Preventing the spread of COVID-19 in custodial settings.

Dear Editor,

Prisons have been identified as hotspots for the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)1. Prisons are generally overcrowded, less well ventilated and have less access to healthcare services relative to that in community settings (Hawks et al., 2020),2. Incarceration is associated with poor health outcomes such as hypertension, infectious diseases and mental health issues (Wang et al., 2020).

Once Coronavirus Disease 2019 (COVID-19) has been detected in a prison population, transmission is likely to be widespread and has led to calls for release of prisoners on humanitarian and public health grounds (Simpson and Butler, 2020). It is imperative that national responses to COVID-19 include strategies to prevent COVID-19 transmission in prisons and custodial settings (Kinner et al., 2020) . This is to protect incarcerated persons, their families and staff who ultimately are part of the wider community and have an impact on overall containment of the pandemic.

Singapore has experienced widespread community transmission of COVID-19. There have been 52 000 cases of COVID-19 in the country at the end of July 2020(https://www.moh.gov.sg/covid-19). The number of cases peaked in April and May 2020 necessitating the government to impose an unprecedented partial lockdown to control the transmission of the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Singapore still sees triple digit daily rise in cases at the time of writing this article, however the majority of cases are amongst the younger migrant worker population. Mortality rate from COVID-19 remains very low at <0.001% (27 deaths). This is due to the bulk of infections occurring in this younger population who are less likely to succumb to the disease. Whilst community transmission has not been fully eradicated, Singapore has put in place measures to actively protect vulnerable groups such as long-term care facilities that look after the elderly and prison inmates. A strategy to prevent transmission in vulnerable settings can help to minimise morbidity and mortality from the pandemic amidst ongoing community transmission (Wang et al., 2020).

There are 10,570 inmates in Singapore prisons, with one in three are aged 50 years and above 6. As of end July 2020, four inmates and one staff nurse from Singapore’s prisons have tested positive for COVID-19. They were not linked to each other. These inmates were newly admitted from community to prison on different days and had tested positive during their segregation period. Upon diagnosis with COVID-19, the inmates were isolated and transferred to a separate prison facility. Apart from these isolated cases, no evidence of transmission within Singapore prisons has been detected. As long as there is ongoing community transmission of SARS-CoV-2, prisons are at risk of COVID-19 and precautions (Kinner et al., 2020) must be taken to prevent a potentially disastrous outbreak amongst this population who are at higher risk of complications.

The key strategies in preventing COVID-19 transmission in Singapore’s prisons are as follow (https://www.mha.gov.sg/newsroom/in-parliament/written-replies-to-parliamentary-questions/news/written-reply-to-pq-on-covid-19-cases-among-prison-inmates-and-singapore-prison-service-staff-and-anti-covid-measures-for-the-prisons-after-2-june-2020):

Management of newly admitted inmates. As there is community spread of COVID-19 in Singapore, policies have been put in place to screen and segregate new admissions to prisons. All newly admitted inmates are segregated for 14 days from the general prison population and undergo COVID-19 swab tests upon admission and at the end of the segregation period prior to transfer to the general prison.

Management of visitors. In-person visits to inmates have been stopped since a partial lockdown was instituted in Singapore. Even as lockdown measures eased, visitors have not yet been allowed to make in-person visits whilst the community spread of COVID-19 is still being monitored. The Singapore Prison Services implemented teleconferencing two decades ago to facilitate regular contact between inmates and their families. Visitors are able to tele-conference inmates from various community satellite centres across the country. Such virtual conferences are highly encouraged especially during a pandemic. They provide convenience to inmates’ families and minimise unnecessary travel during this time.

Management of prison population numbers. The prison population in Singapore has been falling, in contrast to many other countries worldwide (Hawks et al., 2020). Prison occupancy levels are at 80% (Singapore Prison Service, 2019). Overcrowding is a key factor in the rapid spread of COVID-19 and keeping prison numbers manageable is a key strategy in preventing COVID-19 transmission. Singapore prison numbers were not always low. In the 1990s, Singapore prisons faced issues of overcrowding, understaffing and low morale. This led to the push to establish rehabilitation as a key pillar of the Singapore prisons strategy, culminating in the launch of the Yellow Ribbon Project (YRB) (https://www.yellowribbon.gov.sg/) in 2004. The YRB seeks to reintegrate prisoners and prevent recidivism through community engagement and rebuilding the lives of ex-inmates through increasing their employability. Its tagline “unlock the second prison” recognises the many barriers and stigma that ex-inmates face upon release. The success of these rehabilitation efforts has reaped benefits in the time of a pandemic where isolated community cases have not led to the spread of COVID-19 in Singapore prisons.

COVID-19 has revealed many societal cracks and cast a spotlight on vulnerable populations. Prison release especially of those at highest risk from COVID-19 has been proposed (Hawks et al., 2020; Simpson and Butler, 2020) but efficacy and future ramifications are uncertain. The COVID-19 pandemic is likely to persist for some time. It is imperative that preventive measures are undertaken to protect prison populations as part of any comprehensive strategy to combat the pandemic To et al. (2020). A high index of suspicion, constant adaptability and review of measures to minimise transmission of COVID-19 is crucial as the pandemic continues to evolve. Furthermore, continued community engagement and measures to release ex-inmates from the ‘second prison’ are key to an overall strategy to reduce prison numbers and prevent future outbreaks in custodial settings.

Authors’ statement

No funding was received for this article.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.