How Puerto Rico Kept COVID-19 Out of Its State Prisons in 2020

State prisons are a high-risk congregate setting for an infectious disease. Yet by August 17, 2020 — when the Puerto Rico Department of Health had reported 11,723 confirmed and 15,037 probable COVID-19 cases and 335 deaths across the island — people held in the island’s state prisons accounted for only two cases and no deaths. (Four more cases were found among people awaiting trial.)

In mid-March 2020, the Department of Correction and Rehabilitation had adopted a protocol for diagnosing, managing and preventing COVID-19 in all its prisons, based on CDC’s interim guidance for correctional and detention facilities. It ranged from limits on visitors to extra cleaning. This report, written by staff of CDC, the Puerto Rico Department of Health and Physician Correctional, describes the measures aimed at the incarcerated population itself.

Admission through one door

• A single intake site. Every new admission to a state prison now goes through one location, in the municipality of Bayamón.
• Test everyone. Each new arrival has an RT-PCR test for the virus, whether or not they have symptoms.
• Small cohorts. People without symptoms wait for results in groups of no more than 20. If everyone in the group tests negative and stays well through 14 days of quarantine, the group joins the general population.
• Reset on any positive. Anyone who tests positive or has a medical concern is isolated at once and sent to the on-site medical unit — and if any member of a cohort tests positive, at intake or after developing symptoms in quarantine, the whole cohort starts over.
• Every return counts as new. People who leave prison grounds for any reason, such as a medical appointment or a court date, go through intake again when they come back.

From March 16 to July 31, 2020, 1,340 people entered the state prisons. Two tested positive by RT-PCR. Neither had symptoms, and no one in their cohorts developed COVID-19.

Closed groups inside

The general population is divided into groups of 40 to 75 people who do not share common areas with anyone else. If anyone in a group shows COVID-19 symptoms, as defined by CDC, that person is isolated in the prison’s medical unit and the whole group is quarantined until the person tests negative. There had been no suspected cases in the general population.

Checking for missed infections

Because so few new arrivals tested positive, antibody testing was offered to every incarcerated adult in May 2020 using a point-of-care test. Of 8,619 adults tested, 31 had IgG antibodies, a sign of past infection, and none had IgM antibodies, which would indicate active or recent infection.

What it shows

Rigorous screening at intake and strict cohorting probably helped prevent an outbreak among the state prison population. The authors offer Puerto Rico’s experience as a case study in putting CDC’s correctional-facility guidance, particularly its prevention practices for incarcerated and detained people, successfully into practice.

Sources

Based on Davlantes E, Toro M, Villalobos R, Sanchez-Gonzalez L, "Notes from the Field: COVID-19 Prevention Practices in State Prisons — Puerto Rico, 2020," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; written with the Puerto Rico Department of Health and rewritten in hubnx’s own words.