Correctional Institutions and Human Health Risk
The Long-Term Benefits of Performing a Facility Health Risk Assessment
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America’s correctional institutions are never top of mind when considering exposures to harmful substances and subsequent risk control strategies. But the U.S. Bureau of Justice Statistics reports that in 2020, approximately 5.5 million individuals were housed in some type of correctional institution (CI). Watching over them are an estimated 402,000 correction officers and jailers, according to the Bureau of Labor Statistics. Compare that with the national estimates of firefighters (326,000), dentists (146,000), and aircraft pilots and flight engineers (135,000), and you will note that the number of people employed in CIs is not insignificant. Add in the fact that CIs routinely face overcrowding and you have the perfect scenario for indoor environmental quality issues to exacerbate occupants’ health impacts. This article explores the importance of performing a facility health risk assessment at CIs to identify the cause of human health risk drivers within the built environment as well as control pathways for minimizing human health impacts. The term “CI,” as used in this article, encompasses domestic federal, state, and local facilities, including both publicly and privately operated jails and prisons. Each facility type is slightly different, but they all generally face the same issues, to differing degrees. “Inmate” refers to individuals who are in these facilities to serve sentences or for purposes of detainment (before they are tried, for example).
While a fair number of people are behind a correctional institution’s walls either for a shift or a sentence, the health and safety aspects of their living or working conditions are generally not considered high priorities. New headlines appear often in media outlets with serious accusations such as “Legionella Bacteria Found in Correctional Facility Water Supply” or “How Prisons are Poisoning Their Inmates.” The possibility of negative press should be a driving factor in how CI management responds to future pandemic-level events and addresses the safety and health of occupants moving into the post-pandemic landscape. ENVIRONMENTAL HAZARDS Understanding the hazard types present at CIs will require a facility health risk assessment. Traditionally, facility risk assessment terminology has been used to describe risks in a variety of contexts, including healthcare centers and locations where security is an element of the facility risk assessment. This terminology is intended to qualitatively identify high risks at a facility that can affect the health of occupants. Thus, the overall health of the CI can impact occupants’ health. Identifying risks during the assessment allows OEHS professionals to prescribe effective controls. The following public health hazards that affect CI occupants fall into two general categories: indoor environmental sources and environmental contaminants. COVID-19. One major indoor environmental impact that CIs recently dealt with was the COVID-19 pandemic. A paper published in October 2021 by the Journal of the American Medical Association reported that inmates at state and federal institutions were found to have five times the COVID-19 incidence rate compared to the U.S. population. The pandemic’s impacts were so widespread that funding for addressing SARS-CoV-2 effects in confinement facilities was made available through the American Rescue Plan Act of 2021. As built, many of these facilities lack the means to adequately mitigate COVID-19 human health risks. Overcrowding. Because of continued overcrowding, many facilities are not being used as they were designed and intended. This creates an indoor environment where human pathogen impacts can be exacerbated. CDC reports that inmate incidence of Mycobacterium tuberculosis (TB) infections is elevated compared to the nonincarcerated population, and those incarcerated individuals are at a higher risk of TB infections compared with the U.S. population. Additionally, CDC and others have documented influenza outbreaks at various correctional facilities. Reduced water quality. Due to the age, design, and use conditions of many CIs, reduced water quality is often an issue. Plumbing specifications for CI construction may require the use of specialized systems to prevent tampering by inmates. Repurposing of buildings or rooms in older facilities may have unintended consequences downstream that can manifest as waterborne pathogen growth and cause health impacts to the inmates and employees. Legionella bacteria are the primary waterborne pathogen associated with CI water systems. Other bacteria (for example, Pseudomonas) or parasites (such as giardia) could also pose a health risk to those exposed. Contraband. Contraband within these facilities can present a risk to life and health. There are many reports of fentanyl-associated deaths within CIs and secondary, indirect exposures where inmates and employees were reportedly sickened by contaminated building materials. A recent study of Canadian CIs in the International Journal of Drug Policy reported that fentanyl was identified by correctional officers as “the greatest risk to their safety in prisons.” It is vital for CIs to have plans in place to mitigate risks should an exposure occur.
Because of the lack of attention to risk-mitigating design, health issues plague America’s prisons and prisoners.
Location-specific hazards. The location of a CI is a factor in what risk drivers may be present. Facilities on the west coast of the U.S. may be impacted by particulates from wildfire smoke or from inhalation of airborne Coccidioides, which causes coccidioidomycosis (Valley Fever). East coast facilities have their own issues, including Lyme disease and hurricanes. During Hurricane Ian in September, the Florida Department of Corrections evacuated 25 facilities in the path of the storm. In addition to potential sewage backup, mold is a concern after the water recedes, especially during prolonged interruptions of indoor thermal conditioning. Thermal stressors must also be considered in the context of location and indoor environmental quality. For example, occupants of CIs along the southern border face heat stress to a greater degree than facilities in the north, while northern facilities are more likely to face hypothermia risks. Location also influences the impacts of environmental contaminants on CIs. A CI may have been constructed on land that has legacy contaminants or near facilities whose operations may negatively impact the CI. For example, a recent paper in the journal Integrated Environmental Assessment and Management describes a CI in New Jersey constructed on marshland that was reportedly a site for city sanitation waste, stormwater drainage, and illegal landfill dumping. A human health risk assessment performed at the facility identified mercury and beryllium as contaminants of concern. CONSIDERATIONS FOR FACILITY HEALTH RISK ASSESSMENTS These hazards are just a few that may impact the indoor environment at CIs. The hazards that plague CIs depend on factors such as population, geography, and location. Inmates are not the only people affected by unkept buildings. The health and safety of employees, visitors, and vendors is also on the line. It is recommended that CIs undergo facility health risk assessments to evaluate and control any potential risk driver that may be present. These assessments can be tailored to unique conditions and populations. It is important to correlate potential human health risk drivers with current usage of CIs. While newer CIs have been designed according to the most current guidelines from the U.S. National Institute of Corrections, older CIs were built under older standards. Aged CIs, especially those that are overcrowded, may not be used as originally designed and intended. Facility health risk assessments of all CIs should be based on current conditions, but older facilities may require more scrutiny because of changes that occurred over the years, such as the repurposing of campus buildings. Standards from national facility accreditation organizations may also dictate the acceptability of facility conditions. Starting at the micro building level, it is important to identify and document the nature of the occupants, including demographics, incarceration status (that is, low versus medium risk), general health status (such as the presence of transmissible infections like MRSA), and background—for example, how inmates interact within cliques formed either before or during incarceration. The employed population of the CI must also be considered in the context of demographics and elevated risk. Information about individual vendors and visitors may be difficult to obtain, so a general understanding of their makeup may be more helpful. Understanding the nature of the occupants indicates how they interact with the facility. On the macro building level, documenting the types of buildings and areas within those buildings is crucial for identifying locations that could pose a higher risk based on the nature of the space and the occupants. For example, understanding the areas within the CI—such as sleeping accommodations, holding cells, guard towers, dining areas, meeting rooms, showers, day rooms, administration areas, and so on—is vital for understanding how individuals and populations move through the facility. This knowledge allows for the identification of high-risk areas, which is integral to the risk assessment. For example, facilities that have a detox area may house occupants who have a higher probability of entering the CI with a positive disease status. Campus-wide evaluations should consider the usage of different facilities. Many CIs have “special housing” or accommodations that are used infrequently, which can lead to stagnant water, a breeding ground for pathogenic bacteria such as Legionella. Some CIs might have special facilities for elderly inmates; according to the National Commission on Correctional Health Care, incarcerated individuals 65 and older are the fastest growing demographic in CIs. Because the elderly have a higher risk from exposure to a number of substances, and infections are common occurrences at end of life, CIs may retrofit a building on campus to hold this elderly population or provide palliative care. But using buildings for purposes they were not designed to meet may contribute to health impacts. The facility health risk assessment should ensure that the unique needs of this population are addressed. CONTROLS While some CIs have pre-existing controls such as HVAC systems, the primary historical architectural design purpose for most domestic CIs was not to minimize the impact of adverse health outcomes. Based on hazards identified during the COVID-19 pandemic, CIs need more effective administrative and engineering controls to effectively reduce risks for inmates, employees, vendors, and visitors. Evaluation of the administrative operations at CIs can be effective in reducing risk. Many administrative operations involve the interactions of inmates and employees with the facility and with each other, including cleaning and disinfection programs based on specific use conditions. The assessment should evaluate whether changes in occupant flow alter the risk of a human health outcome. For example, if there is a pod of inmates who have a higher incidence of a communicable disease such as COVID-19, then risk may be reduced by restricting older guards from entering the pod or interacting with guards who have worked in the pod. While some administrative changes may reduce work efficiencies, this consequence must be weighed against increased risks to human health.
Engineering controls must be effective in operation and maintained appropriately. Understanding the design of the ventilation system in each campus building is crucial for understanding how diseases can be transmitted and how different populations are affected. As stated earlier, many CIs struggle with overcrowding and their facilities are not necessarily being used as they were designed. Repurposing a building or space can result in an airflow imbalance that may lead to insufficient air recirculation, low air change rates, or increased occupant heat stress. Older facilities likely were not designed with directional airflow in mind. Additionally, increasing the amount of outdoor air in older CIs may overtax the system and reduce efficiency. While newer facilities may have dehumidification systems, many older facilities lack these necessary updates; in some parts of the country, older facilities lack HVAC systems entirely, relying on natural forced-air ventilation. The adequate upkeep of facility systems is important to ensure efficient operation and reduce the risk of adverse health effects. But in correctional facilities, maintenance can be inconsistent or difficult to perform. For example, a paper in Epidemiology and Infection describes how, in 2015, cooling towers at a California state prison were identified as the cause of a Legionnaires’ disease outbreak involving inmates. When evaluated, these towers had thick layers of biofilm and sludge deposits, and virtually no water management plan. The health department found that no records existed for maintenance of the cooling towers. This example highlights the need for either staff or vendors at CIs to verify that the system was maintained as reported. Unfortunately, vendors often charge a premium to work in an institution, and lack of funds is the most common reason why maintenance work gets postponed. Deferring maintenance has two main consequences. First, it can result in downstream health impacts from increased incidence of mold, waterborne pathogens, endotoxins, or aerosol transmission of pathogens. Second, fixing a problem is often more expensive than preventing it: a report by the Volcker Alliance found that the cost of deferred maintenance for infrastructure in the U.S. tops $1 trillion. A proactive approach to maintaining a building is much better for everyone in the long run.

A facility health risk assessment is vital to protect the long-term health of inmates, employees, vendors, and guests. There is no one-size-fits-all approach to creating a health risk assessment; each CI needs an individualized assessment based on its age, design, populations, overcrowding, and any area repurposing that has occurred. Most CIs were built not to minimize the impact of adverse health outcomes on occupants but to hold large numbers of people in a secure location as penance for their violation of the social contract between citizens. Seldom has the design of these buildings previously been of high concern when it comes to indoor air quality or environmental health issues. Because of the lack of attention to risk-mitigating design, health issues plague America’s prisons and prisoners. Whether these issues originate from the inmates, employees, visitors, the water system, or other environmental sources, the human health risk from occupying some of these facilities is elevated due to the age of the building alone. Overall, American CIs need facility health risk assessments and a renewed focus on the health of the inmates, guards, and staff who occupy them.
ALEXIS JENNINGS, MPH, is an environmental toxicologist at Exposure Assessment Consulting LLC in Orlando, Florida. ALEX LEBEAU, PhD, MPH, CIH, is a principal toxicologist at Exposure Assessment Consulting LLC in Orlando, Florida. Alex currently serves as chair of the AIHA Indoor Environmental Quality Committee. Send feedback to The Synergist. eddiesimages/Getty Images spiritofamerica/Adobe Stock
Bureau of Justice Statistics: “Number of Persons Under the Supervision of Adult Correctional Systems in the United States, 2010–2020” (March 2022).
Bureau of Labor Statistics: Employment by Detailed Occupation.
CDC: “Detection and Mitigation of COVID-19 in Confinement Facilities Guidance” (PDF).
CDC: Morbidity and Mortality Weekly Report, “Influenza Outbreaks at Two Correctional Facilities—Maine, March 2011” (April 2012).
CDC: “TB and People Living in Correctional Facilities in the United States.”
Epidemiology and Infection: “Outbreak of Legionnaires’ Disease Associated with Cooling Towers at a California State Prison, 2015” (February 2018).
Integrated Environmental Assessment and Management: “Indoor Air Quality Investigation and Health Risk Assessment at Correctional Institutions” (April 2005).
International Journal of Drug Policy: “Fentanyl Behind Bars: The Implications of Synthetic Opiates for Prisoners and Correctional Officers” (September 2019).
Journal of the American Medical Association: “COVID-19 Incidence and Mortality in Federal and State Prisons Compared with the US Population, April 5, 2020, to April 3, 2021” (October 2021).
National Commission on Correctional Health Care: “Aging Prison Population.”
NIOSH: “NIOSH Fact Sheet: Managers: Protect Correctional Staff from MRSA” (PDF, January 2013).
The Outline: “How Prisons Are Poisoning Their Inmates” (July 2018).
The Volcker Alliance: “America’s Trillion-Dollar Repair Bill: Capital Budgeting and the Disclosure of State Infrastructure Needs” (November 2019).
WCSJ News: “Legionella Bacteria Found in Correctional Facility Water Supply; Precautionary Measures Taken” (March 2022).