COVID-19 in ICE Facilities Could Overwhelm Local ICUs, Study Finds

First Detainee Death Reported in ICE Facility in California

Troy Brown, RN

May 09, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Immigration and Customs Enforcement (ICE) reported the first death from COVID-19 among detainees at US facilities this week at a southern California facility. Another 133 detainees and 10 staff at the facility also have confirmed COVID-19. Experts fear local hospitals could soon be overwhelmed.

It may already be too late, according to an April 28 letter from officials at Scripps Health and Sharp HealthCare, both in San Diego, California, to Secretary of Health and Human Services Alex Azar and Acting Secretary of Homeland Security Chad F. Wolf.

High numbers of border crossings, the large outbreak in the ICE facility, and inadequate healthcare conditions just south of the California-Mexico border are all making the situation particularly urgent there, they explain.

Cases in the region are increasing quickly, and the two health systems are together caring for more than 60% of the region's patients with COVID-19, write Chris D. Van Gorder, FACHE, president and chief executive officer of Scripps Health, and Daniel L. Gross, executive consultant with Sharp HealthCare COVID‐19 Strategic Response.

The Otay Mesa Detention Center, located near the border and not far from the two hospitals, this week reported the death of 57-year-old Carlos Ernesto Escobar Mejia. The facility is considered the virus' epicenter with respect to immigrant detention, with 139 cases as of May 8, but cases in similar facilities appear to be widespread. Nationwide, ICE facilities have reported 788 confirmed cases among detainees in 41 ICE detention facilities.

In addition, 42 employees working at 15 ICE detention facilities have confirmed COVID-19, as do another 102 ICE employees who are not assigned to detention facilities (as of May 7). Although ICE is not required to report cases among employees of private prison companies working in detention facilities, the Associated Press reported last week that two guards died after contracting COVID-19 while working at an ICE facility in Louisiana.

Van Gorder and Gross are asking the US Centers for Disease Control and Prevention and US Customs and Border Protection to conduct medical checks — including at least body temperature checks — at the border and to quarantine those with suspected COVID-19. They also urge the federal government to pressure Mexico to implement "social-distancing and shelter-in-place policies" similar to those in the United States.

Nearby Hospitals Likely to Be Overwhelmed, Study Shows

Results from a recent modeling study suggest that Van Gorder and Gross are right to be worried. The model predicts that intensive care units (ICUs) in more than half of hospitals within 10 miles of an ICE detention facility would be overwhelmed by day 90 in the event of a COVID-19 outbreak. Expanding that radius to 50 miles lessens the risks, but 8% of hospitals would still be unable to meet the need for ICU beds, the study authors warn.

"As COVID-19 continues to spread in communities, and inevitably into the nation's detention centers, it is critical that we understand the U.S. healthcare system's capacity to care for a large influx of patients who require critical care," write Daniel Coombs, PhD, MSc, of the Department of Mathematics and Institute of Applied Mathematics at the University of British Columbia, Canada, and colleagues. The researchers published the results of their modeling study April 28 in the Journal of Urban Health.

Coombs and colleagues used ICE detainee population data available on the ICE Enforcement and Removal Operations website as of March 2 of this year, to estimate the COVID-19 transmission rate within 111 ICE detention facilities and studied the effects on regional ICU capacity. Their model considered multiple transmission rates (basic reproduction numbers [R0s] of 2.5, 3.5, and 7), outbreak duration (30, 60, and 90 days), and number of detainees in the facility (50, 100, 500, and 1000 detainees).

This "carefully constructed simulation study…uses the most common model for epidemic modeling," F. Perry Wilson, MD, MSCE, associate professor of medicine and interim director, Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, told Medscape Medical News.

Nevertheless, "the outcome varies depending on the assumptions the modelers make," he said. The R0 of 2.5 is consistent with the general population and it could be even higher because of the close conditions in detention facilities, But, Wilson noted, it could be lower if authorities enforced social distancing. "[T]hese individuals in theory could be forced to engage in social distancing that the general population cannot," he said.

"Potential Powder Kegs"

In the most optimistic scenario tested (R0 = 2.5), 72% to 80% of ICE detainees would likely be infected by day 90, depending on the size of the facility. That proportion would jump to 90% to 99% of detainees if the R0 reaches 7, as tested in the most pessimistic scenario.

If there were a synchronous outbreak affecting all of the ICE facilities, the researchers estimate that 917 individuals system-wide would require hospitalization within the first 30 days in the most optimistic scenario (R0 = 2.5) and would increase to 4909 individuals by day 90.

With an R0 of 7, a median of 5145 detainees system-wide would become infected and require hospitalization within the first 30 days, rising to an aggregate of 6408 patients by day 90 — or 15.1% of all detainees system-wide.

"The high hospitalization rate is driven by sustained transmission leading to very high fractions of detainees becoming infected, in the absence of robust and sustained countermeasures," Coombs and colleagues explain.

Wilson echoed that point. These sorts of "confined spaces with lots of people in them are potential powder kegs. Even as caseloads decrease, a small number of cases in these facilities can quickly balloon," he said.

Local ICUs Quickly Overwhelmed

The authors estimate that even with the lowest R0, 139 detainees system-wide would require ICU care by day 30 and the number would climb to a cumulative total of 745 by day 90, which is 1.8% of the total population.

Thirty-three ICE facilities have no hospital within 10 miles, although all are within 50 miles of a hospital. An outbreak at several facilities could exceed local ICU capacity within 10 and 50 miles of each facility.

Even under the best conditions and with the lowest transmission rate, the model predicts that ICU capacity would be overwhelmed at more than half of hospitals at all time points — and it goes downhill as conditions worsen.

Although the study shows hospitals in a 10-mile radius might be overwhelmed within 30 to 60 days, Wilson believes this is a "fairly small area" to consider. "Transport out to 50 miles is not crazy in the US where there is so much open space."

But even expanding hospital access to the 50-mile radius does not entirely eliminate the problem, according to the model. A few facilities within 50 miles are also expected to exceed ICU capacity during the first 30 days of an outbreak (six facilities for R0 of 2.5 or 3.5 and nine facilities for R0 of 7).

Wilson notes that many hospitals are converting regular beds and even operating rooms to ICU beds, so the researchers may have underestimated the ICU capacity. But whether those changes are sufficient is unknown at this point.

The findings of this "strong study" are not surprising, William D. Lopez, PhD, MPH, clinical assistant professor, Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, told Medscape Medical News.

"[D]etention centers are made to house as many people as possible in small spaces and have little access to resources — such as sinks and showers — that are needed to follow CDC recommendations to prevent the spread of the virus," he said.

"Clinicians should be aware that, if ICE does not begin releasing those in custody, their nearby hospital and clinical facilities will be overwhelmed with new COVID-19 cases. Because detention staff may also contract and spread the disease, the communities in which detention staff return home at night are also at risk," Lopez remarked. 

"We need to start preparing for 'hotspot' outbreaks, even if the nation (or various states) end up seeing gradual downturns," Wilson explained. "These events will happen, and ICE detention centers may be powder-kegs waiting to go off. It is not unreasonable to consider policy changes (like release of detainees) to decrease the risk of an explosion."

Reducing population density in detention facilities is an effective approach if there is no vaccination or effective treatment, the researchers explain, adding that this could slow the virus' spread by reducing its R0. "[T]he total number of infections drop, the time to peak infection shifts, and the proportion of the population infected is lower."

"[T]aken together, I think the study should be a wake-up call for policymakers and physicians who work near detention centers. Yes, this could be a major problem. But we can't be certain until we see actual data (not simulations)," Wilson concluded.

The authors, Wilson, and Lopez have disclosed no relevant financial relationships.

J Urban Health. Published online April 28, 2020. Full text

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