We Can Prevent Another Summer mPox Outbreak

In May 2022, when the spread of mpox virus began to be reported outside of Central Africa for the first time, queer health advocates imagined it would become a clear demonstration of a successful emergency response. Because of the similarity between mpox and smallpox, the U.S. government had not only already developed and tested effective diagnostics, a treatment (the antiviral drug TPOXX) and a vaccine but had stockpiles of them all.

That medical stockpile, however, wasn’t the real key to stopping mpox. A recent global study of mpox’s phylogenetics—its family tree—estimated the virus’s prevalence in the absence of sufficient testing at the time of the outbreak. A key result: the mpox epidemic stopped growing and started receding before the theoretical threshold of vaccinated people needed to stymie it. The Centers for Disease Control and Prevention reported that roughly 50 percent of people within queer sexual networks (especifically gay men) had altered their sexual behavior in response to mpox even sooner.

While those of us in the queer community waited for vaccination, changing our sexual behaviors was vital to stopping the virus from spreading. Although mpox has persisted in the U.S., the number of cases remained low through 2023.

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Now multiple lines of evidence suggest that vaccine immunity to mpox is waning just as cases are ticking up across the U.S. and as authorities are seeing an “alarming rise” in cases in Africa. If mpox cases again increase dramatically, the lack of booster vaccine doses may once more leave the queer community with only behavioral changes to combat the disease. Another failure, this time to study vaccine and booster efficacy until an emergency forces a response, would again leave communities vulnerable to an avoidable disease.

It happened before: in May 2022 I stood nursing a drink on the roof of the Eagle, a New York City gay bar, with my friend James Krellenstein, co-founder and former managing director of the HIV prevention organization PrEP4All, wondering if the mpox epidemic would get in the way of our slutty summer.

“If we do things right,” I remember him telling me, “everyone can have exactly the summer they want.” After years of social distancing following the emergence of COVID, queer people were anxiously awaiting a Pride Season with more freedom to dance, travel, gather and, yes, have sex.

But the next few weeks would see a harrowing failure to activate biomedical resources against mpox. Ultimately more than 30,000 Americans contracted the virus, including 55 who died of the disease.

Multiple studies highlight the essential role of changes in sexual behavior in stemming the transmission of mpox prior to widespread vaccination. The genetics findings are consistent with data from Washington, D.C., and Italy, which used computational modeling to compare the relative importance of vaccination and behavioral changes in stemming mpox transmission. Mpox infection dynamics are complex and depend on behaviors, immunity from prior infection and immunity from vaccination. The studies in the U.S. and Italy point to behavioral changes as the most important driver in reducing the spread of the disease in 2022.

I spoke to the mpox genetics paper’s lead author Miguel Paredes, an M.D./Ph.D. student at the University of Washington, who explained that it was his “frustrating” experience trying to get vaccinated for mpox in Seattle in 2022 that drove him toward research on the virus to show the “hidden trains of transmission that were missed by public health [experts]” early in the epidemic.

“It went hand in hand with my personal life, queer advocacy,” he told me. He used his work in molecular evolution to evaluate “how good of a job public health does or does not do when responding to infectious disease outbreaks.”

For those in queer sexual networks who may have still received only one dose of the two-dose JYNNEOS mpox vaccine, it is now widely available and free (and two doses increase the vaccine’s efficacy). The CDC estimated that as of January 2023, only 23 percent of those who were eligible for mpox vaccination had received both doses.

From HIV to COVID, queer people have a long history of stepping up and using community efforts to tackle viral epidemics. At the same time, health disparities leave so many queer people vulnerable to disease. If mpox hadn’t disproportionately impacted queer people, the government almost certainly would have responded with more urgency in May of 2022.

Given that mpox often spreads through sex, the queer community had difficult conversations about how to educate one another about mpox. While some people wrote disparagingly of sexual contact in bathhouses and encouraged monogamy or even abstinence, many others took a decidedly more sex-positive approach that focused on the specific modes of mpox transmission: skin-to-skin contact. In New York City, commercial sex venues closed and then reopened with community-led vaccination on site. They featured prominent and playful messaging about vaccines, including naming one party “Sub/Cute/Anus,” a play on the subcutaneous method of mpox vaccination.

Still, vaccines, testing and treatment are required for long-term disease control. An ongoing mpox crisis in the Democratic Republic of the Congo (DRC) has now killed hundreds of children. Mpox cases, and even deaths, only became a pressing global emergency when people outside of Central and West Africa began getting sick. This month the CDC released the U.S.’s preparedness plan for the outbreak that is currently spreading in the DRC. But in the past decade the U.S. let millions of doses of JYNNEOS—the mpox vaccine—expire rather than investing in vaccinating individuals in the DRC or Nigeria.

The difference between the situation in the DRC and the global one is not behavioral; the disease is killing people in the DRC because of a lack of access to medicine and vaccination. Behavioral changes, such as the ones that were successful at stopping mpox in 2022, were likely effective over the long term in the U.S. and Europe precisely because of the vaccine rollout that followed.

I wonder how many mpox cases could have been prevented if more queer people were in the government scientific apparatus that ignored mpox for so long. I wonder the same regarding the ongoing suffering of people in the DRC: What if we valued their lives and took their suffering as seriously as that of anyone else on the planet?

In our conversation, Paredes emphasized that his work should not place the onus on a community or on individual behaviors to prevent the spread of infectious disease. “I’m never saying it’s the job of the queer community to control mpox,” he said. “But rather, given the governmental delays and bureaucracy, [the study is] a little bit of a love letter [to the community]. It should not be the community’s responsibility. But given that it felt like we had to protect ourselves, it seems like we did.”

Behavioral changes will always be a Band-Aid to prevent disease until long-term solutions arrive. In 2022 queer people stepped up, and then our government followed through with its obligation to provide us with the available care we needed. In 2024 it is clear that the people of the DRC have been waiting too long, and it may be only a matter of time before the ramifications are once again global.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.