Inmates in the U.S.’s Overcrowded Prison System Face a New Threat

C. auris fungus is poised to overtake a medically inadequate prison system

The United States is in the infamous position of incarcerating more of her citizens than any other country, worldwide. At the end of 2023, approximately 1.8 million people were in jails and prisons in the United States. Even China—whose population of approximately 1.4 billion eclipses that of the U.S. at about 337 hundred—has fewer incarcerated citizens (1.69 million). No other nation comes close to matching the U.S. and China’s prison populations. (1)

According to Statista, a “global data and business intelligence platform,” African-Americans make up the largest share of U.S. prisoners in federal correctional facilities. The states of Texas, California and Florida had the largest number of prisoners as of 2022. (1)

Now a rapidly spreading, drug-resistant fungal infection—Candida auris—is showing up in prisons, from its other stronghold of medical facilities.

In March 2024, the Centers for Disease Control and Prevention (CDC) published an article examining the problem of C. auris in correctional facilities: federal and state prisons for which they had reported cases of the fungal infection. (2)

The first case in an incarcerated person was reported to CDC in 2020. Over the next two years, 13 cases in all were reported to CDC. All occurred in state or federal prisons in people who were already under medical care. In that respect, inmates resemble individuals in nursing homes and other institutions for people with complex and invasive care.

Inmates ranged from 26 to 66 years but the median age was 55; all but one were men. Eight were being treated very invasively with mechanical breathing machines, central venous catheters and tracheostomy tubes, but all had chronic illnesses. Chronic kidney disease, diabetes, chronic heart disease, and chronic wounds were among the illnesses that made them susceptible to C. auris infection. (2)

The characteristic that separates C. auris from other Candida species is that people can become “silent carriers” of the fungus: it can colonize healthy skin and be transmitted to others without the original carrier getting sick. If C. auris enters the bloodstream, a patient can die rapidly of sepsis or shock. (3)

Most protocols for preventing C. auris involve basic cleanliness: sterilizing medical devices, disinfecting surfaces, handwashing, etc., as well as isolating anyone known to have a C. auris infection. (3)

Obviously, it’s much harder to achieve that level of hygiene in a prison, considering that hospitals and nursing homes can’t keep C. auris from spreading. And most individuals who contract serious C. auris infections, like the prisoners in the CDC study, have underlying diseases.

And that’s just the beginning of the problems of controlling C. auris in prisons. Inmates are generally forbidden to possess bars of soap and alcohol-based hand sanitizer for security reasons. Not all prisons have medical units large enough to include isolation areas. And overcrowding contributes to the spread of C. auris once it is present in a correctional facility.

These CDC investigators acknowledge that their survey of C. auris in prisons probably underestimates the number of infections, given the “unique challenges” presented by correctional facilities.

The CDC suggests that prison officials keep inmates’ multidrug resistant organism (MDRO) confidential to prevent “stigma.” (2)

We learned a lot about eliminating “stigma” among prisoners and prison staff during the AIDS epidemic in the 1980s (and beyond)—mostly, that it can’t be eliminated. Infection by a microscopic organism that can be transmitted from a seemingly healthy individual, or an invisibly contaminated surface, can and probably will cause discrimination against inmates with C. auris, given that prisoners are often not even allowed to have supplies to clean their hands. (4)

Modern medicine is sadly deficient in drug development efforts. Since more and more bacterial, fungus, and almost all viral infections are either drug-resistant or completely lacking in drugs to fight them, why don’t we work on creating them in the near future?

Author’s Note: This is a developing story about an emerging disease and will be revisited as warranted.

BIBLIOGRAPHY
1.        “Countries with the largest number of prisoners per 100,000 of the national population, as of January 2024.” Statista. https://www.statista.com/statistics/262962/countries-with-the-most-prisoners-per-100-000-inhabitants/#:~:text=The%20United%20States%20is%20home,nations%20had%20far%20fewer%20prisoners.
2.        Ian Hennessee, Kaitlin Forsberg, Jalysa Erskine, et al. “Candida auris in US Correctional Facilities.” Emerging Infectious Diseases, Vol. 30, Supplement: Infectious Diseases and Carceral Health. March 31, 2024. https://doi.org/10.3201/eid3013.230860
3.        “Candida auris.” The Cleveland Clinic. 7/21/23. https://my.clevelandclinic.org/health/diseases/25152-candida-auris
4.        Steven Belenko, Richard Dembo, Michael Copenhaver, Matthew Hiller, Holly Swan, Carmen Albizu Garcia, Daniel O’Connell, Carrie Oser, Frank Pearson, and Jennifer Pankow. “HIV Stigma in Prisons and Jails: Results from a Staff Survey.” AIDS Behav. 2016 January ; 20(1): 71–84. doi:10.1007/s10461-015-1098-7.