Addressing mpox at a Frontline Community Health Center: Lessons for the Next Outbreak

Abstract

The 2022 mpox (formerly monkeypox) outbreak affected predominantly men who have sex with men (MSM), likely through sexual transmission, which resulted in institutions specializing in sexual health being at the frontlines of the mpox outbreak. Fenway Health in Boston serves close to 10 000 MSM annually, which includes more than 2400 MSM who are living with HIV and 3320 MSM with active HIV preexposure prophylaxis (PrEP) prescriptions. We report on the programs implemented and changes to clinical practice at Fenway Health during the mpox outbreak. Fenway Health diagnosed its first case of mpox in June 2022 and treated this patient with tecovirimat. In early July 2022, Fenway Health administered its first dose of the Jynneos vaccine under the Emergency Use Authorization for protection against mpox. As of October 6, 2022, 69 people had tested positive for the mpox virus at Fenway Health. Among the 69 people who tested positive, 43 (62.3%) self-identified as male, with the remaining not reporting a sex or gender identity, and 40 (58.0%) reported their sexual orientation as gay or bisexual. Twenty-five people (36.2%) were treated with tecovirimat. As of October 30, 2022, Fenway Health had administered 6376 doses of the Jynneos vaccine. The programmatic changes involved in rollout and scale-up of vaccination, treatment, and community outreach services at Fenway Health during the 2022 mpox outbreak that we describe here could inform strategies to address subsequent outbreaks.

The evolving mpox (formerly monkeypox) outbreak has constituted an international public health emergency. ¹ Although prior mpox outbreaks have occurred predominantly via animal-to-human transmission and less frequently via human-to-human transmission through close physical contact, ² the 2022 mpox outbreak demonstrated a predominance of sexual transmission,^3-7 with a particularly high prevalence of disease in the United States among racial and ethnic minority populations. ⁸ Thus, clinics specializing in sexual health, particularly clinics focused on sexual and gender minority groups, have become the frontline of public health interventions on mpox, monitoring and tracking of new mpox infections, and implementation of mpox vaccinations and therapies. However, community sexual health centers that faced the rapidly evolving outbreak encountered numerous challenges, including limited supplies of vaccines and therapeutics, delays in obtaining test results, the need to mobilize already busy clinic staff, and addressing community education to combat stigmatization.

Because of similarities with smallpox, a unique feature of the 2022 mpox outbreak was that diagnostic tests, therapeutics (ie, tecovirimat), and vaccines (ie, Jynneos vaccine, which has been used for both pre- and postexposure prophylaxis) had already been developed,^9-12 in contrast with other recent viral outbreaks, such as the HIV epidemic and COVID-19 pandemic. Thus, early in the mpox outbreak, sexual health clinics were able to use these tools to brace for the expected wave of cases. However, despite the already developed diagnostics, therapeutics, and vaccines, availability, particularly early in the outbreak, was limited.

Purpose

After the first case of mpox was identified in Boston, Massachusetts, in mid-May 2022, Fenway Health began preparing staff in anticipation of an outbreak among local gay, bisexual, and other men who have sex with men (MSM) by building on lessons learned during the HIV epidemic and COVID-19 pandemic. Fenway Health aimed to implement and rapidly scale up vaccination, treatment, and community outreach and education programs to meet community needs. We report on the programs implemented and changes to clinical practice, information on which could be used to inform future related efforts.

Methods

The Fenway Community Health Institutional Review Board considered this study not human subjects research because of the lack of interaction with or collection of identifiable information about human subjects and because it was conducted as part of public health surveillance.

Program Setting

Fenway Health provides primary care for close to 35 000 people, including almost 10 000 MSM, of whom 3194 (30%) identify as members of a racial or ethnic minority group. Fenway Health serves more than 2400 people living with HIV and 3320 with an active prescription for HIV preexposure prophylaxis (PrEP). Fenway Health has a unique background in providing comprehensive care for sexual and gender minority patients ¹³ and began treating patients with mpox and implementing programs to stop the spread of disease during the early days of the 2022 mpox outbreak in the United States. The Massachusetts State Department of Public Health (MDPH) designated Fenway Health as 1 of the first of 4 facilities to offer vaccinations to people exposed to mpox and at high risk of mpox infection (Amu Multani, MD, Fenway Health, email communication, July 12, 2022).

Programmatic Changes

Fenway Health conducted training for staff, including reviews of the epidemiology of the mpox outbreak; the clinical manifestations, diagnostic criteria, and infection control procedures for mpox; and the clinical care of patients with mpox. Fenway Health also collected data on staff impressions of the training experience.

Given the limited initial availability of medications and vaccines, Fenway Health developed treatment and vaccination protocols for people at highest risk of mpox virus infection based on Centers for Disease Control and Prevention (CDC) and MDPH recommendations, ¹⁴ which Fenway Health adapted as new recommendations emerged. Initially, Fenway Health provided vaccines only to close contacts and/or recent sex partners (in the previous 14 days) of a person diagnosed with mpox. Patients who reported multiple sex partners in the previous 14 days in a jurisdiction with known cases of mpox were also eligible. On October 3, 2022, CDC and MDPH expanded the eligibility criteria for the Jynneos vaccine (Bavarian Nordic) to include people taking HIV PrEP and expanded use of the vaccine for postexposure prophylaxis. ¹⁵ Fenway Health offered tecovirimat treatment to any patient with a painful lesion suspected of having mpox and who signed informed consent after reviewing the risks and benefits of therapy.

Fenway Health staff instructed patients diagnosed with mpox infection to follow CDC quarantine guidelines. ¹⁶ Nurses from Fenway Health called patients diagnosed with mpox infection twice weekly to assess symptoms and confirm adherence to the recommended quarantine criteria. Fenway Health staff monitored tolerability of tecovirimat during 2 follow-up visits of patients after the initial prescription, during which Fenway Health tracked outcomes via the provided expanded-access investigational new drug protocol. ¹⁷ Fenway Health instructed patients who received tecovirimat therapy to keep a diary of symptoms.

To address rapidly changing circumstances, Fenway Health relied on iterative adaptations of its mpox virus testing, treatment, vaccination, and community engagement program; Fenway Health made adaptations to the program by having close communications among all members of the clinic workforce. To accommodate workload, Fenway Health drafted staff from other departments to assist with the vaccination efforts; for example, we reassigned occupational health staff to do clinic check-ins. Nurses who usually provided primary care staffed the vaccination clinic until MDPH provided travel nurses who were not Fenway Health employees. Fenway Health hired no additional staff but redeployed 1 primary care provider to lead the mpox symptom clinic.

Fenway Health repurposed HEPA-filtered negative-pressure rooms previously used for the evaluation of patients suspected of having SARS-CoV-2 infection for mpox virus testing rooms, to ensure patients could be rapidly evaluated in a safe environment. Fenway Health used the HEPA-filtered negative-pressure rooms as a precautionary measure and because they were available. Fenway Health created additional clinic appointments to accommodate same-day visits for symptomatic patients or patients at high risk of mpox infection who were seeking vaccination, testing, and/or treatment.

Fenway Health recognized that community engagement and education to promote changes in sexual practice were integral to curbing transmission, consistent with other recent findings. ¹⁸ Fenway Health also recognized that early and intentional engagement of racial and ethnic minority populations was important, based on the assessment of prior outbreaks that disproportionately affected such populations. To raise awareness about mpox among MSM and other people at risk of mpox infection, Fenway Health initiated a community education campaign that included having trained nurses available at scheduled times to field questions and provide advice.

To ensure equitable care among financially and medically disenfranchised communities, Fenway Health directed dissemination of information toward racial and ethnic minority populations through direct outreach and through affiliated organizations that traditionally have had strong outreach into racial and ethnic minority communities. Fenway Health, in conjunction with the city and state public health departments, convened several community forums and webinars. Fenway Health also created numerous social media and blog postings with relevant information ¹⁹ and attempted to reach people at high risk of mpox through emails, text messages, and telephone calls.

Data Collection

We retrospectively reviewed electronic medical record data among all cases of mpox diagnosed at Fenway Health. We extracted sociodemographic and clinical data, which included coinfection with HIV or another sexually transmitted infection, PrEP use, recent travel, number and type of lesions identified on clinical examination, presence and type of systemic symptoms (eg, fever, fatigue, body aches), treatment and date of treatment with tecovirimat, and report of prior Jynneos vaccine. In addition, we gathered population-level data on the number of Jynneos vaccines provided by Fenway Health. We reported frequencies and descriptive statistics.

Outcomes

Fenway Health diagnosed its first case of mpox in mid-June 2022. As the disease spread, the number of daily cases peaked in Massachusetts toward the end of July (Figure). Fenway Health administered tecovirimat to its first patient with a case of mpox in mid-June 2022 and administered its first dose of the Jynneos vaccine in early July 2022. We summarized Fenway Health staff reflections on patient concerns, strategies employed by Fenway Health, and lessons learned during the mpox outbreak (Table).

Figure.

Number of mpox cases in Massachusetts and number of Jynneos vaccines administered in relation to key developments in the local outbreak response, 2022 mpox outbreak. Abbreviations: CDC, Centers for Disease Control and Prevention; FDA, US Food and Drug Administration; LGBTQ, lesbian, gay, bisexual, transgender, and queer. Centers for Disease Control and Prevention recommendations were released on August 4, 2022.

¹ First case of mpox diagnosed in Massachusetts. Fenway Health offers first webinar, “Mpox in the United States: An Update for Clinicians & the LGBTQ Community.” Panelists were from CDC, Emory University, Fenway Health, and community organizations.

² Fenway Health diagnosed its first case of mpox infection.

³ Fenway Health administered its first dose of the Jynneos vaccine.

⁴ Fenway Health increased advertisements on mpox vaccines in all clinical areas of Fenway Health and in the community.

⁵ Fenway Health implemented specific protocols for nurses’ weekly outreach to mpox cases during the quarantine period. Fenway Health informed patients that they will have to forgo the second Jynneos vaccine dose because of shortage.

⁶ Fenway Health treated 8 people with tecovirimat. FDA releases interim guidance on dose-sparing strategy converting to intradermal injection with planned implementation on August 22, 2022.

⁷ FDA permits commercial laboratories to test for mpox virus, and Quest Diagnostics rolled out nationwide testing (Brian Bakofen, DO, Fenway Health, email communication, July 15, 2022). Massachusetts Department of Public Health stopped contacting individuals with negative test results.

⁸ Fenway Health switches to Quest Diagnostics for mpox virus testing.

⁹ Persistent decreases in mpox cases nationwide. Fenway Health received >4000 doses of Jynneos vaccine.

¹⁰ The Fenway Institute publishes blueprint for federal response to mpox outbreak. ²⁰

¹¹ Fenway Health offers walk-in Jynneos vaccine clinic.

¹² Fenway Health offers webinar, “Navigating mpox and HIV in Our Community,” cosponsored by Harvard Center for AIDS Research.

Table.

Fenway Health staff reflections on patient concerns, Fenway Health’s response to outbreak, and lessons learned, 2022 mpox outbreak, Boston, Massachusetts, October 2022

Topic	Staff member’s role and involvement	Quotation
Patient concerns	Medical director of infectious diseases	[M]ultiple patients in the beginning of the onset . . . reported feeling scared and isolated and nervous their health information would be breached and leaked to medical journals. . . . As time passed, I feel education became more widespread and treatment more available, which changed patients’ concerns over the outbreak to feel more accepted and offer what information they could to their providers in an attempt to educate and help other patients.
	Nurse practitioner in medical department, direct provider	[Patients voiced] being scared about the outbreak and the symptoms that may occur and possible scarring after the rashes.
Fenway Health’s response to the outbreak	Medical director of infectious diseases	In the weeks after [the first case diagnosed in Massachusetts], the medical and nursing leadership met weekly to create evaluation and testing workflows for mpox and to ensure [postexposure prophylaxis] with [Jynneos vaccine] . . . and to create an mpox testing unit using our negative prior pods previously used for COVID-19 evaluation.
	Nurse practitioner in medical department, direct provider	Fenway acted quickly to start a dedicated [mpox] clinic as soon as they had the means to do so. They also got test kits up and ready for providers to use.
	Nurse and medical assistant for educator	Fenway was quick to act in creating a response group [and to] get a vaccine clinic up and running. Given the population Fenway traditionally serves and the population deemed at risk, it was essential that Fenway be on the forefront.
Lessons learned	Medical director of infectious diseases	We were hindered by staffing, unfortunately, which would have allowed our vaccine response to be more robust.
	Nurse and medical assistant for educator	Guidelines and information [are] critical to having an informed response. However, being weighed down by requiring all individuals [to be] in the room slows down the process. We must have a clear understanding of roles, understand urgency, and remain flexible to ensure that responses are appropriate.
	Nurse practitioner in medical department, direct provider	Fenway did not provide vaccine to their frontline workers. . . . If providers were to have been infected with [mpox virus], then our staff shortage would have drastically changed in [that] we would not have been able to provide care to those in need.

As of October 6, 2022, 69 people had tested positive for mpox virus at Fenway Health; 43 people (62.3%) self-identified as male, and the remaining did not report a sex or gender identity. Among 69 people who tested positive for mpox, 40 patients (58.0%) reported their sexual orientation as homosexual or bisexual (1 patient identified as heterosexual, 28 patients did not report their sexual orientation), 16 (23.2%) identified as Hispanic or Latinx, and 5 (7.3%) identified as non-Hispanic Black. Of those who tested positive for mpox virus, 11 (15.9%) were living with HIV and 30 (44.9%) were taking HIV PrEP. All 69 patients had lesions at the time of testing, with 56 patients (81.2%) having genital, inguinal, rectal, or perirectal lesions and 54 patients (78.3%) reporting systemic symptoms. Thirty-seven patients (53.6%) were diagnosed with concurrent sexually transmitted bacterial infections. No patients traveled to Africa, but 7 patients (10.1%) reported recent travel within the United States, Canada, or Europe. Among the 69 patients who tested positive for mpox, 32 (46.4%) thought they acquired the infection sexually, with 14 (20.3%) reporting sex with someone known to be infected with mpox virus.

Of the 69 patients who tested positive for mpox, 18 patients (26.1%) reported that they had previously received the Jynneos vaccine. Twenty-five patients were treated with tecovirimat. As of October 30, 2022, Fenway Health had administered 6376 doses of the Jynneos vaccine (Figure), of which 1864 (29.2%) doses were administered to individuals who identified as members of a racial or ethnic minority group.

Lessons Learned

We report the experiences of Fenway Health in the rollout and scale-up of testing, immunization, treatment, and community outreach services during the 2022 mpox outbreak. Unlike during the early days of the HIV epidemic or the COVID-19 pandemic, at the outset of the mpox outbreak, effective diagnostics, therapeutics, and vaccines were available.^9-12 However, diagnostics, therapeutics, and vaccinations were not implemented promptly and on a large enough scale to stop the spread of the outbreak before more than 79 000 people became infected in 110 countries. ²¹ In the United States, 26 384 cases of mpox were reported as of October 6, 2022, ⁷ 409 in Massachusetts (58 [14.2%] and 128 [31.3%] among people who identified as non-Hispanic Black and Hispanic or Latinx, respectively). ⁸ Fenway Health attempted to use its newly developed intervention strategies to quickly mitigate spread in the population at high risk of mpox infection in the Boston area. Those efforts, and the efforts of many other frontline agencies, may have helped to blunt the outbreak curve.

Other clinics specializing in sexual health across the United States have seen increases in cases of mpox similar to the increase shown at Fenway Health, due to the nature of the transmission dynamics of mpox virus.^3-7 Understanding the epidemiology of the disease can inform future efforts to control mpox. For example, in our patient population, nearly one-half who tested positive for mpox were receiving PrEP. Thus, instituting programs among PrEP users may prove an efficient means of notifying populations at high risk of mpox virus infection. Although we did not have data to evaluate the direct effects of the approach used by Fenway Health, our results suggest that the strategies used, including reassignment of personnel, iteratively adapting protocols based on updated information, rapid implementation of new policies and procedures, and focused community outreach, were able to reach people at high risk of mpox virus infection. The approach described for Fenway Health might inform strategies in similar centers looking to implement and expand testing, treatment, and vaccination programs for mpox virus.

One additional consideration from our experience was the high rate of mpox infection among people who reported previously receiving the Jynneos vaccine (26.1%) compared with 12.8% reported in another study. ²² We asked those patients if they had received the vaccine previously, but we did not ask them when they received it or whether they had received 2 doses. Thus, we could not determine whether the immunization was used for PrEP or postexposure prophylaxis, the time from immunization to diagnosis of mpox, or the number of doses received; therefore, that high rate should be interpreted with caution. Of the 18 people who reported having received the Jynneos vaccine, 10 (55.6%) presented in July or the first week of August, likely indicating that these 10 patients had received only a single dose of the vaccine or that insufficient time since vaccination had elapsed to develop a robust immune response.

Given the disparities in prevalence noted among racial and ethnic minority groups previously and in our data,^8,23 future programs must be proactive to ensure that such groups are engaged in routine preventive services to reduce inequities as new outbreaks emerge. Moreover, the slow and initially suboptimally coordinated federal response to a nationwide outbreak for which vaccines and treatment already existed underscores the importance of engaging community leaders in outbreak and epidemic preparedness. Preparedness efforts should include use of routine ongoing engagement and ensure that adequate resources and staffing are in place to facilitate focused responses in a timely manner, specifically for populations at risk of mpox virus infection and racial and ethnic minority groups.

We noted that communication with and funding from public health authorities allowed for implementation and expansion of the local response. The sustainability of the Fenway Health program was therefore inherently dependent on public health prioritization, as determined by local and regional public health authorities. The lack of preexisting support to address emerging outbreaks and epidemics may portend future challenges when addressing the next rapidly spreading outbreak. Furthermore, given the rapid increase in patients arriving at Fenway Health for mpox care and the consequent redistribution of its resources, routine services provided by Fenway Health may have been deprioritized. Future iterations of similar programs should have pandemic contingency plans in place to minimize the likely inescapable interruptions in other routine components of care.

The mpox outbreak caused an international public health emergency, disproportionately experienced by racial, ethnic, and sexual and gender minority groups. Frontline community sexual health centers such as Fenway Health were at the forefront of the response but needed to disrupt routine care to combat the emerging outbreak. The strategies used by Fenway Health could be used by other health centers during rollout and scale-up of vaccination, treatment, and community outreach services in future outbreaks of infectious diseases. Those strategies may be particularly important in light of the recently reported resurgence of mpox. ²⁴ They include redistribution of resources and personnel, intentional allocation of space for testing and counseling services, timely provision of appropriate training and protective equipment to staff, establishment of channels for clear and regular communication, and ongoing iterative community engagement. Our experience also suggests the need for public health authorities to plan now for future outbreaks and public health emergencies in conjunction with community-based frontline health centers.