The utility of video technology and enhanced infection control in reducing COVID-19 disease burden in a custodial setting.

We describe the use of video technology to enhance case interviews, identify COVID-19 contacts, and determine exposures risk within a large juvenile temporary detention center. We created a COVID-19 outbreak management protocol which included the formation of an outbreak management team and enhanced infection control practices using video surveillance. Currently, our institution's positivity rate remains low for both staff and residents largely because of the outbreak management team. Video technology combined with enhanced infection control practices can be a useful technique to reduce COVID-19 infections in custodial settings.

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On Wednesday, March 11, 2020, the World Health Organization (WHO) declared COVID-19, the disease caused by the virus known as SARS-CoV-2, a pandemic. SARS-CoV-2 is transmitted via respiratory droplets and has caused significant morbidity and mortality worldwide. At the end of July 2020, more than 4 million cases of COVID-19 and 140,000 deaths were reported in the United States. There have been multiple large outbreaks within custodial secured settings because these settings have complex internal and external factors that place them at high risk for the rapid spread of infection. Those factors include poor ventilation, lack of negative pressure rooms, outdated environmental engineering designs, and difficulties maintaining social distancing. , The odds of a viral outbreak, including SARS-CoV-2, in custodial settings is high and is often introduced into these settings by employees, contractors, and visitors. In light of the many accounts of rapid transmission and high morbidity from the SARS-CoV-2 virus in federal and state correctional facilities, , this article presents an example of how video technology combined with enhanced infection control measures was used to reduce disease burden at our facility. Cook County Juvenile Temporary Detention Center (JTDC) is the largest juvenile correctional facility in the nation with 601 full-time employees. This facility provides care and custodial services for minors waiting adjudication and has a daily rolling average population of 180 minors, both male and female, ranging in age from 10 to 20 years old. The JTDC is open 24 hours, 365 days and operates 3 main shifts with flexible staffing patterns depending on operational needs. JTDC has 700 digital video cameras that continuously record activities in all areas except washrooms and offices. All feeds are linked to the recording system hard drive which stores video recording for the previous 30 days. In early March 2020, with news of the pandemic dominating the news cycle, the medical team began joint response planning with the executive team. The focus was disease burden reduction by creating infection control protocols centered around recognition of symptoms for early case detection, proper use of personal protective equipment training, hand washing, social distancing, and respiratory etiquette. The highest priority was placed on training employees on the proper use of personal protective equipment. As a result, more than 150 training sessions were conducted by the nursing team in 30 days. We created a COVID-19 outbreak management team (OMT) which consisted of employees from human resources (HR), the medical team, the general counsel, video review specialists, and management. The team met daily or as needed and modified operations as the state, county, and city declared states of emergency and as public health recommendations changed. Infection control protocols included universal mask wearing, daily temperature checks for employees upon entry into the main facility and then again when entering the secured areas of the building. When a residential unit was placed on quarantine, our team of nurses and correctional medical technicians completed temperature checks on every shift for the duration of the quarantine. The following social distancing measures were implemented: Only 3 people were allowed on elevators at any one time, and 6-foot distance markers were placed throughout the facility. Additionally, employees received regular training and reminders to maintain a social distance of 6 feet, practice respiratory etiquette, wash their hands regularly, always wear their masks, and immediately report any COVID-19 symptoms to their direct supervisor.

Upon case notification, a member of the OMT interviewed the infected employee or resident to determine contacts and last locations. The interview was supplemented with time clock confirmation for employee's location and entry point into the facility and the surveillance video which was reviewed by a specialized team within 48 hours. Identified close contacts who were employees were instructed by HR to quarantine, get tested for SAR-COV-2, complete daily temperate check, and at the end of 14 days obtain medical clearance from their health care provider before returning to the facility (Fig 1 ). In cases where the close contact was a resident, that resident was monitored using established isolation and quarantine guidelines. From March through July 2020, video technology was used for 43 contact tracing investigations by OMT. These investigations revealed 306 and 417 close contacts for employee and residents respectively. Total cumulative hours of video footage reviewed were 484 hours. We actively identified resident and employee cases by reviewing residents sick call notes, testing either during point prevalence studies, when symptomatic, or after exposure, which meant that occasionally, individuals were tested multiple times. Primary attack rates were calculated by dividing the number of infected individuals by the population at risk. When one of the residential units had a cluster of infections, the team was able to identify the source by reviewing video footage. By using contact tracing, the team was able to identify any employees who had close contacts with residents. All residents exposed to an infected employee were tested to determine the secondary attack rate. The primary and secondary attack rates for residents were 5.4% and 2.9% compared with 7.2% and undetermined for employees. The secondary attack rate for employees could not be determined for the following reasons: Employees could be close contacts to other employees and their own household members simultaneously making the exact source of infection difficult to determine, the temporal nature of COVID-19, disease incidence pattern, asymptomatic carriage, and widespread community transmission. As a result of these investigations, cumulative number of medical isolation days for infected employees and residents were 602 and 314 compared with number of quarantine days for close contacts of 3,060 and 4,170, respectively. The high rates of employee absenteeism because of isolation and quarantine days made it necessary to hire temporary employees from an external agency to meet the acute staffing needs. The number of SARS-COV-2 reverse transcription–polymerase chain reaction (RT-PCR) tests obtained because of contact tracing and point surveillance studies for employees and residents was 800 and 917 (Table 1 ).

Fig 1.

Outbreak management workflow. Case: Employee or resident with a positive test for SARS-CoV-2, the virus that causes COVID-19, by reverse transcription–polymerase chain reaction (RT-PCR). Close contact: Any individual within 6 feet of an infected employee or resident for at least 15 minutes

Table 1.

Characteristics and outcome of OMT investigations

Characteristics	Employee (N = 601)	Resident (N = 505)
Age (Mean (SD))	41 (11)	17 (12)
Number of laboratory confirmed SAR-COV-2 Infections (N)	43	27*
Number of SAR-COV-2 RT-PCR tests completed (N)	800	917
Positivity rate	5.4%	2.9%
Primary attack rate	7.2%	5.4%
Secondary attack rate	†	2.0%
Number of close contacts identified (N)	306	417
Cumulative medical isolation days (N)	602	314
Cumulative quarantine days (N)	3,060	4,170

NOTE. Residents = Minor in custody awaiting adjudication.

Newly admitted cohort = 19 General population = 8.

Could not be determined because of temporal nature of disease and widespread community infection; Positivity rate = Total number of positive test/Total number of tests; Primary attack rate= Total of positive test/total number of people tested; Secondary attack rate = Number of infections from primary case.

The use of video technology to enhance case interviews and identify COVID-19 contacts and exposures within a detention center is innovative. Typically, video technology is used to monitor the activities of inmates or residents in correctional or detention settings. Our outbreak management protocol is similar to the one developed by the Irish Prison System and described by Clark et al. The advantages of video review include the following: (1) Immediate identification of close contacts allowing recommendations for immediate testing, medical isolation, and quarantine; (2) 360° video angles of the route and location of the individual for up to 30 days prior to identification; (3) Identification of the details of each exposure incident, including observation of whether employees adhered to the recommended infection control practices, and quantification of the duration of exposure using the video timestamp; (4) Supplementation of the oral interview in cases where the narrative regarding activities or contacts was unclear. Video review helped improve compliance with infection control protocols because it revealed unidentified issues and areas in need of improvement, such as, appropriate masking and enforcement of social distancing. It also allowed the OMT to implement changes such as requiring floor nurses to wear face shields, and installation of sneeze guards on nursing carts. Authors in an earlier study describe limitations such as the lengthy time required to review the video footage, and the accuracy of individual identification if the video was outside the facility or in one of the camera blind spots. , For residents, none of the secondary cases led to further infections thus justifying the cost benefit of the labor intensive video footage reviews to identify unprotected exposures to confirmed cases. In addition, the OMT's use of video technology in combination with enhanced infection control measures was crucial in maintaining low positivity rates for employees and residents. While not often available in settings outside of highly monitored custodial facilities, this technique may be useful for other correctional facilities and juvenile detention centers to perform in depth contact tracing for employees, inmates, and residents.