Rising Cases of COVID-19 Among Inmates in South Africa: A Concerning Public Health Matter

In December 2019, Wuhan in China became the centre of an outbreak of pneumonia of unknown cause.¹ In January 2020, the Chinese Health authority confirmed that they have identified the cause of the pneumonia, novel coronavirus (COVID 19). COVID-19 is a respiratory tract infection, transmitted by droplet infection from person to person. Therefore, Chinese Health Authority took a rapid measure to isolate suspected and confirmed cases of COVID-19 [1]. One of the key factors for the rapid spread of COVID19 is the international travel, therefore, the World Health Organisation in March 2020, declared COVID -19 as a pandemic [2]. 

The first reported case of COVID-19 in South Africa was in KwaZulu Natal Province, announced by the Health Minister on 5 March 2020. Following the first case of COVID-19 in South Africa, and subsequent surging in the cases of confirmed COVID-19, the government declared a national state of disaster; urged South Africans to observe simple hygiene rules of regular handwashing, social distancing, restricted public gatherings and meetings to less than 100 people [3]. In addition, restaurants, shops, hubs, churches, mosques etc. were directed to restrict admittance to less than 50 persons at a time. Moreover, liquor stores’ operation times were prohibited to 18:00 hours. These measures were to minimize social contact and to prevent spread of the disease. However, the continued increase of COVID-19 cases in the country based on scientific evidence and experts’ opinion, the government ‘lockdown’ the country on 26 March 2020.  The lockdown measure meant that people should stay at home, and refrain from non-essential movements. To the inmates, they are already home. Correctional services are their home. Intuitively, one would expect that inmates would be safe, and would not contract the virus. However, this is a dream, as the situation plays out differently. Despite the measures taken to lockdown the country, cases of COVID-19 are on the increase, and the inmates are not spare either from contracting the virus.

COVID-19 outbreak is the overwhelming public health challenge, worldwide. As of 20 May 2020, global confirmed cases of COVID -19 stood at 4 904 413, with 323 412 confirmed deaths cases across 216 countries in the world. In South Africa, the confirmed COVID -19 cases were 19 137 and 369 confirmed deaths in the 9 provinces. In the Eastern Cape Province, confirmed cases of COVID-19 were 2324 and 50 deaths [4]. 

COVID-19 has also posed a new challenge in the already congested correctional centres of Eastern Cape Province.  South Africa has 243 correctional centers which accommodate 164 000 inmates. Eastern Cape Province has 42 correctional services, and 10 of these correctional services are closed for renovations, however, 32 correctional services in Eastern Cape Province preserve 18336 inmates [5,6]. Statistics for 2018/19 financial year indicated that correctional centres in South Africa are 37% overcrowded, with 162 875 prisoners against an accommodation capacity of 118 572 bed spaces. Ever before, the level of overcrowding in South African Correctional Services is disturbing and a worrying issue, judging from a public health perspective. The situation is equally a matter of concern with the devastating surge of COVID-19 pandemic. The disease has now spread even to the very isolated people, the incarcerated ones, in the correctional centres of South Africa. The first case registered for COVID-19 in Eastern Cape Prison was in East London female section [7]. A single female correctional official attended a funeral, when the official came back to work, came into contact with “30 officials” who were subsequently requested to self-quarantine while waiting for their test results. 

Disturbingly, the East London Correctional Services has the highest number of COVID-19 cases in the Eastern Cape Province [8]. The Eastern Cape correctional centres remained the hardest-hit province with a growing number of inmates and officials tested positive for COVID-19, the Department of Correctional Services recorded 87 infections: 56 inmates and 31 officials [9]. People who are incarceration are more prone to infection like COVID-19 due to their living conditions in the correctional centres [10]. The most prominent mode of transmission of COVID-19 in correctional services is by physical contact.  Inmates are living in a very close proximity with one another in the cells where they are detained. Consequently, the potentially lethal combination the risk of coronavirus to incarcerated population is high, due to their advanced age, coupled with the challenges of practicing even the most basic disease prevention measures in prison and congestion. Worryingly, correctional facilities are often ill equipped to care for sick inmates, who are more likely to suffer from communicable diseases and chronic health conditions. As they are incarceration, their health needs to be taken care of, subsequently, social distancing was provoked as a strategy to curb the spread of COVID-19 [11]. However, in East London prison physical distancing is not a practical strategy, it is impossible due to congestion and poor basic health practises. 

The COVID-19 pandemic has potentially exposed the living conditions of the inmates in the correctional centres [12]. The effects of COVID-19 on inmates include infection due to poor hygiene, poor ventilation, and daily routine of in and out of officials, who can transmit COVID-19 to the community, as happened in East London correctional centre [13]. Consequently, there is fast spread of the COVID-19 between the officials and the inmates. Subsequently, the correctional officials and visitors transmit the virus back to the community. This contact with inmates can amplify, trigger, serve as reservoir for the wide-spread of the virus within the centre and the community. This emphasize the need to give priority to inmates; and further as explains the public health concerns that should be accorded to the inmates, incarcerated during COVID-19 pandemic. Conversely, the inmates are constrain to practise physical distancing due to congested correctional centres. 

The increase death rate of inmates due to COVID-19 threatens the health of other inmate [14-16]. The inmates are in perpetuate fear of contracting the virus from fellow inmates or officials, thus they are emotionally stressed of the looming fear of death if contracted by the virus [17].Notably, staff members and correctional officers also serve as route of transmission of COVID-19 due their regular home visits; attendance to events such funerals, and subsequent reportage back to work to infect the inmates [18]. The inmates interact with the officials, friends, police, families etc. and these people in turn, relates back to the community. Thus, the propensity of transmitting the COVID-19 back to the community and promoting community spread is imminent. Such scenario would trigger infections and create a burden on healthcare system, which is already overstretch with poor resources. This emphasis the need to give priority to inmates, and explains the public health concerns that should be accorded to the inmates in this era of the COVID-19. What measures could be instituted to protect the inmates and the re-infection of correctional officials?  

Some of the Correctional facilities in South Africa are more than 100% overpopulated; an outbreak of a disease in the Correctional centres would be catastrophic; consequently, it is difficult to prevent the spread of COVID-19 in the facilities without decongestion. Therefore, there is a need to transform the policy related to detention of inmates. 

Catastrophe, such as COVID-19, can cause adversity in the government systems, which include justice, policing, education, food security, health systems etc. To curb the spread of COVID -19, in correctional facilities, to the UN call for all countries to reduce prison populations so that physical distancing and self-isolation conditions can be observe during the COVID-19 period [19]. In response to the COVID-19 pandemic, the South African government authorised the placement on parole of selected categories of sentenced offenders as a measure to combat the spread of COVID-19 in correctional facilities, which are considered high-risk areas for infection (Correctional Services Act of 1998). The decision taken to combat the spread of COVID-19 in correctional centres expected to relieve correctional services facilities by at least 19 000 inmates out of a population of 155 000 [20]. The Parole placement was aimed at addressing health and hygienic challenges within overcrowded South African correctional facilities. 

Practical prevention measures to reduce the number of people in correctional centres, include releasing offenders, processing awaiting-trial detainees, and encouraging judges to use alternatives to incarceration and to prohibit prison visits [21]. However, the correctional officers are allowed to go home and come back to work, with this in and out of officials, cross infection can pose a challenge in curbing COVID -19. The officials are the link between the community and the correctional centres. Therefore, stringent measures need to be considered to prevent cross infection from the community to the centres through officers and vice versa.  The correctional officers should were personal protective clothing, masks, gloves to prevent infecting the inmates. 

Practical and necessary way to address overcrowding is through assessment, categorisation and placement of prisoners in “out of prison sentence” programmes [22]. A suite of alternative sentences is needed such as community service, house arrest and fines, which should be imposed particularly for first-time, young and nonviolent offenders and the parole regime should be re-examined [23]. Other alternative measures could include stepping out community policing in towns and locations settlements. This strategy of visible policing has shown a decrease in crime rate in South Africa due to decrease activities of the people during shut down. There is evidence that there is relationship between COVID -19 and crime. For example, public park purse-snatching has seemingly halted as there are no people in the park due to fear of contracting the virus [24]. Disaster Management Response Strategy across South African Correctional centres and offices is saddled with the responsibility of ensuring entails prevention, containment, treatment and recovery after the pandemic.⁵ Therefore, the decongestion of the correctional serves will assist in flattening of COVID 19. The dispensation announcement excluded inmates’ sentence to life imprisonment or serving terms for specified or other serious crimes, including sexual offences, murder and attempted murder, gender-based violence and child abuse [25,26]. 

It is a critical to implement primary prevention strategies by providing incarcerated population with reading material on COVID 19 written in home language. Knowledge is the power. Correctional service officers and health workers should be trained on management of COVID 19 [27]. Basic hygiene should be practised in the correctional services, the incarcerated population should wash their hands with soap, have sanitisers, taught coughing technique to mitigate the transmition of the disease from person to person. The correctional service officers and health providers should wear personal protective clothing, gloves and masks to prevent infecting the incarcerated population. Limitation of visitors by use of telephones or teleconference to avoid contact with incarcerated from the community [28]. Officers, medical staff legal visitors and general visitors should be screening to avoid sick people attending and visiting the incarcerated. Policies should be updated which will include decongestion of the correctional services, infection control, quality assurance, screening and isolation of infected incarcerated population by the disease. There should be adequate ventilation to promote air flow in the cells [29]. Controlling of COVID 19 in South Africa had cost effect therefore, prevention is the key. Consequently, with these strategies in place, COVID -19 can be flattened in South African correctional services, especially in the Eastern Cape centres.

There are valuable lessons that Correctional centres would learn from the outbreak of the COVID-19 concerning disaster preparedness, infection control regarding poor hygiene and transmission of infectious diseases. Congestion in the correctional centres would implies inmates could amplify, trigger, and serve as reservoir for the wide-spread of the virus among inmates themselves, the officials and by extension the community. Therefore, decongestion of the correctional centres could be one way of flattening the COVID-19 curve. Wellness of the inmates is a public health concern; even without the outbreak of COVID-19, the congestion of inmates in the correctional services ought to be a public health concern, and now, in the era of the COVID-19 pandemic should be a top health priority agenda to decongest the correctional services. The inmates are vulnerable to contracting the disease due to the seemingly deplorable conditions of the prisons. The inmates have a right to safe and healthy living. Their health in this ravaging COVID-19 should be our concerns and care, therefore, efforts to prevent the spread of COVID-19 among inmates in SA is desirable and a priority.

The authors have declared that no competing interest exist

NM and MS conceived and wrote the first draft and DTG provided inputs and edited the article. All authors contributed to the writing of the manuscript, read and approved the final version of the manuscript.

This article used data and information from the public domain and primary authors are cited where applicable.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views and opinions expressed in this article are those of the authors and do not necessary reflect the official policy or position of any affiliated agency of the author