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 dismissing the WHO emergency committee. of advisory committee disputes reflected the debates that have unfolded among public officials, on social media and on opinion sites over the past few weeks. Is monkeypox a public health emergency when it’s spreading “only” among gay and bisexual men and trans women? To what extent should other populations be concerned?
Behind these questions are concerns about stigma and how best to allocate scarce resources. But they also reflect an individualistic understanding of public health. Instead of asking what the monkeypox outbreak means for them now, the public can ask how the monkeypox outbreak might affect them in the future and why and how it can be stopped now.
The longer monkeypox transmission goes unchecked, the more likely it is to spread to other populations. There have already been a small number of cases among women and some cases in children due to family transmission. In otherwise healthy people, monkeypox can be extremely painful and disfiguring. But in pregnant women, newborns, young children and immunocompromised people, monkeypox can be deadly. All of these groups would be at risk if monkeypox were to take hold in this country.
Stopping transmission among men who have sex with men will protect them here and now and the most vulnerable populations in the future. But with a limited supply of monkeypox vaccine available, how can public health officials best target vaccines equally for impact?
Vaccinating close contacts of people with monkeypox will not be enough to stop the spread. Public health officials 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 would exceed supply. Such a strategy also risks the stigmatization of these groups.
The Centers for Disease Control and Prevention recently extended adaptability for monkeypox vaccination include people who know that a sexual partner in the past 14 days has been diagnosed with monkeypox or who has had multiple sexual partners in the past 14 days in a jurisdiction with known cases of monkeypox . But this approach depends on the people who have access to the test. Clinicians are testing far more in some jurisdictions than in others.
Alternatively, public health officials may target monkeypox vaccination for gay and bisexual trans men and women who have HIV or are considered at high risk for HIV and are eligible for pre-exposure prophylaxis, or PrEP (medicine 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 described it, and this percentage drops to 16% and 9% among Hispanic and black people, respectively. This approach risks missing out on many people who are at risk and exacerbating racial and ethnic disparities.
That’s why some LGBTQ+ activists are advocating for more aggressive outreach. “We talk 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 actively look for cases by going where people are. There are parties, social settings, sex clubs where we can do monkeypox testing. “
This will be particularly critical outside gay-friendly citieswhere both patients and providers may be less informed and gay sex more stigmatized.
In New York City, the epicenter of monkeypox in the US, disparities in access to monkeypox vaccines 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. Those initial doses were administered at a sexual health clinic in the affluent Chelsea neighborhood.
“It was broad daylight,” Gonsalves said. “It was in a predominantly white gay neighborhood. … It really targeted a demographic that’s going to be first in line for everything. That’s the problem with supporting passive surveillance and people coming to you.”
Michael LeVasseur, an epidemiologist at Drexel University, said, “The demographics of that population may not reflect the highest-risk group. I’m not even sure we know the highest-risk group in New York City right now.” .”
Given, three quarters of the city’s cases were 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 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 hurts already marginalized populations.
The health department opened a second vaccination site, in Harlem, to better reach black communities, but most of those with access to monkeypox vaccines have had white men. And then New York City began three sites of mass vaccination in the Bronx, Queens and Brooklyn, which were only open for one day. To get the vaccine, you had to be conscious, have a day off, and be willing and able to stand in line in public.
How can public health officials do the active surveillance that Gonsalves is talking about to target monkeypox vaccination equally and to those at higher risk? Part of the answer may lie in efforts to map the sexual networks and spread of monkeypox, such as the Rapid Epidemiological Study of the Prevalence, Networks, and Demography of Monkeypox Infection, or reply-to. Your risk of exposure to monkeypox depends on the probability that someone in your sexual network has monkeypox. The study, for example, could help clarify the relative importance of group sex at parties and large events versus dating apps in the spread of monkeypox through sexual networks.
“A network map can tell us, given that the vaccine is so scarce, the most important demographics of people who should get the vaccine first, not just to protect themselves, but to actually slow the spread,” Joe said. Osmundson, a molecular microbiologist at New York University and co-principal investigator of the RESPND-MI study.
During the initial phase of the Covid-19 vaccine rollout, when vaccines were given in pharmacies and mass vaccination centers, a racial gap in vaccination rates emerged. Public health officials 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 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. 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 them limited hours of operationonly on weekdays.
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 leveraging these relationships to vaccinate people at higher risk for monkeypox.
Massimo Pacilli, Chicago’s deputy commissioner for disease control, said: “The vaccine has not been indicated for the general public and, at this point, for any [man who has sex with men]Chicago is distributing monkeypox vaccines to countries like gay bathrooms and bars to target those at higher risk. “We don’t have to control when people are present because we’re doing it upstream by doing the alignment in a different way,” Pacilli said.
Monkeypox vaccination “is deliberately decentralized,” he said. “And because of that, the ways in which each individual comes to the vaccine are also very different.”
Another reason to collaborate with LGBTQ+ community organizations is capacity building. The New York City Department of Health and Mental Hygiene is one of the largest and most well-funded health departments in the country, and is even struggling to respond quickly and forcefully until the monkeypox outbreak.
“Covid has overwhelmed many public health departments, and they could use the help of LGBTQ and HIV/AIDS organizations” in controlling 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 in men who have sex with men. Strategies for monkeypox control will need to be informed by local epidemiology. Social and sexual mapping will be even more critical but challenging in countries, such as Nigeria, where gay sex is illegal. Sadly, wealthier nations are already hoarding supplies of monkeypox vaccines, just as they did Covid vaccines. If access to the monkeypox vaccine remains uneven, it will leave all countries vulnerable to future resurgences.
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