To the Editor —In most countries worldwide, prisons are overcrowded, unsanitary places that are favorable environments for transmissible diseases like coronavirus disease 2019 (COVID-19). In fact, 59% of all countries worldwide have prison occupancy levels exceeding their officially reported capacity, which imposes high risk of infection transmission and adverse health issues. ¹ In addition, the difficulty of applying preventive methods in prisons, such as practicing physical distancing, and the inability to access care for the prisoners, poor sanitation, and poor ventilation of prison rooms, contribute to prison health catastrophes. ^{Reference Dolan, Wirtz and Moazen2}

Historically, similar disease outbreaks in prisons have had high mortality rates in jails, such as typhoid fever in English jails. Similarly, tuberculosis outbreaks occurred in Russian prisons in 1997 and 2001, which led to public re-emergence of this highly infectious disease and subsequent deterioration of health systems worldwide. ³

Unfortunately, similar concerns are emerging about COVID-19 outbreaks in prisons, which threaten the health and lives of inmates, guards, as well as the broader population, and such outbreaks could lead to global re-emergence of the pandemic. ⁴ A senior Yaounde Central Prison official stated, “Of 832 samples collected from inmates released from 5 prisons in April, 358 tested positive for COVID-19, according to the unpublished government data, [which was] 16% of the national total at the beginning of May, where the infection rate of those released and tested was 58%.” ^{Reference McAllister and Kouagheu5} In Russia, the number of confirmed cases of disease caused by COVID-19 among suspects, defendants, and convicts stands at 238, with 980 additional cases among staff and workers. ⁶ These outbreaks have been linked to higher mortality rates that can reach up to one-third of a prison’s population. A report released by the Public Defender’s Office in Rio de Janeiro stated that deaths in Brazilian prisons increased by 33% during the COVID-19 pandemic compared to the same period in 2019, as noted by a Daily Mail report. ⁷ Also, prisons are considered incubation areas that facilitate rapid viral transmission. In mid-March 2020, the first case of novel COVID-19 was diagnosed at Riker’s Island, the main jail complex in New York City. Within 2 weeks, >200 cases were diagnosed within the facility, despite efforts to curb the spread. The situation at the Cook County jail in Chicago was similar, with ∼350 incarcerated persons and staff members testing positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as of early April 2020. Many other jails and prisons have reported outbreaks of COVID-19 and related deaths. ^{Reference Hawks, Woolhandler and McCormick8}

Collectively, these outbreaks raise concerns about the health status of prisoners, especially their mortality rate, and awareness of this critical issue has increased worldwide. The World Health Organization (WHO) has released guidelines, “Preparedness, Prevention and Control of COVID-19 in Prisons and Other Places of Detention,” that provide helpful tips and advice for prison staff and healthcare professionals who deal with inmates directly. These guidelines make thorough recommendations on how to prevent and manage potential outbreaks, and they focus on the importance of respecting basic human rights. Moreover, each country has a crucial role in improving the identification, management, and treatment of new cases of COVID-19. The WHO guidelines emphasize that there is no single approach or method for handling COVID-19 cases and outbreaks and that each country should adapt their approach to their local context. ⁹

Current measures emerging to prevent and control outbreaks of COVID-19 will improve health conditions worldwide, but such measures may not be achievable in many jails or in all prisons. We should increase the public awareness about the risk to inmates, and we should establish strong systems to ensure their safety. Citizens held in prisons and other detention facilities must be considered part of the broader public health response to COVID-19 given their vulnerability to infection.