by Michael D. Cohen, M.D.

There is growing concern that communities that host jails and prisons will never be able to control the coronavirus unless the epidemic in correctional institutions is well controlled.

If staff continue to get infected and introduce the virus back into the community, there will still be outbreaks that can spread widely if not well controlled. Such concerns should lead first to fewer arrests, bookings and jailings for minor crimes, as well as to greater efforts to identify cases and control the spread in jails and prisons.

An editorial in the July American Journal of Public Health summed up the reasons that prisons are high-risk institutions (i.e. overcrowding and unsanitary living conditions) and a potential source of re-infection for local communities and beyond.

And an important report from Illinois was discussed in an opinion article in The New York Times on July 6. It examined the impact of people booked into Cook County jail on the spread of coronavirus in Chicago and on Illinois as a whole. That jail was the site of one of the larger outbreaks of COVID-19 in the country. As reported, “The cycle of arrests, jailings and releases was the most significant predictor of the spread of coronavirus in Chicago and the rest of Illinois. Roughly one-sixth of all cases in the city and state were linked to people who were jailed and released from this single jail, according to data through April 19.”

Diagnostic Tests

On July 7, 2020 the federal Centers for Disease Control and Prevention (CDC) issued new guidance for coronavirus testing in correctional facilities. In the older April guidance, CDC recommended only testing people with symptoms of COVID-19. When diagnostic tests were not readily available, the CDC found it reasonable to limit testing in the community and institutions to only the patients with greatest need, such as hospitalized patients, people with symptoms, health-care workers and people living or working in nursing homes.

With more widespread availability of diagnostic tests, it is now practical to test asymptomatic people, too. The new CDC guidance discusses testing people exposed to an infected person more often during their quarantine.  The new guidance also provides information about testing asymptomatic people who have no known exposure to a case. This would apply in communities with ongoing transmission of COVID-19. The guidance also discusses testing all current residents in a facility and all new admissions before housing them in the general population. These are major changes. Screening all new admissions with a diagnostic test is a much better approach to preventing the virus from entering a facility. Staff need to be screened with diagnostic tests, too.

Widespread testing of symptomatic and asymptomatic people is necessary to control the coronavirus pandemic. Testing is necessary for control, but not sufficient. It must be coupled with isolation of cases, and identification, testing, and quarantine of close contacts for 14 days.

Testing is the cornerstone of control and prevention. Request tests. Accept tests when offered or recommended.

You can know what test you are getting by what specimen is collected.

• A Q-tip up the nose or spit in a cup are used to diagnose COVID-19 by looking for coronavirus in nasal and oral fluids.

• Blood drawn from a vein is used to determine if the person was previously infected with coronavirus by looking for antibodies produced by the body in response when the person was infected.

• A sensor held in front of the forehead only measures the body temperature to see if the person has fever. That is not a test for coronavirus.

Testing is still constrained by shortages of the chemicals the labs need to run the tests. “Batch testing” is a new approach that responds to these chemical shortages. The idea is to mix the specimens together for five or more patients. Instead of running five separate tests, they run one mixed test. If the mixed test is negative, all five were negative and only one test was done instead of five. If the mixed test is positive then all five patients’ tests must be run separately to determine who among them were positive. This strategy to increase testing without increasing the number of tests will only work when most of the mixed tests are negative. This will only occur when the virus is not widespread in the community.

Infection

There was discussion in the news in July about whether the coronavirus is spread “airborne” like the measles virus. Previous discussions focused on infectious droplets of mucus and viruses expelled by sneezing, coughing, yelling or singing. These eventually settle out of the air onto surfaces. “Airborne” refers to single virus particles or very, very small droplets that do not settle out of the air. In that case, an infected person speaking in a normal tone of voice in a poorly ventilated room would emit a cloud of infectious particles.

When that occurs, people who are closer together and spend more time face-to-face are at substantially increased risk of infection. Stay far apart. Spend as little time as possible in closed indoor spaces. Wear cloth or surgical masks when other people are nearby to prevent putting infectious droplets into the air.

Introduction to the Immune System

The immune system helps the body prevent or overcome infections. I want to provide a brief description of the immune system so readers can better understand news stories about it as it is discussed in so many current news stories.

The immune system has three interconnected parts: organs, cells and special proteins like antibodies, complement, and proteins that cause inflammation. The immune system organs, like the spleen in the abdomen and lymph nodes scattered all over the body, are lined with immune cells that engulf and remove germs or cells that have antibodies or complement attached to them.

The immune system cells include many different types of white blood cells that circulate in the blood and also live in the tissues like the gut, liver and lungs. They do many different things. Some cells eat bacteria (neutrophils, for example). Some cells make antibodies (B-lymphocytes or B-cells). Some cells attack specific viruses (activated T-lymphocytes or T-cells).

The special proteins that are part of the immune system work with the other parts to destroy germs. Antibodies are proteins that attach to specific germs and make them more vulnerable to destruction by immune cells in the immune organs. Complement proteins attach to germs and also make them more vulnerable to destruction. Proteins that cause inflammation are released by cells in the tissues where the germs are causing injury. Inflammation brings immune system resources to the area where the infection is located. This can involve swelling, increased blood flow, and gathering of white blood cells at the site of infection. But too much inflammation can also be harmful.

The body learns to make antibodies against a specific germ when it is exposed to the germ. It takes some time for the B-cells to “learn” to make antibodies to a new virus. But once there are cells that can make antibodies to a virus, for example, a group of those cells is kept in reserve to activate and make more antibodies quickly if the virus comes back again. This is called “immune memory.” After an infection is over and the specific antibodies to that virus are no longer found in the blood, the immune memory is there to quickly increase production if the virus returns.

Following exposure to a new virus, the body also learns to activate T-cells against that particular virus. Some of those T-cells are also kept in reserve to react and multiply if the virus comes back again.

Candidate Coronavirus Vaccines and the Immune System

Vaccines try to mimic infection to stimulate the immune system to make a specific response to a particular germ. Vaccines use whole viruses or parts of viruses to stimulate specific antibody and T-cell responses to a particular virus. A successful vaccine is safe and produces an immune response that prevents infection by that virus.

For some viruses, the T-cells activated against that virus are the most effective part of the immune response. We don’t know yet if that is true for the coronavirus. We probably need a vaccine that will help the body make specific antibodies and T-cells activated against the coronavirus. A candidate vaccine produced by the team at Oxford University in the UK has been found to make both specific antibodies and activated T-cells against the coronavirus.

When a virus infects through the nose and lungs, like the coronavirus, it would be good to have some resistance right there on the tissues lining the nose and lungs. Some of the antibodies the body makes are spread onto surface tissues in the nose, sinuses, lungs, gut, bladder and elsewhere (called secretory IgA). Vaccines sprayed up the nose are particularly good for making that type of antibody. There is a seasonal flu vaccine that is sprayed up the nose and works very well. It may turn out that an oral or nasal vaccine for coronavirus will be easier to administer to masses of people and highly effective at stopping infection. Some drug companies are attempting to produce a nasal coronavirus vaccine.

Some candidate vaccines have been shown to be safe and to make an immune response in patients. But not every immune response is capable of preventing infection. No candidate vaccine has yet been shown to prevent coronavirus infection and COVID-19 disease.

Seasonal flu vaccine

There is another epidemic viral disease that we already have a vaccine for: influenza or “the flu.” Public health and medical professional societies recommend the flu vaccine for all children and adults, including all residents and staff in correctional facilities.

The flu virus changes all the time, and there are new types of flu every year. Immunity to old types does not protect you from the new ones. Public Health monitors types around the world to identify new ones that are emerging. The seasonal flu vaccine is redesigned every year to try to provide immunity for the new types that are expected to be in circulation during the next flu season.

Public health and professional medical organizations recommend that everyone get the current seasonal flu vaccine every year. Flu outbreaks can easily occur in residential institutions such as prisons and jails. For this reason, prisoners and staff are at higher risk for exposure to flu and will benefit more from getting the flu vaccine. Similar to COVID-19, people with various chronic illnesses or disabilities are at greater risk for severe cases of flu. They benefit the most from the seasonal flu vaccine that protects them from severe illness and death. 

Michael Cohen was the Medical Director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie, N.Y. For 10 years, he participated in a support group for people with diabetes at Great Meadow CF in Comstock, N.Y. With the group, he co-authored the Prisoner Diabetes Handbook published by Southern Poverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.

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