by Michael D. Cohen, M.D.

Introduction

The novel coronavirus is now a global pandemic and is widespread in the United States, causing a disease called COVID-19. It is likely that a majority of the population will eventually become infected with this virus. Here is some information about the coronavirus and some thoughts about taking care of yourself and your facility during this pandemic. Recommendations are changing daily as the virus spreads more widely. Try to get newer information from trusted sources such as the Centers for Disease Control (CDC), the World Health Organization (WHO) or your state Department of Health. Don’t trust rumors. False information is widely circulating already.

Residential institutions with congregate living like boarding schools, mental hospitals, homeless shelters and prisons or jails bring together a large number of people into a very small space for prolonged periods of time. Communicable diseases are readily introduced from outside and spread more easily where people live in close quarters.

Coronavirus is coming to all of us in the free world. Prisons and jails will likely be hard hit, with rapid spread inside when the disease becomes widespread in the local community or home communities. Prisoner representative councils should try to work with facility administration to develop the institutional response to COVID-19. Some jurisdictions are trying to release prisoners to reduce populations and allow people to survive the epidemic with family in the free world.

This virus is new to humans. It appears to have spread from animals to people in markets where wild animals are sold for meat. Because it is new to us, no one has been exposed to it before and there is no immunity to it in the population yet.

COVID-19 illness takes different forms

The majority of people who become infected may have no symptoms, may be unaware that they are infected, and recover fully. Nevertheless, they are infectious to others.

Some people develop symptoms. The disease caused by the novel coronavirus is called “COVID-19” which stands for Corona Virus Infectious Disease-19. Of those who develop symptoms, the majority have mild symptoms like a common cold, including runny nose, sneezing, mild cough and possibly some nausea, vomiting or diarrhea. On average, symptoms develop about 5 days after infection, but patients are infectious to others starting 2 or 3 days before symptoms start.

Therefore, people who are feeling well can still be infectious and spread the virus to others.

Some patients develop more severe disease with symptoms such as fever, cough, shortness of breath, and pneumonia. People with more severe disease may need hospitalization for supportive medical and nursing care. In some cases, the lungs are unable to move oxygen into the blood and carbon dioxide waste out of the blood. Those people need mechanical breathing with a respirator in intensive care.

Anyone at any age may develop more severe disease. However, some people are more likely to have severe disease because their bodies are weaker due to age or chronic illness. People over 60 in the general population are at higher risk. I have observed that people who have lived hard lives age faster and show the effects at a younger age. So prisoners may be at higher risk starting at age 50. People at higher risk for more severe disease due to chronic illness include those with lung disease (such as COPD, chronic bronchitis, emphysema, or asthma), heart disease (such as congestive heart failure or poorly controlled hypertension), weak immune system (such as untreated HIV infection, chemotherapy, prolonged corticosteroid treatment), diabetes, cancer, or any other chronic disease with organ damage such as kidney, liver or intestinal diseases. Everyone needs to be careful not to spread infection to these people. People at higher risk of severe disease should be released if at all possible.

Only a small fraction of those who are infected will develop severe disease. However, when a lot of people are infected, even a small percentage of them is a very large number. In February in northern Italy so many people became infected quickly that the hospitals were overwhelmed with severely ill patients. There is concern that the same thing is occurring in the U.S. as the virus spreads rapidly. Some estimates are that we are only two or three weeks behind Italy. If that is correct, if nothing is done, by mid-April the health care system will be overwhelmed in some regions.

Slow down the spread of infection

There is currently no vaccine to help prevent infection with the novel coronavirus. The first vaccine trial has started, but there is no evidence yet that it is safe or effective. There is currently no treatment for COVID-19. Several drug trials have started around the world to see if existing medicines may be helpful to cure the virus or reduce the severity of the lung disease. Those trials have just started. We don’t know yet if any of these drugs will be effective. Treatment at present is simply care needed to support the patient while their body’s immune system responds to cure the virus.

The WHO and the CDC have issued guidelines for prevention and management of COVID-19 disease. The basic idea behind these guidelines is to slow down the spread of the disease so the health care system is not overwhelmed and necessary services can be maintained even though many people are sick.

If everyone gets sick at once, there will not be enough hospital beds and breathing machines to support all the sick people. There will not be enough healthy people to maintain critical services like fire, police, nursing home care, food transport and yes, even correctional facility staffing.

On the other hand, if the disease spreads slowly over a period of months instead of days or weeks, fewer people will be severely ill at one time and there could be enough hospital beds and respirators to handle the case load. That is the goal of the public health interventions that are being recommended now for all Americans.

The recommended behaviors for all Americans to slow the spread of coronavirus infection include protecting yourself (personal cleanliness), keeping away from other people (social distancing), and disinfecting environmental surfaces (environmental cleanliness). The same approach applies to people in prisons and jails, adapted to the high-risk environment of a residential institution.

How does it spread?

Pandemic coronavirus spreads from person to person. When an infected person coughs, sneezes, yells or even sings loudly small droplets of saliva or mucus teaming with viruses are ejected from the mouth into the air. Someone else inhales those droplets and gets infected. Or possibly a droplet lands on a hard surface, sits there for a while and then someone else touches that surface, picks up the virus on a finger, later touches his face and transfers that virus to his eye, nose or mouth and gets infected. Or an infected person may have virus on his hands and touches a hard surface, which deposits virus there. Later another person touches that hard surface and then his own eye, nose or mouth and gets infected. In general, close contact with an infected person will result in infection unless very careful precautions are taken.

Efforts to prevent spread focus on personal cleanliness, especially careful and frequent handwashing to keep the hands from getting contaminated. Prevention also requires efforts to keep the hands away from the face and to suppress infectious droplets by covering coughs and sneezes. Social distancing keeps people separate to avoid close contact, and environmental cleanliness disinfects hard surfaces that may harbor virus.

Personal Cleanliness

1. Keep a clean cell: The virus can survive on hard surfaces for days. A droplet with virus in it can float around for hours and finally land somewhere in your cell. Disinfecting surfaces regularly helps prevent the spread of disease from contaminated hard surfaces to hand to face. Disinfectants can be hard to get in prison. Maybe some commissaries carry disinfectant wipes. Soap and warm water is better than nothing. Household bleach diluted 1/3 cup to a gallon of water is a pretty good disinfectant. Household hydrogen peroxide is somewhat effective as a disinfectant but may not kill coronavirus. Some facilities use a disinfectant soap for mopping floors and cleaning toilets and showers, but it is usually not available for use in the cell. Maybe the facility administration could mandate that officers send around a bucket of sanitizer solution twice a day for cell disinfection. Or maybe pass around a disinfectant spray bottle twice a day.

2. Hand washing: You may become infected by germs that get onto your hands. You may spread infection to others on your hands. Wash your hands often. Hand washing with soap and warm water for 20 seconds actually kills the virus. Hand washing done well is as effective as hand sanitizer. Hand sanitizer is more convenient than washing, but not better.

Of course, always wash your hands after using the toilet. Wash your hands when you get up in the morning. Wash your hands after you cough or sneeze anywhere near them. Wash your hands before you leave your cell. Wash your hands when you return to your cell.

Soap must be available for effective hand washing in your cell and in public bathrooms. Stock up at commissary for yourself. If you don’t already do so, try to keep a 3-month supply of hand soap. Facilities must make soap available at public bathrooms, distributing daily if necessary. Don’t take and hoard soap from public bathrooms. Everyone needs soap to be there.

3. Hand sanitizer: You need hand sanitizer when you are out of your cell moving around the facility in contact with people and hard surfaces that may harbor the virus. The common hand sanitizers with alcohol are generally banned in correctional facilities due to fire prevention standards and risk of using it as a weapon. Nevertheless, the practical solution to the immediate problem is to put hand sanitizer wall dispensers in positions where they can be closely observed and thereby make sanitizer available to all people moving about the facility. If it becomes available, use it when you enter an area; use it again when you exit. Disinfectant wipes work and cannot be easily weaponized but are expensive compared to sanitizer gel.

4. Hand protection: Try to avoid contaminating your hands on public hard surfaces. If you can, avoid touching hand rails. Try not to touch doorknobs. Maybe most doors could be propped open so there is no need to touch them? Use hand sanitizer if it is available after touching public hard surfaces like hand rails and doorknobs.

5. Don’t touch your face: By touching the eyes, nose or mouth with contaminated fingers the virus can enter the body and spread. Avoid touching your eyes, nose and mouth at all times. Face masks are uncomfortable to wear, but sometimes a face mask can help you avoid touching your mouth and nose.

6. Cover coughs and sneezes: Cover coughs and sneezes to prevent droplets from being expelled into the air. Even if you think you are not sick you should cover. You may be infectious already but not showing symptoms. Model the best behavior for others to learn and follow. You are protecting each other. Use tissue to cover the nose and mouth if you can, throw it away and wash or sanitize your hands. Cough or sneeze into the crook of your elbow or upper arm if no tissue is available.

7. Face masks: You see a lot of pictures of people wearing face masks. Public health is currently recommending face masks only for people who are sick. This helps prevent them from coughing infectious droplets into the air. Public health generally does not recommend face masks for healthy people to prevent infection because masks are not very effective for that purpose. Air and infectious droplets can rush in around the edges of a typical disposable mask. There is an acute shortage of masks and they are desperately needed for sick people and health care workers.

On the other hand, something is better than nothing. A face mask may block some of the larger infectious droplets that are floating in the air. And a face mask can help people avoid touching the mouth and nose. A very basic face mask can easily be made from the sleeve of a T-shirt and two rubber bands, or from a pleated paper towel with the ends tied by rubber bands.

Face masks may be banned in many general population settings. Facility administrations should be encouraged to allow face masks when appropriate for disease control. They will likely insist on following current public health recommendations that masks are only appropriate for sick people.

Social Distancing

The idea behind social distancing is to reduce close contact between people to reduce disease spread. This has the greatest effect on the epidemic if it is implemented early and more intensely from the beginning. Americans are having a hard time waking up to the fact that stricter isolation needs to be implemented right now, not later. By the time you read this in April, the epidemic likely will have exploded already. Even so, these prevention measures are still important.

1. Hand shaking: Virus can be passed from one person to another by shaking hands. Then it enters the body by touching the eyes, nose or mouth. Avoid hand shaking. Use alternatives: bump elbows, touch feet, whatever. Don’t touch hands.

2. Group activities: When groups of people are together in a room there is an increased risk of disease transmission due to infectious droplets in the air, touching contaminated surfaces or touching hands. Group activities should be reduced in size to 10 or less, or eliminated entirely. Avoid all social gatherings if at all possible on the unit, in the yard, at meals, etc. If you must gather in a group, keep well apart. Don’t touch anything or each other. Wash or sanitize before and after.

If possible, do not go to meals in the cafeteria, but if you must, try to maintain a safe six-foot distance from other diners. If you must go to work, maintain six-foot separation from others working there. Don’t go to the medical clinic unless you are really sick. If you are required to go to medical to get your medicine, try to maintain safe six-foot separation with other people in line. Do not go to assemblies, movies, gym, religious services or anywhere else that people gather. Facilities have probably stopped all such group activities already. Single person outdoor activities are safer. Group activities like sports are risky: too much close contact, yelling, touching, probably coughing too.

3. Keep well apart: When people do come together for any reason they should stay at least 6 feet apart. This helps reduce the risk of inhaling aerosol droplets spread by another person. It also helps ensure no direct contact that might result in spread of virus from one person to another.

4. Healthy stay in your cell: People who are not sick should stay in to maintain the maximum social separation possible. It may be hard to isolate yourself like that, but it will definitely slow down spread of the virus. The facility may even impose a lock down at some point just to slow or prevent spread of disease. If you are able, be prepared to self-isolate or be locked down by obtaining a good supply of food, soap, toothpaste and other personal hygiene items from commissary. Prisoners I have worked with said they generally maintain a three-week supply of food even in the best of times in case they miss a commissary day due to lockdown.

5. Sick stay in your cell: People who are mildly ill should choose to stay in their cells as much as possible during their illness. Wear a mask if you can to prevent droplet spread. Cover coughs and sneezes with tissue or cough into your elbow. If you can, avoid the medical clinic so you don’t risk spreading the disease to others who must be there. However, a patient’s condition can deteriorate fairly quickly. If you feel short of breath, pain or pressure in your chest, confusion or excessive sleepiness, or notice bluish lips, face or fingertips you need prompt medical care to evaluate your condition. You may need oxygen and hospitalization urgently.

6. Protect caregivers: In some correctional systems prisoner volunteers assist in care of sick prisoners, such as hospice programs. Volunteer caregivers who work with people who may be sick with COVID-19 should be provided with appropriate personal protective equipment such as gloves, gown, and N-95 mask fitted to their face. Since there is a shortage of N-95 masks this is unlikely to occur. Any mask, even a bandana, is better than no mask when working directly with sick people.

7. Help the sick: Facility health services are responsible for medical care for the sick. They have to figure out how to best manage the mildly ill; whether they can stabilize the moderately ill in an infirmary setting; and when to transfer out to community hospitals for more advanced medical care. Please keep an eye on the people in your unit who are sick in their cells. If they develop shortness of breath or worsen in any way, they need access to the clinic for further medical evaluation. Others on the unit who recognize the seriousness of their condition must help them obtain access to the facility medical clinic.

Facility Cleanliness

Environmental cleanliness is crucial to prevent rapid disease spread with so many people living and working together in a prison. Facility administration should take responsibility for organizing environmental cleanliness activities including making needed soap and disinfectant available at no cost. But if they do not do so, it will be up to prisoners to do what needs to be done to protect themselves and each other, and the officers and staff who work with them.

1. Hand sanitizer available: Hand sanitizer stations should be available throughout the public spaces in a facility and in dormitories. Work with facility administration to try to get this implemented.

2. Masks permitted: Masks should be permitted for people who are sick while in their cells or, when movement is necessary, when sick people move about in the facility. Others who wish to wear masks should also be permitted to wear them.

3. Disinfect public hard surfaces: Facility administration should plan to disinfect hard surfaces in public spaces at least twice a day. Prisoners should support and encourage these efforts if possible. The primary focus should be on things people touch routinely like door knobs and hand rails. Also, floors and walls within reach should be disinfected regularly.

4. Disinfect group cells and dorms: Facility administration should institute a policy of at least twice daily disinfection of floors, walls, doorknobs, handrails, and all other hard surfaces in common areas of group cells, unit day rooms, dormitories and bathrooms. Or at least make disinfectant available to prisoners to do so themselves.

5. Disinfect single cells: Facilities should make disinfectant available to prisoners to disinfect their single cells at least twice a day.

6. Doors propped open: Where doors can be safely propped open without compromising security it should be done to reduce contact with doorknobs.

Efforts to slow the spread of coronavirus focus on:

Personal cleanliness:

- Keep the hands from getting contaminated with coronavirus.

- Keep the hands away from the face.

- Suppress infectious droplets by covering coughs and sneezes.

Social distancing:

- Keep people separate to avoid close contact.

Environmental cleanliness:

-Regularly disinfect high contact hard surfaces that may harbor virus.

These are the behaviors that will slow down the spread of coronavirus infection in your facility. They are no different from the new behaviors that everyone is being urged to do. It is harder in a prison, but even more important there because so many people are together living and working in a partially closed environment. We can do this, and we will get through it together. 

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