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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 observed for symptoms or who received serologic testing. Although the patient reported no skin-to-skin contact or sexual contact with other residents, all residents slept in the same room as the patient and shared living and dining and sanitary facilities. These findings suggest that transmission of monkeypox may be limited in such clusters in the absence of higher-risk exposures, such as skin-to-skin or sexual contact (the main modes of transmission identified during the current multinational outbreak). Current CDC guidelines do not recommend quarantine for exposed individuals who remain asymptomatic; these findings support the application of this guideline within group settings.§§§
Although this investigation found no evidence of skin-to-skin or sexual contact among CCJ residents, previous research has highlighted that incarcerated individuals may not disclose intimate or sexual contact in the facility due to potential stigma, retaliation, or disciplinary concerns. consequences (3). Additionally, transmission of monkeypox has been documented in correctional facilities previously, including a cluster of five cases and an outbreak of 21 cases in Nigerian prisons in 2017 and 2022, respectively, where modes of transmission could not be definitively established (4,5). In this investigation, some residents revealed patterns of contact in the dormitory as a whole (not necessarily with the monkeypox patient) that had previously been associated with transmission in household studies (eg, sharing cutlery and bedding) (6). Therefore, correctional facilities should remain vigilant for potential cases of monkeypox as long as transmission continues to occur in the United States.
Results of PCR testing of surfaces in CCJ’s dormitory rooms indicated 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 usually lean on this type of surface while sitting in bed, or drape damp clothes and towels over them to dry. Although no viable virus was detected on the surface at the time of sampling, studies with vaccinia virus found that viable virus persisted for up to 28 days on such a surface, indicating the importance of thorough disinfection of all areas where a person with monkeypox has spent some time, including any surfaces they may have touched or that may have come into contact with their clothing or underwear (7). Facilities must ensure that residents and staff members responsible for cleaning and disinfection receive appropriate training, supplies, and supervision to perform these tasks.
Approximately one-third of CCJ residents who were exposed to a monkeypox patient 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). Of note, acceptance of PEP 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 enrolled in the CCJ after the conclusion of this investigation privately disclosed a recent hospitalization for monkeypox, having previously answered no to all screening questions asked in a semi-public reception area.
The findings in this report are subject to at least five limitations. First, assessment of exposure risk was challenging in the housing stock setting, and some residents classified as having an intermediate risk exposure may actually have a lower risk exposure. Second, serologic testing and symptom surveillance were completed for only 25% and 62% of exposed residents, respectively. Third, serological testing was performed 7 days after potential exposure for some residents, when they may not yet have seroconverted, possibly leading to misclassification of secondary cases. Fourth, monkeypox-related stigma or a desire to avoid isolation may have limited self-reporting of symptoms or higher-risk exposure, such as sexual activity. Finally, findings may not be generalizable to all collection sites due to variations in facility layout, ventilation, housing density, laundry practices, and adherence to infection prevention and control protocols, as well as differences in shedding viruses and the infectious period among humans with monkeypox. Additional data may further elucidate the risk of transmission in general crowding conditions.
Correctional facilities can reduce the risk of monkeypox transmission by following public health recommendations (box). First, facilities must maintain infection control protocols in response to cases, including isolating individuals with suspected monkeypox and promptly and thoroughly cleaning and disinfecting all areas where the individual has spent time¶¶¶ (9). Second, facilities should provide monkeypox prevention information to residents and staff members, including information on avoiding sexual contact in the detention facility and avoiding common practices such as sharing eating utensils and bedding. Third, facility staff should follow health department guidelines for post-exposure symptom monitoring and PEP, provide information on signs and symptoms of monkeypox and how to report them confidentially, and provide prompt evaluation when residents report symptoms. The use of private spaces during admission screening, exposure notification, and PEP counseling can aid disclosure of sensitive information and may improve uptake of public health recommendations.
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