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This is the second story in a series by MedPage Today that examines the impact of COVID-19 on vulnerable populations. The first story on the homeless can be found here.

U.S. Immigration and Customs Enforcement (ICE) has released 160 vulnerable detainees from detention centers, but 600 high risk individuals -- such as pregnant women and those over 60 -- remain detained, as officials consider their release on a "case-by-case" basis, .

The action comes amidst many of which have against the agency alleging the squalid and cramped detention centers prevent social distancing and accelerate the spread of the virus.

Advocates worry those conditions make the 34,000 people currently under ICE custody particularly vulnerable to coronavirus infection. About a week ago, on April 8, a total of 19 detainees, 7 detention facility staffers, and 48 other employees had tested positive for COVID-19, according to the agency. As of April 14, those numbers had risen to 77, 19, and 72, respectively. (Numbers are updated daily on the under the "confirmed cases tab.")

At the Monroe County detention center in Detroit, Michigan, detainees sleep close together in a facility infested with maggots, share a single gallon of liquid soap, and have not been given facemasks, alleges a against ICE officials.

"Given the greater risk of infection posed by COVID-19, and the fact that inmates cannot engage in proper hygiene and isolate themselves from infected residents or staff, it is only a matter of time until the virus reaches Monroe," according to the lawsuit.

In March, a group of about calling on ICE to release detainees amidst the pandemic, saying conditions in detention centers posed an "extreme risk" that made it "impossible to ensure that detainees will be in a 'safe, secure, and humane environment,' as ICE's own National Detention Standards state."

Last year, physicians protested Customs and Border Protection (CBP)'s refusal to provide flu vaccines to migrants in detention centers, despite recommendations from the CDC that doing so could cause preventable deaths and hospitalizations.

Just as the detention centers served as a breeding ground for influenza and saw the death of three children under ICE custody last year, they are optimal conditions for the spread of COVID-19, said Mark Travassos, MD, a pediatric infectious disease specialist at the University of Maryland School of Medicine.

"This has parallels to the influenza outbreak last year and has all the red flags of a very dangerous situation," Travassos told MedPage Today.

Although ICE tests detainees in house or at a local hospital, asymptomatic coronavirus cases may be missed, resulting in a higher number of actual cases.

"The positive cases we've seen are most likely the tip of the iceberg," Travassos said. "When we finally identify an outbreak within a center, we'll be several steps behind the spread of disease."

Beyond Detention Centers

ICE does not operate all of the facilities in which migrants are held and has only reported cases in 23 centers. Local jails or other shelters run by the Office of Refugee Resettlement (ORR), however, have independently reported positive COVID-19 cases.

At the Heartland Alliance facility in Chicago, have tested positive for COVID-19, ProPublica reported.

At the Bristol County House of Correction in Dartmouth, Massachusetts, against county sheriff Thomas Hodgson and other ICE officials for not taking adequate action to prevent the spread of the virus in closed centers among immunocompromised and otherwise vulnerable people.

"No 'social distancing' has taken place in Defendants' facilities -- and it cannot," according to the lawsuit. "Plaintiffs are unaware of any meaningful safety measures enacted by Defendants since the inception of this crisis."

In a hearing held last week, a spokesperson with the Bristol County Sheriff's office said none of the ICE detainees had been tested for coronavirus and called the lawsuit ". Hours before, a nurse at that very facility tested positive for the virus.

The following day, a federal judge with no criminal charges or convictions and asked for a list of 50 additional detainees to be considered for release.

Limiting Migration

As ICE released its first wave of migrants, the agency's Enforcement and Removal Operations (ERO) has also limited the number of migrants being introduced into the system to mitigate the spread of COVID-19, reducing the population within detention facilities to 70% or less.

"Utilizing CDC guidance along with the advice of medical professionals, ICE may place individuals in a number of alternatives to detention options," according to a statement provided to MedPage Today. "Decisions to release individuals in ICE custody occur every day on a case-by-case basis."

Customs and Border Protection (CBP) has completely restricted entrance into the U.S. for individuals from certain countries, that denies entry to people who may spread "infectious disease" in the U.S.

Thus far, along the U.S. border under this authority "in the interest of public health," according to CBP data.

This follows the Trump administration's or "Remain in Mexico" policy, implemented in January 2019: individuals who enter the U.S. illegally, as well as certain asylum seekers, are sent to Mexico to wait for the duration of their immigration proceedings.

Together these policies have reduced ICE's detained population by more than 4,000 individuals since March 1, 2020, with a more than 60% drop in book-ins year-over-year.

Care Across the Border

As a result, migrants seeking asylum in the U.S. are lining up in places like Matamoros, Mexico, across the border from Brownsville, Texas.

There, about 2,500 people seeking asylum live in tents on a muddy stretch of land, where a mobile medical clinic run by Global Response Management (GRM) provides care. An additional 1,000 people are spread throughout the city in apartments and use the camp as their primary clinic.

Border closures have sent a wave of fear throughout the camp, and those seeking asylum are concerned they will be deported while they await court proceedings, which would only increase the spread of the virus, said Andrea Leiner, MSN, of Mass General Global Health.

"People who came to apply for [asylum] could easily be rounded up and deported," Leiner told MedPage Today. "There have been buses of people taking voluntary evacuees from shelters and our camp and sending them down to Chiapas on the Mexico-Guatemala border."

Due to the nature of the camp -- with tents jammed closely together and limited running water -- isolation and containment are near-impossible, Leiner said.

Leiner and a group of about 10 healthcare providers handle mild and moderate cases at the camp's facilities, and they send severely ill or emergency patients to a nearby hospital. Many migrants are certified healthcare professionals in their home countries and are also staffing the clinic, she said.

Although the population GRM treats is generally young and healthy, able to traverse long distances to arrive there, they are also chronically malnourished and living in conditions that easily spread disease, said GRM medical director Maura Sammon, MD, of Temple University in Philadelphia.

"How do you practice social distancing when you're sleeping five to a tent?" Sammon told MedPage Today.

Using data from prior infectious disease outbreaks in prisons, Sammon calculated that roughly 350 individuals in the camp will need medical treatment for COVID-19 related complications, and that 100 will need oxygen, assuming an infection rate of 50% and that about 80% of those cases would be mild.

However, the staff there have 20 oxygen concentrators and one ventilator, which if used at low doses, could treat a maximum of about 40 people, Sammon said.

"We are facing what we realize is an insurmountable task," Sammon said.

Although their group has been given permission to cross the border for transporting supplies, Leiner said they were concerned their supply lines may be cut collaterally as a result of the border closure.

"If people see the challenges their local hospital is facing [getting supplies], imagine being a tiny nonprofit with a small budget," Sammon said.

This is a community that has been turned away "time and time again," she added.

"I'm terrified it's going to be devastating," Sammon said.

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