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.

Public Health Response

CDPH recommended PEP and daily symptom monitoring for 21 days after last exposure for all 57 potentially exposed residents.*** CCJ notified the residents of their potential exposure and, out of an abundance of caution, placed them under quarantine precautions within dormitories A and B. One resident reported a rash on investigation day 22 and was evaluated the same day; test results for NVO were negative. Among the 57 residents, 35 (61%) remained in detention for their full 21-day monitoring period (33 in CCJ and two transferred to a state prison). The remaining 22 (39%) residents were discharged to the community before conclusion of their 21-day monitoring period and were lost to follow-up. However, CDPH cross-checked the names of the discharged residents with the Illinois state testing database and confirmed that none had a record of monkeypox testing in the 30 days after their last potential exposure in CCJ.^†††

On investigation day 15, PEP with JYNNEOS vaccine was offered to the 36 (63%) potentially exposed residents who were still in detention at that time (the same 36 residents who were also offered serologic testing on day 15 as part of the investigation). Dormitory B residents received PEP information as a large group, followed by a public roll call offering PEP to each resident. Staff members reported difficulty communicating effectively in the large group; only three of 25 (12%) residents who were offered PEP in this setting accepted. In subsequent individual interviews, several dormitory B residents indicated they did not want to receive the vaccine in front of others, did not know enough about the vaccine or potential side effects, or thought they were being offered a COVID-19 vaccine. In contrast, dormitory A residents were escorted to a separate room individually or in groups of two, where they were counseled and offered PEP; six of 11 offered PEP in this setting accepted. On day 22, PEP was reoffered individually to eight residents from dormitories A and B participating in individual interviews who had declined the first PEP offer; four accepted. Overall, 13 (23%) of 57 residents received PEP 7–14 days after their last potential exposure (median = 12 days).

In early August, CCJ added monkeypox screening questions (presence of rash or known close contact with someone with monkeypox) to the intake process for new residents entering CCJ. Shortly thereafter, a newly detained resident answered "no" to all screening questions but later, in a private exam room with a medical provider, disclosed that he had been hospitalized with monkeypox 2 weeks before his arrest.

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***Nursing staff members checked vital signs and asked residents about symptoms once daily. During days 11–13, monitoring included symptoms of influenza-like illness and COVID-19; on day 15, new-onset rash was added. Staff members who worked in dormitories A or B were determined to have lower-risk exposures and were not offered PEP or advised to self-monitor for symptoms.
^†††Telephone numbers were available for 17 of the 22 potentially exposed residents discharged to the community before their 21-day monitoring period ended. CDPH staff members called all 17 numbers but were unable to reach any of the discharged residents to ask about monkeypox symptoms they might have experienced during the monitoring period.

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.

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

Chicago, Illinois, July-August 2022

Public Health Response

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Authors and Disclosures

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