On July 23, the World Health Organization declared monkeypox a public health emergency of international concern. It was a controversial decision, and WHO Director-General Dr Tedros made the final decision and overruled the WHO’s emergency committee. The advisory committee’s disagreement mirrors the debate that has unfolded over the past few weeks among public officials, social media and opinion pages. When monkeypox spreads “justly” among gay, bisexual men and trans women, is it a public health emergency? To what extent do other groups need to worry?
Behind these issues are concerns about stigma and how to best allocate scarce resources. But they also reflect an individualistic understanding of public health. Rather than asking what a monkeypox outbreak means to them now, the public can ask how a monkeypox outbreak will affect them in the future, why and how to control it now.
The longer monkeypox spreads, the more likely it is to spread to other populations if left unchecked. There have been a handful of cases in women and several cases in children due to family transmission. In otherwise healthy people, monkeypox can be very painful and disfiguring. But monkeypox can be deadly for pregnant women, newborns, young children and the immunocompromised. If monkeypox takes hold in this country, these groups will all be at risk.
Stopping transmission between MSM will protect their more vulnerable populations here and now and in the future. But with the limited supply of monkeypox vaccine available, how can public health officials best impact the vaccine fairly and equitably?
It is not enough to vaccinate close contacts of monkeypox patients to stop transmission. Public health officials were unable to trace all chains of transmission, which meant many cases went undiagnosed. At the same time, the risk of monkeypox (and other STDs) is unevenly distributed among gay, bisexual men and transgender women, and targeting all of these individuals will be in short supply. This strategy also has the potential to humiliate these groups.
The Centers for Disease Control and Prevention recently expanded eligibility for the monkeypox vaccine to include people who know that a sexual partner has been diagnosed with or has monkeypox in the past 14 days. People who have had multiple sexual partners in the past 14 days in jurisdictions with known cases of monkeypox. But this approach depends on who can do the test. Clinicians are conducting far more tests in some jurisdictions than others.
Alternatively, public health officials may vaccinate gay, bisexual men and transgender women who are HIV-infected or considered to be at high risk for HIV infection with monkeypox vaccine and are eligible for pre-exposure prophylaxis or PrEP (drugs to prevent HIV infection). After all, there is a lot of overlap between these populations and those at risk for monkeypox. But in the U.S., only 25 percent of those eligible for PrEP are prescribed it, and that drops to 16 percent and 9 percent of Hispanics and Blacks, respectively. This approach has the potential to miss many at-risk individuals and exacerbate racial and ethnic disparities.
This is why some LGBTQ+ activists are advocating for more active outreach. “We discussed two kinds of surveillance,” said Greg Gonsalves, an epidemiologist and longtime AIDS activist at the Yale School of Public Health. “Passive surveillance, I show up at my doctor’s office. Active surveillance is where we go out, we actively look for cases by going where people are. We can do monkeypox testing at parties, social places, sex clubs.”
This is especially important outside gay-friendly cities, where both patients and providers may be less aware of gay sex
New York City, the epicenter of monkeypox in the US , gaps in access to monkeypox vaccines have emerged. The city’s health department ordered the first dose of the vaccine through an online portal and promoted it on Twitter. These initial doses were administered at a sexual health clinic in the affluent Chelsea neighborhood.
“It was at noon,” Gonsalves said. “It’s in a predominantly gay white community. … It really targets a population where everything comes first. That’s the problem with relying on passive surveillance and people who come to you.”
Michael Levasseur, an epidemiologist at Drexel University, said, “The demographics of this population may not actually reflect the highest risk groups. I’m not even sure we know at the moment. New York City’s highest risk group.”
Granted, three-quarters of the city’s reported cases are in Chelsea, a well-known neighborhood for its large LGBTQ+ community, but it also reflects people awareness and access to testing. Despite an increasing number of labs offering monkeypox testing, many clinicians are still unaware of monkeypox or reluctant to test patients. You have to advocate strongly for yourself to get tested, it’s not good for people who are already marginalized.
The health department opens a second vaccination site in Harlem to better reach communities of color, but most of those who get the monkeypox vaccine are white. Then New York City launched three mass vaccination sites in the Bronx, Queens and Brooklyn, which were only open for one day. To be vaccinated, you must be informed, take time off work, and be willing and able to line up in public.
How are public health officials conducting active surveillance of Gonsalves talking about equitably targeting monkeypox vaccinations and targeting those most at risk? Part of the answer may lie in efforts to map sexual networks and monkeypox transmission, such as the prevalence of monkeypox infection, the Rapid Epidemiological Study of Networks and Demographics, or RESPND-MI. Your risk of exposure to monkeypox depends on the probability of someone in your sexual network getting monkeypox. For example, this study may help shed light on the relative importance of group sex and dating apps at parties and large events in the transmission of monkeypox across the Internet.
“The web map can tell us that, given the scarcity of this vaccine, the most important populations need to be vaccinated first, not only to protect themselves, but actually to slow the spread,” NYU Molecular microbiologist and co-principal investigator Joe Osmondson said. RESPND-MI study.
In the initial stages of covid-19 vaccine rollout, racial disparities in vaccination rates emerged when vaccines were administered in pharmacies and mass vaccination centers. For example, public health officials have closed the gap by meeting people in an approachable community setting and by meeting them with a mobile van. They work with trusted messengers to reach people of color who may be wary of the health care system.
Likewise, sexual health clinics may not be a one-size-fits-all solution for monkeypox testing and vaccinations. While sexual health clinics may be popular with some, others may be terrified of being seen there. Others may not be able to go to sexual health clinics because of their limited hours of operation, which are limited to weekdays.
Public health officials meeting with members of their LGBTQ+ community are not new. During the 2013 outbreak of meningitis among gay, bisexual men and transgender women, health departments across the country partnered with community-based LGBTQ+ organizations to distribute meningitis vaccines. Unlike New York, Chicago is now using these relationships to vaccinate people at high risk for monkeypox.
Chicago Deputy Commissioner for Disease Control Massimo Pasili said: “Vaccines are not for the general population. Open, at this point, for any [Men who have sex with men].” Chicago is passing Venues such as gay bathhouses and bars distribute monkeypox vaccines to target those most at risk. “We don’t have to do screening in the presence of people because we’re doing outreach upstream in a different way,” Pacilli said.
Monkeypox vaccinations “are deliberately scattered,” he said. . “Because of this, the way any individual can get a vaccine is also very diverse.”
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 United States, even as it struggles to respond quickly and forcefully to a monkeypox outbreak.
” Gonsalves says Covid has overwhelmed many public health departments who, frankly, could use help from LGBTQ and HIV/AIDS groups to control monkeypox.
But even as public health officials try to control the spread of monkeypox among gay and bisexual men and trans women in this country, it’s important not to forget that monkeypox has been circulating in West and Central Africa for years. Not all of this spread Both occur in men who have sex with men. Strategies to control monkeypox require knowledge of local epidemiology. In countries like Nigeria, where homosexuality is illegal, social and sexual mapping will become more important, but also more challenging. Sadly, wealthier countries are already hoarding monkeypox vaccine supplies, just as they are buying Covid-19 vaccines. If access to monkeypox vaccines remains unfair, this will leave all countries vulnerable to re-emergence in the future.
