Looking Back and Moving Forward from the U.S. Mpox Outbreak

September 07, 2023 | Sidnie Christian, Amelia Poulin, Chris Taylor

In May 2022, the first case in what would become the largest outbreak of mpox (formerly monkeypox) in the United States was diagnosed in Boston. Mpox, an orthopoxvirus, is similar to smallpox but typically less severe and has become endemic in some regions worldwide. It is primarily transmitted through contact with bodily fluids, skin lesions, or internal mucosal surfaces such as the mouth or throat, respiratory droplets, and contaminated objects.

Since mpox outbreaks were seen globally in regions that were not previously endemic, WHO declared mpox a global health emergency. Unlike previous outbreaks, those most affected were gay, bisexual, and other men who have sex with men (MSM), including those with other infections such as HIV. Moreover, the outbreak highlighted the health inequities among those disproportionately affected in the United States, which was—and continues to be—people of color.

One year after the first case was identified, during a time of declining case counts and vaccine deployments and administration in tandem, U.S. health agencies were on alert as reports of an increase in cases of mpox made headlines in Chicago. With this in mind, we explore the impact of mpox, state health agency response, and the way forward.

Health Equity

The 2022 mpox outbreak disproportionately affected communities across the U.S. Sexual and gender minorities and certain racial and ethnic groups experienced disparities in infection and vaccination due to several factors, including stigma and access to resources.

Sexual and Gender Identity

Sexual contact among MSM was identified as the primary risk factor in this outbreak, with 94% of cases reporting male-to-male sexual contact in the past 21 days. Many of these cases were among MSM who attended large events or gatherings. The clustering of cases in this community was primarily due to dense sexual networks, though there remained the possibility that the virus would extend to other populations. Health departments were cautious in delivering prevention messages to groups at greatest risk for infection and severe disease while not furthering existing stigma or suggesting that only gay or bisexual men were at risk. For example, the Hawaii Department of Health posted a Frequently Asked Questions document from Fenway Health clarifying that mpox was not a “gay disease”. Mpox, after all, is transmitted by behavior, not identity.

Another communications challenge was that prevention messaging and outreach tailored for gay and bisexual men may not have resonated with other groups at high risk, namely MSM who do not identify as gay or bisexual and transwomen, including those that have sex with MSM. Transwomen and people who are non-binary were, in fact, disproportionately affected by mpox.

Race and Ethnicity

There were notable differences in the racial and ethnic disparities in mpox-related deaths. Non-Hispanic African American people made up 26% of cases where race/ethnicity data was reported despite only accounting for 12% of the total U.S. population. Furthermore, between May 10, 2022-March 7,2023, there were 38 mpox-associated deaths nationwide. Among them, most were non-Hispanic African Americans. Additionally, HIV and other sexually transmitted infections were common among those with mpox. Among 33 decedents with available information, 93.9% were immunocompromised because of HIV, and 24 had advanced HIV.

Throughout the 2022 mpox outbreak, it was evident that health agencies needed to address the unique circumstances of marginalized communities, including Black and Hispanic populations and people living with HIV. Among people living with HIV, African Americans are most likely to not be virally suppressed, have lower mpox vaccination rates, and make up a large percentage of mpox diagnoses. Access to vaccines should be prioritized, especially for communities of color, ensuring those who want to receive the mpox vaccine can do so regardless of stigma, access, or any other circumstances. To ensure that the mpox outbreak remains controlled, ongoing vaccination dissemination must be equitable and reach all populations.

Stigma

The stigma around mpox has been a significant concern throughout the outbreak. Stigma was initially associated with the former name “monkeypox,” as it prompted misinformation about transmission, suggesting that monkeys were the primary source of spreading the virus. Moreover, the stigma around mpox has been associated with the LGBTQ+ population and used alongside other homophobic slurs. The effects of this have not only contributed to homophobic rhetoric but further prompted misinformation on how the virus spreads and who is at risk.

Throughout the summer of the 2022 mpox outbreak, some MSM faced challenges getting tested and accessing vaccination despite being identified as those at greatest risk.

Social Determinants of Health

To address health inequities related to education, income, language, transportation, homophobia, racism, and more, CDC launched the Mpox Vaccine Equity Pilot Program, which provided vaccine replenishment to state, territorial, or local health departments, tribal organizations, and non-governmental organizations that conducted outreach events.

This project consisted of two strategies: vaccination events to reach disproportionately affected populations and bringing vaccines to public festivals, Pride events, and other venues frequently accessed by members of the LGBTQ+ community as implemented by the Hawaii and Louisiana Departments of Health.

Health Agency Response in Chicago

With cases steadily declining, WHO declared that mpox was no longer a global health emergency in May 2023. Around that same time, Chicago experienced an uptick in cases, which sparked concerns about a possible summer resurgence.

David Kern, Deputy Commissioner at the Chicago Department of Public Health (CDPH), said, “While Chicago had a small resurgence of mpox, even when cases were declining, we remained vigilant, continuing to regularly engage with community organizations, healthcare providers, and impacted communities. When the resurgence began, we were able to quickly inform folks what was happening and what they could do.”

While the emergency declaration for mpox has been lifted, health agencies should remain vigilant.

Kern continued, “Our 2022 Mpox response efforts never stopped. So, when we experienced our recent resurgence, we continued messaging to engage community members, quickly communicate new information and guidance to clinical and non-clinical partners and scale up vaccination efforts.”

He shared that CDPH consistently ensured their messages were well-informed and resonated with the people they needed to reach by:

• Co-developing all media/messaging with a community group they convened weekly, including community members, organizations, and elected officials.
• Sharing information on dating apps used by MSM.
• Creating and disseminating mpox awareness posters, cocktail napkins, coasters, and paper coffee cup sleeves, which were given to bars, restaurants, and other businesses.
• Working with specific communities, such as leather/kink and ballroom, to create messaging that works best for them and supply representatives with posters, swag, and other materials.
• Providing mpox and LGBTQ+ health updates via the health commissioner’s weekly live streamed address.
• Posting various social media messages based on summer events and vaccination schedules.
• Releasing alert messages to healthcare providers to offer essential guidance and guidance tailored to people at high risk for severe disease.

CDPH routinely convenes healthcare providers who administer the vaccine to ensure they have easy access to information and products. They have partnered with two local healthcare institutions (the University of Illinois at Chicago and RUSH University Medical Center) to provide vaccination in community-based settings, including hyper-local community organizations that serve the priority communities. Lastly, they provide vaccination through three STI clinics.

All materials are available on CDPH’s mpox resource page and are freely available to partners.

Looking Ahead

Although cases are declining, state health agencies should continue navigating their mpox response with vigilance by:

1. Making sure the vaccine is accessible to those for whom it is recommended.
2. Continue communicating with their communities about the virus, vaccination, and clear messaging about mpox and those at risk.

CDC has made communication materials available to jurisdictions, providers, and individuals, including toolkits, digital resources, and webinars. Equity toolkits are also available for outreach and messaging aimed explicitly at the hardest-hit communities.