Mpox: where we were, where we are now

Close-up medical syringe with a vaccine: © weyo-stock.adobe.com

Before Demetre Daskalakis, MD, became the Acting Director of the National Center for Immunization and Respiratory Diseases (NCIRD) at the CDC, he served as a local and national leader in public health. He has led response efforts for outbreaks of measles, COVID-19, and most recently, Mpox.

As deputy coordinator of the White House National Mpox Response in Washington, DC, Daskalakis presented to IDWeek attendees, "Mpox: A case study in syndnemic response.” He discussed how infectious diseases were well-suited for the challenge. In battling a global HIV pandemic for more than 30 years, this community had the infrastructure in place, the capacity to address stigma, and the familiarity in launching biomedical interventions to enact meaningful change.

In May of 2022, Boston, Massachusetts, identified the first US case of Mpox. But unlike past poxvirus outbreaks, where a zoonotic outbreak could be identified, treated, and contained, “we didn’t have a strategy for how this outbreak occurred,” said Daskalakis. This time, there was a specifically triggering name for the disease, inadequate testing, inadequate vaccines, and no access to drugs.

In the ensuing months, an emergency response was initiated, a vaccine strategy was announced, laboratory testing capacity was expanded by an order of magnitude, and an EUA was issued for the JYNNEOS vaccine. By September, 500,000 vaccines were administered, and the Mpox incidence remitted.

To date, with meaningful community engagement and maintained political will, over 1.25 million vaccines have been administered in the United States, and access to tecovirimat has been eased. By way of natural immunity, vaccination, and behavior change, the majority of 30,861 documented cases and 54 deaths were confined to 2022, and the epidemic curve portrays a picture of success.

However, a closer look into the most severely afflicted reveals a familiar story. Vaccination-to-case ratios hit 60 for white patients, while ratios for Hispanic or Black patients didn’t exceed half as much. Here, Daskalakis saw a similar pattern – the known disparity of HIV pre-exposure prophylaxis (PrEP) uptake in the United States.

A syndemic (or synergistic epidemic) is multiple epidemics interacting in a way that exacerbates their adverse effects on the health of a community. Like the HIV/sexually transmitted infection (STI) syndemic, the Mpox syndemic combines Mpox, HIV, STIs and mental health epidemics, revealing the influence of negative social determinants of health like systemic racism, homophobia, transphobia, and housing inequity.

Among all Mpox cases, 38% of patients had HIV, 41% had an STI in past year, and 61% had either HIV or a recent STI, but of those that were hospitalized, 82% had HIV, 72% had a CD4+ T cell count lower than 50, < 9% were on HIV medication, 68% were Black, and 23% were homeless. Severe Mpox was concentrated among those most vulnerable in an already stigmatized population.

“If you have a syndemic problem, you need a strategy that works,” Daskalakis continued, but luckily, the “HIV system and HIV public health kept the system warm.” Broadly across governmental organizations, the United States was able to leverage an existing infrastructure already known to work.

Approaching the summer of 2023, frank, clear messaging was developed so those at risk could make informed decisions about their health. Education surrounding traveler health, sexual health, substance use, and mental health were compiled in support of “events that celebrate the LGBTQ+ community.” With this information, high-risk communities were identified, and with targeted mentoring, plans were successfully deployed.

As the Mpox epidemic demonstrates continued control, Daskalakis now focuses these lessons on another syndemic, the respiratory virus syndemic. He alluded to how he expects vaccines across the lifespan to underlie these efforts, and a packed ballroom seemed eager to see him pioneer this national effort.

Reference
Daskalakis, D. Mpox: A case study of syndemic response. IDWeek 2023. October 12, 2023. Boston, Massachusetts.