The Biden administration has declared the spread of the monkeypox virus a public health emergency. The virus, which is primarily transmitted through skin-to-skin contact, could pose a major threat to millions of people who live behind bars in U.S. jails, prisons, and detention centers. In spite of this, detained and incarcerated people are not being prioritized for preventative monkeypox vaccines, and generally only have access to the vaccine if they have had a known exposure to the virus. 

As demonstrated by the large-scale outbreaks of COVID in jails and prisons, the crowded, poorly ventilated, and filthy conditions behind bars have proven ideal for the spread of highly contagious viruses. In these conditions, social distancing is all but impossible. Monkeypox is spread through close contact, which is hard to avoid in the confines of a jail or prison cell. It’s hard to avoid in tightly packed holding pens, where people often sleep head to toe with many others for days on end, awaiting transfer to prison or to a court appearance. Monkeypox can also be spread through contact with surfaces, or with fabric that has come into contact with the virus. In many cases, detained or incarcerated people are responsible for washing bedding and clothing in shared laundry facilities that serve hundreds of people.

Though anyone can become infected with or transmit monkeypox, the virus has thus far primarily impacted men who have sex with men. Supplies of the monkeypox vaccine are extremely limited, so people who are considered at the highest risk for infection have been prioritized in community vaccination drives. That prioritized list identified by the Centers for Disease Control and Prevention so far includes “gay, bisexual, or other men who have sex with men, or transgender people, who have had any of the following within the past 14 days: sex with multiple partners (or group sex); sex at a commercial sex venue; or sex in association with an event, venue, or defined geographic area where monkeypox transmission is occurring.” 

Queer, transgender, nonbinary people and sex workers are criminalized in the United States and are overrepresented in jails and prisons. A 2019 report from Prison Policy Institute (PPI) found that gay, lesbian, and bisexual people were 2.25 times more likely to be arrested in the previous twelve months than were straight people. The same PPI analysis found that LGB people are incarcerated at a rate over three times that of the total adult population. According to Lambda Legal, nearly one in six transgender Americans has been to prison. For Black trans people, the number is even higher– half have been to prison. It is worth noting that people in jails and prisons have little ability to protect their bodies, as exemplified by recent incidents of rape by prison guards and others in positions of power. Although queer and transgender people are supposed to be prioritized for vaccination, it is unclear when or if the monkeypox vaccine will be made available to vulnerable people behind bars. 

So far, individual monkeypox cases have been reported among people detained in the Cook County Jail in Illinois, the Maricopa County Jail in Arizona, the San Francisco Jail in California, the Miami Dade County Jails in Florida, and the Mecklenburg County Detention Center in North Carolina. At least two Department of Correction staff members at New York’s Rikers Island have contracted the virus. 

Unfortunately, it is unlikely that these seven reported cases give us an accurate picture of the scope of monkeypox behind bars. As we have learned from the severe underreporting and under-testing of COVID cases during the pandemic, there are likely many more cases that have gone undetected or unreported by jails and departments of correction. In the same period in which the Omicron variant drove another surge in COVID infections across the United States, many jail systems and departments of corrections chose to stop publicly reporting COVID data altogether. Public reporting of data about infectious outbreaks in jails and prisons is essential to public health efforts to control them, and data transparency is even more important now that there is another dangerous virus circulating. 

The Biden administration has not prioritized people held in federal prisons for the monkeypox vaccine. According to reporting from The 19th, “Randilee Giamusso of the Federal Bureau of Prisons said that due to limited supplies, federal prisons will not vaccinate the incarcerated unless they are already exposed to monkeypox.”

Vaccinating people who have been exposed to monkeypox is effective in preventing symptom onset and limiting further viral spread. This strategy, called, “ring vaccination,” involves vaccinating everyone who may have been exposed to an infected person, to contain further spread. However, for this strategy to work, infections must be promptly and consistently diagnosed, and those exposed must be made aware. There may be no way for a detained person to know if a person sharing their cell has monkeypox, as the person could have a rash under their clothing, or they may not recognize their own mild symptoms. People held in jails and prisons are often hesitant to report symptoms of illness, for fear of reprisals, isolation, discrimination based on their sexual orientation or gender identity, or an inability to pay copays for medical visits. Once there is a large outbreak in a jail or prison, it may be hard to get it under control. 

People in prison are often denied essential medical care once they become ill. Although at least 55,000 people held in federal prisons have contracted COVID, federal prison officials have only prescribed 363 doses of antiviral drugs like remdesivir or paxlovid since these drugs were approved. Antivirals like the drug tecovirimat (TPOXX) are recommended for the treatment of monkeypox infections in people who are immunocompromised or are more vulnerable to severe illness. People in jails and prisons are disproportionately likely to have chronic illnesses, including diabetes, HIV, and heart disease, and should have access to antiviral treatments for monkeypox like TPOXX. 

During the COVID pandemic, jails and prisons have served as disease incubators, intensifying the spread of COVID. As we have seen over the past two and a half years, outbreaks in jails and prisons do not stay within their walls. Instead, people come and go each day, carrying the virus into the institution, where it quickly spreads, and then back home again to their families and communities. Studies of COVID in the Cook County Jail demonstrated that infections inside the jail propelled community transmission, especially in Black and Latinx communities around Chicago that are disproportionately impacted by mass incarceration. 

We have seen during the COVID pandemic the ways that mass incarceration can accelerate the spread of a dangerous virus. Unfortunately, this experience does not leave great cause for optimism that jails and prisons are prepared to respond effectively to monkeypox outbreaks. To prevent widespread monkeypox infections in jails and prisons, officials must take immediate steps to reduce crowding in jails and prisons by releasing people who pose no threat to public safety, ensuring access to quality health care, eliminating copays for testing and healthcare behind bars, and making every effort to get staff and incarcerated people preventatively vaccinated for monkeypox.