A new cluster of mpox cases in the United States — following nearly seven months of steady decline — is leading health officials to warn of a possible rebound outbreak this summer.
Chicago health officials recently reported 20 new cases and are urging people there to get vaccinated.
Major cities like Los Angeles, San Francisco and New York are ramping up public awareness campaigns and vaccination programs, especially targeting men who have sex with men and transgender people.
They warn that cases of mpox, formerly called monkeypox, could easily spread as the summer LGBTQ pride parades get underway.
“Spring and summer season in 2023 could lead to a resurgence of mpox as people gather for festivals and other events,” the Centers for Disease Control and Prevention said in a health alert on Monday.
The CDC warned that without additional vaccination and other virus-mitigating measures, a rebound outbreak could “be as large or larger than in 2022.”
While anyone can get mpox, the virus has so far largely affected gay and bisexual men in the U.S. It is not a sexually transmitted virus, but close physical contact is the primary mode of infection.
On May 11, the World Health Organization declared the mpox global health emergency over, a year after the virus spread beyond its endemic regions.
The decline in cases over the past year has led to a sharp drop in vaccinations. In Los Angeles County, for example, weekly vaccinations dropped from 8,000 last year to about 100-150 in recent months, officials said.
But Biden administration officials said Tuesday they were not letting down their guard, particularly amid the recent uptick in cases in some places.
“Definitely what we are seeing in Chicago is a reminder that… we are not out of the woods. We have a vaccine mission that is not complete yet,” said Dr. Demetre Daskalakis, deputy coordinator for the National Mpox Response at the White House.
Among other things, his office is moving quickly to ensure that local health departments have the resources to deal with new cases.
“We are in that place where we are going to expect seeing clusters, but we have our mission, which is to vaccinate people so we can make sure that we prevent them,” he told The Times.
The current outbreak of mpox is the largest and most geographically widespread since the virus was discovered in 1958.
There have been over 87,000 global cases in 111 countries with 140 deaths reported to the WHO in the last year.
The United States has recorded nearly 31,000 cases and 42 deaths over the last year. The current U.S. outbreak was first recorded in Boston. California leads with 5,759 cases, according to the latest available data from the CDC.
Despite the worries of a rebound, the dramatic decline in cases —from 600 cases nationwide on Aug. 1, 2022, to a weekly average of one in April — represents somewhat of a success story in suppressing the virus, at least for now.
It also offers lessons for future outbreaks.
Some health experts credit President Biden for moving aggressively to address the mpox health crisis.
Days after the Boston case was confirmed, Biden said the virus was “something that everybody should be concerned about.”
His Department of Health and Human Services contracted with a Danish vaccine maker the same day. He assembled a widely respected coordinating team to lead the response and had previously reversed President Trump’s decision to withdraw the United States from the WHO.
Even so, the current mpox outbreak became far larger and more widespread than previous ones have been. Previous outbreaks were limited to a handful of cases that could be traced to recent travelers to mpox endemic regions in Africa, and were quickly contained.
The current outbreak has seen widespread community transmission and been detected in all 50 states, the District of Columbia and Puerto Rico.
Stretched thin by the ongoing COVID-19 pandemic, health systems struggled to get a handle on mpox in the beginning.
Initially, testing for mpox was limited to select labs and medical professionals, who had to weave through a mesh of red tape to order them and to prescribe Tpoxx, an investigational drug used to treat the virus.
“There was a lot of paperwork that you need to fill out with an antiquated public health system, where you had to go through the local health department, the CDC to get authorization,” said Dr. Peter Chin-Hong, professor of medicine and infectious disease specialist at UC San Francisco.
The standard time to fill the form for Tpoxx took doctors two hours, Daskalakis said, before efforts were made to shorten it to 15 minutes.
Then there were squabbles with the Danish vaccine maker. When some vaccines were in stock, local health officials struggled to manage distribution with websites that often crashed as worried men and trans people sought appointments.
Some delays were caused as officials debated how to best communicate with the LGBTQ community and what advice to give concerning sexual behavior.
“That was very challenging given the fact that people wanted to be as sex positive as possible,” Chin-Hong said. “There was a lot of hesitancy because you didn’t want to seem to be shaming people.”
These early challenges may have helped the virus gain a foothold across the country.
“The concern is the delay allowed the virus to become more established within the United States,” said Dr. Bruce Y. Lee, professor of health policy management at the School of Public Health, City University of New York. “And if that is the case, then we are going to continue to pay the costs of not responding quicker and more effectively, many years to come.”
One thing aiding in the fight against mpox was the LGBTQ community itself.
That community has already lived through an HIV/AIDS epidemic that took the lives of many. It has also seen how public health interventions and scientific breakthroughs especially with pharmaceutical developments can not only allow those living with HIV to live long fulfilling lives, but also prevent new infections with PrEP and PEP.
So when a new virus threatened that community, compliance with public health messaging was strong and — in stark contrast to COVID-19 — there was little resistance to vaccinations.
“I can’t think of anybody who didn’t want it. In fact, it was the opposite; it became a very hot-ticket item,” said Chin-Hong, referring to the vaccine. “The legacy of HIV, I think, informed a lot of the way in which the community rallied not just for acceptance of interventions like vaccines or seeking help, but into activism,” he added.
A survey by researchers at Emory University found that aside from embracing the vaccine, many gay men also modified their sexual behavior in response to the mpox outbreak. It found that 48% of respondents reduced their sexual partners and 50% of respondents reduced sex with partners found on dating apps like Grindr and at sex parties.
That change in behavior, “I think, surprised even people who know the community well like me,” Chin-Hong said, and contributed to the decline.
However, there is still a lot of work to be done. The CDC estimates that only 23% of people in the at-risk groups have gotten the vaccine. This is perhaps a symptom of pandemic fatigue after many unsuccessful attempts to get the vaccine combined with a perceived reduction of risk as cases waned.
The administration hopes that trusted community voices like Daskalakis, who is gay, would deliver the message of mpox vaccination alongside other sexual health practices. “I would tell people that it’s really good to be proactive with your summer planning… check your oil and kicking the tires as you approach the pride season.”
A final lesson, experts say, is the importance of working globally to identify and combat deadly viruses.
Unlike COVID-19, mpox was not novel. For decades, countries in West and Central Africa battled smaller outbreaks.
Had wealthier nations like the U.S. done more to share existing treatments and vaccines with these African countries, they might have prevented the mpox pandemic from spreading globally, experts say.
“As long as something is a threat in one part of the world, it could very easily spread to other parts,” Lee said. “If more efforts are made to control infectious diseases in countries with lower resources, that will actually end up protecting the U.S.”