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Research Letter | Public Health

Association of State COVID-19 Vaccination Prioritization With Vaccination Rates
Among Incarcerated Persons
Breanne E. Biondi, MPH; Kathryn M. Leifheit, PhD, MSPH; Carmen R. Mitchell, MPH; Alexandra Skinner, MPH; Lauren Brinkley-Rubinstein, PhD; Julia Raifman, ScD, SM

Introduction

+ Supplemental content

Risk of COVID-19 transmission is increased in prisons and surrounding communities. COVID-19 can

Author affiliations and article information are
listed at the end of this article.

spread rapidly in these facilities owing to crowding, inability to socially distance, poor ventilation,
continuous admissions and releases, and daily work staff.1 High rates of chronic and
immunocompromising conditions such as HIV among incarcerated persons are associated with
greater risk of COVID-19.2
Owing to limited vaccine supply in December 2020 and early 2021, the Advisory Committee on
Immunization Practices recommended that states allocate COVID-19 vaccines in phases and did not
prioritize incarcerated persons for vaccination, nor did many states.3 In contrast, the National
Academies of Sciences, Engineering, and Medicine recommended that incarcerated persons be
vaccinated in the second phase.4 This study assessed COVID-19 vaccine rollout in state prison
systems and the association between vaccination prioritization policies and the percentage of
incarcerated persons vaccinated for COVID-19.

Methods
This longitudinal cross-sectional study used state data on weekly COVID-19 vaccination counts
among incarcerated persons and monthly prison population counts from the Marshall Project and
Associated Press. Phases and dates of incarcerated persons' vaccination eligibility were obtained
from the COVID-19 US State Policy database. Boston University’s institutional review board waived
deemed the study non–human participants research and waived informed consent. We followed the
STROBE reporting guideline.
The sample included states with complete data on incarcerated persons’ vaccination (eTable
and eAppendix in the Supplement). The outcome was the cumulative percentage of fully vaccinated
incarcerated persons per state. The exposure was the phase/date of incarcerated persons'
vaccination eligibility. We estimated the exposure-outcome association using an event study analysis.
For the exposure, we created binary indicators for weeks relative to vaccine prioritization, setting
values to 0 for states that never prioritized incarcerated persons for vaccination. The event-study
effect estimates represent absolute percentage-point differences in cumulative incarcerated
persons’ vaccination rates in each week before and after prioritization vs the period immediately
before.5 The analysis period was October 20, 2020, to June 20, 2021 (last week of available data);
the unit of analysis was state-week. Models included fixed effects for state and week to control for
time-invariant differences between treated and untreated states and national trends in incarcerated
persons’ vaccination. A secondary analysis assessed June 2021 vaccination rates among incarcerated
persons vs the general adult population by month of incarcerated persons’ vaccination prioritization.

Results
Of 36 analyzed states (mean, 690 343 incarcerated persons [range, 663 747-712 716]), 21 prioritized
incarcerated persons for vaccination and 15 did not. Incarcerated persons became eligible for
Open Access. This is an open access article distributed under the terms of the CC-BY License.
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COVID-19 Vaccination Prioritization and Vaccination Rates Among Incarcerated Persons

vaccination from December 12, 2020, to April 12, 2021. States with policies prioritizing incarcerated
persons’ vaccination had significant increases in vaccination rates vs other states over time (Figure 1).
Only 10 states vaccinated more than 70% of incarcerated persons (of these, 7 prioritized
vaccinations for incarcerated persons), and only North Dakota fully vaccinated more than 80%. By
June 2021, states prioritizing vaccinations for incarcerated persons earlier in 2021 had higher
incarcerated persons’ vaccination rates vs states prioritizing incarcerated persons later or not at all
and vs the general population (Figure 2). Even after prioritization, 42.0% of incarcerated persons
remained unvaccinated in June 2021.

Discussion
Low vaccination rates among incarcerated persons have implications for health equity. Racist policies
in policing and drug criminalization sentencing created racial and ethnic disparities in incarceration
and chronic disease, which are associated with increased risk of COVID-19 and complications among
racial and ethnic minoritized individuals.6
Our data suggest that state prioritization of incarcerated persons was associated with increased
vaccination rates in this population, although vaccination rates may vary owing to state vaccine

Figure 1. Associations Between State COVID-19 Vaccination Prioritization and Cumulative Vaccination Rate
Among Incarcerated Persons in 36 States

Difference in cumulative vaccination rate,
percentage points

50

40

30

20

10

0

–10
–20

–10

0

10

20

Time since state prioritization of vaccinations for incarcerated persons, wk

Event-study coefficients estimated the mean treatment
effect in states that prioritized vaccination of incarcerated persons (ie, the absolute difference in the cumulative percentage vaccinated in states that prioritized vs
did not prioritize vaccination for incarcerated persons).
Fixed effects were used for state and week, and SEs
were clustered at the state level. Shading indicates 95%
CIs. The dashed horizontal line indicates no difference in
vaccination rates among states with a policy prioritizing
incarcerated persons to be vaccinated against COVID-19
compared with states that did not prioritize incarcerated persons to be vaccinated, and the dashed vertical
line indicates the time point when a state created a
policy prioritizing vaccination among
incarcerated persons.

Figure 2. Vaccination Rates Among Incarcerated Persons and the General Population by Month of Vaccination
Prioritization for Incarcerated Persons

I•

Incarcerated persons

□ General population aged ≥18y

Proportion vaccinated, %

80

60

-

-

40

20

0
Dec
2020
(n = 1)

Jan
2021
(n = 4)

Feb
2021
(n = 2)

Mar
2021
(n = 9)

Apr
2021
(n = 5)

No
prioritization
(n = 17)

Month of state prioritization of vaccines for Incarcerated persons

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N values indicate the number of states in that month
that prioritized vaccination of incarcerated persons.

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5. Goodman-Bacon A. Difference-in-differences with variation in treatment timing. National Bureau of Economic
Research working paper 25018. September 2018. Accessed June 10, 2021. https://www.nber.org/system/files/
working_papers/w25018/w25018.pdf

4. Kahn B, Brown L, Foege W, Gayle H. A Framework for Equitable Allocation of COVID-19 Vaccine. National
Academies of Sciences, Engineering, and Medicine; 2020.

3. Dooling K, Marin M, Wallace M, et al. The Advisory Committee on Immunization Practices’ updated interim
recommendation for allocation of COVID-19 vaccine—United States, December 2020. MMWR Morb Mortal Wkly
Rep. 2021;69(5152):1657-1660. doi:10.15585/mmwr.mm695152e2

2. Akiyama MJ, Spaulding AC, Rich JD. Flattening the curve for incarcerated populations—COVID-19 in jails and
prisons. N Engl J Med. 2020;382(22):2075-2077. doi:10.1056/NEJMp2005687

REFERENCES
1. Montoya-Barthelemy AG, Lee CD, Cundiff DR, Smith EB. COVID-19 and the correctional environment: the
American prison as a focal point for public health. Am J Prev Med. 2020;58(6):888-891. doi:10.1016/j.amepre.
2020.04.001

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official
views of the NIH.

Conflict of Interest Disclosures: Ms Biondi reported receiving a training grant from the National Institute of Drug
Abuse, National Institutes of Health (NIH) during the conduct of the study. Dr Leifheit reported receiving a grant
from the Agency for Healthcare Research and Quality during the conduct of the study. Ms Skinner reported
receiving grants from the Robert Wood Johnson Foundation during the conduct of the study and from the NIH
outside the submitted work. Dr Raifman reported receiving grants from the NIH and the Robert Wood Johnson
Foundation during the conduct of the study. No other disclosures were reported.

Supervision: Raifman.

Administrative, technical, or material support: Leifheit, Brinkley-Rubinstein.

Obtained funding: Raifman.

Statistical analysis: Biondi.

Critical revision of the manuscript for important intellectual content: All authors.

Drafting of the manuscript: Biondi, Leifheit, Brinkley-Rubinstein.

Acquisition, analysis, or interpretation of data: Biondi, Leifheit, Skinner, Brinkley-Rubinstein, Raifman.

Concept and design: Biondi, Leifheit, Mitchell, Skinner, Raifman.

Author Contributions: Ms Biondi had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.

Author Affiliations: Department of Health Law, Policy and Management, Boston University School of Public
Health, Boston, Massachusetts (Biondi, Skinner, Raifman); Fielding School of Public Health, Department of Health
Policy and Management, University of California, Los Angeles (Leifheit); Department of Health Management and
System Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
(Mitchell); Department of Social Medicine, University of North Carolina at Chapel Hill (Brinkley-Rubinstein).

Corresponding Author: Breanne E. Biondi, MPH, Department of Health Law, Policy and Management, Boston
University School of Public Health, 715 Albany St, Talbot Building, Boston, MA 02118 (bebiondi@bu.edu).

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Biondi BE
et al. JAMA Network Open.

Published: April 12, 2022. doi:10.1001/jamanetworkopen.2022.6960

ARTICLE INFORMATION
Accepted for Publication: February 24, 2022.

vaccinations and vaccinations by race and ethnicity, is needed to evaluate vaccinations in prisons.

generalizable to the US prison population. Better data transparency, including full COVID-19

Our analysis only included states that reported full doses of vaccination and thus may not be

how to encourage vaccination among incarcerated persons should be considered.

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COVID-19 Vaccination Prioritization and Vaccination Rates Among Incarcerated Persons

rollout, availability, or incarcerated persons’ preference. Distrust of staff is common in prisons, and

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JAMA Network Open. 2022;5(4):e226960. doi:10.1001/jamanetworkopen.2022.6960 (Reprinted)

SUPPLEMENT.
eTable. States Used in Analysis and Prioritization Status
eAppendix. Methods
eReferences

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6. Reinhart E, Chen DL. Carceral-community epidemiology, structural racism, and COVID-19 disparities. Proc Natl
Acad Sci U S A. 2021;118(21):e2026577118. doi:10.1073/pnas.2026577118

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