The Best Way to Slow the Spread of Monkeypox

On July 23rd, World Health Organization declared monkeypox a public health emergency of international concern (PHEIC). It was a contentious decision, with WHO Director General Dr. Tedros Adhanom Ghebreyesus making the final call and overruling the WHO’s Emergency Committee. The advisory committee’s disagreements mirrored debates unfolding among public officials, on social media, and in opinion pages over the last several weeks. Is monkeypox a public health emergency when it’s “just” spreading among gay and bisexual men and trans women? To what degree do cisgender men, women, and kids need to worry?

Behind these questions are concerns about stigma and how best to allocate limited resources. But they also reflect an individualistic understanding of public health. Rather than asking what the monkeypox outbreak means for them now, the whole public should be asking how the monkeypox outbreak could impact them in the future and why and how it could be contained now.

The longer monkeypox transmission goes unchecked, the more likely it is to spill over into other populations. There have already been a handful of cases among women and a couple cases in children due to household transmission. In healthy people, monkeypox can be extremely painful and disfiguring. But in pregnant women, newborns, young children, and immunocompromised people, monkeypox can be deadly. These populations would all be in danger if monkeypox becomes entrenched in this country.

Stopping transmission among men who have sex with men will protect them in the here and now and 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?

It won’t be enough to vaccinate close contacts of people with monkeypox to stop the spread. Public health officials have been unable to follow all chains of transmission, which means that many cases are going undiagnosed. Meanwhile the risk of monkeypox (and other sexually transmissible diseases) isn’t evenly distributed among gay and bisexual men and trans women, and targeting all of them would outstrip supply. Such a strategy also risks stigmatizing these groups on the basis of their identity.

The CDC recently expanded eligibility for monkeypox vaccination to include people who know that a sexual partner in the past 14 days was diagnosed with monkeypox or who had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox cases. But this approach depends on people having access to testing. Clinicians in some jurisdictions are testing much more than in others.

Alternatively, public health officials could target monkeypox vaccinations to gay and bisexual men and trans women who have HIV or are considered to be at high-risk for HIV and are eligible for pre-exposure prophylaxis (PrEP, i.e. taking medications to prevent HIV infection). Afterall, there’s a lot of overlap between these populations and those at risk for monkeypox. But only 25% of people eligible for PrEP in the U.S. are prescribed it, and that proportion drops to 16% and 9% among Hispanic and Black people respectively. This approach risks missing many at risk and exacerbating existing racial and ethnic disparities.

This is why some LGBTQ activists are advocating for more aggressive outreach. “We talk about two kinds of surveillance. Passive surveillance, where I show up to my doctor’s office,” says Dr. Gregg Gonsalves, an epidemiologist at the Yale School of Public Health and a longtime AIDS activist. “Active surveillance is where we go out and we seek cases actively by going where people are at. There are parties, social venues, sex clubs where we could be doing monkeypox testing,” he says. This will be especially critical outside gay-friendly cities, where both patients and providers may be less informed and gay sex more stigmatized.

In New York City, the epicenter of monkeypox in the U.S., disparities in access to monkeypox vaccine have already emerged. The city’s health department offered appointments for first doses of monkeypox vaccine through an online web portal and promoted them on Twitter. Those initial doses were administered at a sexual health clinic in the well-to-do Chelsea neighborhood.

Read More: Why Is It So Hard to Find Monkeypox Vaccines

According to Gonsalves, “It was in the middle of the day. It was in a predominantly gay white neighborhood… It really was targeted at a demographic that will be first in line for everything. This is the problem with relying on passive surveillance and people coming to you.” According to Dr. Michael Levasseur, an epidemiologist at Drexel University, “The demographics of that population may not actually reflect the highest risk group. I’m not even sure that we know the highest risk group in New York City at the moment.”

Granted, three-quarters of the city’s cases had been reported in Chelsea, a neighborhood that is known for having a large LGBTQ community, but that’s also a reflection of awareness and access to testing. Although more labs are offering monkeypox testing, many clinicians are still unaware of or unwilling to test patients for monkeypox. You have to be a strong advocate for yourself to get tested, which disadvantages already marginalized populations.

The NYC health department then opened a second vaccination site in Central Harlem to better reach communities of color, and yet, most of those accessing monkeypox vaccines there have been white men. And in the last week, NYC launched three mass vaccination sites in the Bronx, Queens, and Brooklyn, which were open for one day only. To get the monkeypox vaccine, you had to be in the know, have the day off, and be willing and able to stand in line in public.

How can public health officials do that active surveillance Gonsalves is talking about in order to target monkeypox vaccination equitably and to those at highest risk? Part of the answer may lie in efforts to map sexual networks and the spread of monkeypox, like the Rapid Epidemiologic Study of Prevalence, Network, and Demographics of Monkeypox Infection (RESPND-MI). Your risk of exposure to monkeypox depends on the probability of someone in your sexual network having 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 across sexual networks. “A network map can tell us, given that vaccine is so scarce, the most important demographics of folk who need to get vaccine first, not just to protect themselves, but actually to slow the spread,” says Dr. Joe Osmundson, a molecular microbiologist at New York University and co-Principal Investigator of the RESPND-MI study.

During the initial phase of COVID-19 vaccine rollout, when vaccines were given at pharmacies and mass vaccination centers, a racial gap emerged in vaccination rates. Public health officials closed that gap by meeting people where they were, in approachable community-based settings and through mobile vans, for example. They worked hard with trusted messengers to reach people of color who may be wary of the health care system.

Similarly, sexual health clinics may not be a one-size-fits-all solution for monkeypox testing and vaccination. Though sexual health clinics may feel more welcoming to some, others may fear being seen attending one. Others may not be able to go to sexual health clinics due to their limited hours of operation on weekdays only.

It isn’t new for public health officials to meet members of the LGBTQ community where they are. During a 2013 outbreak of meningitis among gay and bisexual men and trans women, health departments across the country forged relationships with LGBTQ community-based organizations to distribute meningitis vaccines. Unlike New York City, Chicago is now leveraging those relationships to vaccinate those at highest risk for monkeypox.

According to Massimo Pacilli, Chicago’s Deputy Commissioner for Disease Control, “The vaccine isn’t indicated for the general public nor, at this point, for any MSM.” Chicago is distributing monkeypox vaccines through venues like gay bathhouses and bars to target those at highest risk. “We’re not having to screen out when people present because we’re doing so upstream by doing the outreach in a different way,” says Pacilli. He says that monkeypox vaccination “is intentionally decentralized. And because of that, the modes by which any individual comes to vaccine is 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 biggest and best funded health departments in the country, and yet, even they are struggling to respond quickly and robustly to the monkeypox outbreak. “COVID has overwhelmed many public health departments, and they could use the help, frankly, of LGBTQ and HIV/AIDS organizations,” in controlling monkeypox, says Gonsalves.

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’s important not to forget that monkeypox has been spreading in West and Central Africa for years. Not all of that transmission has been occurring among the MSM community. Strategies for controlling monkeypox will need to be informed by the local epidemiology. Social and sexual mapping will be even more critical but challenging in countries, like Nigeria, where gay sex is illegal. Sadly, wealthier nations are already hoarding monkeypox vaccine supply as they did COVID vaccines. If access to monkeypox vaccine remains inequitable, it will leave all countries vulnerable to resurgences in the future.