urban (n = 55), No. (range) or (%) | P |
| No. of days physicians or nurses on sitea | 4.0 (0–30) | 8.5 (0–27.8) | ≤ .001 |
| Medical care corporation providing medical care | 32 (25.4) | 35 (63.6) | ≤ .001 |
| Provides flu vaccine | 4 (3.1) | 14 (25.5) | ≤ .001 |
| Who would administer vaccines | |||
| Jail medical staff | 41 (31.5) | 44 (80.0) | ≤ .001 |
| Local health department | 58 (44.6) | 24 (43.6) | ≥ .99 |
| Other | 10 (7.7) | 2 (3.6) | .51 |
Combined days for medical doctor, advanced practice provider (general nurse practitioner and physician assistant), registered nurse, and licensed practical nurse.
Operational Factors
Most administrators said wardens (51%) or jail medical staff (29%) would coordinate HPV vaccine administration planning. Cost (cited by 66% of administrators), short length of stay of incarcerated persons (62%), and medical staff availability (47%) were the top concerns for providing vaccine. Half of the administrators (52%) had physical safety concerns for staff. Administrators were split on who they would prefer administering HPV vaccine, with 45% saying jail medical staff and 44% saying local health department staff. Urban jails were more likely to say that jail medical staff would offer the vaccine (P < .001). There were also differences in expectations for who would pay: incarcerated persons paying out of pocket or through their insurance (54%), local health departments (24%), and jails (17%). To educate about the vaccine, administrators favored written information distributed to incarcerated persons (63%) or education from local health departments (21%). Administrators also wanted direct education for jail medical (25%) and correctional (25%) staff.
ADVERSE EFFECTS
Our study is not without limitations, and we extrapolated data from direct application to HPV vaccine administration to anticipated applicability to COVID-19 vaccine administration. The extent to which empirical research can inform planning efforts is critical to the shared responsibility of counties, local public health systems, and criminal legal systems to best address the jail population and communities.
SUSTAINABILITY
Although the HPV vaccine is clearly different from the COVID-19 vaccine, key similarities suggest that factors associated with HPV vaccine delivery might align with COVID-19 vaccine delivery: two-dose schedules and vaccine hesitancy. We offer the following recommendations:
Capacity (Who, Where, How)
Given a shortage of jail medical staff and varied organization of medical care, jails will have to negotiate, on a facility-by-facility basis, who is best positioned to deliver the vaccine (jail nurses, local health department nurses, or staff from local safety net clinics). Urban jails will have an advantage in the number of staff available at the jail. Rural jails may have to rely on outside partners.
The COVID-19 vaccine is likely to be best administered on a medical cart brought to housing units, using an approach possibly aligned with other types of mobile vaccination outreach.
The first dose of the vaccine should be administered in jail, and incarcerated persons should be given instructions about when to receive a second dose and where (inside the facility through a no-cost health request or outside the facility at a local health department), in addition to a Centers for Disease Control and Prevention–provided vaccine-tracking card. Entering incarcerated persons should be asked if they have already received their first dose during intake. If eligible for the second dose during their jail term, vaccination should be administered. Administration information for any doses given in jails should be captured in the required immunization information systems per state regulations.
Operational (Costs, Security, and Information)
The federal government is providing COVID-19 vaccine at no cost to recipients. However, costs of gloves, sharps containers, staff, and administration will have to be negotiated locally.
Physical security concerns for all parties involved are real, and jails should plan for security staffing needs during vaccine administration in housing units.
Given the history of vaccine mistrust in the public, health care mistrust in detention settings, and the differential power dynamics of players, information will have to be provided in a transparent, clear, and consistent manner to boost uptake. Jails may ultimately be ill equipped to provide adequate health education and must be supported with clear public health strategies.
PUBLIC HEALTH SIGNIFICANCE
Jails have struggled to limit daily population movement, effectively quarantine incarcerated persons who test positive for COVID-19, refresh staff, and transport sick incarcerated persons to receive medical care during COVID-19.3 We also know that less than half of inmates are willing to get vaccinated thus far (https://bit.ly/3uOlZwA). Without a plan to vaccinate locally incarcerated persons and correctional officers, the community can expect to continue to be affected by COVID-19 outbreaks in jails. Such superspreader sites can overwhelm local hospitals and put family members and communities at risk.3 States and local jurisdictions will need to initiate planning that fits with local incarcerated persons’ vaccination and engage nontraditional medical partners, such as federally qualified health centers and safety net clinics, when local health departments reach capacity in communities.
ACKNOWLEDGMENTS
Data collection for this study was funded by the National Cancer Institute, National Institutes of Health (NIH; grant R21 CA204767, “Correctional and public health links to bolster HPV vaccine and cancer prevention” to M. R. [primary investigator]).
Note. The content of this editorial is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
HUMAN PARTICIPANT PROTECTION
This study was approved by the University of Kansas Medical Center institutional review board. All participants gave verbal informed consent to participate, as approved by the institutional review board. Written consent was waived, as the study posed only minimal harm to respondents.
REFERENCES
- 1.Maner M. The COVID Prison Project. An analysis of interim COVID-19 vaccination plans. December 18, 2020. Available at: https://covidprisonproject.com/blog/data/data-analysis/an-analysis-of-interim-covid-19-vaccination-plans. Accessed March 18, 2021.
- 2.American Jail Association. Jail statistics. 2018. Available at: https://www.americanjail.org/jail-statistics. Accessed December 15, 2020.
- 3.Oladeru OT, Tran N-T, Al-Rousan T, Williams B, Zaller N. A call to protect patients, correctional staff and healthcare professionals in jails and prisons during the COVID-19 pandemic. Health Justice. 2020;8(1):17. doi: 10.1186/s40352-020-00119-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Vicente-Alcalde N, Ruescas-Escolano E, Harboe ZB, Tuells J. Vaccination coverage among prisoners: a systematic review. Int J Environ Res Public Health. 2020;17(20):7589. doi: 10.3390/ijerph17207589. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ramaswamy M, Allison M, Musser B, Satterwhite CL, Armstrong R, Kelly PJ. Local health department interest in implementation of a jail-based human papillomavirus vaccination program in Kansas, Iowa, Missouri, and Nebraska. J Public Health Manag Pract. 2020;26(2):168–175. doi: 10.1097/PHH.0000000000001021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi: 10.1186/1748-5908-4-50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Allison M, Musser B, Satterwhite CL, Ault K, Kelly P, Ramaswamy M. Human papillomavirus vaccine knowledge and intention among adult inmates in Kansas, 2016–2017. Am J Public Health. 2018;108(8):1000–1002. doi: 10.2105/AJPH.2018.304499. [DOI] [PMC free article] [PubMed] [Google Scholar]