Monkeypox outbreak: The need to include prisons in public health response.

Amid global efforts to combat the ongoing coronavirus disease 2019 (COVID-19) pandemic brought on by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the monkeypox virus has arisen as a unique menace to humanity [1]. In developed countries, monkeypox, a zoonotic orthopoxviral illness that manifests clinically as a smallpox-like infection in people, is becoming more common [2]. Although the Democratic Republic of the Congo saw the first cases of the monkeypox virus in the 1970s, it has since spread to several other nations [3]. As of August 19, 2022, monkeypox has caused 41,358 cases and 12 deaths worldwide, and the threat is growing [4]. The WHO recently declared monkeypox a global health emergency with a number of response initiatives seen across countries, including efforts to increase access to vaccines and increase surveillance [5]. However, efforts to control the monkeypox outbreak in infectious disease-prone environments like prisons have not received much attention. This neglect in prisons is similar to what is seen with the ongoing COVID-19 pandemic.

Prisons, jails, and other closed settings are ideal for monkeypox transmission. Inmates are frequently housed in crowded conditions and may be unable to avoid close contact with one another or with bedding and other fabrics, which are known means of transmission [[6], [7], [8], [9]]. Additionally, the multi-morbidity that is typical in prisons might lower immunity, increasing intrinsic susceptibility to infectious diseases like monkeypox. Some prisons have reported monkeypox cases [10], and the upcoming months will significantly change how we perceive this outbreak. Tens of thousands of monkeypox cases have already been reported in many countries, with most cases affecting men who have sex with other men [11]. This is concerning because homosexual behavior is not uncommon in prisons, making them a major hotspot for monkeypox outbreaks. However, because of many of our prison system's bleak realities, we must take immediate action to address how mass incarceration may hasten the spread of this virus.

An important feature of monkeypox is that it can be transmitted through bodily fluids other than mucosal surfaces and during sexual contact [12]. Transmission can also occur when there is physical skin-to-skin contact during these intimate interactions (and possibly respiratory droplet exposure) [12]. In addition to being purposely cut off from our community health systems and oversight, jails, prisons, and detention facilities are places where frequent close physical contact occurs. Because of this distinction, we must prepare for transmission in environments where such intimate contact occurs. Health officials should take immediate action and make recommendations to the criminal justice system to reduce intimate contact and improve detection and treatment of monkeypox. This requires them to be more forthright than they were with COVID-19 about the unbearably crowded and filthy conditions in facility intake and court pens, where people spend hours to days standing shoulder to shoulder, laying on the ground, or sitting on benches while waiting to be processed into facilities or appear in court. This close contact, frequently skin-to-skin, will considerably aid the spread of monkeypox in prisons. In a manner similar to COVID-19, a large number of the initial cases of monkeypox will be brought on by staff members moving throughout all facilities as well as by guests during visit hours. Along with their frequent physical interaction with inmates at the prisons, this will undoubtedly be a characteristic of how monkeypox spreads.

It is obvious that prisons and other closed settings are potential hotspots for monkeypox. There is an urgent need to increase diagnostic efforts and surveillance of monkeypox in correctional facilities. Neglecting them simply means that we are creating an ecological reservoir among the inmates, making containment efforts more difficult. Additionally, inmates must be educated on how monkeypox spreads and must report any symptoms to prison health authorities as soon as possible. To achieve this, educational resources should be made available. Health authorities should also provide training materials for correctional administrators on the precautions staff should take and ensure that structures are in place to care for people in correctional facilities in order to prevent an outbreak of monkeypox. In addition, in the midst of these twin viral disease health emergencies, COVID-19 and Monkeypox, it is critical to increase infection and prevention control measures, such as handwashing and encouraging safe sex behavior, in correctional facilities.

Priority vaccination for inmates is without a doubt required. The vast majority of those affected are men who have sex with other men, and as a result, this group is being given special attention throughout the vaccination campaign. Inmates, unlike the general population, are less likely to admit to having sex with men or with each other. This is because many of them do not identify as homosexual or bisexual, and they are afraid of the consequences of disclosing their sexual orientation or sexual behavior. However, like COVID-19, both infections and vaccinations exhibit typical patterns of inequity [13,14]. For example, a potential outbreak site such as prisons is largely ignored in the response. It should not be assumed that inmates are not at risk because there have not been any significant outbreaks in prisons; rather, it should be viewed as an opportunity to halt the spread in areas that could become major infection hotspots. In addition to increasing vaccination efforts, the criminal justice system can implement other mitigating measures, such as accelerated hearings, bail reform, and other strategies for reducing the correctional facility population.

Monkeypox has brought to light inequities in public health responses to health emergencies once more. Pathogens are not going away, but how people react to pathogens determines who is perceived to be infected, who is infected, and who is treated. With monkeypox and other outbreaks on the horizon, we must make the decision to address all the equities in responses to health issues. Besides the putative physical and psychological consequences for both inmates and staff within prisons, preventive strategies should be strengthened to avoid potential clustering of monkeypox cases. Neglecting prison health endangers everyone, because no one is truly safe unless everyone is safe.

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All the authors contributed equally to this paper and approved it for publication.

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Yusuff Adebayo Adebisi.

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