May 1, 2024 – Mary Foote, MD, MPH, has vivid memories of patients "writhing in pain" during the mpox outbreak in the spring and summer of 2022.
Patients were "crying, begging to come in for anything that could help them with their symptoms,” recalled Foote, an infectious disease specialist and medical director at the New York City Department of Health and Mental Hygiene. “We were doing everything we could think of for symptom control.”
Although nowhere near the tens of thousands of cases seen during that outbreak, mpox cases are up the first few months of 2024, compared to the same time last year, according to the CDC. While Foote said health care professionals may be a bit "hypervigilant right now," she's concerned that a summer mpox surge looms.
"Just having seen the trends over the last couple months, there is certainly a decent chance that we could see more cases over the summer,” said Foote, who is also an Infectious Diseases Society of America member. “But we are in a much better place than we were, of course, in 2022, when we really had no testing, no treatment infrastructure, and no vaccine."
She said she is concerned that mpox is "very out of sight, out of mind" for most people now, 2 years on from the 2022 surge. But, she warned, there are still people who are at risk of getting "very, very sick" from the virus.
“I just really want people to know that we are still seeing very severe cases,” Foote said, including one person who died from mpox this year.
There have been about 570 mpox cases in the U.S. this year, up through March 28, for example, compared to fewer than 300 cases at the same time last year, according to CDC numbers.
Although national numbers were down in 2023, Los Angeles County did see more cases of mpox last summer. The increase in cases coincided with the start of seasonal LGBTQ+ Pride events, the Los Angeles County Department of Health said, and most of those infected were unvaccinated.
The department is preparing for a possible outbreak of cases this summer. They plan to support mpox vaccination campaigns and improve mpox awareness among the public and health care providers.
Why are Some People at Higher Risk?
Members of the LGBTQ+ community have been at higher risk for mpox over the last few years, but why?
There are “certain social networks where we now know that this can spread really easily through skin-to-skin contact, including the kind of skin contact that happens during sex,” Foote said. “Once it gets into a certain social network, it can then spread more effectively.”
Unlike smallpox, which can be spread through breathing, sneezing, and coughing, mpox generally requires physical contact.
Mpox “doesn't spread by the respiratory route to any increased notable degree. It requires close contact,” said Stephen Morse, PhD, an epidemiologist at the Mailman School of Public Health at Columbia University in New York City. “That's why it's spread most notably within certain populations.”
Gay and bisexual men who have sex with men are at particular risk.
“There are different health concerns for people who are LGBTQ+,” said Jona Tanguay, MMSc, president-elect of GLMA: Health Professionals Advancing LGBTQ+ Equality. “The reasons why it's happening in this community is the sexual networks are very different, the context of how sex happens is very different, and there are things that exist in queer communities that don't really exist in heterosexual communities.”
For example, “sexualized drug use that in the research is really not a phenomenon that happens in people who are heterosexual.”
Mpox Vaccine Gets Wider Distribution
The only FDA-approved mpox vaccine, Jynneos, was available during and after the 2022 outbreak under FDA emergency use authorization. At the time, the vaccine was distributed through limited channels such as public health departments and specialty clinics.
But starting last October, the CDC changed its recommendation toward routine use, meaning people at risk can get the mpox vaccine at drugstores and doctors’ offices. In early April, the vaccine maker confirmed commercial availability began in the United States.
“I think that will expand access,” Tanguay said. Just as with many other infectious diseases, the more people who get vaccinated, the greater the protection for communities. “So I think that's great.”
Foote commended the federal government for planning to keep channels of distribution active through the summer to give drugstores and doctors’ offices time to stock and administer the vaccine.
Marginalized People Are at Higher Risk
Focusing on people at highest risk remains essential, including people with weakened immune systems living with HIV, people who take part in sexualized drug use, and also trans people – specifically trans women, Tanguay said. “It's important to reach those communities that are very marginalized to protect them as much as possible with the vaccine.”
“It’s not anything related directly to the biology of that identity. It's just about the facing multiple different forms of discrimination,” Tanguay said. Trans women of color can go through racism, misogyny, and transphobia at once. “And that's why their health outcomes tend to be so much worse – they're at risk for so many more things.”
People who are struggling economically are less likely to have health care access, Tanguay said. So a more widely available mpox vaccine “is not going to increase access for people who are very low income.” Many members of this community do not have a primary care doctor, but having the vaccine available at drugstores could help.
“It’s on our radar, but I'm not sounding the alarm about mpox in 2024,” Tanguay said. “But I still recommend all my patients get vaccinated.” Maximum protection with the mpox vaccine requires a two-dose series.
Foote’s final message: If you haven’t received the vaccine or finished the two-dose series, “come in.” If you get symptoms that might be mpox, “please, please, come in.”
“We can get you started about treatment early,” Foote said. “We do have evidence to show that starting treatment early in people at high risk could save them from the worst outcomes.”