Ultimate magazine theme for WordPress.

Monkeypox Case Investigation — Cook County Jail, Chicago, Illinois, July-August 2022

Discussion

After a CCJ resident with symptomatic monkeypox spent 7 days in congregate housing, no additional cases were detected among a subset of residents classified as having intermediate-risk exposures (62%) who were monitored for symptoms or who received serologic testing. Although the patient reported no skin-to-skin or sexual contact with other residents, all residents slept in the same room with the patient and shared living and dining spaces and bathroom facilities. These findings suggest that monkeypox transmission might be limited in similar congregate settings in the absence of higher-risk exposures such as skin-to-skin or sexual contact (the primary transmission modes identified during the current multinational outbreak). Current CDC guidance does not recommend quarantine for exposed persons who remain asymptomatic; these findings affirm application of this guidance within congregate settings.§§§

Although this investigation found no evidence of skin-to-skin or sexual contact among residents in CCJ, previous research emphasizes that persons who are incarcerated might not disclose intimate or sexual contact within the facility because of potential stigma, retaliation, or disciplinary consequences (3 ). Furthermore, monkeypox transmission has been documented in correctional settings previously, including a cluster of five cases and an outbreak of 21 cases in Nigerian prisons in 2017 and 2022, respectively, where the transmission modes could not be definitely ascertained (4,5). In this investigation, some residents disclosed contact patterns in the dormitory overall (not necessarily with the patient with monkeypox) that have previously been associated with transmission in household studies (eg, sharing eating utensils and linens) (6). Thus, correctional facilities need to remain vigilant for potential cases of monkeypox while transmission continues to occur in the United States.

Results of PCR testing of surfaces in the shared CCJ dormitories indicate that at least one surface retained MPXV DNA at the time of sampling: a vertical, painted concrete slab at the head of the patient’s bed. Residents commonly lean against this type of surface while sitting in bed, or drape damp clothing and towels over it to dry. Although no viable virus was detected on the surface at the time of sampling, studies with vaccinia virus have found viable virus persisting up to 28 days on a similar surface, indicating the importance of thoroughly disinfecting all areas where a person with monkeypox has spent time, including all surfaces they might have touched or that might have had contact with their clothing or linens (7). Facilities should ensure that residents and staff members responsible for cleaning and disinfection receive adequate training, supplies, and oversight to complete these tasks.

Approximately one third of CCJ residents who were exposed to the patient with monkeypox were discharged before PEP was offered, and those who accepted PEP received it 7-14 days after exposure, outside the 4-day window recommended to prevent infection. Among residents offered PEP, approximately one third accepted it, a rate lower than that reported among community and health care contacts during previous monkeypox outbreaks (8). Notably, PEP acceptance was higher among residents who received individual or small group counseling (55%) than among those who were offered PEP while in a large group (12%). Similarly, a resident booked into CCJ after the conclusion of this investigation privately disclosed a recent hospitalization for monkeypox after previously answering “no” to all screening questions asked in a semipublic intake space.

The findings in this report are subject to at least five limitations. First, exposure risk assessment was challenging in the congregate housing setting, and some residents classified as having intermediate-risk exposure actually could have had a lower-risk exposure. Second, serologic testing and symptom monitoring were completed for only 25% and 62% of exposed residents, respectively. Third, serologic testing was performed 7 days after potential exposure for some residents, when they might not yet have seroconverted, possibly resulting in misclassification of secondary cases. Fourth, monkeypox-related stigma or desire to avoid isolation could have limited self-report of symptoms or higher-risk contact such as sexual activity. Finally, findings might not be generalizable to all congregate settings because of variation in facility layout, ventilation, housing density, laundry practices, and adherence to infection prevention and control protocols, and because of differences in viral shedding and infectious period among persons with monkeypox. Additional data can further elucidate transmission risk in congregate settings overall.

Correctional facilities can reduce monkeypox transmission risk by following public health recommendations (Box). First, facilities should maintain infection control protocols in response to cases, including isolation of persons with suspected monkeypox and prompt and thorough cleaning and disinfection of all areas where the person has spent time¶¶¶ (9). Second, facilities should provide monkeypox prevention information to residents and staff members, including information about avoiding sexual contact in the custody setting and avoiding common practices such as sharing eating utensils and linens. Third, facility officials should follow health department guidance for postexposure symptom monitoring and PEP, provide information about monkeypox signs and symptoms and how to report them confidentially, and ensure prompt evaluation when residents do report symptoms. Using private spaces during intake screening, exposure notification, and PEP counseling can support disclosure of sensitive information and could improve acceptance of public health recommendations.

Comments are closed.