To stem the spread of monkeypox, health services are tapping into the networks of those most at risk

On July 23, the World Health Organization declared monkeypox a public health emergency of international concern. It was a controversial decision, with WHO Director-General Dr Tedros Adhanom Ghebreyesus taking the final appeal and overturning the decision of the WHO emergency committee. The advisory board disagreements mirrored the debates unfolding among officials, on social media and in opinion pages over the past few weeks. Is monkeypox a public health emergency as it “only” spreads among gay and bisexual men and trans women? How worried should other populations be?

Behind these questions lie concerns about stigma and how best to allocate scarce resources. But they also reflect an individualistic understanding of public health. Rather than wondering what the monkeypox outbreak means to them now, the public might wonder how the monkeypox outbreak might affect them in the future and why and how it might be contained now.

The longer the transmission of monkeypox goes unchecked, the more likely it is to spread to other populations. There have already been a handful of cases in women and a few cases in children due to family transmission. In otherwise healthy people, monkeypox can be extremely painful and disfiguring. But in pregnant women, newborns, young children, and immunocompromised people, monkeypox can be fatal. These groups would all be in danger if monkeypox took root in this country.

Stopping transmission among men who have sex with men will protect them here and now and protect more vulnerable populations in the future. But with a limited supply of monkeypox vaccine available, how can public health officials best target vaccines equitably for impact?

Vaccinating close contacts of people with monkeypox will not be enough to stop the spread. Public health officials have not been able to track all chains of transmission, meaning many cases go undiagnosed. Meanwhile, the risk of monkeypox (and other sexually transmitted diseases) is not evenly distributed between gay and bisexual men and trans women, and targeting them all would exceed supply. Such a strategy also risks stigmatizing these groups.

The Centers for Disease Control and Prevention recently expanded eligibility for monkeypox vaccination to include people who know that a sexual partner in the last 14 days has been diagnosed with monkeypox or who have had multiple sexual partners in the last 14 days in a jurisdiction with known cases of monkeypox. But this approach depends on people’s access to testing. Clinicians test far more in some jurisdictions than in others.

Alternatively, public health officials could target monkeypox vaccinations at gay and bisexual men and trans women who have HIV or are considered at high risk for HIV and are eligible for pre-exposure prophylaxis, or PrEP (medicine to prevent HIV infection). After all, there is a lot of overlap between these populations and those at risk for monkeypox. But only 25% of people eligible for PrEP in the United States are prescribed, and this proportion drops to 16% and 9% among Hispanics and Blacks, respectively. This approach risks missing many at-risk people and exacerbating racial and ethnic disparities.

This is why some LGBTQ+ activists are advocating for more aggressive outreach. “We’re talking about two types of surveillance,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health and longtime AIDS activist. “Passive surveillance, where I show up at my doctor’s office. Active surveillance is where we go out and actively look for cases by going to where people are. There are parties, social places, sex clubs where we could test for monkeypox.”

This will be particularly critical outside of gay-friendly citieswhere patients and providers may be less informed and gay sex more stigmatized.

In New York, the epicenter of monkeypox in the United States, disparities in access to monkeypox vaccines have already emerged. The city’s health department offered appointments for the first doses of the vaccine through an online portal and promoted it on Twitter. These initial doses were administered at a sexual health clinic in affluent Chelsea.

“It was in the middle of the day,” Gonsalves said. “It was in a predominantly gay white neighborhood. … It was really aimed at a demographic that will be on the front lines for everything. That’s the problem with relying on passive surveillance and people coming to you.”

Michael LeVasseur, an epidemiologist at Drexel University, said: “The demographics of this population may not really reflect the most-at-risk group. I’m not even sure we even know the most-at-risk group in New York right now.”

Granted, three quarters City cases had been reported in Chelsea, a neighborhood known for its large LGBTQ+ community, but it also reflects awareness and access to testing. Although more laboratories offer screening tests for monkeypox, many clinicians are still unaware of monkeypox or unwilling to test patients for it. You have to be a strong advocate for yourself to get tested, which puts already marginalized populations at a disadvantage.

The health department has opened a second vaccination site, in Harlem, to better reach communities of color, but most of those who have access to monkeypox vaccines there have been White man. And then New York launched three mass vaccination sites in the Bronx, Queens and Brooklyn, which were only open for one day. To get vaccinated, you had to be in the know, have the day off, and be willing and able to line up in public.

How can public health officials exercise the active surveillance that Gonsalves talks about to fairly target monkeypox vaccination and those most at risk? Part of the answer may lie in efforts to map the sexual networks and spread of monkeypox, such as the rapid epidemiological study of the prevalence, networks, and demographics of monkeypox infection, or RESPND-MI. Your risk of exposure to monkeypox depends on how likely someone in your sexual network has monkeypox. The study may, for example, help clarify the relative importance of group sex at parties and large events versus dating apps in the spread of monkeypox on sex networks.

“A network map can tell us, given that the vaccine is so rare, the most important demographics of people who need to get vaccinated first, not just to protect themselves, but actually to slow the spread,” said Joe Osmundson, molecular microbiologist at New York University and co-principal investigator of the RESPND-MI study.

During the initial phase of the covid-19 vaccine rollout, when vaccines were administered at pharmacies and mass vaccination centers, a racial gap emerged in vaccination rates. Public health officials have bridged that gap by meeting people where they are, in accessible community settings and through mobile vans, for example. They worked hard with trusted messengers to reach people of color who might be suspicious of the healthcare system.

Likewise, sexual health clinics may not be a one-stop solution for monkeypox screening and vaccination. While sexual health clinics may be welcoming to some, others may fear being seen there. Others may not be able to attend sexual health clinics because of their limited opening hoursweekdays only.

It’s nothing new for public health officials to meet members of the LGBTQ+ community where they are. During a 2013 meningitis outbreak among gay and bisexual men and trans women, the country’s health departments relationships forged with LGBTQ+ community organizations to distribute meningitis vaccines. Unlike New York, Chicago is now leveraging those relationships to vaccinate those most at risk for monkeypox.

Massimo Pacilli, Chicago’s assistant commissioner for disease control, said: “The vaccine is not indicated for the general public or, at this point, for any [man who has sex with men].” Chicago distributes monkeypox vaccines in places like gay public baths and bars to target those most at risk. “We don’t have to screen when people show up because we do that up front by doing outreach in a different way,” Pacilli said.

The monkeypox vaccination “is intentionally decentralized,” he said. “And because of that, the modes by which any individual comes to the vaccine are also very diverse.”

Another reason to partner with LGBTQ+ community organizations is to expand capacity. The New York City Department of Health and Mental Hygiene is one of the largest and best-funded health departments in the country, and even it is difficulty reacting quickly and vigorously to the monkeypox epidemic.

“Covid has overwhelmed many public health departments, and they could use help, frankly, from LGBTQ and HIV/AIDS organizations” to control monkeypox, Gonsalves said.

But even as public health officials try to control the transmission of monkeypox among gay and bisexual men and trans women in this country, it is important to remember that monkeypox is spreading in West Africa and center for years. Not all of these transmissions occurred among men who have sex with men. Monkeypox control strategies will need to be informed by local epidemiology. Social and gender mapping will be even more critical but difficult in countries like Nigeria, where gay sex is illegal. Unfortunately, the wealthiest countries are already hoarding the supply of monkeypox vaccines as they have for covid vaccines. If access to the monkeypox vaccine remains inequitable, all countries will be vulnerable to resurgences in the future.

This article was taken from courtesy of the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.

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