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

Chicago, Illinois, July-August 2022

Liesl M. Hagan, MPH; Amy Beeson, MD; Sarah Hughes, MPH; Rashida Hassan, MSPH; Lauren Tietje, MPH; Ashley A. Meehan, MPH; Hillary Spencer, MD; Janice Turner, MPH; Morgan Richardson, MFA; Jourdan Howard, MPH; Anne Schultz, MPH; Salma Ali, MPH; Margaret Mary Butler, MSN; Diana Arce Garza, MS; Clint N. Morgan, MS; Chantal Kling; Nicolle Baird, PhD; Michael B. Townsend, PhD; William C. Carson; David Lowe, PhD; Nhien T. Wynn, MS; Stephanie R. Black, MD; Janna L. Kerins, VMD; Josh Rafinski, MBA; Andrew Defuniak, MD; Priscilla Auguston, MD; Emily Mosites, PhD; Isaac Ghinai, MBBS; Chad Zawitz, MD

Disclosures

Morbidity and Mortality Weekly Report. 2022;71(40):1271-1277.

Investigation and Results

CCJ houses approximately 6,000 residents in cell-based and dormitory-based units across 16 buildings. The monkeypox case occurred in a resident who was booked into jail in mid-July 2022 (investigation day 1) and assigned to two congregate dormitories used for intake (dormitories A and B)^† during the 7 days preceding his isolation for suspected monkeypox. On day 7, the resident placed a written request for health services, reporting swollen genitals, and CCJ health care personnel ordered a sexually transmitted infection laboratory panel. On day 8, health care administrators received a call from one of the patient's family members alerting them to the possibility that the patient might have monkeypox; he was then evaluated in person and isolated. Lesion swab specimens collected for nonvariola Orthopoxvirus (NVO) testing on day 9 returned a positive result on day 11. During evaluation, the patient reported first noticing a localized rash on day 2, which subsequently spread over much of his body and was accompanied by fatigue and body aches before he was isolated. IDPH requested a CDC deployment team to assist with the investigation. This activity was reviewed and approved by CDC and conducted consistent with applicable federal law and CDC policy.^§

Fifty-seven other residents were housed with the patient for 1–7 nights (median = 5 nights) before he was isolated (Table) (Figure). Although CCJ policy required indoor mask use as a COVID-19 prevention strategy during the period of this investigation, enforcing mask use 24 hours per day in correctional facilities is challenging and mask usage is often low; the patient and other residents were not observed wearing masks consistently during this time. The patient reported during an interview that he had had no skin-to-skin or sexual contact with other residents, and no such contact between the patient and other residents was observed during review of security video footage. Because of the difficulty in ascertaining whether each resident sharing a dormitory with the patient met criteria for intermediate-risk exposure versus lower-risk exposure (simply entering the living space of a person with monkeypox), all 57 residents were conservatively categorized as having had intermediate-risk exposure.^¶

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Figure.

Follow-up of 57 residents potentially exposed to Monkeypox virus — Cook County Jail, Chicago, Illinois, July–August 2022
Abbreviation: PEP = postexposure prophylaxis.

On investigation day 15, serologic testing was offered to the 36 potentially exposed residents who were still in detention. One week later, on investigation day 22, serologic testing was again offered to those who had declined the first offer. Among all 36 residents still in detention, a total of 14 (39%) consented to testing. Specimens were tested by enzyme-linked immunosorbent assay for anti-Orthopoxvirus immunoglobulin (Ig) M (a transient marker of acute infection or recent vaccination) and IgG (a long-lived marker generated during infection or vaccination).^[1] None of the specimens tested positive for IgM. Specimens from three residents tested positive for IgG; all three were old enough to have received routine childhood smallpox vaccination, although their previous smallpox vaccination history could not be confirmed.**

On investigation day 8, after the patient was isolated, CCJ resident-workers cleaned and disinfected dormitories A and B. To evaluate the extent of remaining surface contamination, 54 environmental samples were collected from both dormitories on investigation day 21, which was 18 days after the patient had been in dormitory A and 13 days after he had been in dormitory B.^†† One dormitory B sample, collected from a vertical, painted concrete slab at the head of the patient's bed, tested positive for NVO DNA by real-time polymerase chain reaction (PCR) and was confirmed by Clade II MPXV-specific PCR; viral culture was negative^§§.^[2]

To identify possible exposure patterns in the dormitories and to assess residents' knowledge about monkeypox, 16 potentially exposed residents were interviewed individually.^¶¶ The majority of residents (12) reported washing their clothes in communal showers or sinks in the dormitory. Some residents reported sharing personal hygiene items (five) or eating utensils (four) with other residents, engaging in physical altercations (four), sitting on other residents' beds (three), or sharing or touching other residents' linens (two). None reported sexual contact with others while in CCJ. The majority (13) also reported hearing about monkeypox for the first time while detained in CCJ. Residents' knowledge about monkeypox symptoms, transmission modes, and exposure risks varied but was generally low.

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^†Dormitories A and B are each 2,950 ft² with 10.5-ft high ceilings and a congregate bathroom with five combination toilet-sink units and five shower stalls. Each has 39 fixed single bed platforms spaced a minimum of 3 ft apart. During the investigation period, the ventilation system typically provided five to six air changes per hour for both dormitories; when outdoor air temperature was >90°F (>32°C) for brief periods on 2 days, three to four air changes per hour occurred. During the period when the patient with monkeypox was housed in dormitories A and B, residents were served meals at communal tables inside the dormitories and spent an average of 20–24 hrs per day in the dormitories.
^§45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
^¶ https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html
**One resident had an equivocal IgM result 7 days after last potential exposure to the patient but reported no symptoms at the time of specimen collection or during his 21-day incubation period. Because he received PEP, repeat serologic testing was not performed; seroconversion in progress cannot be definitively ruled out.
^††Surfaces included painted concrete bed platforms, desks, and stools in the spaces assigned to the patient before he was isolated, as well as metal toilet rims and flush buttons, metal sink and shower buttons, and plastic telephone receivers shared in communal spaces.
^§§Polyester-tipped applicator swabs were prewetted with phosphate buffered saline (PBS) solution before swabbing environmental surfaces, then stored and transported in 300 μL of PBS solution and kept frozen until processing using the swab extraction tube system (Roche); DNA was extracted from the swab eluate before PCR testing.
^¶¶Residents were asked about their monkeypox knowledge (including transmission modes, prevention, and symptoms) and the types of contact they had with other persons in the jail or with shared objects. The identity of the patient with monkeypox was not disclosed; thus, questions about contact with others in the jail did not specify whether it occurred with the patient versus with other persons in the dormitory.

Table. Characteristics of residents potentially exposed to *Monkeypox virus* and who participated in elements of a field investigation (N = 57) — Cook County Jail, Chicago, Illinois, July–August 2022
Characteristic	No. (%)
Characteristic	Potentially exposed*	Offered PEP^†	Accepted PEP^†	Accepted testing	Individually interviewed
Total	57	36	13	14	16
Age, yrs, median (range)	38 (21–63)	38 (21–62)	33 (22–58)	38 (21–62)	43 (21–62)
No. of nights potentially exposed, median (range)	5 (1–7)	5 (1–7)	5 (1–6)	5 (1–7)	5 (1–7)
Sex
Male	57 (100)	36 (100)	13 (100)	14 (100)	16 (100)
Race or ethnicity
Black or African American, non-Hispanic	30 (53)	18 (50)	4 (31)	7 (50)	9 (56)
White or Caucasian, non-Hispanic	17 (30)	12 (33)	4 (31)	4 (29)	4 (25)
Hispanic or Latino	8 (14)	5 (14)	4 (31)	2 (14)	2 (13)
Asian, non-Hispanic	2 (4)	1 (3)	1 (8)	1 (7)	1 (6)

Abbreviation: PEP = postexposure prophylaxis.
*Classified as having intermediate-risk exposure to the patient with monkeypox (i.e., were potentially within 6 ft of the patient for a cumulative period of ≥3 hours without wearing a surgical mask or respirator, or potentially had contact between their own intact skin or clothing and the skin lesions or body fluids from the patient with monkeypox or with materials that were in contact with the patient's skin lesions or body fluids).
^†JYNNEOS vaccine.

Box. Public health messages related to monkeypox prevention in correctional settings — United States, 2022
When monkeypox is suspected, promptly isolate the affected person, evaluate them for testing, and alert the health department for further support and guidance (https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html). • Multiple residents with confirmed monkeypox can be housed together. • Persons entering the isolation space or handling laundry from persons with monkeypox should wear recommended PPE (https://www.cdc.gov/poxvirus/monkeypox/community/congregate.html). Patients should wear a mask and cover lesions if they leave the isolation space. • Collect and contain soiled laundry and linens from a person with monkeypox in a container that can be disinfected, or a laundry bag that can be laundered along with the soiled items from the person with monkeypox. Do not shake or handle laundry in a manner that might disperse infectious material. Launder separately from other residents' laundry using regular detergent. • Support patients' mental health during isolation, and ensure they have regular access to showers, hygiene supplies, and clean clothing and linens. *Surface contamination with Monkeypox virus* can occur and can contribute to transmission. • Ensure prompt and thorough cleaning and disinfection in spaces where a person with monkeypox has spent time. Include all surfaces that someone with monkeypox might have touched or places they might have stored or placed soiled clothing, towels, or linens. • Perform disinfection using an EPA-registered disinfectant with an Emerging Viral Pathogens claim (https://www.epa.gov/coronavirus/what-emerging-viral-pathogen-claim) found on EPA's List Q (https://www.epa.gov/pesticide-registration/disinfectants-emerging-viral-pathogens-evps-list-q), according to instructions on the product label. • Provide sufficient training, supplies, oversight, and PPE (https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html) to residents and staff members responsible for cleaning and disinfection. For more information, see Workplace Solutions: Safe and Proper Use of Disinfectants to Reduce Viral Surface Contamination in Correctional Facilities (https://www.cdc.gov/niosh/docs/wp-solutions/2021-121/). Contact tracing can help to prevent further transmission. However, persons exposed to Monkeypox virus do not need to quarantine if they do not have signs or symptoms consistent with monkeypox. Confidentially inform residents and staff members of potential exposure to prevent stigma and to encourage disclosure of high-risk contact that might have occurred (https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html). Follow health department guidance for symptom monitoring and PEP for residents and staff members who have been exposed. Ensure that residents and staff members know the symptoms of monkeypox and ensure that residents can confidentially report symptoms or contact with a person with monkeypox. Evaluate residents promptly when they report symptoms. When indicated, offer PEP as soon as possible after exposure to prevent loss to follow-up (especially in high-throughput settings like jails) and to best prevent infection. • For maximum effectiveness, PEP should be offered within 4 days of exposure. • Discuss options with the health department for offering PrEP vaccination to residents who might be at increased risk for monkeypox in the facility or after release (https://www.cdc.gov/poxvirus/monkeypox/vaccines/vaccine-basics.html). • PEP acceptability might be lower in some correctional environments than in other settings and can be supported through individual, confidential discussions between residents and trusted communicators, such as medical providers. Facilitate disclosure of a known monkeypox diagnosis, symptoms, or risk factors at intake by asking screening questions in private spaces. Residents and staff members might not have adequate information about monkeypox or adequate access to hygiene and cleaning supplies to protect themselves. Provide correctional facility residents with no-cost supplies to enable them to wash their hands and clean their living areas frequently and provide information about avoiding skin-to-skin and sexual contact in custody settings and avoiding common interactions that could lead to exposure, such as sharing personal items, clothing, linens, eating utensils, cups, and bowls. Abbreviations:** EPA = Environmental Protection Agency; PEP = postexposure prophylaxis; PPE = personal protective equipment; PrEP = preexposure prophylaxis.