Interim Considerations for SARS-CoV-2 Testing in Correctional and Detention Facilities

Interim Considerations for SARS-CoV-2 Testing in Correctional and Detention Facilities
Summary of Recent Changes

A revision was made on 10/21/2020 to reflect the following:

  • Added links to the updated close contact definition.
  • Updated language to align with updated definition.

A revision was made on 8/10/2020 to reflect the following:

  • Accumulating evidence supports ending isolation and precautions for persons with COVID-19 using a symptom-based strategy. This update incorporates recent evidence to inform the duration of isolation and precautions recommended to prevent transmission of SARS-CoV-2 to others, while limiting unnecessary prolonged isolation and unnecessary use of laboratory testing resources.

These interim considerations are based on what is currently known about SARS-CoV-2 and COVID-19 as of the date of posting, August 10, 2020.

The US Centers for Disease Control and Prevention (CDC) will update these considerations as needed and as additional information becomes available. Please check the CDC website periodically for updated interim guidance.

Note:  This document is intended to provide considerations on the appropriate use of testing and does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency. CDC is a non-regulatory agency; therefore, the information in this document is meant to assist correctional and detention facilities in making decisions rather than establishing regulatory requirements.

Correctional and detention facilities can determine, in collaboration with state and local health officials, whether and how to implement the following proposed testing strategies. Implementation should be guided by what is feasible, practical, and acceptable, and should be tailored to the needs of each facility. These considerations are meant to supplement—not replace—any state, local, territorial, or tribal health and safety laws, rules, and regulations with which facilities must comply.

CDC offers considerations for correctional and detention facilities to plan, prepare, and respond to coronavirus disease 2019 (COVID-19) in Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities. Testing to diagnose COVID-19 is one component of a comprehensive strategy and should be used in conjunction with a number of other prevention and mitigation activities described in the interim guidance.

Testing symptomatic and asymptomatic individuals and initiating medical isolation for suspected and confirmed cases and quarantine for close contacts (within 6 feet for a total of 15 minutes or more) can help prevent the spread of SARS-CoV-2, the virus that causes COVID-19, in correctional and detention facilities. This page provides considerations for implementing SARS-CoV-2 testing among incarcerated and detained persons and facility staff. Any time a positive test result is identified, ensure that the individual is rapidly notified, connected to appropriate medical care, and medical isolation is initiated. See CDC’s Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities for further details related to responding to cases. Correctional and detention facilities should follow guidance from the Equal Employment Opportunity Commissionexternal icon when instituting and offering testing to staff, and when staff are preparing to return to work. Note that symptom screening, testing, and contact tracing strategies should be carried out in a way that protects privacy and confidentiality to the extent possible and that is consistent with applicable laws and regulations.

Types of COVID-19 tests

Viral tests are recommended to diagnose current infection with SARS-CoV-2, the virus that causes COVID-19. Viral tests evaluate whether the virus is present in a respiratory sample. Results from viral tests help identify and isolate people who are infected in order to minimize SARS-CoV-2 transmission.

Antibody tests are used to detect a past infection with SARS-CoV-2. CDC does not currently recommend using antibody testing as the sole basis for diagnosing current infection. Depending on when someone was infected and the timing of the test, the test may not find antibodies in someone with a current SARS-CoV-2 infection. In addition, it is currently not proven whether a positive antibody test indicates protection against future SARS-CoV-2 infection; therefore, antibody tests should not be used at this time to determine if an individual is immune.

CDC recommendations for SARS-CoV-2 testing are based on what is currently known about the virus. SARS-CoV-2 is new, and what is known about it changes rapidly.  Information on testing for SARS-CoV-2 will be updated as more information becomes available.

When testing might be needed

This page describes three scenarios when incarcerated or detained persons (IDP) or staff in correctional and detention facilities may need to have an initial SARS-CoV-2 viral test:

  • Testing individuals with signs or symptoms consistent with COVID-19
  • Testing asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission
  • Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification

This page also outlines considerations for planning broad-based testing in correctional and detention facilities (i.e., testing both symptomatic and asymptomatic persons), including:

  • Practical considerations for implementing broad testing for SARS-CoV-2 in correctional and detention facilities
  • Checklist of considerations to help facilities make decisions about how and when to test broadly for SARS-CoV-2

These considerations are intended to provide evidence-based strategies for SARS-CoV-2 testing among IDP and staff who work in correctional and detention facilities. Depending on the context, specific testing considerations may be applied to IDP, staff, or both.

Testing individuals with signs or symptoms consistent with COVID-19

Consistent with CDC’s recommendations, individuals (including staff and IDP) with COVID-19 signs or symptoms should be referred to a healthcare provider for evaluation for testing.

  • One strategy to identify individuals with COVID-19 signs or symptoms and to help lower the risk of transmission is to conduct temperature screening and/or symptom checks. To identify individuals with symptoms, facilities should integrate temperature screening and symptom checks into their standard practices (i.e., among IDP at intake, prior to discharge/release or transfer; daily staff screening; screening of volunteers and vendors upon entry). Screenings should be conducted safely and respectfully and in accordance with any applicable privacy laws and regulations. See guidance on how to conduct temperature screening and symptom checks in the Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities.
  • Note that symptom screenings cannot identify individuals with COVID-19 who may be asymptomatic or pre-symptomatic, and therefore will not prevent all individuals with COVID-19 from entering the facility.

Testing asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission

Testing is recommended for all close contacts of persons with SARS-CoV-2 infection:

Broader testing strategy beyond close contacts

Congregate living or working conditions, such as in correctional and detention facilities, have potential for rapid and widespread transmission of SARS-CoV-2. Performing contact tracing in correctional and detention settings may be resource-intensive and challenging (e.g., the number of close contacts of infected IDP in a housing unit with a dormitory-style sleeping area and shared restrooms and shower facilities may be large; outside public health staff conducting contact tracing may have limited access to correctional and detention facilities, and it may be necessary to conduct interviews with cases and close contacts over the phone). If contact tracing is not practicable, or if there is concern for widespread transmission following identification of new-onset SARS-CoV-2 infection among IDP or staff, facility management should consider a broader testing strategy, beyond testing only close contacts within the facility, to reduce the chances of a large outbreak.

Practical considerations for implementing a broader testing strategy should include the availability of resources and the ability to act on results of testing. Decisions about testing strategies in correctional and detention facilities should be made in collaboration with state/local health departments.

  • Depending on fac­ility characteristics and available resources, targeted (e.g., a specific housing unit) or facility-wide testing should be considered if a single IDP or staff member in the facility tests positive for SARS-CoV-2.
  • Incoming IDPs testing positive at intake should be placed immediately into medical isolation and provided medical care. As long as these individuals have not yet been in contact with the rest of the facility’s population, this circumstance would not trigger broader testing,

Quarantine and additional testing for close contacts

All persons who are close contacts of someone with COVID-19 (e.g., IDP and staff assigned to the housing unit where someone tested positive for SARS-CoV-2) should be provided with cloth face coverings (if not already wearing them, and unless contraindicated), and the IDP should be placed under quarantine restrictions for 14 days after their last exposure.

Staff

  • Management should consider requiring asymptomatic staff who have been identified as close contacts of a confirmed COVID-19 case to home quarantine to the maximum extent possible, while understanding the need to maintain adequate staffing levels of critical workers. Workers in critical infrastructure sectors (including correctional and detention facilities) may be permitted to work if they remain asymptomatic after a potential exposure to SARS-CoV-2, provided that worker infection prevention recommendations and controls are implemented, including requiring the staff member to wear a cloth face covering (unless contraindicated) at all times while in the workplace for 14 days after the last exposure (if not already wearing one due to universal use of cloth face coverings).
  • If the exposed staff members test positive, they should follow local health department and health care provider instructions regarding home isolation.

Incarcerated or detained persons (IDP)

  • Because correctional and detention facilities may not have enough space to provide an individual cell for each quarantined IDP, they may need to form cohorts of quarantined IDP who were exposed to SARS-CoV-2 at the same time.
  • Some IDP in a quarantined cohort may be infected without showing symptoms or may not test positive due to early stage infection. Infected persons may transmit SARS-CoV-2 to others several days before the onset of symptoms, or even if they never develop symptoms. To prevent continued transmission of the virus within a quarantined cohort, re-testing those who originally tested negative every 3 to 7 days could be considered, until no new cases are identified for 14 days after the most recent positive result. The specific re-testing interval that a facility chooses could be based on:
    • The stage of the ongoing outbreak (i.e., more frequent testing in the context of escalating outbreaks, less frequent testing when transmission has slowed)
    • The availability of testing supplies and capacity of staff to perform repeat testing without negatively impacting other essential health care services
    • Financial resources to fund repeat testing, including procurement of testing supplies, laboratory testing services, and personal protective equipment (PPE)
    • The capacity of on-site, contract laboratories, or public health laboratories that will be performing the tests
    • The expected wait time for test results (and resulting capacity for timely action based on the results)
  • If IDP who are close contacts of a confirmed COVID-19 case test positive for SARS-CoV-2, they should be placed under medical isolation. If an IDP who tested positive was part of a quarantine cohort, restart the 14-day quarantine clock for the remainder of the cohort.
  • See detailed guidance on recommendations for how to organize quarantine and medical isolation in correctional and detention settings in Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities.

Limitations of a re-testing strategy include:

  • Facilities may not have staff and testing capacity to organize testing of large numbers of IDP on a serial basis.
  • Long wait times for receiving large numbers of test results may make frequent re-testing impractical to implement.
  • Frequent re-testing within a quarantine cohort may result in a prolonged quarantine period for the entire cohort if one individual tests positive part-way through quarantine and the 14-day clock must be restarted. It may become challenging to find space to quarantine individuals in correctional or detention facilities for extended periods of time.
  • Frequent re-testing may become burdensome for IDP and increase the proportion of individuals who decline testing.

Practical considerations for implementing re-testing of quarantined individuals should include the availability of space, resources, potential limitations of this strategy and the ability to act on results. The decision about frequency of re-testing in correctional and detention facilities should be made in collaboration with state/local health departments.

Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification

Correctional and detention facilities may consider testing asymptomatic individuals without known or suspected SARS-CoV-2 exposure in communities with moderate to substantial levels of community transmission. Practical considerations for implementing this strategy include the availability of resources, timeliness of results, and the ability for a coordinated response between the health department or other testing agency/provider and the correctional or detention facility. Decisions about testing strategies in correctional and detention facilities should be made in collaboration with state/local health departments. The testing strategies below aim to reduce the risk of introducing SARS-CoV-2 into the correctional or detention facility (i.e., testing newly incarcerated or detained persons) and to reduce the risk of widespread transmission through early identification of infection among existing IDP and staff. Facilities in communities with moderate to substantial levels of community transmission can consider the following:

  • Baseline testing for all current IDP.
  • Testing all new IDP at intake before they join the rest of the population in the facility, and housing them individually while test results are pending to prevent potential transmission. Some facilities may choose to implement a “routine intake quarantine” in which new IDP are housed individually for 14 days before being integrated into general housing.
  • Testing for SARS-CoV-2 and reviewing results before transferring IDP to another facility or releasing them to the community, particularly if an IDP will transition to a congregate setting with persons at increased risk for severe illness from COVID-19. Refer to Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities for more information about transfer and release recommendations. Consider combining pre-transfer/release testing with a 14-day quarantine (ideally in single cells) before an individual’s projected transfer or release date to further reduce risk of transmission to other facilities or the community.

Transmission-based precautions for suspected and confirmed COVID-19 cases

Staff

  • All staff with suspected or confirmed COVID-19 should wear cloth face coverings (if not already wearing one, and unless contraindicated), self-isolate at home, connect with appropriate medical care as soon as possible, and follow medical care and instructions.

Incarcerated or detained persons (IDP)

  • All IDP with suspected or confirmed COVID-19 should be provided with cloth face coverings (if not already wearing one, and unless contraindicated), connected to appropriate medical care as soon as possible, and placed in medical isolation until medical care and instructions can be provided.

Criteria for discontinuing medical isolation of IDP with COVID-19

  • For persons with mild to moderate COVID-19 illness who are not severely immunocompromised, medical isolation can be discontinued when:
    • At least 10 days have passed since symptoms first appeared (or since first positive viral test, if asymptomatic),
    • At least 24 hours have passed since last fever, without the use of fever-reducing medications, and
    • Symptoms have improved.
  • For persons with severe illness or who are severely immunocompromised, medical isolation can be discontinued when:
    • At least 20 days have passed since symptoms first appeared (or since first positive viral test, if asymptomatic),
    • At least 24 hours have passed since last fever, without the use of fever-reducing medications, and
    • Symptoms have improved.
    • Consider consultation with infection control experts.

See Duration of isolation for more information.

Practical considerations for implementing broad-based testing for SARS-CoV-2 in correctional and detention facilities

For more information on testing procedures, including choosing a physical location for testing, ensuring adequate ventilation, planning movement through the testing location, and ensuring appropriate PPE, please see Performing Broad-Based Testing for SARS-CoV-2 in Congregate Settings.

Checklist of considerations to assist facilities in their decision-making process about how and when to test broadly for SARS-CoV-2
check light icon

Work with state/local health departments to help inform decision-making about broad-based testing in correctional and detention facilities.

check light icon

If a facility decides to implement broad-based testing, use viral tests with Emergency Use Authorizationexternal icon from FDA, and ensure that the manufacturers’ instructions regarding sample collection and transport are strictly followed to maximize accuracy of results. Work with state/local health departments and laboratories to choose appropriate tests and necessary supplies.

check light icon

If pursuing broad-based testing, strongly consider a program that includes testing for both IDP and staff. 

check light icon

If pursuing broad-based testing, strongly consider a program that includes testing for both IDP and staff. 

  • In some facilities, COVID-19 cases have been initially identified among staff, before any cases have been identified among IDP.
  • Because staff move between the facility and the community daily, the risks of introducing infection into the facility from the community and/or bringing infection from the facility back into the community is ongoing.
  • If there are operational, contractual, and/or legal reasons to refrain from testing staff within the facility or concerns about using facility resources/personnel to test staff, investigate options to work with community partners or state/local health departments to implement staff testing.

Planning for how the facility will modify operations based on test results

  • Identify additional isolation spaces that can be used to house infected individuals identified during broad-based testing and additional quarantine spaces to house their close contacts. Consider what isolation/quarantine spaces are necessary to meet other security or medical needs as well (e.g., Special Housing Unit, medical beds, mental health beds, Protective Custody, etc.)
  • Given the potential for high numbers of asymptomatic infections, ensure that plans include isolation options to house large numbers of infected individuals and quarantine options to house large numbers of close contacts. For example, consider how the facility’s housing operations could be modified for multiple test result scenarios (e.g., if testing reveals that 10%, 30%, 50% or more of incarcerated or detained persons test positive for SARS-CoV-2).
  • Questions to consider and address in a testing plan for IDP include:
    • Will specific housing units/pods be designated for people who test positive?
    • How will the facility manage those who decline testing?
    • How often will broad-based testing be conducted? What will be the threshold/indicator for repeat testing?
    • If testing reveals that more IDP are positive than negative, will those who test negative be reassigned to different housing (rather than reassigning those who test positive)?
    • How will housing areas be systematically and thoroughly cleaned and disinfected if large numbers of positive individuals are identified and housing units are rearranged?
    • How will the facility manage the logistics of moving large numbers of people into different housing arrangements? For example, where will IDP go while the housing units are being cleaned and disinfected, and how will positive and negative individuals be separated during this time?
    • Who will report testing results to local or state health departments as required by state and local public health laws?
  •  When testing staff:
    • Can the employer legally mandate testing for staff? If not, how will the employer encourage testing? How will the employer manage staff who decline testing?
    • What entity will perform the testing, and how will results be reported to the employer and staff member?
    • Who will report testing results from staff to local or state health departments as required by state and local public health laws?
    • How will adequate staffing levels be maintained if a large percentage of staff test positive? (See Guidance for Critical Infrastructure Workers.)