More work necessary to build trust around vaccines among people who are incarcerated.

Written by Sarah Khorasani and Alysse Wurcel, MD MS, Tufts Medical Center, Department of Medicine

Criminal-legal involved populations, including people incarcerated in jail and prison, face a disproportionate burden of both chronic and infectious diseases. In particular, the conditions of confinement increase the transmission risks of respiratory infections like COVID-19 and influenza in carceral settings. Amid the ongoing COVID-19 vaccine distribution efforts, many reports have highlighted hesitation to get the vaccine, particularly among communities of color and people from lower-income communities.

In Massachusetts, people in congregate settings, including people incarcerated in jail, have been prioritized for COVID-19 vaccination. Although prioritization is a crucial and necessary step to vaccinating an already vulnerable population, we must acknowledge that offers of vaccination may not be universally accepted.

Influenza, which shares a transmission mechanism with COVID-19, is responsible for millions of illnesses and tens of thousands of deaths annually in the US despite the existence of effective vaccines. However, there has been limited research and policy related to influenza vaccinations in jails, and no research that we are aware of examines the acceptance of flu vaccines among people incarcerated in jails.

Our work in Massachusetts has identified heterogeneous flu-related policies and infrequent acceptance of influenza vaccines in jails. We gathered flu vaccine acceptance data from first-pass vaccination efforts in Massachusetts jails in the hope that these data would shed light on gaps in care that may impact health outcomes and delivery of the COVID-19 vaccine among people who are incarcerated.

Influenza vaccine acceptance rates among people incarcerated in Massachusetts jails, September-October 2020 (Total n=3246)

Of the fourteen jails in Massachusetts, seven responded to our request for information. Overall, the flu vaccine acceptance rate was 28.1%, ranging between 15.9% and 46.4% across facilities. Not all people experiencing incarceration in each facility were offered vaccines during initial vaccination efforts. Four of the seven facilities had an acceptance rate at or below 25% among over 2000 people offered vaccines. Two of the facilities with an acceptance rate over 40% offered the vaccine to fewer than 200 people, while the third facility offered the influenza vaccine to nearly 1000 individuals.

While prioritizing vaccination for infectious diseases among those experiencing incarceration is essential for improved outcomes and health equity, ensuring that people in carceral settings are vaccinated requires more than getting vaccines to correctional facilities.

Vaccine delivery to carceral settings is in itself a particular and under-studied challenge that bears careful examination as COVID-19 vaccine distribution efforts continue. During the H1N1 influenza pandemic in 2009-2010, a narrow majority of federal and state prisons received the vaccine though only 28% of jails did. Distribution of vaccinations to all carceral settings regardless of size and type must improve. Even with improved distribution mechanisms, however, the presence of vaccines means little if the people who need them do not want them.

Low vaccine acceptance is particularly likely in a population that has faced decades of exploitation by the criminal-legal and medical establishments and is often forgotten about in discussions of public health. The structure of the correctional system itself also serves to augment already incredible racial inequities. This is particularly meaningful given that studies on vaccine hesitancy, or the factors, behaviors, and attitudes related to the delay or refusal of vaccination, have noted marked racial differences in influenza vaccination rates and in reasons for avoiding vaccination. Communities of color regularly express more hesitancy than their white peers with reasons for vaccine hesitancy including perceived need for vaccine, perceived safety and efficacy of vaccines, and childhood experiences. Perceived racial fairness has also been associated with increased probability of vaccination among black adults.

COVID-19 has highlighted the unique risks and the significant health inequities experienced by people incarcerated in jails and prisons. The close quarters and limited movement allowed in carceral settings particularly restrict infection mitigation efforts. The spread of COVID-19 in carceral settings not only affects the health of those who are incarcerated but also the health of the surrounding communities. Vaccines offer a safe and cost-effective way to prevent many infectious diseases, including COVID-19 and influenza.

Correctional facilities are critical sites for preventive care including through safe and effective vaccines for influenza, but people incarcerated in Massachusetts jails during initial influenza vaccination efforts for the 2020-2021 influenza season were unlikely to accept vaccination. Though the data discussed here represent only a small subsection of correctional facilities and the populations they house, they are evidence that further work is necessary to identify barriers to vaccination. These data also indicate significant potential challenges in COVID-19 vaccination efforts.

We must prioritize and engage people experiencing incarceration to build trust in vaccination efforts with the ultimate goal of improving health outcomes and health equity. Further research into vaccine hesitancy both for influenza vaccines and for the COVID-19 vaccines in correctional settings will be essential to protect the health of our communities and their most vulnerable members.

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