Monkeypox In Prisons: Urgent Action Needed To Avoid A Public Health Crisis – healthaffairs.org

September 14, 2022
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The United States leads the world in monkeypox infections. Monkeypox is a contagious disease caused by a virus in the same family as smallpox that is spread via respiratory droplets and by person-to-person contact and results in a rash, swollen lymph nodes, fever, and body aches. Vaccines are available, and more than 99 percent of those infected with the type of monkeypox in the current outbreak survive. As of late August 2022, there have been more than 17,000 confirmed cases of monkeypox in the United States. The virus has been reported in nearly every state. Five states have more than 1,000 confirmed cases, with New York reporting the highest caseload of 3,117.
Simultaneously, the United States continues to lead the world in mass incarceration with carceral facilities being places at extreme risk for the spread of infectious diseases. Prisons, jails, and detention centers are overcrowded and often lack access to basic hygiene, which leads to an increased transmission of contagious diseases. As we have seen in the past two years, prisons and jails have become an epicenter of the COVID-19 pandemic. They were consistently among the largest single, site cluster outbreaks of COVID-19 throughout the country, with the rate of infection among incarcerated people being four times and the age-adjusted rate of death three times that of the general population.
Several cases of monkeypox have already been reported in jails nationwide. Yet, as we will detail in this article, there is no centralized tracking of the number of monkeypox cases in carceral facilities nor is there any guidance for prisons and jails from the Centers for Disease Control and Prevention (CDC) or state health departments. Without the necessary protective measures in place, monkeypox outbreaks inside of carceral facilities will happen, and they will also impact the communities near these facilities. These consequences were seen during COVID-19, as an estimated 13 percent of new COVID-19 cases across the United States were linked to mass incarceration during the summer of 2020.
Observing the lack of response as monkeypox ramps up around the country, we feel like we are back at the beginning of the COVID-19 pandemic. Then, our group started the COVID Prison Project, which became one of the only national voices aggregating COVID-19 data behind bars and subsequently ringing the alarm once the broad scope of harm became clear. Using the COVID Prison Project infrastructure, we set out to understand to what degree prisons were responding and making data available relevant to America’s new public health crisis—monkeypox—and to again ring the alarm.
Our team surveyed the 53 prison system websites in the United States that is, each state and Puerto Rico’s Department of Corrections [DOC] and the Federal Bureau of Prisons, Immigration, and Customs Enforcement). We looked for the following: whether prison system websites had any information available on monkeypox at all, and if yes, what the content of any information included, and whether prison systems made any data available relevant to monkeypox testing or incidence. We had two coders code each website and were prepared to have a third coder resolve any discrepancies between the initial coders (although the need for this did not arise). We reviewed prison system websites given that this is where DOCs historically post information relevant to policies and protocols (for example, quarantine and isolation, collaborations with Departments of Health), and it is where all prior information on COVID-19 testing and incidence has been posted (for example, California).
After extensively reviewing each prison system’s website for information, documentation, guidance, or data, we found that no prison systems had any information on addressing or tracking monkeypox.
As during the COVID-19 pandemic, it is becoming painfully clear that DOCs are not adequately prepared, resourced, or supported to mitigate monkeypox among incarcerated people and staff. And, as with COVID-19, this lack of preparation is not just on the part of carceral facilities: The CDC has issued no monkeypox guidance for jails and prisons. More than two months ago, the CDC published information on monkeypox for congregate living facilities; notably absent were any specific strategies for carceral settings. Additionally, several years into the COVID-19 pandemic, it is impossible to understand if mitigation strategies have been put in place in carceral settings; we can only expect more of the same with monkeypox.
The conditions that allowed for and facilitated the wildfire spread of COVID-19 in prisons and jails—and can do so for monkeypox—over the past many years are precisely the same now. Looking ahead, guidance and transparency are urgently needed to mitigate potential large-scale monkeypox outbreaks in carceral facilities across the country. Here are our recommendations:
Often, DOCs are making public health decisions in a silo, but state and national health authorities should weigh in and aid in the evolution of health promoting practices. The CDC should issue guidance for monkeypox specific to carceral settings, to highlight the need for collaboration and communication between carceral facilities and state Departments of Health. This guidance could include proposals for the co-creation of guidance documents and the ongoing deployment of recommendations based on best public health practices, as well as guidance for testing and incidence reporting.
Similarly, state Departments of Health should form and strengthen their collaborations with prison systems. Departments of Health should offer best public health practices around monkeypox prevention and treatment and should recommend that prison systems provide transparent information on monkeypox policies, testing, and cases—and make it available to the public. It is only through prison systems publicly reporting information in real time that we can know the true scope of illness, understand how best to allocate resources, and hold the prison systems accountable for their response to monkeypox and other public health crises. Lack of information does not necessarily mean that there are no mitigation strategies being implemented, but this lack of transparency regarding response or number of cases means that public health actors cannot respond and family members of incarcerated people do not know the health status of their loved ones behind bars.
Making monkeypox testing and vaccination available in carceral facilities is particularly important for Black communities, who are disproportionately incarcerated and disproportionately acquiring monkeypox due to preexisting inequities. Furthermore, early data show that Black individuals are receiving a disproportionately low amount of monkeypox vaccines. These risks are heightened for men who have sex with men (MSM). MSM, particularly Black MSM, are at increased risk for criminal legal involvement and for monkeypox infection.
State and local authorities should continue to pursue decarceration, as reduction in population is one of the most effective ways to mitigate spread. Using the example of COVID-19, one recent study found that prisons in Texas that were at 85 percent capacity or less were less likely to experience an outbreak. Reducing the number of people incarcerated is critical for improving health, reducing the spread of infectious disease, and has been advocated for by the American Public Health Association as a public health solution. This should be coupled with investments in other systems such as housing, health care, and improvement in civic engagement. In 2020, small-scale efforts toward decarceration were made, with jails, in particular, reducing their population by 30 percent and prisons, albeit much less, by 15 percent. Yet, by the end of 2021, these numbers had returned to near pre-pandemic levels, and the calls for permanent public health alternatives to incarceration went largely unheeded. Decarceration is being raised again as a way to mitigate the threat of monkeypox in carceral facilities.
The COVID-19 pandemic shone a light on the extreme risk and negative health impact that carceral settings impose to both those incarcerated and their communities. The absence of data and mitigation guidance provided by the CDC, Departments of Health, and carceral facilities themselves underscores the de-prioritization and exacerbates the marginalization of the millions of people incarcerated in this country. Action is urgently needed to prevent yet another public health crisis among this vulnerable population.
DOI: 10.1377/forefront.20220909.516339

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