Table 1.

Application of the Hierarchy of Controls to Strategies for the Prevention and Mitigation of COVID-19 Transmission in Carceral Settings

Recommendation	Implementation Guidance	Hierarchy of Controls
Prioritize the health, wellbeing, and dignity of incarcerated persons	• Support the physical and mental health needs of people who are incarcerated by maintaining all existing healthcare services without interruption and addressing the risk of health harms caused by the imposition of further restrictive measures and loss of privileges from COVID-19 mitigation measures    ◦ Particularly during the pandemic, meeting federal/international mandates regarding healthcare provision in carceral settings relies on the urgent implementation of decarceration strategies • Communicate clearly, effectively, honestly, and non-coercively through trusted avenues with people who are currently incarcerated and their loved ones    ◦ Consult people who are currently and formerly incarcerated, as well as their families, in co-developing and implementing prevention and intervention approaches	Overarching
Urgently decarcerate	• Let public health imperatives (e.g., physical distancing requirements, minimizing shared airspace, maintaining existing healthcare services, and meeting new care demands) guide minimum requirements for population reduction. • Do not rely on transfers to meet population reduction targets as transfers between facilities to relieve crowding at one institution necessarily increases density at another and therefore transmission risk. • Include support for reentry (e.g., housing, health care access) through investments in and collaborations with existing non-carceral, community-led reentry services. • Monitor and report number of people decarcerated at the institution-level in addition to system-wide	1: Elimination
Prioritize people who are incarcerated and staff for vaccination	• Couple vaccination with decarceration to maximize individual and population health • Given the uniquely hazardous risk that carceral settings – and staff movement within, to, and from carceral settings – pose, implement mandatory vaccination requirement as a condition of employment for custody and staff • Make vaccination universally available to people who are incarcerated and obtain their informed, free from coercion consent to be vaccinated	2: Substitution
Maximize air exchange in all indoor facilities	• Minimize potential for rebreathing air through reductions in population density • Categorize population density on the basis of individuals within a common airspace - not based upon potentially porous physical barriers like walls and doors that may be circumvented by heating and cooling systems. • Maximize opportunities for time spent outdoors to reduce the accumulation of virus-laden aerosols • Consult external HVAC (Heating, ventilation and air conditioning) experts to evaluate unique facility characteristics: expert determination is necessary to ensure ventilation, air exchange, and air filtration systems meet recommendations for airborne infectious aerosol exposure established by the American Society of Heating; Refrigerating; and Air Conditioning Engineers (ASHRAE)	3: Engineering controls
Limit density of housing units	• Coordinate strategies to limit the size and density of housing units through decarceration • Prioritize the use of single-occupancy units with closed doors and adequate ventilation (not recirculated air) whenever possible, especially for individuals with multiple underlying conditions that increase risk for adverse COVID-19 outcomes • Prioritize reducing the occupancy of large dorms, reserving them for group isolation of people who have tested positive for SARS-CoV-2	4: Administrative controls
Employ rapid testing, screening, and epidemiologic surveillance of staff and incarcerated people	• Urgently decarcerate facilities with support for re-entry to maximize the effectiveness of testing, screening, and epidemiologic surveillance efforts • Ensure that system-wide procedures include systematic and voluntary: (1) diagnostic testing of symptomatic individuals (with turnaround times ≤24 hours for results); (2) frequent testing of exposed individuals; (3) widespread screening of staff and incarcerated people • Align widespread screening frequency with transmission risks and disease prevalence in surrounding communities • For prisons with particularly low prevalence, ongoing pooled testing can minimize burden and increase rapid outbreak detection	4: Administrative controls
Prioritize prevention and control measures among staff	• Urgently decarcerate facilities with support for re-entry to minimize risks associated with staff introductions of SARS-CoV-2. • Ensure proper and consistent use of PPE and provision of standard N95 masks (without one-way valves) – including frequent replacement with new masks or effective disinfection of used masks – is facilitated for staff and people who are incarcerated • Designate locations for the quarantine and medical isolation of staff in order to protect incarcerated people, families of staff, and the surrounding community • Negotiate with union representatives and state agencies in charge of staffing procedures to facilitate proper cohorting of staff within and between facilities • Given the outsized risk posed to the safety and wellbeing of incarcerated people and surrounding community, implement protocols for frequent testing and mandatory vaccination among staff	4: Administrative controls 5: PPE

Notes. Each recommendation (Column 1) is accompanied by guidance on key considerations for optimal implementation (Column 2). The recommendations are listed according to the Lopez et al. Hierarchy of Controls framework (Column 3). This framework, adapted specifically for carceral settings, emphasizes how known COVID-19 control and prevention strategies situated at the lower end of the Hierarchy of Controls are dependent on those at the higher end to be successful, therefore facilitating the prioritization of strategies.

Sources. Lopez, W.D., et al., Preventing the Spread of COVID-19 in Immigration Detention Centers Requires the Release of Detainees. American Journal of Public Health, 2020(0): p. e1-e5.; UNODC, WHO, UNAIDS and OHCHR joint statement on COVID-19 in prisons and other closed settings. 2020 [cited 2021 January 26]; Available from: https://www.who.int/news/item/13-05-2020-unodc-who-unaids-and-ohchr-joint-statement-on-covid-19-in-prisons-and-other-closed-settings.; ASHRAE Epidemic Task Force. [n.d.] “Core Recommendations for Reducing Airborne Infectious Aerosol Exposure” Available from: https://www.ashrae.org/file%20library/technical%20resources/covid-19/core-recommendations-for-reducing-airborne-infectious-aerosol-exposure.pdf; ASHRAE Epidemic Task Force. 20 October 2020. “Building Readiness.” Available from: https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-building-readiness.pdf; Science Brief: SARS-CoV-2 and Potential Airborne Transmission. 2020 [cited 2021 March 16]; Available from: https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html.; Preparedness, prevention, and control of COVID-19 in prisons and other places of detention: interim guidance. Copenhagen: WHO Regional Office for Europe, 2021, February 8. Available from: https://www.euro.who.int/en/health-topics/health-determinants/prisons-and-health/publications/2021/preparedness,-prevention-and-control-of-covid-19-in-prisons-and-other-places-of-detention-interim-guidance,-8-february-2021-produced-by-whoeurope