NEW YORK (AP) — Less than six months ago, mpox was an explosive health crisis. What had been an obscure disease from Africa was sweeping the European and American gay communities. Valuable doses of an untested vaccine were in short supply. International officials declared a health emergency.
Today, reports of new cases are down to a trickle in the US Health officials are shutting down emergency mobilizations. The threat seems to have virtually disappeared from public consciousness.
“We are in a remarkably different place,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. “It’s really impressive how that peak has come down to very, very low levels.”
So who deserves the credit? It’s an unresolved question, but experts cite a combination of factors.
Some praise public health officials. Others say most of the credit should go to members of the gay and bisexual community who took their own steps to reduce the spread of disease when the threat became apparent. Some wonder if the characteristics of the virus itself played a role.
“It’s a mixed story” in that some things could have gone better but others did well, said Dr. Tom Frieden, former director of the US Centers for Disease Control and Prevention.
CASES RISE, THEN FALL
Mpox, formerly known as monkeypox, is a rare disease caused by infection with a virus that belongs to the same family as the one that causes smallpox. It is endemic in parts of Africa, where people have been infected through rodent or small animal bites, but it is not known to spread easily from person to person.
Mpox cases began to emerge in Europe and the United States in May, mainly among men who have sex with men. Cases rose rapidly in dozens of countries in June and July, around the time of gay pride events. The infections were rarely fatal, but many people suffered painful skin lesions for weeks.
At the end of July, the World Health Organization declared an international health crisis. In early August, the United States declared a public health emergency.
Soon after, the outbreak began to subside. The daily average of new cases reported in the US went from almost 500 in August to about 100 in October. Now, there are fewer than five new cases in the US per day. (Europe has seen a similar drop.)
Experts said a combination of factors likely turned the tide.
Health officials seized an early opportunity: An existing two-dose vaccine called Jynneos, developed to fight smallpox, has also been approved for use against monkeypox.
Initially, only a few thousand doses were available in the US, and most countries did not have any. Regulatory and shipping delays left local health departments unable to meet demand for vaccines.
In early August, US health officials decided to stretch the limited supply by giving people only a fifth of the usual dose. The plan called for giving the vaccine with an injection just under the skin, rather than into deeper tissue.
Some in the public health community worried that it was a big call based on a small amount of research: a single study from 2015. But the Centers for Disease Control and Prevention has since confirmed that there was no difference in the vaccine yield between the two methods.
“They were criticized for the revised dosing strategy, but it was the right call,” said Frieden, who is currently president of Resolve to Save Lives, a nonprofit organization focused on epidemic prevention.
However, cases had already started to decline when the government made the change.
Current CDC director Dr. Rochelle Walensky cited efforts to educate doctors on how to better diagnose and treat mpox. Other experts said it was even more important to reach sexually active gay and bisexual men who are most at risk.
In the early months of the outbreak, the government was wary of focusing warnings too much on gay and bisexual men for fear of stigmatizing men and, in doing so, undermining efforts to identify infections. (In fact, in November, the WHO changed the name of the disease from monkeypox to mpox in an effort to reduce the stigma.)
“They were a little coy about the primarily affected population,” Schaffner said.
Many say queer activists and community organizations have stepped up to fill the void, quickly offering outspoken education and assistance. In an online survey conducted in early August, many men who have sex with men reported fewer sexual encounters and partners due to the outbreak.
“The success was really down to grassroots activities,” said Amira Roess, a professor of epidemiology and global health at George Mason University. Gay community leaders “took it upon themselves to step in when the government response was really lacking” in a way that was reminiscent of what happened during the laborious government response to the HIV/AIDS epidemic in the 1980s, she said.
Among those efforts was called RESPND-MI: Rapid Epidemiological Study of Prevalence, Networks, and Demography of Monkeypox Infection. The grant-funded organization published transmission prevention messages, conducted a community-led survey on mpox symptoms, and mapped the social and sexual networks of queer and transgender people in New York City.
Nick Diamond, one of the leaders of the effort, said the government’s response improved only after gay activists lobbied officials and did much of the outreach and education themselves.
“Many HIV activists knew that it would be up to us to launch a response to monkeypox,” he said.
But Diamond also pointed to another possible reason for the declines: The spread of mpox at LGBTQ celebrations in June, along with a lack of testing and vaccinations, likely contributed to the July spike. “A lot of people came out of Pride, after being in close contact, symptomatic,” she said. They suffered blisters and scabs, sending the message to other men at risk that the virus was a very real danger.
BIOLOGY VS. CONDUCT
There are also possible explanations that have more to do with biology than behavior.
The number of new infections may have been limited by increases in infection-acquired immunity in the socially media-active men who fueled the outbreak, CDC scientists said in a recent report.
Previous research has suggested there may be limits to the number of times the monkeypox virus is transmitted from person to person, said Stephen Morse, a virologist at Columbia University.
“The monkeypox virus essentially runs out of steam after a couple of rounds in humans,” Morse said. “Everyone credits the interventions, but I don’t know what the reason really is.”
Maria Cheng in London contributed to this report.
The Associated Press Department of Health and Science receives support from the Howard Hughes Medical Institute Science and Educational Media Group. The AP is solely responsible for all content.
Mike Stobbe, Associated Press
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