The
Next Epidemic
Coming to Your Local Jail?
Kyler Moore, MPH and Anne C. Spaulding, MD, MPH
Imagine This Scenario
It is a sweltering hot morning, late July 2022. The headlines on your news apps are focusing on monkeypox, an infection you’ve never heard of before, primarily impacting men who have sex with men. You hop in your car and drive to work, where you are a shift commander at the city’s jail.
Later that day, you hear rumors—one of the detainees has developed a raised rash that looks like chickenpox. Your medical director’s report focuses just on infection control implications—a man needs to move from a dorm into an isolation cell in the medical unit. Monkeypox tests will be conducted on persons who were housed in the two dorms where he had previously been. Can rosters be forwarded to health services? You sigh—there are over 50 individuals exposed.
This is the story of what happened at Chicago’s Cook County Jail last summer. A new entrant was Monkeypox-symptom free when he was admitted but he had some risk factors. The rash started on his first full day inside. Placement on the sick call list followed—the facility’s medical services scheduled him about a week after admission, after they were notified by family. Immediate isolation was ordered following notification. Then the next morning, specimens were collected and sent out to the health department. Three days later, a monkeypox diagnosis was confirmed and a team from the CDC was on its way. Educational sessions on prevention by vaccine were offered in the housing units. Having health services address residents in small groups, rather than the whole dorm at the same time, proved more effective in persuading exposed persons to get the inoculation. This is also a story about how any infection circulating in the community can come inside the walls of a jail. More infections, previously confined to remote regions continents away, may soon be in your jail.
What Is Monkeypox?
Monkeypox is a disease caused by a person getting infected with a virus that is related to the smallpox virus, but unlike smallpox, the disease is rarely fatal. Any person can get infected by skin-to-skin contact. The biggest misconception is that it comes from monkeys. Most documented chains of transmission in the African countries where it was previously confined have been linked to rodent exposure. The name, however, came from its initial discovery in lab monkeys in 1958. Monkeys, it turned out, are a rare host of monkeypox.
For a viral disease, an incubation period is the number of days between exposure to the virus and when symptoms first appear. For example, the period may be two to three days for flu. For chickenpox in kids who are not vaccinated, symptoms usually appear two to three weeks after exposure. The incubation period for monkeypox is three days to three weeks, meaning the individual at Cook County Jail was exposed in the community.
The rash may initially be itchy. At first, it may look like pimples or blisters. The rash will last and progress over two to four weeks after onset of symptoms. The disease is contagious from when the rash still appears until the skin is healed, scabs are gone, and fresh new skin appears. Flu-like symptoms (fever, chills, muscle aches, fatigue, and cough) may be the first symptoms. In the present outbreak among men who have sex with men, about 45% experience rectal pain.
More severe cases of monkeypox may occur among people who are younger, pregnant people, the immunocompromised (such as HIV), and those who have atopic dermatitis or eczema. Knowing the symptoms may not be enough for your medical staff to diagnose the disease promptly. While jails conduct entry medical exams, symptoms may start after admission (as was the case in Chicago), or persons may be reticent to disclose pre-entry diagnoses due to issues of stigma or perceived poor confidentiality.
How Does Monkeypox Spread?
Because of disproportionate minority confinement, jail populations bear an outsized proportion of health problems associated with underserved populations. Current data has shown that men who have sex with men make up most monkeypox cases, however, it is possible for anyone to contract the virus. An outsized proportion of persons with the infection are men living with HIV. Nonetheless, those at risk include all persons who have had known skin-to-skin contact with someone who has monkeypox, people who have had a diagnosed sexual partner within the past two weeks, or people who have had multiple partners within an affected area of the country.
In the US, 35% of persons in jails are Black, who make up only 13% of the US population. Nearly all monkeypox virus infections in the US have been in men, and men make up 85% of jail populations. In some cities, such as Atlanta, 80% of the cases of monkeypox infection have been in Black men.
HIV is also over-represented in men compared to women, and in Black people compared to White. One in six people living with HIV spend part of their year incarcerated. As a disease that can spread to anyone in the community, having cases in jails should have been anticipated. Jail cases have accompanied community-wide outbreaks of monkeypox infection, both in Nigeria, and in 2022, Chicago and other cities with substantial communities of men who have sex with men.
Transmission associated with sex is the dominant mode of transmission in the present epidemic. However, there are a few ways monkeypox virus can spread between humans. Most often it is spread through direct contact exchange with the rashes, scabs, or bodily fluids of a person who has monkeypox. Direct contact can occur during intimate contact, allowing monkeypox to spread through oral, anal, and vaginal sex or touching of the genitals or anus with a person who has monkeypox. There is also the risk of getting exposed when hugging, massaging, or kissing a person with monkeypox. Touching an object, fabric, or surface a symptomatic person has used can potentially spread the virus, even without having direct contact with the infected person. During long face-to-face interactions, there is a chance of monkeypox spreading through contact with respiratory secretions, but experts are still studying how often and when this occurs. The major difference between monkeypox and COVID-19 is the importance of direct contact, often skin-to-skin, for the former and airborne transmission for the latter. People exposed to infection are not required to quarantine, but recommendations are that they get vaccinated. They should also closely monitor themselves for symptoms. Only people with symptoms need to be isolated. At Cook County, despite extensive investigation, no secondary case within the jail were found.
Vaccination, Testing, Treatment
Unlike COVID-19, this was not a new disease, so a preventative vaccine and protocols for diagnosis are available. At the onset of the 2022 outbreak, a vaccine was being distributed through health departments. The first group of people at highest priority to receive vaccine are those who have been exposed but do not yet have symptoms. Receiving the vaccine before symptoms can prevent disease. Your medical staff will want to take swabs of lesions for those who have rashes. In the summer of 2022, commercial labs including ones that service jails quickly ramped up their ability to accept and process specimens. An antiviral medication typically used for smallpox is available to treat the disease through an expanded access protocol. Having effective treatment is another feature of a disease that, unlike COVID-19, is not new.
First COVID-19, Then Monkeypox—What’s Next?
With air travel, viruses and other pathogens once present in just isolated pockets can move around the world quickly. For much of the past three years, travel has been limited, but restrictions were relaxed in 2022.
We should expect more and more outbreaks of unusual infections at an ever-increasing pace in the future. What can jails do now? We recommend:
• Build relationships with your local health department now to prepare better for future outbreaks.
• Work with your medical staff on isolation and quarantine protocols. Safely housing your population and keeping your workforce protected represents a collaboration between custody and health services. One cannot function well without the other.
• Develop ways to educate residents and staff to undertake protective measures. In the Cook County case, addressing exposed residents in small groups, rather than whole dorms at once, proved more effective in persuading individuals to take steps to prevent infection.
• Keep abreast of public health news. For instance, the future could bring outbreaks such as hepatitis A from fecal-oral transmission, or norovirus spreading by contaminated foods and surfaces or even “bird flu” from airborne respiratory droplets.
Conclusion
Even the highest walls, and most secure locks, can’t keep new infectious diseases out of jails. It was COVID-19 three years ago, Monkeypox last summer, and another pathogen affecting jail populations could arrive in 2023 or 2024. Welcome to the new chapter of jail management.
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Kyler Moore, MPH, is a Dallas native and a recent graduate of Emory University, where she received her MPH in epidemiology. Before relocating to Atlanta, she earned a BSA from the University of Texas at Austin where she studied biochemistry. Her passion for furthering public health in marginalized populations stems from her interest in the social determinants of health. This led to her becoming involved in Emory’s Center for the Health of Incarcerated Persons, specifically on research in COVID-19 management in jails led by the Center. For more information, she can be reached at kyler.moore@emory.edu.
Anne Spaulding, MD, MPH, earned a Sc.B. from Brown University, her MD from the Medical College of Virginia, and her MPH from Johns Hopkins University. As an infectious disease physician, she served as the statewide medical director for Rhode Island’s Department of Corrections and the state STI clinic. She moved to Atlanta to work in correctional health at the CDC. For the past 16 years, she has been a member of the faculty of Emory University’s Rollins School of Public Health, where she is an associate professor. She leads Emory’s Center for the Health of Incarcerated Persons. For more information, she can be reached ataspauld@emory.edu.
References
Slides and recording available for Free Webinar on Monkeypox in corrections. National Commission on Correctional Health Care. (2022, September 6). Retrieved September 9, 2022, from https://www.ncchc.org/slides-and-recording-available-for-free-webinar-on-monkeypox-in-corrections/
Centers for Disease Control and Prevention. (2022, August 22). Congregate living settings. Centers for Disease Control and Prevention. Retrieved September 14, 2022, from https://www.cdc.gov/poxvirus/monkeypox/community/congregate.html
Centers for Disease Control and Prevention. (2022, August 5). Signs and symptoms. Centers for Disease Control and Prevention. Retrieved September 9, 2022, from https://www.cdc.gov/poxvirus/monkeypox/symptoms/index.html
Centers for Disease Control and Prevention. (2022, July 22). About Monkeypox. Centers for Disease Control and Prevention. Retrieved September 9, 2022, from https://www.cdc.gov/poxvirus/monkeypox/about/index.html
Centers for Disease Control and Prevention. (2022, July 29). How it spreads. Centers for Disease Control and Prevention. Retrieved September 9, 2022, from https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html
Centers for Disease Control and Prevention. (2022, September 14). 2022 outbreak cases and data. Centers for Disease Control and Prevention. Retrieved September 9, 2022, from https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html
Bauer, K. (2022, July 26). Monkeypox case reported in Cook County Jail detainee. Block Club Chicago. Retrieved September 9, 2022, from https://blockclubchicago.org/2022/07/26/monkeypox-case-reported-in-cook-county-jail-detainee/