by Michael D. Cohen, M.D.

Recommendations for behaviors to reduce exposure to coronavirus and infection are changing as more knowledge is gained about the virus and the disease. Of course, implementing these behaviors in a prison setting is often impossible, but it’s worth passing on newer information so prisoners can do their best to stay safe.

Initial recommendations were based on our best knowledge at the time. We knew very little about this new coronavirus, so recommendations were based on experience with other viruses.

We know that influenza (the “flu”) spreads through direct contact with droplets or mucus from the nose and lungs. This is very important for spread of flu, but recent observations suggest it is less important for spread of COVID-19. You need to protect yourself from seasonal flu, so all the habits to avoid direct contact with secretions are still very important for your health:

• No shaking hands.
• Avoid touching your face especially eyes, nose and mouth.
• Proper handwashing techniques.
• Hand sanitizer after contact with any surfaces frequently touched by others.
• Routine sanitizing of surfaces in your cell and especially in common areas like dayrooms, toilets, showers, cafeterias, etc.

These hygiene practices are still important even after you get the seasonal flu vaccine.

We knew that large respiratory droplets expelled by cough, sneeze, yell, or singing carry the virus and can infect people. The idea that 6 feet apart is a “safe” distance was based on how far droplets can be expected to travel before they settle out of the air onto floors, tables or other surfaces. Now we understand that coronavirus can also spread via airborne virus or microdroplets that stay floating in the air and may never settle out. So, 6 feet may not be as “safe” as we were told initially. In fact, a closed room may stay infectious due to the airborne virus, even after the infected person has left the room.

Here are some current “safer” distancing recommendations:

• Always wear a face mask covering the nose and mouth when you are in the presence of other people.
• Outdoors is safer than indoors.
• Further apart is safer than closer together.
• Less time with other people is safer than more time.
• Face-to-face encounters close together are very unsafe, especially indoors without masks.
• Fewer people together is safer than large groups.
• Larger rooms with high ceilings and effective ventilation systems are safer than smaller rooms with still air.
• Rooms with open windows and rapid air exchanges are safer than closed rooms with still air.

In other words: keep apart; limit face-to-face time; avoid crowds; masks do make a difference, and ventilation matters, too.

Testing

So far, most of the COVID-19 tests have looked for genetic sequences (viral RNA) that are unique to this particular coronavirus. It proves that the person is or was infected. Those tests use specimens from the swab up the nose, are more expensive, more complicated to run in a lab, and results are not available for one day or more (sometimes a week or more). Viral RNA may be present when live or dead viruses are present in the specimen. Some people who have recovered from COVID-19 still test positive because RNA fragments are still present in their secretions. In that situation, they are not infectious to others any longer because the viruses are all dead.

Another type of test is about to become widely available. These tests look for proteins on the surface of the virus (“spike proteins”). It can be done using spit (saliva), is cheaper to produce, and easier to run. Results can be available in as little as 15 minutes. Some companies may eventually produce tests that can be done at home like a home pregnancy test (but using a saliva specimen, not urine).

Antibody tests show the presence of intact virus particles. This means the person is not only infected but also infectious to others. Mass availability of antibody tests will provide critical information about who is infectious to others on a timely basis. Isolation, contact tracing and quarantine of contacts can then be accomplished before the person has spread the disease to many other people.

Immunity and the Risk of Re-infection

Research on how long antibodies and activated immune cells against COVID-19 last in the body is advancing. There is now better evidence that immunity persists longer than a few months, probably much longer.

There is no good evidence that people can get COVID-19 twice. However, there is no good evidence yet that they cannot either. It does appear that immunity persists and re-infection, if it does occur at all, is uncommon. With so many millions of people infected worldwide, many documented cases of re-infection would be expected if it does occur.

But consider two other factors that could affect the likelihood of re-infection. A person whose immune system is damaged may not be able to mount a persistent immune response that prevents re-infection. Also, the virus itself may change (mutate) with the result that the immune system no longer recognizes it and new infection occurs. The virus has not mutated in that way yet, but could in the future.

There have been a few case reports that suggested re-infection had occurred. A patient recovered from COVID-19, tested negative on the viral RNA test repeatedly, and then later tested positive again. Rather than re-infection, these cases were probably examples of dead viral RNA fragments persisting in the secretions and causing repeat positive tests. But there was no new infection and no new disease symptoms.

Isolation and Emotional Distress

Isolation to prevent the spread of COVID-19 has been stressful for people in the free world. It is even more so for incarcerated people who are restricted to their cells. Isolation imposes emotional burdens and can make pre-existing PTSD, depression or serious mental illness worse. Restrictions on family visits also impose a burden, as does worry about family and loved ones’ well-being.

An opinion article in the August American Journal of Public Health points out the importance of increasing the use of web-based virtual family visits, telepsychiatry and virtual individual or group counseling sessions. The article recommends that corrections programs set a high priority on expanding systems to provide these services in prisons and jails. Such services can reduce anxiety, irritability, fear and anger. Scaling up mental health programs in corrections may help prevent increases in suicides and assaults. 

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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