During the summer of 2022, mpox (then known as monkeypox) was spreading rapidly across the US, largely affecting gay and bisexual men who have sex with men (GBMSM).1 Fifteen months later, the outbreak looks very different. Cases are down to an average of approximately 1 to 2 per day (from a peak of 600 per day),2 the summer 2023 wave that was widely predicted did not materialize, and the clusters that occur now are quickly controlled (Figure). How did we get here? And what did the lessons of the mpox response teach us about managing future outbreaks? Even though the biomedical tools (tests, vaccines, and therapeutics) were available at the start of the outbreak, how they were deployed provides important lessons. There are 3 key lessons from the response that can help better manage infectious disease outbreaks in the future.
Based on data from the US Centers for Disease Control and Prevention.
The primary strategy for mpox containment was to take an approach that deeply engaged the community most affected. Rather than the community as the object of a public health intervention, they became the vehicle. The views (often criticisms) of those most affected by the virus were used to inform policy and create shared accountability. One example was creating the equity mpox workshop composed of GBMSM and transgender racial and ethnic minority individuals. This monthly workshop, suggested by a prominent member of the GBMSM community, provided feedback to the White House that helped calibrate the community-driven response. The White House Mpox Response Team (WHMRT) built trust among the community by engaging, listening, and acting on their suggestions. In return, the community became the trusted messengers.
A variety of strategies were used to distribute information from accessible webinars to infographics circulated on social media. These communications allowed local and state public health leaders to transparently answer questions on the minds of community members. One key lesson from the COVID-19 response was that outbreaks create information needs and filling those needs with high-quality, easily comprehensible information is critical to prevent misinformation from propagating. Letting the community identify the information needs and then transparently filling those needs, including acknowledging scientific uncertainty, was critical to managing the mpox outbreak.
A second lesson from the mpox response was that public health responses must be flexible and responsive. Even though vaccines were available in traditional places for administration (such as physician offices and retail pharmacies), the community partners emphasized the importance of also making vaccinations available where those who would most benefit were likely to be present and comfortable. Applying lessons learned in HIV-related outreach, vaccines were offered in safe spaces outside night clubs, pop-up events, social venues, sex parties, and other community-focused events such as Atlanta Black Pride and Southern Decadence.3–5 This level of community engagement enhanced equity in mpox vaccination and better aligned vaccine providers with the community they served, both of which were essential to curbing the outbreak.
Risk assessment is another example of a key change made due to feedback from community partners. After initially using the traditional public health approach of conducting risk assessments before administering vaccines, we quickly heard from community partners that risk assessments are often stigmatizing and could dissuade many of the highest-risk individuals from even engaging. Therefore, the need for extensive risk assessment was removed and trusted partners were leveraged to help identify the people most likely to benefit from vaccines, education, and prevention messaging. We also heard clear concerns that the temporary mark left at the mpox injection site might disclose information on sexuality or gender identity. More flexible clinical guidance was adopted that allowed the vaccine to be administered on less visible parts of the body, and encouraged people to express a preference for the injection site. This seemingly small change may have had a large effect on both creating greater vaccine acceptance and generally building community trust.
The third lesson was the importance of flexible resources and investments in public health infrastructure for preparedness and rapid response during public health emergencies. When the Secretary of the US Department of Health and Human Services determined that mpox had the potential to become an infectious disease emergency, public health officials were able to use the US Centers for Disease Control and Prevention infectious diseases rapid response reserve fund to deploy resources quickly. Public health officials working on HIV and sexually transmitted infections prevention activities were able to conduct mpox prevention work in conjunction with these ongoing activities. Given that the communities most vulnerable to mpox overlap significantly with those most affected by HIV (between 35%-47% of those diagnosed with mpox also had HIV),6 drawing on the capabilities and infrastructure that already existed for HIV proved extremely useful in containing the mpox outbreak. The WHMRT also coordinated activities across the US Department of Health and Human Services and the US Department of Housing and Urban Development to provide additional resources for the response.
Beyond those 3 key elements of the response, there is one more critical issue to consider. As the number of new cases declined during the fall of 2022, there was intense pressure to bring the mpox response to an end and fold it into ongoing public health work around sexually transmitted infections. It is tempting to see declining case numbers as an invitation to declare the effort a success.
Despite what is often a short attention span of policymakers, the White House recognized that declining case numbers or even an end to the declared public health emergency should not end the mpox response. The WHMRT was concerned with the disproportionate effect mpox had on Black and Latino communities and people living with HIV and recognized that mpox required ongoing attention and critical work to prevent resurgence.7 Instead of pulling back, the WHMRT redoubled its efforts in the spring of 2023 to build trust and vaccinate those who were vulnerable. As we neared the summer and seasonal festivities that could increase opportunities for the virus to spread, the team made additional efforts to partner with event organizers and the communities they serve to provide people with a holistic toolkit to inform their decisions about how to keep their summer healthy.8,9 The lack of a second wave of mpox this past summer was due in large part to the ongoing work with the communities most affected and the decision to continue driving awareness. Persistence is the key lesson. Even after the infection numbers decline, it is paramount to prevent outbreak resurgence.
The last few years have been remarkable in how infectious diseases have taken a toll. The lesson from the mpox response is clear: community engagement and flexibility of response are necessary as well as the existing public health infrastructure that can be deployed to manage outbreaks. Medical countermeasures are key, but so are community partnerships, flexibility, and persistence. That is how infectious disease outbreaks should be managed now and in the future.
ARYAN'S BLOG 