A Retrospective Analysis and Comparison of Prisoners and Community-Based Patients with COVID-19 Requiring Intensive Care During the First Phase of the Pandemic in West Texas.

BACKGROUND: COVID-19 is a highly infectious disease which usually presents with respiratory symptoms. This virus is disseminated through respiratory droplets, and, therefore, individuals residing in close quarters are at a higher risk for the acquisition of infection. The prison population is at a significantly increased risk for infection.
METHODS: Prisoners from the Montford Correctional facility in Lubbock, Texas, hospitalized in the medical intensive care unit at University Medical Center between March 1, 2020 and May 15, 2020 were compared to community-based patients hospitalized in the same medical intensive care unit. Clinical information, laboratory results, radiographic results, management requirements, and outcomes were compared.
RESULTS: A total of 15 community-based patients with a mean age of 67.4 ± 15.5 years were compared to 5 prisoners with a mean age of 56.0 ± 9.0 years. All prisoners were men; 10 community-based patients were men. Prisoners presented with fever, dyspnea, and GI symptoms. The mean number of comorbidities in prisoners was 2.4 compared to 1.8 in community-based patients. Prisoners had significantly lower heart rates and respiratory rates at presentation than community-based patients. The mean length of stay in prisoners was 12.6 ± 8.9 days; the mean length of stay in community-based patients was 8.6 ± 6.5. The case fatality rate was 60% in both groups.
CONCLUSIONS: Prisoners were younger than community-based patients but required longer lengths of stay and had the same mortality rate. This study provides a basis for comparisons with future studies which could involve new treatment options currently under study.

Introduction

COVID-19 has impacted the entire United States, and the prison community is no exception.[1,2] Among the prisoners, the first COVID-19 related death was in Georgia on March 26th, when a prisoner named Anthony Cheek died in Lee State Prison. Since then, the Marshall Project has tracked COVID-19 related deaths in prison systems nationwide.[3] Both prisoners and staff members alike have had a 150% increase in COVID-19 infections compared to the general United States population. As of July 3, 2020, the total number of cases in Texas prisons was 8240 with a rate of 588 per 10 000 prisoners; 79 prisoners have died with a rate of 6 per 10 000. The first 2 cases of COVID-19 in Lubbock, Texas were reported by the local media on March 17, 2020. This raised immediate concerns regarding the possibility of additional cases in vulnerable populations, including the Lubbock County Jail and prisons in this region. The Montford Correctional Facility in Lubbock, Texas, has fifty skilled nursing beds, including 6 respiratory isolation rooms, and forty-four long-term care beds, for a total of 94 beds. There is also area with 30 additional beds and 550 in-patient mental health beds. The official protocol at the Montford facility requires the placement of prisoners testing positive for COVID-19 in isolation in a separate area of the facility with 1 prisoner per room. When the maximum capacity has been reached, prisoners are placed in a specific housing order: negative pressure respiratory isolation rooms on the ward, then rooms for single occupants, then rooms for 2 occupants, then rooms for 4 occupants on the ward. Patients presenting with similar symptoms are also grouped in the same area until test results are available. COVID-19 positive prisoners are checked twice daily to measure O2 saturations, temperatures, and vital signs and are referred to an emergency facility if they are unable to maintain O2 saturations of at least 92%.

This report compares the clinical presentation and outcomes of COVID-19 positive community-based patients with the COVID-19 positive prisoners from the Montford Correctional Facility in Lubbock, Texas, hospitalized between March 1, 2020 and May 15, 2020 in the medical intensive care unit at University Medical Center in Lubbock, Texas.

Methods

Demographic and clinical information

A list of patients with COVID-19 infections established by PCR tests was obtained from the Infection Control and Prevention Office at University Medical Center in Lubbock, Texas. The PCR tests used in our hospital include Xpert® Xpress SARS-CoV-2 (Cepheid, Sunnyvale, California), The BD SARS-CoV-2 Reagents for BD MAX™ System (Becton, Dickinson and Company, Sparks, Maryland), and The DiaSorin Molecular Simplexa™ COVID-19 Direct real-time RT-PCR (DiaSorin Molecular LLC, Cypress, California). The timeframe for hospitalization for these patients ranged from March 1 through a May 15 discharge date. Medical records of all patients admitted to the medical intensive care unit were reviewed to determine demographic characteristics, symptoms, comorbidity, initial vital signs, initial laboratory tests, initial chest x-ray abnormalities. Outcomes, including the requirement for mechanical ventilation, the requirement for continuous renal replacement therapy, the requirement for vasopressors, the length of stay, and mortality, were recorded.

Data analysis

Results were summarized using means and standard deviations, medians and interquartile ranges, and numbers with percentages. Differences between community-based patients and prisoners hospitalized in an intensive care unit were determined using t tests for continuous variables and Fisher exact tests for categorical variables using the Excel statistics package.

Study approval

This study was approved by the Institutional Review Board (L20-172) at Texas Tech University Health Sciences Center in Lubbock, Texas, and by administrative review at University Medical Center in Lubbock, Texas.

Results

The initial hospitalized cohort included 63 patients; 43 patients were admitted to the hospital and 20 patients were admitted to the MICU. Of these 20 MICU patients, 5 were from the Montford Correctional Facility. Table 1 reports the mean age, gender, and ethnicities of the community-based patients and prisoners in the MICU. The mean age difference between the prisoners and non-prisoners was11.4 years (P = .07). Table 2 reports the symptoms and comorbidities for the prisoners and non-prisoners at initial presentation. More prisoners presented with dyspnea, nausea and vomiting, diarrhea, and fever than the non-prisoners. This table also reports the mean number of comorbidities in both groups; the mean was 2.4 in prisoners and 1.8 in community-based patients.

Table 1.

Demographics.

		Non-prisoners N = 15	Prisoners N = 5
Age	Years, mean ± SD	67.4 ± 15.1	56 ± 9.0*
Gender	Male, N (%)	10 (66.6%)	5 (100%)
	Female, N (%)	5 (33.3%)	0 (0%)
Ethnicity	White, N (%)	7 (46.7%)	1 (20%)
	Hispanic, N(%)	6 (40%)	2 (40%)
	Black, N (%)	1 (6.7%)	1 (20%)
	Other, N (%)	1 (6.7%)	1 (20%)

P = .07, t test.

Table 2.

Initial Symptoms and Comorbidity.

	Non-prisoners N = 15	Prisoners N = 5
Symptoms
Fever, N (%)	8 (53.3%)	4 (80%)
Dyspnea, N (%)	12 (80.00%)	5 (100%)
Cough, N (%)	9 (60%)	3 (60%)
Chest Pain, N (%)	1 (6.7%)	0 (0%)
N/V, N (%)	0 (0%)	2 (40%)
Diarrhea, N (%)	0 (0%)	1 (20%)
Abd Pain, N (%)	0 (0%)	0 (0%)
Comorbidities
Diabetes, N (%)	6 (46.7%)	4 (80%)
HTN, N (%)	14 (86.7%)	5 (100%)
CHF, N (%)	1 (6.7%)	0 (0%)
COPD, N (%)	0 (0%)	1 (20%)
CKD, N (%)	2 (13.3%)	2 (40%)
Cirrhosis, N (%)	1 (6.7%)	0 (0%)
Cancer, N (%)	1 (6.7%)	0 (0%)
Comorbidities*	1.8 (1.4)	2.4 (0.6)
Charlson Comorbidity Index*	4.9 (2.9)	4.0 (1.2)

Abbreviations: Abd: abdominal; HTN: hypertension; CHF: congestive heart failure; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease.

Mean and standard deviation.

Table 3 reports initial vital signs in prisoners and non-prisoners. Prisoners had lower blood pressures, respiration rates, and heart rates. Table 4 includes the admission laboratory tests and chest x-ray results. Prisoners had lower WBC counts, neutrophil/lymphocyte (N/L) ratios, and BUN levels than community-based patients. In prisoners, 20% of chest x-rays were clear. Non-prisoners presented with higher rates of diffuse infiltrates, cardiomegaly, and pleural effusions. Management of the prisoners included higher rates of mechanical ventilation and convalescent plasma transfusion and lower rates of vasopressor administration and continuous renal replacement therapy (Table 5). Prisoners stayed in the MICU for an average of 4.01 more days than non-prisoners. However, the case fatality rate for the younger prisoners was the same as the older community-based MICU patients (both 60%)

Table 3.

Initial Vital Signs.

		Non prisoners N = 15	Prisoners N = 5
Vital signs	HR, beats/minute mean (SD)	102.7 (27.0)	81.0 (9.1)*
	BP systolic, mmHg mean (SD)	116.6 (22.2)	99.6 (39.9)
	BP diastolic, mmHg mean (SD)	70.2 (21.1)	58.2 (20.4)
	BP mean, mmHg mean (SD)	94.8 (21.5)	78.9 (29.6)
	RR, breaths/minute mean (SD)	27.4 (8.2)	21.0 (3.9)*
	O2 sat, % mean (SD)	85.6 (10.3)	87.6 (10.0)
	Temperature, °F mean (SD)	99.4 (2.0)	98.5 (2.2)

Abbreviations: BP: blood pressure; HR: heart rate; RR: respiratory rate; sat: saturation; SD: standard deviation.

P < .05.

Table 4.

Laboratory and Chest X-Ray Results.

		Non-prisoners	Prisoners
Lab	Hb gm/dL mean (SD)	12.9 (3.5)	13.2 (0.99)
	WBC, k/µL mean (SD)	10.1 (6.2)	5.7 (3.6)
	% N, mean (SD)	83.3 (10.0)	66.8 (8.8)
	% L, mean (SD)	9.9 (6.4)	20.1 (3.6)*
	N/L ratio, mean (SD)	15.8 (18.4)	3.4 (1.0)*
	Platelets, k/µL mean (SD)	239.2 (108.0)	170.2 (101.2)
	Na, meq/L mean (SD)	136.0 (7.7)	135.2 (4.3)
	BUN, mg/dL mean (SD)	38.1 (31.5)	26.4 (16.4)
	Cr, mg/dL mean (SD)	1.95 (1.72)	1.9 (1.4)
	Glucose, mg/dL mean (SD)	187.2 (129.0)	121.0 (40.4)
	Albumin, gm/dL mean (SD)	3.46 (0.6)	3.0 (0.6)
	CRP, mg/L Mean (SD)	21.8 (7.6)	11.3 (5.0)
Chest x-rays	Clear lung fields N (%)	0 (0)	1 (20 %)
	Focal infiltrates N (%)	0 (0.00 %)	1 (20.00%)
	Diffuse infiltrates N (%)	14 (70.00%)	3 (60.00%)
	Cardiomegaly N (%)	6 (40.00%)	0 (0.00%)
	Pleural effusion N (%)	1 (6.67%)	0 (0.00%)

Abbreviations: BUN: blood urea nitrogen; Cr: creatinine; CRP: C reactive protein; Hb: hemoglobin; L: lymphocytes; N: neutrophils; N: number; Na: sodium; SD: standard deviation; WBC: white blood count.

P < .05.

Table 5.

Management, LOS, and Mortality.

		Non-prisoners	Prisoners
Mechanical ventilation	N (%)	6 (40.00%)	4 (80.00%)
PaO2/FiO2 ratio mmHg	Mean (SD)	116 (69)	137 (131)
CRRT	N(%)	2 (13.00%)	0 (0.00%)
Vasopressors	N (%)	9 (60.00%)	1 (20.00%)
Plasma, convalescent	N (%)	3 (20.00%)	2 (40.00%)
LOS	Days, mean ± SD	8.6 ± 6.5	12.6 ± 8.9
Mortality	N (%)	9 (60.00%)	3 (60.00%)

Abbreviations: CRRT: continuous renal replacement therapy; LOS: length of stay; N: number; SD: standard deviation.

Discussion

This study compares the presentation of community-based patients and prisoners from a local correctional unit who required admission to the medical intensive care unit during the first phase of the COVID-19 pandemic in West Texas. The prisoners were younger, presented with both respiratory and gastrointestinal symptoms, and had more comorbidity. They often required mechanical ventilation and received convalescent plasma through a multicenter study. Their length of stay in the ICU was longer; the case fatality rate was the same as community-based patients even though they were on average a decade younger. Although this study included a small number of prisoners, it provides clinical information not available in larger reports which just provide summary statistics on infection and mortality in prisoners.[1-4]

The Marshall project has tracked the frequency of COVID-19 infections in prisons throughout the United States.[3] As of July 3, 2020, the total number of cases in Texas was 8240 for a rate of 5880 per 100 000 prisoners; 79 prisoners have died for a rate of 60 per 100 000. In addition, 1455 prison staff personnel have had COVID-19 infections, and 8 have died. Saloner et al. reported that the age and sex standardized mortality ratio for prisoners in United States was approximately 2.95 times the expected mortality rate based on the US population.[4] This information demonstrates that the COVID-19 infections are frequent in prisons and are probably accelerated by the crowded conditions. These crowded conditions make it possible that prisoners would have multiple exposures to infected source cases and potentially have a higher viral load. Pujadas et al. reported that high viral loads are a significant predictor of mortality.[5] Wang and colleagues measured viral loads and antibody responses in 12 patients with severe COVID-19 disease requiring mechanical ventilation and in 11 patients with mild disease. Patients with severe disease had viral shedding in a variety of tissues for 20 to 40 days. Patients with mild disease had viral shedding restricted to the respiratory tract and had no virus detectable at 10 days after the onset of their illness.[6]

The prisoners in our study had gastrointestinal symptoms, and this might suggest that they have disseminated viral infection and, therefore, higher viral loads and more inflammation. Huang et al. have recovered coronavirus from nasal swabs, sputum/endotracheal tube aspirates, gastric fluid, and feces.[7] This indicates viral infections are not limited to the upper and lower respiratory tracts and can involve other tissues. It also indicates additional sources for infection that greatly complicate facility management. The prisoners in this study had lower blood pressures, lower heart rates, and lower respiratory rates then community-based patients at presentation. These “more normal” vital signs might cause health care personnel to underestimate the severity of illness at presentation, and this could delay transfer to higher levels of care. In addition, the logistics of transferring prisoners from one facility to another could cause delays.

The prisoners had more comorbidity, especially hypertension and diabetes. Wilper et al. reported a similar increased prevalence of chronic conditions in prisoners when compared to the same age noninstitutionalized non-prisoners.[8] These comorbidities increase the aggregate disease burden and potentially explain high mortality rates in all age groups in comparison to patients with less comorbidity. In addition, some types of comorbidity may be associated with less effective host defense responses and increased viral replication and dissemination. Understanding of these interactions will require prospective studies with quantitative viral load measurements. Price-Haywood and colleagues analyzed outcomes in a large number of patients with COVID-19 infections hospitalized in integrated delivery healthcare system in Louisiana.[9] This study demonstrated that age, respiratory rate, absolute lymphocyte counts below 1000/µL, platelet counts below 150 000/µL, and creatinine levels >1.5 mg/dL were associated with in-hospital mortality. These relatively simple clinical parameters can help identify patients at risk for mortality. However, the complexity of disease presentation in COVID-19 patients makes it unlikely that a single set of parameters will consistently identify high risk patients.

The main limitation in this study is the small number of prisoners and non-prisoners since it included only the first phase (from March 1–May 15, 2020) of the COVID-19 pandemic in West Texas. Future studies should compare this information to later time periods as COVID-19 continues to spread in prisons and the community, as hospitals and healthcare workers gain more experience managing these patients, and as controlled studies identify better treatment options.

Conclusion

The recent COVID-19 pandemic has affected the general population and, more severely, prisoners. This study demonstrates that prisoners may have slightly different clinical presentations, have frequent comorbidity, and have very poor outcomes even with intensive care management. The study demonstrates that routine vital signs may not reliably detect critically ill patients and that gastrointestinal symptoms should not be ignored in these patients. Correctional healthcare systems have a tremendous burden managing patients and protecting staff. Short-term solutions include more rapid detection of infected cases and rigorous isolation procedures in these cases.[10]