On 23 July, 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 making the final call and overruling the WHO’s emergency committee. The advisory committee’s disagreements mirrored debates that have played out among public officials, on social media and on opinion sites in recent weeks. Is monkeypox a public health emergency when it spreads “only” among gay and bisexual men and trans women? To what extent do other populations need to worry?
Behind these questions are concerns about stigma and how best to distribute scarce resources. But they also reflect an individualistic understanding of public health. Instead of asking what the monkeypox outbreak means to them now, the public can ask how the monkeypox outbreak might affect them in the future and why and how it can be contained now.
The longer monkeypox transmission goes unchecked, the more likely it is to spread to other populations. There have already been a handful of cases among women and a couple of cases in children due to infection in the household. 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 at risk if monkeypox became entrenched in this country.
Stopping transmission among men who have sex with men will protect them now and more vulnerable populations in the future. But with a limited supply of monkeypox vaccine, how can public health authorities best target vaccines fairly for efficacy?
Vaccinating close contacts of people with monkeypox will not be enough to stop the spread. Public health authorities have not been able to follow all chains of transmission, meaning many cases go undiagnosed. Meanwhile, the risk of monkeypox (and other sexually transmitted diseases) is not evenly distributed among gay and bisexual men and trans women, and targeting all of them will 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 past 14 days was diagnosed with monkeypox or who had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox. But this approach depends on people having access to testing. Clinicians test much more in some jurisdictions than in others.
Alternatively, public health authorities may target monkeypox vaccinations to 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 (medicines to prevent HIV infection). After all, there is a lot of overlap between these populations and those at risk of monkeypox. But only 25% of people eligible for PrEP in the US are prescribed it, and that share drops to 16% and 9% among Hispanics and blacks, respectively. This approach risks missing many people at risk and exacerbating racial and ethnic disparities.
This is why some LGBTQ+ activists advocate 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 a longtime AIDS activist. “Passive surveillance, where I show up at my doctor’s office. Active surveillance is where we go out and we actively seek cases by going where people are. There are parties, social venues, sex clubs where we can do monkeypox testing.”
This will be particularly critical outside gay-friendly cities, where both patients and carers may be less informed and gay sex more stigmatised.
In New York City, 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 first doses of the vaccine through an online portal and promoted them on Twitter. These first doses were administered at a sexual health clinic in the affluent Chelsea area.
“It was the middle of the day,” Gonsalves said. “It was in a predominantly gay white neighborhood. … It was really targeting a demographic that wants to be first in line for everything. This is 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 reflect the highest risk group. I’m not even sure we know the highest risk group in New York City at this time.”
True, three-quarters of the city’s cases had been reported in Chelsea, a neighborhood known for its large LGBTQ+ community, but that’s also a reflection of awareness and access to testing. Although several laboratories offer monkeypox testing, 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 disadvantages already marginalized populations.
The health department opened another vaccination site, in Harlem, to better reach communities of color, but most people who have had access to monkeypox vaccines have been white men. And then New York City launched three mass vaccination sites in the Bronx, Queens and Brooklyn, which were only open for one day. To get the vaccine you had to be informed, have time off and be willing and able to queue in public.
How can public health authorities perform the active surveillance of which Gonsalves speaks in order to target monkeypox vaccination fairly and at those most at risk? Part of the answer may lie in efforts to map sexual networks and the spread of monkeypox, such as the Rapid Epidemiologic Study of Prevalence, Networks, and Demographics of Monkeypox Infection, or RESPND-MI. The risk of exposure to monkeypox depends on the likelihood that someone in your sexual network has monkeypox. For example, the study may help to 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 the vaccine is so scarce, 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, a molecular microbiologist at New York University and co-principal investigator of the RESPND-MI study.
In the initial phase of the covid-19 vaccine rollout, when vaccines were administered at pharmacies and mass vaccination centers, a racial gap in vaccination rates emerged. Public health authorities closed this gap by meeting people where they were, in accessible, 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 health care.
Similarly, sexual health clinics may not be a one-size-fits-all solution for monkeypox testing and vaccination. Although sexual health clinics may feel welcoming to some, others may fear being seen there. Others may not be able to go to sexual health clinics because of their limited opening hours, weekdays only.
It is not 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 community-based LGBTQ+ organizations to distribute meningitis vaccines. Unlike New York, Chicago is now taking advantage of these conditions to vaccinate people at highest risk of monkeypox.
Massimo Pacilli, Chicago’s deputy director of disease control, said: “The vaccine is not indicated for the general public or, at this time, for any [man who has sex with men].” Chicago distributes monkeypox vaccines through venues such as gay bathhouses and bars to target those at highest risk. “We don’t have to screen out when people are present because we’re doing it upstream by doing the outreach in a different way,” Pacilli said.
Monkeypox vaccination “is deliberately decentralized,” he said. “And because of that, the modes by which an individual gets to the vaccine are also very different.”
Another reason to work 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 struggling to respond quickly and robustly to the monkeypox outbreak.
“Covid has overwhelmed a lot of public health departments, and they could honestly use the help of 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’s important not to forget that monkeypox has been spreading in West and Central Africa for years. Not all of this transmission has occurred among men who have sex with men. Strategies to control monkeypox must be informed by the local epidemiology. Social and sexual mapping will be even more critical but challenging in countries, such as Nigeria, where gay sex is illegal. Unfortunately, wealthier nations are already hoarding monkeypox vaccine supplies like they did covid vaccines. If access to monkeypox vaccine remains inequitable, it will leave all countries vulnerable to future outbreaks.
This article was reprinted from khn.org with permission from 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 care research organization not affiliated with Kaiser Permanente.
