Covid-19 in prisons: fewer cases than feared but it’s not the whole story

With newly released data showing how many people of different ages have tested positive for Covid-19 in prisons, for the first time it is now possible to compare how rates of the coronavirus across prisons in England and Wales compare to those seen in the wider population.

The absolute numbers of Covid-19 cases in prisons seem to be much lower than initially feared. Up to August 31st, there were 560 reported cases across all prisons in England and Wales, which is a far better picture than the early estimations in April that case numbers could exceed 77,000 without intervention.

However, using the latest data with reported ages (up to July 10^th), we have found that rates in prison, when adjusted for age, are higher than those seen in the wider community. There have been 7.6 cases per 1,000 population in prison, compared to 4.9 in the English and Welsh populations overall.

Bearing in mind there has been a prolonged and severe lockdown in prisons, this raises a number of questions. Why have people in prisons been more likely to contract the virus, and what are the wider implications of restrictions on prisoners’ physical and mental health?

Confirmed cases of Covid-19 in prison by age

Across all ages, the rate testing positive for Covid-19 has been higher in prison than in the general population. But prisoners over 60 years old have been at particular risk, with a rate (15.5 per 1,000) that is almost double what we’ve seen for the general population.

This reinforces the longstanding call for a national strategy for the care of older prisoners – most recently made by the Justice Select Committee in their inquiry into the ageing prisoner population.

Why have rates been higher in prison?

There are various reasons why rates of Covid-19 in prison may be higher. As in the wider community, there have been challenges with testing in order to confirm cases, but there are also specific factors about both prisons and prisoners that may shed further light on the matter.

The figures are not just down to how many tests for Covid-19 have been taking place in prisons. In the early stages of the pandemic, when tests were not widely available, Public Health England reported that not all prisoners with symptoms of Covid-19 were tested. Some with symptoms were assumed to have the virus, and were recorded as ‘possible/probable’ rather than ‘confirmed’ cases.

In the absence of information about who was tested in prison, the higher rates of confirmed cases for prisoners compared to the general population may partly reflect, for example, testing being focused on prisoners who by virtue of their age and/or poor health have exhibited more overt symptoms. The release of data on testing by age band, as well as rates of hospitalisation, would allow more conclusions to be drawn on this.

Prisoners also face many other risk factors for the virus.

The physical environment of prisons is a particular risk. Many prisoners live in shared cells, and overcrowding and inconsistent sanitation means it is much harder to implement basic infection controls for Covid-19 – such as social distancing and frequent hand-washing.

The number of prisoners with pre-existing health conditions may be another reason for the higher rates, as certain health conditions put people at greater risk of Covid-19 and of experiencing more severe symptoms. We also know that Black, Asian and Minority Ethnic (BAME) people are overrepresented in prison, and that rates of severe Covid-19 cases in the wider community have been higher in the BAME population.

The impact of lockdown on prisoners

Lockdown in prison has lasted longer and been more restrictive than in the general population. The higher rates of Covid-19 seen in prison are particularly notable given the toll that lockdown restrictions have taken on those in prison. For around four months, people in prison have faced extended periods of time in their cells (at least 23 hours a day), alongside a halt to most employment and education opportunities.

Even before Covid-19, self-harm in prison was rising year on year. After their scrutiny visits to see how prisons were managing the response to the pandemic, HM Inspectorate of Prisons raised concerns about the impact of extended periods of isolation – amounting to indefinite solitary confinement in some cases – on prisoners’ mental health and wellbeing. The report also noted no access to secondary care except for cancer referrals and emergency care. 

The stopping of visits during lockdown meant no opportunity for prisoners to see their family in person, which is hard for family as well as prisoners themselves. In prisons where visits are restarting, there are multiple rules to be adhered to. Possibly as a result, uptake has been low. In some prisons, visit days have even been cancelled as families don’t want to attend under such conditions.

While the extended and severe lockdown in prisons may have prevented a large spike in cases, it is likely to have had a serious impact on the mental and physical health of people in prison – while still leaving them more likely to have contracted Covid-19 than people in the wider community.