To prevent the spread of monkeypox, the health department taps into their networks

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, making the final call and canceling the WHO Emergency Committee. The advisory committee’s differences have mirrored the debates over the past few weeks among government officials, on social media and on opinion pages. Is monkeypox a public health emergency when it is spreading “only” among gay and bisexual men and trans women? To what degree do other populations care?

Behind these questions are concerns about stigma and how to allocate scarce resources. But they also reflect a distinct understanding of public health. Instead of asking what a monkeypox outbreak means for them now, the public can ask how a monkeypox outbreak might affect them in the future and why and how it can be contained now.

The longer the monkeypox infection lasts, the more likely it is to spread to other populations. There have already been a few cases among women and a few among children due to household transmission. In otherwise healthy people, monkeypox can be extremely painful and disfiguring. But monkeypox can be fatal in pregnant women, newborns, young children and immunocompromised people. Those groups will be in danger if monkeypox enters this country.

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

Vaccination of close contacts of people with monkeypox will not be sufficient to stop spread. Public health officials have been unable to follow all chains of transmission, meaning many cases go undiagnosed. Meanwhile, the risk of monkeypox (and other sexually transmitted diseases) is not equally distributed among gay and bisexual men and trans women, and targeting all of them would exceed supply. Such a strategy also risks stigmatizing this group.

The Centers for Disease Control and Prevention recently expanded eligibility for monkeypox vaccination to people who know that a sexual partner has been infected with monkeypox in the past 14 days or who have had multiple sexual partners with known cases of monkeypox in the past 14 days. But this approach depends on people having access to the test. Physicians are doing much more testing in some jurisdictions than in others.

Alternatively, public health officials may target monkeypox vaccination to gay and bisexual men and trans women who have HIV or who are considered at high risk for HIV and eligible for pre-exposure prophylaxis, or PrEP (medication 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 US are prescribed it, and that proportion drops to 16% and 9% among Hispanics and blacks, respectively. This approach risks missing out on many people who are at risk and exacerbating racial and ethnic inequality.

That’s why some LGBTQ+ activists are advocating for more aggressive outreach. “We talk about two types of surveillance,” says Greg 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 actively look for cases where people are. There are parties, social places, sex clubs where we can test for monkeypox.”

This will be especially critical outside of gay-friendly cities, where both patients and providers may be less informed and homosexuality may be more stigmatized.

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

“It was in the middle of the day,” Gonsalves said. “It was in predominately gay white neighborhoods. … It was really targeting a population that would be first for everything. That’s the problem with passive surveillance and relying on people coming to you.”

“That demographic may not actually reflect the highest risk group,” says Michael Levasseur, an epidemiologist at Drexel University. I’m not sure we know the highest-risk group in New York City at this point.”

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

The health department opened a second vaccination site in Harlem, to better reach communities of color, but most of those who access monkeypox vaccines are there. white male. And then New York City turns up Three mass vaccination sites in the Bronx, Queens and Brooklyn, which were only open for one day. To get the vaccine, you need to know, have the day off, and be willing and able to stand in line in public.

How can public health officials proactively monitor what Gonsalves advocates for monkeypox vaccination to be equitably targeted and at highest 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. Your risk of exposure to monkeypox depends on how likely someone in your sexual network is to have monkeypox. The study, for example, could help clarify the relative importance of dating apps versus group sex at parties and large events in the spread of monkeypox across sexual networks.

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

In the early stages of the Covid-19 vaccine rollout, when the vaccine was administered at pharmacies and mass vaccination centers, a racial disparity in vaccination rates emerged. Public health officials closed the gap where they were by meeting in approachable, community-based settings and via mobile vans. They worked hard with trusted messengers to reach people of color who might 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. While sexual health clinics may feel welcoming to some, others may fear being visited there. Others may not be able to visit sexual health clinics due to their limited hours of operation only on weekdays.

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

“The vaccine is not indicated for the general public or, at this point, for anyone,” said Massimo Pacilli, Chicago’s deputy commissioner for disease control. [man who has sex with men]”Chicago is distributing the monkeypox vaccine through venues like gay bathhouses and bars, targeting those at highest risk. “We don’t have to screen people out when they show up because we’re doing it upstream through outreach in other ways,” Pacilli said.

Monkeypox vaccination is “deliberately decentralized,” he said. “And because of that, the modes by which any individual comes for the vaccine are also very varied.”

Empowerment is another reason to partner with LGBTQ+ community organizations. The New York City Department of Health and Mental Hygiene is one of the largest and best-funded health departments in the country, even though it Struggle to respond quickly and firmly Towards an outbreak of monkeypox.

“Covid has overwhelmed many public health departments, and they could use the help of, frankly, LGBTQ and HIV/AIDS organizations” in controlling monkeypox, Gonsalves said.

But while public health officials are trying 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 rampant in West and Central Africa for years. Not all transmission has occurred between men who have sex with men. Monkeypox control strategies should be informed by local epidemiology. Social and sexual mapping will be even more critical but challenging in countries like Nigeria, where homosexuality is illegal. Sadly, rich countries are already stockpiling monkeypox vaccine supplies like the Covid vaccine. If access to monkeypox vaccine remains inequitable, it will put all countries at risk of future resurgences.

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