Since monkeypox was detected outside of Africa in May, 35,000 cases have been confirmed around the world. Out of them, more than 14,000 were identified in the US, primarily in the states of New York, California, Texas, Florida, and Georgia.
The overwhelming majority of the cases have occurred among men who have sex with men, and the vaccination campaign is giving them priority as an at-risk group. But much like with covid, both the infections and the vaccinations are following the usual patterns of inequality: Black men are experiencing more cases, but receiving fewer vaccines.
And, as with covid, the response is all but ignoring a likely site of outbreaks: prisons.
So far, only one case of monkeypox has been confirmed in a prison or jail, at Cook County Jail in Chicago, the same jail system that was one of the largest known sources of covid infections for incarcerated people in the country. More suspected cases have emerged, and like in the general population, it is likely that many cases are escaping detection because of a lack of widespread testing.
Still, the absence of large outbreaks in prisons should be taken as an opportunity to prevent the spread in what could be big sites of infection, not as a sign that inmates aren’t at risk.
Prisons and jails, which house about 2.2 million people in the US, are ideal sites for monkeypox exposure. Inmates are often in crowded spaces, and might not be able to avoid close contact with each other or bedding and other fabrics, which are known means of transmission.
“There should absolutely be priority vaccination in jails and prisons,” says Eric Reinhart, a physician and anthropologist at Northwestern University who researches the role of prisons in infectious outbreaks.
But unlike the general population, vaccines should be offered to all inmates, irrespective of sexual orientations and habits, says DeAnna Hoskins, the head of criminal justice reform organization JustLeadershipUSA.
“You can’t really pick and choose—everyone is a sitting duck,” says Hoskins.
Unlike the general population, she says, inmates are less likely to come forward as having sex with men or among themselves, both because many don’t identify as gay or bisexual, and because they fear repercussions should they admit their sexual orientation or sexual activity.
“It stands to reason that sexual encounters in prisons are more common due to the length of incarceration for both consenting and non-consenting sexual activity that that long periods behind bars drive,” says Reinhart.
Correctional officers, too, should be offered the vaccine, as they routinely have sex with inmates, says Hoskins.
Monkeypox spreads mostly by skin-to-skin contact or through fabrics. Further, says Reinhart, the incubation period is longer than covid and vaccination works even post-exposure to reduce the severity and control the spread, as individuals are mostly contagious when they are experiencing symptoms.
This makes monkeypox easier than covid to contain, even in the prison system. While vaccines are in short supply, it could help establish different priority groups than among the general population, offering the vaccine first to prison inmates and workers, and later to people in jail, who usually remain for shorter stays and are less likely to have opportunities to skin-to-skin or sexual contact.
But this doesn’t mean the populations in detention centers other than prisons aren’t at risk, as the the notoriously overcrowded Cook County Jail shows. So while vaccines are not available for everyone in the correctional system, criminal justice authorities—which are legally entrusted with the care, as well as the custody of incarcerated people—can introduce other mitigation measures such as expedited hearings, bail reform, and other means of jail population reduction.
“You see people held in crowded contexts like bullpens and the use of hot-bunking—people rotating as they use the same beds, usually with unchanged linens—much more commonly in jails and ICE facilities, which provides plausible opportunity for non-sexual routes of transmission,” says Reinhart.
