COVID-19 Case and Mortality Rates in the Federal Bureau of Prisons

INTRODUCTION

People living in correctional facilities are at high risk for contracting COVID-19. To characterize the burden of COVID-19 in the Federal Bureau of Prisons, inmate testing, case, and mortality rates are calculated and compared with those of the U.S.

METHODS

Federal Bureau of Prisons data were derived from its inmate management system and a Federal Bureau of Prisons COVID-19-specific database. U.S. data were derived from the Centers for Disease Control and Prevention and the U.S. Census. Data were aggregated from February to September 2020 and accessed in September and November 2020. Testing rates were calculated for both the Federal Bureau of Prisons and the U.S. Case and infection fatality rates were calculated overall and by institution and compared with those of the U.S. An age- and sex-standardized mortality ratio was calculated.

RESULTS

The Federal Bureau of Prisons tested more than half of its inmates (50.3%); its crude case and mortality rates were 11,710.1 and 77.4 per 100,000, respectively. Compared with the U.S., the case ratio was 4.7, and the standardized mortality ratio was 2.6. The infection fatality rate for both the Federal Bureau of Prisons and the U.S. was 0.7%. Among institutions that tested ≥85% of inmates, the combined infection fatality rate was 0.8% and ranged from 0.0% to 3.0%.

CONCLUSIONS

The Federal Bureau of Prisons COVID-19 case rates and standard mortality ratio were approximately 5 and 2.5 times those in U.S. adults, respectively, consistent with those of prisons nationwide. High testing rates and standardized death reporting could result in a more accurate infection fatality rate in the Federal Bureau of Prisons than in the U.S. Testing and other mitigation strategies, including reducing the population, have likely prevented further transmission and mortality in the Federal Bureau of Prisons.

SARS-CoV-2 Infection Among Correctional Staff in the Federal Bureau of Prisons

Objectives. To examine SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) epidemiology and risk factors among Federal Bureau of Prisons (BOP) staff in the United States.Methods. We calculated the SARS-CoV-2 case rate among 37 640 BOP staff from March 12 to June 17, 2020, using payroll and COVID-19-specific data. We compared occupational factors among staff with and without known SARS-CoV-2 using multiple logistic regression, controlling for demographic characteristics. We calculated relative risk among staff in stand-alone institutions versus complexes (> 1 institution).Results. SARS-CoV-2 was reported by 665 staff across 59.8% of institutions, a case rate of 1766.6 per 100 000. Working in dorm-style housing and in detention centers were strong risk factors, whereas cell-based housing was protective; these effects were erased in complexes. Occupational category was not associated with SARS-CoV-2.Conclusions. SARS-CoV-2 infection was more likely among staff working in institutions where physical distancing and limiting exposure to a consistent set of staff and inmates are challenging.Public Health Implications. Mitigation strategies-including augmented staff testing, entry and exit testing among inmates, limiting staff interactions across complexes, and increasing physical distancing by reducing occupancy in dorm-style housing-may prevent SARS-CoV-2 infections among correctional staff.

County-Level COVID-19 Vaccination Coverage and Social Vulnerability - United States, December 14, 2020-March 1, 2021

The U.S. COVID-19 vaccination program began in December 2020, and ensuring equitable COVID-19 vaccine access remains a national priority.* COVID-19 has disproportionately affected racial/ethnic minority groups and those who are economically and socially disadvantaged (1,2). Thus, achieving not just vaccine equality (i.e., similar allocation of vaccine supply proportional to its population across jurisdictions) but equity (i.e., preferential access and administra-tion to those who have been most affected by COVID-19 disease) is an important goal. The CDC social vulnerability index (SVI) uses 15 indicators grouped into four themes that comprise an overall SVI measure, resulting in 20 metrics, each of which has national and state-specific county rankings. The 20 metric-specific rankings were each divided into lowest to highest tertiles to categorize counties as low, moderate, or high social vulnerability counties. These tertiles were combined with vaccine administration data for 49,264,338 U.S. residents in 49 states and the District of Columbia (DC) who received at least one COVID-19 vaccine dose during December 14, 2020-March 1, 2021. Nationally, for the overall SVI measure, vaccination coverage was higher (15.8%) in low social vulnerability counties than in high social vulnerability counties (13.9%), with the largest coverage disparity in the socioeconomic status theme (2.5 percentage points higher coverage in low than in high vulnerability counties). Wide state variations in equity across SVI metrics were found. Whereas in the majority of states, vaccination coverage was higher in low vulnerability counties, some states had equitable coverage at the county level. CDC, state, and local jurisdictions should continue to monitor vaccination coverage by SVI metrics to focus public health interventions to achieve equitable coverage with COVID-19 vaccine.

School Use and Normative Perceptions of Electronic Nicotine Product Use Among Middle and High School Students-November 2018

PURPOSE

This study examined U.S. middle and high school student observations of electronic nicotine product (ENP) use in and around the school building and students' normative perceptions of use among peers.

METHODS

Adolescents and young adult participants enrolled in middle (n = 672) or high school (n = 962) were recruited from an online nationally representative panel and surveyed from November 2 to 15, 2018. They answered questions on observed ENP use in and around the school building as well as perceptions of use among peers.

RESULTS

Nearly one in five U.S. middle and high school students believed that at least half of their peers used ENPs. Confirming anecdotal reports, nearly six in 10 reported ever seeing someone use ENPs in or around their school, most often outside the school building and in bathrooms or locker rooms.

CONCLUSIONS

The findings of this study underscore the importance of targeted prevention strategies and education efforts to prevent and combat adolescent ENP use in and around schools.

Demographic Characteristics of Persons Vaccinated During the First Month of the COVID-19 Vaccination Program - United States, December 14, 2020-January 14, 2021

In December 2020, two COVID-19 vaccines (Pfizer-BioNTech and Moderna) were authorized for emergency use in the United States for the prevention of coronavirus disease 2019 (COVID-19).* Because of limited initial vaccine supply, the Advisory Committee on Immunization Practices (ACIP) prioritized vaccination of health care personnel† and residents and staff members of long-term care facilities (LTCF) during the first phase of the U.S. COVID-19 vaccination program (1). Both vaccines require 2 doses to complete the series. Data on vaccines administered during December 14, 2020-January 14, 2021, and reported to CDC by January 26, 2021, were analyzed to describe demographic characteristics, including sex, age, and race/ethnicity, of persons who received ≥1 dose of COVID-19 vaccine (i.e., initiated vaccination). During this period, 12,928,749 persons in the United States in 64 jurisdictions and five federal entities§ initiated COVID-19 vaccination. Data on sex were reported for 97.0%, age for 99.9%, and race/ethnicity for 51.9% of vaccine recipients. Among persons who received the first vaccine dose and had reported demographic data, 63.0% were women, 55.0% were aged ≥50 years, and 60.4% were non-Hispanic White (White). More complete reporting of race and ethnicity data at the provider and jurisdictional levels is critical to ensure rapid detection of and response to potential disparities in COVID-19 vaccination. As the U.S. COVID-19 vaccination program expands, public health officials should ensure that vaccine is administered efficiently and equitably within each successive vaccination priority category, especially among those at highest risk for infection and severe adverse health outcomes, many of whom are non-Hispanic Black (Black), non-Hispanic American Indian/Alaska Native (AI/AN), and Hispanic persons (2,3).

LINKS Training and Unit Support for Mental Health: a Group-randomized Effectiveness Trial

The LINKS curriculum, adapted from Britt et al. (2018a), was designed to improve unit climate, knowledge, and attitudes about mental health treatment seeking in military personnel. The present study extends this research by examining implementation options, comparing the effectiveness of LINKS to an active control condition with training delivered by non-experts and comparing modules that varied in training length. Eight Army platoons were randomly assigned to one of four conditions: (1) 1-h Active Control, (2) 2-h Active Control, (3) 1-h LINKS, or (4) 2-h LINKS. Two platoons were assigned to each condition. Surveys were administered at pre-training (T1), post-training (T2), and 3 months later (T3). Eighty-four participants completed all study phases. Regardless of training content, participants receiving the 2-h modules reported greater training acceptability than those receiving the 1-h modules. At T3, participants in the LINKS conditions reported more mental health knowledge than participants in the Active Control conditions. Sustained effects were also observed on a number of treatment barriers and facilitators, with the LINKS conditions generally leading to better outcomes. At T3, 2-h LINKS condition participants reported receiving more mental health treatment relative to the other conditions. Findings suggest that LINKS can be effectively delivered by non-expert trainers, is a viable intervention for targeting mental health treatment-seeking, and is optimally packaged in a 2-h module. The training might benefit from additional leadership training efforts.

Self-reported mindfulness and soldier health following a combat deployment

OBJECTIVE

Combat exposure has been linked to health-related challenges associated with postcombat adjustment, including mental health symptoms, behavior-related problems, physical pain, and functional impairment. Mindfulness, or acceptance of the present moment without reactivity or judgment, may be associated with better mental health following a combat deployment. This study examined whether self-reported mindfulness predicted soldier health outcomes over the course of the postdeployment period.

METHOD

U.S. soldiers (n = 627) were surveyed 4 months after a deployment to Afghanistan (T1) and again 3 months later (T2). Mindfulness was assessed using the nonreactivity to inner experience subscale of the Five-Facet Mindfulness Questionnaire. Hierarchical linear regressions examined how mindfulness (T1) moderated the impact of combat exposure (T1) on outcomes at T2.

RESULTS

Controlling for rank, the interaction between combat exposure and mindfulness significantly predicted posttraumatic stress disorder (PTSD) symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment. The interaction term explained 1% to 2% of the variance in these health outcomes. Simple slopes analyses revealed that combat exposure was associated with more PTSD symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment when soldiers reported low levels of mindfulness. There was no effect for alcohol misuse, sleep difficulties, or aggressive behaviors.

CONCLUSIONS

Nonreactivity to inner experience may mitigate the detrimental effects of high-levels of combat exposure on both mental and physical health outcomes. These findings indicate that mindfulness strategies such as nonreactivity may be particularly useful for employees facing potentially traumatic stressors in a high-risk occupational context. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Correlates of current and heavy smoking among U.S. soldiers returning from combat

Smoking rates are higher in U.S. soldiers than civilians, with combat-experienced soldiers particularly at risk for heavy smoking (≥20 cigarettes/day). While heavy smoking is correlated with mental health symptoms in civilian samples, the extent to which these symptoms, background variables, and unit climate (self-reported assessments of cohesion, organizational support, and leadership) are linked to smoking in at-risk soldiers remains unclear. The present study examines a range of correlates of smoking-related behavior. Cross-sectional, anonymous surveys were collected from 3,380 soldiers following a deployment in 2008-2009. Measures included demographics, combat exposures, unit climate (e.g., unit cohesion, perceived organizational support, leadership), short sleep duration, and behavioral health variables (e.g., posttraumatic stress disorder, depression, anxiety, alcohol misuse, aggression, adverse childhood experiences [ACEs]). Logistic regression modeled the effects of these variables on two outcome variables: daily smoking and heavy smoking. In the current sample, nearly half (47%) of soldiers reported smoking daily, with 35% of all smokers reporting heavy smoking (17% of the entire sample). Daily smoking was associated with demographic (age, gender, education, rank), behavioral health (ACE, alcohol misuse, sleep duration, aggression), and unit characteristics (unit cohesion); only increased combat exposures and aggression were specifically associated with heavy smoking. Interventions focused on the postdeployment period could incorporate messages about alternatives to smoking as a coping strategy while unit interventions or individual counseling addressing aggression could also address smoking as a negative coping strategy. (PsycINFO Database Record

Prevalence of Bystander Intervention Opportunities and Behaviors Among U.S. Army Soldiers

The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.

The Impact of Unit Membership on Smoking Among Soldiers

Cultural, organizational, and dyadic influences have been found to be associated with smoking in the military while group-level influences have been identified in the general population. However, there are few studies examining group-level influences in the military and none using group-level analyses. Such studies are essential for understanding how to optimally forestall or cease smoking. This study, using mixed effects modelling, examined whether unit membership influenced smoking behavior in soldiers from brigade combat teams. Unit membership was assessed in 2008 to 2009 at the company level (n = 2204) and in 2012 at the platoon level (n = 452). Smoking was assessed by the number of daily cigarettes smoked (range: 0-99) with smoking status (nonsmoker vs. smoker) and smoking level (none, smoker, and heavy [20 + cigarettes/day]) as the outcomes. For both samples, unit membership was not significantly associated with a soldier's propensity to smoke when comparing either all smokers to nonsmokers or heavy smokers to smokers. These results suggest typical military unit-level training programs are unlikely to be the most effective mode of intervention for smoking prevention or cessation. Smoking rates in the military may be influenced instead by small group or individual relationships or by overall military culture.

The Impact of Unit Membership on Smoking Among Soldiers

Cultural, organizational, and dyadic influences have been found to be associated with smoking in the military while group-level influences have been identified in the general population. However, there are few studies examining group-level influences in the military and none using group-level analyses. Such studies are essential for understanding how to optimally forestall or cease smoking. This study, using mixed effects modelling, examined whether unit membership influenced smoking behavior in soldiers from brigade combat teams. Unit membership was assessed in 2008 to 2009 at the company level (n = 2204) and in 2012 at the platoon level (n = 452). Smoking was assessed by the number of daily cigarettes smoked (range: 0-99) with smoking status (nonsmoker vs. smoker) and smoking level (none, smoker, and heavy [20 + cigarettes/day]) as the outcomes. For both samples, unit membership was not significantly associated with a soldier's propensity to smoke when comparing either all smokers to nonsmokers or heavy smokers to smokers. These results suggest typical military unit-level training programs are unlikely to be the most effective mode of intervention for smoking prevention or cessation. Smoking rates in the military may be influenced instead by small group or individual relationships or by overall military culture.

Provider and Nonprovider Sources of Mental Health Help in the Military and the Effects of Stigma, Negative Attitudes, and Organizational Barriers to Care

OBJECTIVE

This study examined sources of help (providers or nonproviders) used by soldiers for mental health problems. Differences in perceived barriers to care by type of help used were also assessed.

METHODS

Active-duty soldiers from four brigade combat teams (N=3,380) were surveyed in 2008-2009. Items assessed posttraumatic stress disorder; depression; anxiety; help needed because of a stress, emotional, alcohol, or family problem; stigma; negative attitudes toward care; and organizational barriers. Participants reported receipt of help in the past three months from providers (mental health or medical professionals or an Army resource hotline) or nonproviders (fellow soldier, medic, chaplain, or chain of command).

RESULTS

Nearly a third (31%) were identified as being in need of mental health care. Of those, 5% reported using nonprovider help exclusively, 14% used provider help exclusively, and 7% used both types. Stigma was rated significantly lower as a barrier among those who used help exclusively from providers than among those who did not use help from any source; however, no significant differences in stigma scores were found between those who used help from nonproviders and those who did not use help from any source. Soldiers who used help from nonproviders were more likely than those who used help from providers to perceive organizational barriers.

CONCLUSIONS

Results show that soldiers may view nonproviders as alternative sources of mental health help, suggesting that the Army should ensure that such resources are adequately trained and integrated into the mental health community so that soldiers can receive the help they need.

Grief and physical health outcomes in U.S. soldiers returning from combat

BACKGROUND

Few studies have measured the burden of physical health problems after Iraq/Afghanistan deployment, except in association with post-traumatic stress disorder (PTSD) or mild traumatic brain injury (mTBI). Grief, a correlate of health problems in the general population, has not been systematically examined. We aimed to identify the prevalence of post-deployment physical health problems and their association with difficulty coping with grief.

METHODS

Infantry soldiers (n=1522) completed anonymous surveys using validated instruments six months following deployment in November-December 2008. Multiple logistic regression was used to assess the association of difficulty coping with grief and physical health.

RESULTS

The most frequent physical health symptoms reported were: sleep problems (32.8%), musculoskeletal pain (32.7%), fatigue (32.3%), and back pain (28.1%). Difficulty coping with grief over the death of someone close affected 21.3%. There was a dose-response relationship between level of difficulty coping with grief and principal physical health outcomes (ps<.002). Controlling for demographics, combat experiences, injuries, PTSD, depression, and other factors, grief significantly and uniquely contributed to a high somatic symptom score (adjusted odds ratio (AOR)=3.6), poor general health (AOR=2.0), missed work (AOR=1.7), medical utilization (AOR=1.5), difficulty carrying a heavy load (AOR=1.7), and difficulty performing physical training (AOR=1.6; all 95% confidence intervals>1).

LIMITATIONS

Data are cross-sectional and grief was measured with one item.

CONCLUSIONS

Over 20% of soldiers reported difficulty coping with grief. This difficulty was significantly associated with physical health outcomes and occupational impairment. Clinicians should be aware of the unique role grief plays in post-deployment physical health when treating patients.

Mental illness and psychotropic drug use among prescription drug overdose deaths: a medical examiner chart review

OBJECTIVE

Between 1999 and 2006, there was a 120% increase in the rate of unintentional drug overdose deaths in the United States. This study identifies the prevalence of mental illness, a risk factor for substance abuse, and chronic pain among prescription drug overdose deaths in West Virginia and ascertains whether psychotropic drugs contributing to the deaths were used to treat mental illness or for nonmedical purposes.

METHOD

In 2007, we abstracted data on mental illness, pain, and drugs contributing to death from all unintentional prescription drug overdose deaths in 2006 recorded by the West Virginia Office of the Chief Medical Examiner. Decedent prescription records were obtained from the state prescription drug monitoring program.

RESULTS

Histories of mental illness and pain were documented in 42.7% and 56.6% of 295 decedents, respectively. Psychotropic drugs contributed to 48.8% of the deaths, with benzodiazepines involved in 36.6%. Benzodiazepines contributing to death were not associated with mental illness (adjusted odds ratio [AOR] = 1.1; 95% CI, 0.6-1.8), while all other psychotropic drugs were (AOR = 3.9; 95% CI, 2.0-7.6). Of decedents with contributory benzodiazepines, 46.3% had no prescription for the drug.

CONCLUSIONS

Mental illness may have contributed to substance abuse associated with deaths. Clinicians should screen for mental illness when prescribing opioids and recommend psychotherapy as an adjunct or an alternate to pharmacotherapy. Benzodiazepines may have been used nonmedically rather than as a psychotropic drug, reflecting drug diversion. Restricting benzodiazepine prescriptions to a 30-day supply with no refills might be considered.

Patterns of abuse among unintentional pharmaceutical overdose fatalities

CONTEXT

Use and abuse of prescription narcotic analgesics have increased dramatically in the United States since 1990. The effect of this pharmacoepidemic has been most pronounced in rural states, including West Virginia, which experienced the nation's largest increase in drug overdose mortality rates during 1999-2004.

OBJECTIVE

To evaluate the risk characteristics of persons dying of unintentional pharmaceutical overdose in West Virginia, the types of drugs involved, and the role of drug abuse in the deaths.

DESIGN, SETTING, AND PARTICIPANTS

Population-based, observational study using data from medical examiner, prescription drug monitoring program, and opiate treatment program records. The study population was all state residents who died of unintentional pharmaceutical overdoses in West Virginia in 2006.

MAIN OUTCOME MEASURES

Rates and rate ratios for selected demographic variables. Prevalence of specific drugs among decedents and proportion that had been prescribed to decedents. Associations between demographics and substance abuse indicators and evidence of pharmaceutical diversion, defined as a death involving a prescription drug without a documented prescription and having received prescriptions for controlled substances from 5 or more clinicians during the year prior to death (ie, doctor shopping).

RESULTS

Of 295 decedents, 198 (67.1%) were men and 271 (91.9%) were aged 18 through 54 years. Pharmaceutical diversion was associated with 186 (63.1%) deaths, while 63 (21.4%) were accompanied by evidence of doctor shopping. Prevalence of diversion was greatest among decedents aged 18 through 24 years and decreased across each successive age group. Having prescriptions for a controlled substance from 5 or more clinicians in the year prior to death was more common among women (30 [30.9%]) and decedents aged 35 through 44 years (23 [30.7%]) compared with men (33 [16.7%]) and other age groups (40 [18.2%]). Substance abuse indicators were identified in 279 decedents (94.6%), with nonmedical routes of exposure and illicit contributory drugs particularly prevalent among drug diverters. Multiple contributory substances were implicated in 234 deaths (79.3%). Opioid analgesics were taken by 275 decedents (93.2%), of whom only 122 (44.4%) had ever been prescribed these drugs.

CONCLUSION

The majority of overdose deaths in West Virginia in 2006 were associated with nonmedical use and diversion of pharmaceuticals, primarily opioid analgesics.

Unintentional strangulation deaths from the "choking game" among youths aged 6-19 years - United States, 1995-2007

The "choking game" is defined as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. Participants in this activity typically are youths (Andrew & Fallon, 2007). Serious neurologic injury or death can result from engaging in this activity. Recent news media reports have described numerous deaths among youths attributed to the choking game. Because no traditional public health dataset collects data on this practice, CDC used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6-19 years during 1995-2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years. Parents, educators, and health-care providers should become familiar with warning signs that youths are playing the choking game (Urkin & Merrick, 2006). Impact of industry: By learning about the risk factors for and warning signs of the choking game, parents, educators, and health-care providers may be able to identify youth at risk for playing the game and prevent future deaths.