Introduction

In March 2020 the World Health Organization (WHO) declared the COVID-19 pandemic. At the time of writing, there have been 434,154,739 reported cases of COVID-19 and 5,944,342 deaths [1].

Concurrently, there are over 12 million people imprisoned globally [2]. People in prisons are more likely to experience physical and mental illness compared to the general public [3, 4]. The risk of criminality and imprisonment is heightened by the cumulative influence of political, economic, environmental, and social factors, such as poverty and social exclusion, in addition to individual lack of access to healthcare services and behavioural factors [5].

Labelled as ‘epidemiological pumps’ [6], prisons are highly susceptible to COVID-19 due to issues such as overcrowding, insalubrious and unsanitary conditions, suboptimal healthcare services, and high population turnover [7]. Highly transmissible respiratory pathogens can have devastating impacts on overcrowded prison populations, as shown by the historical examples of Spanish Flu in 1918 [8], and tuberculosis in Russian prisons in 2000 [9]. As of December 2021, there were an estimated 612,602 positive cases of COVID-19 among people in prisons, and 4,305 deaths [10]. The true scale of COVID-19 cases and deaths in prisons globally remains unclear because of significant underreporting or non-reporting by at least 148 countries [10]. The higher prevalence of chronic illnesses in imprisoned people puts them at greater risk of severe COVID or death than their peers in the community.

It is often difficult to enforce even the most rudimentary standards of COVID-19 mitigation in prisons. Social distancing is problematic because of overcrowding, which is estimated to occur in the prisons of 60 per cent of countries [11]. While it has been recommended that prisons provide access to clean water and enable hygiene practices, such as handwashing, isolation, and quarantine [12], these are often difficult to implement because of the prison architecture and infrastructure. Prisons also often have limited access to testing and personal protective equipment (PPE) [12]. Thus, disease control strategies in prisons often focus on restrictions of movement, which result in significant stress and anxiety for the imprisoned population [13, 14].

Discussions regarding the pandemic’s impact on prisons often ignore the health impact on prison staff, a situation hindered by the lack of robust data on positive COVID-19 cases and deaths among these workers. Epidemiological studies have found that prison staff are more vulnerable to infectious diseases, with a higher prevalence of physical illness than the general population, including hepatitis, HIV, and tuberculosis than the general population [12, 15]. A higher burden of mental health concerns is also apparent [16]. These are often triggered by organisational and infrastructural issues such as staffing shortages, resulting in both presenteeism and absenteeism [17].

Prison officers have also been found to be at higher risk of COVID-19 infection compared to staff working in health and social care [18]. The oscillation of these individuals between prisons and the community also elevates risks of infection transmission for people in their care. Staff can act as a vector, unwittingly bringing infection into the prison [19, 20]. If infected, staff must undergo self-isolation, which can result in staffing pressures. This may in turn impact people living in prison through reduced time outside cells, meaning less access to activities that might ameliorate their anxiety, fear, and aggression [21, 22]. It may also impact the health and wellbeing of the remaining staff who are working.

Vaccination is key to controlling COVID-19 and reducing its impact on the population. Vaccines have been proven to reduce the prevalence of communicable diseases in prisons [23], and prison vaccination drives enable countries to fulfil existing legal obligations for prison health, such as the Mandela, Bangkok, Beijing, and Havana Rules [24–27]. Collectively, these concordats demand recognition of the vulnerability of prison populations, as well as regard for the principle of equivalence and for governments’ duty to protect those in their care whose liberty has been deprived. Article 12 of the International Covenant on Economic, Social and Cultural Rights realises “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”, which applies to all individuals irrespective of their status under the law.

Nonetheless, people who live and work in prisons continue to be left behind by vaccination programmes [28]. While countries such as Spain, Poland, Finland, Ireland, and Sweden have vaccinated the majority of their prison population [29], many other countries have not. In the US, not all states have prioritised prisons in state vaccination plans [30]. Given emerging evidence that COVID-19 disproportionately affects prison populations resulting in widening health inequalities, prioritising incarcerated populations would accelerate vaccination opportunities to people who are often underserved by community health programmes, while simultaneously promoting the health and wellbeing of all individuals, irrespective of age, in line with Goal 3 of the UN’s Sustainable Development Goals 2030 [31].

The aim of this scoping review is to critically examine the extent, nature, and quality of available literature on COVID-19 vaccinations for people who live and work in prisons. We intend to capture a comprehensive picture of the current debates on this topic, as well as identify relations, gaps, contradictions and inconsistencies in publications on this topic, all the time ensuring rigour and transparency in our research methods. Our analysis of the extant literature on this topic is followed by recommendations for politicians, policymakers, academics, and practitioners for developing policies and interventions which could increase vaccination rates in prisons such that they are in line with those in the wider community, alongside important directions for future research.

Methodology

Our scoping review proceeded using the five-stage process outlined by Arksey and O’Malley [32]: 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and analysing the included literature. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The review was exempt from institutional ethical approval as it did not involve human subjects.

Results

Our search returned a total of 2,307 articles. After removing duplicates and screening titles and abstracts, 112 articles were retained, all of which were reviewed in full against our inclusion and exclusion criteria. In total, 45 papers were included for data extraction. Fig 1 displays the flow of articles through the review process.

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Fig 1. Preferred reporting items for systematic reviews and meta-analyses flowchart.

https://doi.org/10.1371/journal.pone.0267070.g001

Discussion

Evidence from the present review suggests that people who live and work in prisons have generally not been prioritised for COVID-19 vaccination programmes, notwithstanding an awareness of the vulnerability for these populations. This conclusion, to a large extent, discounts the majority of low and middle income countries, given the absence of published vaccination strategies from these countries.

This issue has been exacerbated by political and operational barriers affecting vaccination rollout, and by individual-level issues such as vaccine hesitancy. Ethical and legal arguments on health equity, inequality, the principle of equivalence, and governments’ duty of care provide a backdrop for our analysis.

Many of the included studies used health inequalities as justification for vaccinating people who live and work in prisons. Overwhelming and conclusive evidence that people in prisons experience greater burden of disease than the general population [3, 4], higher levels of pre-existing chronic health conditions, and systemic neglect prior to incarceration justify incarcerated populations being prioritised in national vaccination programmes [12, 56, 57, 70, 74]. There was also recognition of the potential utility of prisons, such that a large number of vulnerable individuals could be vaccinated in one setting [56, 67, 70, 77]. Prioritising people who live and work in prisons could help address the marginalisation and exclusion experienced prior to incarceration, protect these individuals from hospitalisation and death, and prevent the further spread of COVID-19. Equally, prison is an opportunistic setting to improve vaccine coverage in the whole population, especially when people in prisons often do not reach out to community health services despite universal health coverage. Several studies notably framed prison staff as first responders and essential key workers, similar to health and social care staff, who are exposed to higher risk of COVID-19 [18, 56, 76, 77]. Prioritising vaccination for these workers would help to ensure that absenteeism does not impact the effectiveness of prison services [65].

Included studies also emphasised the role of environmental factors amplifying the spread of COVID-19 in prisons. These range from overcrowding and unsanitary prison cells to a lack of testing facilities or adequate protective equipment [51, 57, 63, 70, 71, 74, 76, 77]. These findings are in line with reports that have referred to prisons as ‘epidemiological pumps’, meaning that the environment of people who live and work in prisons increases susceptibility to COVID-19 infection [6]. Prison health is public health, and widespread COVID-19 vaccination in prisons would reduce community transmission stemming from inflow and outflow of staff and the short-term incarcerated [51, 57, 63, 70, 72]. It would also mitigate dependencies on secondary care in the community at facilities that are often financially and operationally stretched [52]. The whole of society stands to benefit from improved vaccination uptake by imprisoned people and prison staff.

Clear evidence of the vulnerability of people who live and work in prisons has unfortunately not translated into them being prioritised in most countries’ COVID-19 vaccination programmes. That said, such gaps in national vaccination programmes can only be observed and addressed if robust data are available. In many cases, such data do not yet exist [60, 74]. Additionally, vaccination registration could be incorporated into the national immunisation information system, which could then inform future assessment of vaccination coverage in prisons.

Our review discovered that only a minority of countries–specifically Brazil, Kenya, Morocco, Nepal, and South Africa–have prioritised people who live and work in prisons for vaccination [71, 75, 77, 79]. Many countries–specifically Austria, Croatia, Cyprus, Germany, Greece, Italy, Latvia, Portugal, Romania, and Spain–have not explicitly prioritised these individuals as part of their vaccine rollout, even though some unambiguously recognised the vulnerability of the prison population in official publications [71, 75, 77]. Such inconsistencies are irrational, unethical and discriminatory, and perpetuate the marginalisation and social exclusion that many imprisoned people experienced both before and during their incarceration. Furthermore, addressing the health needs of imprisoned people is likely to have a positive impact on reducing reoffending, thus benefiting the whole of society.

We found that a small number of countries–specifically Canada, the Czech Republic, Israel, Italy, Russia, Switzerland, the UK, and several US States–have prioritised people in prisons for vaccination based on their age and if they suffer from a chronic illness, in line with recommendations for the general public [71, 73, 77, 78]. There was a lack of evidence to demonstrate the value of such prioritisation. One study in the US found that age prioritisation could reduce death rates in prisons [43], and one UK study found it to have little effectiveness in preventing COVID-19 outbreaks [67]. This approach runs the risk of ignoring physical and environmental risk factors, or the high rates of comorbidities experienced by people in prison, with existing research on older people in prisons calling for an eligibility age of fifty. It can also be difficult to identify eligible populations in prisons as a result of poor data recording and limited previous interaction with healthcare services [63].

Prioritisation of those in prison for vaccination has also been limited by some politicians’ moral relativeness and comparing the worthiness of people in prison with that of other community groups. A small number of publications discussed this issue [51, 79]. A policy of limiting care for those in prison is in line with the principle of less eligibility [81], which negates the fundamental right of imprisoned populations to receive the same level of healthcare as the free population.

Many of the included papers considered ethical arguments. Access to vaccines is a human right, and prison populations should be carefully considered as candidates for COVID-19 vaccine trials. One ethical argument put forward was that humans have equal moral worth, irrespective of their culpability [72, 76]. A second was that prioritising people in prison for vaccination can actually reduce the impact of health inequalities, particularly as prison populations have an overrepresentation of people from ethnic minorities and from lower socioeconomic background [5, 52]. A third argument framed states’ duty of care towards those deprived of liberty using the principle of equivalence, i.e., that these populations are entitled to access the same standards of healthcare available in the community [12, 46, 63].

Our analysis of official documents identified an absence of any unified approach regarding prioritisation of people who live and work in prisons, meaning that there is no clear framework for nations to adopt. The European Centre for Disease Prevention and Control does not explicitly urge prioritisation of people who live and work in prisons [71]. In contrast, the WHO advocated for a more inclusive approach by advocating people living and working in detention facilities should be included in national COVID-19 vaccination plans [77]. The lack of synchronisation across the international health guidance does not conform to the Mandela Rules, the Bangkok Rules, the Beijing Rules, or the Havana Rules, or to the International Covenant on Economic, Social and Cultural Rights, which asserts that governments have a duty to protect those in their care when states deprive their liberty. Furthermore, the UN’s Sustainable Development Goals 2030 cannot be reached if the prison population is “left behind” regarding COVID-19 vaccination [31].

Prior to COVID-19, there was a limited body of research on vaccine hesitance among people in prisons compared to the general population. Yet, our analysis illustrates high rates of COVID-19 vaccine hesitancy among people who live and work in prisons, in line with evidence from the wider population. Hesitancy is higher in incarcerated individuals who are young and who come from a minority ethnic background [37, 39, 54, 63]. Reasons for hesitancy commonly included concerns around vaccine safety and efficacy, often fuelled by individual apathy, scepticism, and belief in conspiracy theories [39, 49, 51, 54, 63, 80]. Studies noted that suspicion and distrust among the incarcerated were likely related to long-standing abuse experienced during their time in the criminal justice system [37, 39, 49, 51, 54].

Nonetheless, there is some hope that such hesitancy is fluid. Studies reported that many hesitant individuals were willing to receive information and have their concerns around vaccine safety and efficacy assuaged [37, 54], and a US study found that a substantial proportion of residents who had declined a first vaccine dose accepted a later offer [54].

Despite the utility of targeting prisons as a setting for COVID-19 vaccination rollout, our analysis demonstrates how logistical barriers can hamper such a policy. The need for cold-chain support to deliver the vaccine at recommended low temperatures, and the necessity of administering vaccinations twice at recommended intervals remain the key challenges [46, 56]. High turnover of people in prisons and difficulty tracing those that return to the community can compound this issue, as can vaccine wastage, whereby vaccines cannot be used in another setting [52, 56, 59, 61, 63, 76, 77]. These findings are in line with earlier studies that illustrate historical issues of underfunding [17, 31]. Economic limitations can limit the government’s ability to purchase vaccines, which means fewer doses are available for people in prisons, and at the same time leading to prisons not having sufficient staff to administer vaccinations, and increased uncertainty when staff are required to self-isolate [61, 67].

Our analysis revealed that the majority of papers on vaccination trials were opposed to the inclusion of people in prisons. Objections included the real and perceived pressure from authorities to participate, demands to participate to receive care that could otherwise not be afforded, risks associated with the vaccines being trialled, limited or no on-site clinical support for participants, and no guarantee that participants would benefit from the vaccines if they were found to be safe and effective [47, 62]. These concerns tended to trump the perceived benefits of participation. Indeed, many publications raised the issue that recruiting trial participants from the prison population would reinforce the perpetual exploitation, abuse, and neglect of people in prison. Other studies suggested precursors for participation, such as closer scrutiny by an oversight board and greater consideration of the lived experiences of incarcerated people [47, 48].

Finally, a limited number of studies acknowledged that vaccination is not a panacea. Virus mutation, lag in vaccination uptake, and vaccine hesitancy mean that non-pharmacological interventions must run in tandem with vaccination for the foreseeable future, a fact that is well-documented. Studies put forward interventions such as reducing the prison population, an ongoing commitment to provide adequate testing and personal protection equipment in prisons, limiting transfers between establishments, and improving prison environments [41, 42, 50, 59, 69]. Implementing any of these interventions would not only be in line with existing government obligations regarding prison health, but would also protect vulnerable populations in a precarious environment. Vaccinating the prison population could enable the relaxation of restrictions on movement, meaning that in-person visitation and prison activities could resume safely, while maintaining an appropriate testing regime.

Conclusion

Our analysis of the published literature on COVID-19 vaccinations illustrates that people who live and work in prisons are not being prioritised for COVID-19 vaccinations despite a recognition of their higher rates of morbidity and mortality.

This issue is compounded by factors such as vaccine populism, often perpetuated by politicians, lack of advocacy by key health organisations, vaccine hesitancy, and logistical issues affecting prison establishments. The high quality of papers included for our assessment supports the strength of our findings but they preclude generalisability given that the main focus of these publications was on high income countries.

Evidence presented in this review shows that governments must prioritise prison populations in national vaccination programmes, and that organisations such as the WHO should request transparent data so that rollout and uptake of vaccines in these populations can be adequately monitored. Additionally, efforts should be geared towards reducing the prison population, challenging vaccine populism, and improving health literacy among people who live and work in prisons to increase vaccination uptake. Court interventions could be used as a last resort. Further empirical studies on COVID-19 vaccination among people who live and work in prisons are also needed to enrich discussions on this topic and operationalise our responses beyond the current pandemic.

In December 2021, the WHO predicted the demise of COVID-19 in 2022 [82]. People who live and work in prisons clearly have a stake in achieving this vision. Treating vaccines as public goods and prioritising high-risk groups in the race against the virus is necessary. For the prison population, the adage that “no one is safe until everyone is safe” certainly rings true.

Supporting information