Similar to other health outcomes, the impact of mpox has proven far more devastating for people of color and communities with fewer health affirming resources. Mpox case rates have been highest in those who identify as Black/African American and Latino/x. The disparate numbers of mpox infections are due to several factors, including but not limited to the spread of mpox within social and sexual networks; limited access to medical care; stigma, fear, and mistrust associated with accessing care and getting vaccinated; and increased risk of infection with severe outcomes due to underlying medical conditions (e.g., immunosuppression). While individual behavior plays a role in a person's level of risk, barriers to accessing protective social determinants of health, including a living wage, health insurance, quality housing, healthy and affordable food, transportation, and safe spaces to gain social support have widened the gaps.
Disparities in mpox outcomes are an important reminder that the conditions that people live, work, and socialize in can place them at much higher risk for both exposure and negative outcomes. These deep disparities mirror the trends seen in other health outcomes. They did not happen by chance and reflect decades of social marginalization, community disinvestment, and the legacy of racism. These inequities create and maintain a persistent and challenging problem that requires collaborative, multi-sector approaches to repair and prevent in the future.
At the onset of the outbreak, it was estimated that approximately 131,000 to 143,000 residents were at risk for mpox exposure and required post-exposure prophylaxis (PEP). The lower bound was based on the number of men who have sex with men (MSM) living with diagnosed HIV and the estimated number of MSM who were eligible for HIV pre-exposure prophylaxis (PrEP). The upper bound was based on the number of MSM living with diagnosed HIV and the estimated number of HIV-negative MSM with multiple partners in the past year.
Despite the large estimate of residents who needed vaccine at the onset of the outbreak, LA County's vaccine strategy was greatly influenced by the evolving supply of JYNNEOS vaccine from USG. This required vaccine eligibility to be expanded in phases to maximize equitable access to vaccine. Though this was necessary due to manage limited vaccine availability, it rapidly devolved to uncover disparities in vaccine access, with Black and Brown residents and least healthy neighborhoods less likely to access vaccine than their White and healthier counterparts. Over time, through regular review of vaccine administration data by race/ethnicity and geography, the evidence of growing disproportionality among highly impacted community groups was stark and served to prompt strategies to facilitate access to vaccination for these vulnerable groups, including Black/African American, Latino/x, transgender people, persons experiencing homelessness, and other vulnerable communities across LA County. Importantly, a consistent strategy interweaved throughout the outbreak response was the early involvement and input of community members and organizations that served the at-risk population. A description of the stepwise process for how LA County's vaccine strategy evolved in support of more sustainable and equitable access to vaccine in the community is described in detail below.
Between May 27, 2022, when the first mpox case was identified in Los Angeles County, to June 23, 2022, LA County received 1,060 doses of JYNNEOS vaccine from the California Department of Public Health to respond to the outbreak. PEP was prioritized for persons who were confirmed by Public Health through case investigations to have high- or intermediate risk contact with someone with confirmed or suspected mpox infection.
On June 24, 2022, LA County received its Phase 1 allotment of JYNNEOS vaccine from USG (6,346 doses) allowing the County to implement its first expansion of PEP to include MSM who were confirmed by LAC DPH to have attended an event where there was high risk of exposure to a suspect or confirmed mpox case, in alignment with the National JYNNEOS Vaccine Strategy. Given that Phase 1 vaccine in LA County would only reach about 4-6% of the estimated population at-risk for mpox, initial vaccine administration was heavily skewed to residents with greater access to resources that enabled them to get to the front of the line for vaccination.
To address this imbalance, on July 11, 2022, LA County expanded vaccine eligibility to maximize access for persons at highest risk for mpox, using sexually transmitted infections (STIs) as a marker for behavior that would place an individual at high risk for mpox exposure. With this expansion, vaccine became available for gay and bisexual men and other MSM or transgender persons who presented to STI and HIV clinics with rectal gonorrhea and early syphilis within the past 3 months. This allowed community-based clinics that provided STI and HIV clinical care for the community at-risk to identify and offer vaccine to their highest risk patients.
To help expand access to vaccine, LAC DPH recruited HIV PrEP Centers of excellences as initial mpox vaccine providers, to offer vaccine to their patients, and soon after, expanded the vaccine provider network to include Ryan White Clinics and other community-based clinics that served high risk residents. Individuals who did not have a provider were able to make appointments at Public Health Centers and access vaccine through walk-up points of dispensing (PODS) vaccination sites to access vaccine.
On July 17, 2022, LAC DPH implemented a SMS text campaign to reach persons who met the eligibility criteria but were not presenting to community providers. Through this text campaign, LAC DPH provided a unique message for all persons in the STD case registry who had been diagnosed with rectal gonorrhea or early syphilis in the past 3 months and indicated that they were eligible for the mpox vaccine and were provided instructions on how to access the vaccine with their provider or at a public vaccinating site.
Two days after the text campaign was launched, on July 19, 2022, an additional 16,636 doses were made available to LA County allowing the County to expand vaccine eligibility even further to include gay, bisexual and other MSM and transgender persons who were diagnosed with gonorrhea or early syphilis within the past 12 months in Los Angeles County (reached through SMS texts); were on HIV pre-exposure prophylaxis; or attended or worked at a commercial sex venue or other venue where they had anonymous sex or sex with multiple partners within past 21 days.
Given that demand for vaccine continued to outpace the current supply of vaccine, Public Health launched an online vaccine pre-registration system on July 20, 2022, where vaccine-eligible residents could sign-up for a vaccine dose by self-attesting to the eligibility criteria. After registering, residents would then receive a text message, in both Spanish and English, notifying them when it was their turn to get vaccinated with instructions for how to access the vaccine. In the text message, they received a link to a list of public vaccination sites and were requested to bring their text message for proof of vaccine registration. Persons who did not have access to a computer to register for vaccine could call Public Health where staff would assist with registration over the phone. Immediately after launching the online registration portal, vaccine administration increased nearly 7-fold from 1,065 doses administered during the week of July 17th, to 7,022 doses administered during the week of July 24th when the was portal went live.
On August 1st, LA County received 48,120 additional doses from Phase 3 of the USG national vaccine strategy. This large number of doses was based on the new intradermal vaccine administration strategy, which allowed one vial of JYNNEOS vaccine to provide up to 5 doses of vaccine, compared to only one dose per vial using the subcutaneous administration route. This greater supply of vaccine allowed the County to expand vaccine eligibility even further to include gay, bisexual and other MSM and transgender persons who had multiple of anonymous partners in the past 14 days, including engaging in survival or transactional sex, and extended further to include persons who were immunocompromised. In addition, this increased number of doses enabled the County to open up eligibility for persons who were due for their second doses. Prior to this, first dose administration had been prioritized over second dose administration due to limited vaccine supply.
Importantly, it was the community clinic provider network that led the charge in switching from subcutaneous administration to intradermal administration in LA County. This was facilitated by the collective goal to meet the high demand from community members that needed the vaccine. As a result, LA County switched to intradermal administration on the same day that the new vaccine administration guidance on was released from CDC and became one of the first jurisdictions in the US to successful scale up the intradermal administration for mpox vaccination.
On August 14th, vaccine eligibility continued to expand to include gay and bisexual men, MSM, and transgender persons who had skin-to-skin or intimate contact at a large venue or event in the past 14 days, and persons of any gender or sexual orientation who engaged in commercial and/or transactional sex in the past 14 days. This expansion was timed with the commitment of Phase 4 vaccine from USG which would bring an additional 123,00 doses to LA County.
Notably at this point in the outbreak, the number of persons registering for vaccine and the number of persons showing up at Public Health vaccinating sites were on a decline. In contrast, demand at community-based clinics remained high, particularly in sites located in the epicenter of the mpox outbreak. First dose administration reached its peak during the week of August 14th; at that point, LA County had vaccinated close to one-third of its at-risk population with 1 dose of JYNNEOS vaccine.
With the receipt of of Phase 4 vaccine in LA County and vaccine supply no longer an issue, during September to October 2022, the County's vaccine strategy shifted to focus on facilitating vaccine access for community groups that were disproportionately impacted by mpox. This included expanding the vaccine provider network to reach underserved geographic areas; working with community providers and bars/clubs to host pop-up vaccine clinics during events tailored for Latino/x, Black/African American, and transgender community members; holding meetings with Latino/x, Black/African American, and transgender community-based organizations and providers to discuss our efforts to expand Mpox response for these communities and discuss areas where they can support; and identifying partners and sites for large community events during September's Latin Heritage Month to reach at-risk Latino/x residents, including those who may not be out” about their sexual orientation.
Though this targeted approach was met with great interest from community stakeholders, the numbers vaccinated through these targeted vaccine events was low. In contrast, since the beginning of October, community clinics have administered higher numbers of mpox vaccinations compared to other vaccine providers in the County and continue to newly vaccinate hundreds of at-risk patients each week in spite of low vaccine demand in the broader community.
The current vaccine strategy in LA County is back where we started at the onset of the outbreak: supporting community-based clinics to offer mpox vaccine for their highest risk patients during routine HIV and STI clinical care and ensuring that they have the resources needed to administer vaccine. Public Health is also actively monitoring the percentage of PLWDH in LA County who have received 1 and 2 doses of vaccine and is sharing this information regularly with community HIV clinics to help boost efforts to improve access to and demand for vaccine among HIV patients. Through close partnership and coordination with community clinics throughout the outbreak, mpox vaccination continues to move closer to a more equitable and stainable model for improving the health of our most vulnerable communities.