Weekend Reads | Lessons From Our Recent Viral Outbreak (and I Don't Mean COVID-19)

by Kevin Schofield

You may recall that in the summer of 2022 there was a global outbreak of mpox (originally called "monkeypox"). It spread rapidly across the United States, disproportionately impacting gay and bisexual men. At the time, many health experts expected it to follow the same pattern as COVID-19 (though not at the same scale): an initial outbreak that eventually started to subside, followed by further spikes as people let their guard down and stopped practicing good hygiene and other behaviors that help stem the spread of the disease. And then, last summer, mpox quietly fizzled out. This weekend's read is an article penned by representatives of the Centers for Disease Control and Prevention (CDC), the White House, and the Brown University School of Public Health explaining why that happened, and the lessons learned by the public health community that helped them control the mpox outbreak. Those lessons are a counterpoint to what happened with COVID-19, and the positive outcome gives us hope that we can learn from our past mistakes.

According to the article, the primary strategy for the public health response to mpox was an approach that "deeply engaged the community most affected," treating them as the vehicle for addressing the outbreak instead of simply the object of the public health intervention. The White House Mpox Response Team convened workshops with representatives of the community, listened to their suggestions (and their criticisms), and — critically — acted on their feedback. The trust built through that process allowed for the community to be "trusted messengers" of accurate, helpful information.

The first key lesson the authors discuss is that "outbreaks create information needs and filling those needs with high-quality, easily comprehensible information is critical to prevent misinformation from propagating." The community identified the information needs themselves, and experts then filled those needs, transparently acknowledging where the science was still uncertain or incomplete. Trusted members of the community could then effectively carry that information to the people who needed it.

The second lesson cited was that "the public health response must be flexible and responsive." The mpox outbreak was somewhat unique in that a vaccine already existed that was largely effective — though not in large enough quantities to vaccinate the entire population. Also, feedback from the community argued it wasn't sufficient to have the vaccine available at doctors' offices and pharmacies; it should be brought to the places where those most impacted would be present, comfortable, and most receptive to it. Vaccines were offered "in safe spaces outside night clubs, pop-up events, social venues, sex parties, and other community-focused events such as Atlanta Black Pride and Southern Decadence." In addition, public health officials departed from the classic "risk assessment" approach to decide who should be vaccinated because it can often be stigmatizing for those most at risk; and because the vaccine could leave a temporary mark at the injection site that might inadvertently disclose information about sexuality or gender identity, public health officials issued guidance to clinics on allowing people to choose their injection site, with options for less visible ones.

The third lesson was "the importance of flexible resources and investments in public health infrastructure for preparedness and rapid response during public health emergencies." The CDC's "rapid response reserve fund" was tapped to allow for deploying resources quickly, for both vaccination and infection prevention.

Finally, the authors point out that an equally important part of the response was the actions taken as infection numbers declined in the fall of 2022. "It is tempting," they suggest, "to see declining case numbers as an invitation to declare the effort a success." Instead, the White House response team recognized that sustained work was required to avoid a second spike, especially within Black and Latino communities and people living with HIV. (According to the authors, between 35% and 47% of those who contracted mpox also had HIV.) So instead of reducing the effort, in the spring of 2023 and continuing into summer, public health officials launched a new push to build community trust and vaccinate more of those at risk. "Persistence is the key lesson," the authors state.

The fact that there wasn't a second mpox wave last summer is remarkable and validates these lessons. It's a clear contrast to the COVID-19 public-health response, which was large-scale and largely undifferentiated by community throughout much of the country (with the exception of pushes to vaccinate the elderly first), and in which misinformation spread rapidly and widely and undermined trust in health professionals. It's also similar to the early days of the HIV epidemic in the 1980s, in which misinformation also spread widely and the community most impacted — which overlaps significantly with those impacted by mpox — was stigmatized by the poorly managed public health response. According to the researchers, the mpox public health response over the past 18 months benefited greatly not just from lessons learned from HIV, but also from the trusted community of support that still exists to get HIV-related information and treatments to those most impacted in the LGBTQ community and other at-risk groups; those trusted health professionals and advocates served as effective and efficient conduits in the rapid mpox response.

We generally don't talk about the public health crises that don't happen. If the COVID-19 response guided our expectations, last summer should have seen a second mpox wave, dealing another round of public health misery upon our country. The health professionals who worked creatively and diligently to chart a different course for us deserve plenty of credit and thanks for their largely unheralded work. And hopefully they have rewritten the playbook for the next viral outbreak.

Lessons From the Mpox Response

Featured image via Gorodenkoff/Shutterstock.com.