Abstract
An outbreak of mpox virus (MPV) among humans in the United States (U.S.) was described in May 2022. This outbreak disproportionately affects Black and Hispanic sexual minority men (SMM) and these groups have lower rates of vaccination compared to Whites. Between July and August 2022, a partnership between a nonprofit and two local health departments successfully designed and implemented a community intervention to administer MPV vaccines to Black SMM in the Washington D.C. metropolitan area. We administered a quantitative survey to 178 respondents across four vaccinations clinics. We found that study participants had high socioeconomic status, high levels of anticipated MPV stigma, and were relatively skeptic about MPV. We demonstrated how a partnership between an urban nonprofit and government agency can facilitate quick and effective dissemination of a community intervention in a relatively low cost manner.
Introduction
Monkeypox (mpox) is a rare disease caused by infection with the mpox virus (MPV), and symptoms for MPV can include fever, headache, chills, swollen lymph nodes, and a blister-like rash on the face, inside the mouth, and other parts of the body [1]. The current mpox outbreak in the United States (U.S.) has resulted in over 24,000 confirmed cases to date and has primarily affected sexual minority men (SMM) [2]. According to the Centers for Disease Control and Prevention (CDC), MPV can spread from person to person through direct contact with the infectious rash, scabs, or body fluids and by respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex [3]. While infections from the current MPV are rarely fatal, individuals with weakened immune systems are more likely to experience serious illness and to die [4]. A majority of MPV cases in the U.S. have been among Black and Hispanic SMM between the ages of 21 and 40 years [1, 3]. In a national survey of SMM, half of respondents reported reducing their number of sexual partners, number of one-time sexual encounters, and sex with partners met through dating apps and at sex venues to curb the spread of MPV [5]. To prevent the further transmission of MPV, the CDC recommends that people avoid close, skin-to-skin contact with people who have a rash that looks like MPV, avoid contact with objects and materials that a person with MPV has used, and wash your hands often with soap and water or use an alcohol-based hand sanitizer. Additionally, the CDC recommends the use of JYNNEOS and ACAM2000 vaccines for the prevention of MPV [6]. A recent study found that MPV incidence was 14 times higher among unvaccinated males compared with those who had received a first MPV vaccine dose [7]. To date, 1.1 million MPV vaccine doses have been administered in the U.S., with Blacks and Hispanics making up only 9% and 16% of vaccine recipients, respectively. There exist a disparity in the burden of MPV and uptake of the MPV vaccine among Black and Hispanic SMM in the U.S., and more research is needed on health interventions to increase vaccination rates in this vulnerable group.
Understanding the characteristics and attributes of MPV vaccine recipients is pivotal to informing the development and implementation of MPV vaccination interventions, especially for Black and Hispanic SMM with low vaccination rates. The primary objective of this study was to assess the demographic characteristics, health status and behaviors, anticipated stigma, and MPV beliefs among Black SMM who received a first dose of the MPV vaccine in the Washington D.C. metropolitan area.
Methods
We designed and implemented a community-based intervention aimed at increasing MPV vaccination rates among Black SMM in the Washington D.C. metropolitan area. This initiative was developed from a strategic partnership between a local nonprofit organization (Us Helping Us, People into Living Inc) and two local health departments (DC Department of Health & Prince George’s County Health Department). We engaged in community education and mobilization efforts and appointment scheduling and provided the location for vaccine administration. We mobilized our clients and other community members to participate in this vaccination initiative through: (1) message blasts through our client email listserv and patient portal, (2) posting on our social media accounts, and (3) word-of-mouth information dissemination through our peer educators and community health workers. Eligible clients were scheduled to receive the vaccine in 10–15 min intervals with 3–4 vaccinations occurring during each interval. The health departments provided clinical staff and the medical supplies needed for vaccine administration. During the vaccine clinics, the clients provided proof of residency (e.g., government issued identification card, lease agreement) and completed an intake form provided by the health department.
A cross-sectional, convenience sample of 178 SMM in the Washington D.C. metropolitan area receiving their first dose of the MPV vaccine (administered by two local health departments) completed our survey between July and August 2022. The paper survey was given to clients upon receipt of their vaccination and it took about 5–10 min to complete. The survey assessed demographic characteristics, health status and behaviors, anticipated stigma related to MPV, and beliefs about MPV. This activity was reviewed and approved by the Sterling Institutional Review Board. We assessed the distribution (percentages and means) of all variables, and data were analyzed using SAS (version 9.4).
Results
Among 178 respondents across four vaccinations clinics, a majority were Black/African American (99%), cisgender male (93%), and gay/homosexual (82%), and 76% had a bachelor’s degree or higher), and 63% had a yearly income of $70,000 or higher (Table 1). Most (90%) were currently sexually active, 35% had a weakened immune system, and 31% had attended a large gathering in close contact with others (sex party and/or dance clubs) in the previous 30 days.
Table 1.
Demographics, health status and behaviors, anticipated stigma, and beliefs about mpox virus among a sample of Black sexual minority men receiving a mpox vaccine in Washington, DC
| Demographics | |
|---|---|
| Race/ethnicity, No. (%) | |
| Black African American | 177 (99.4) |
| Gender, No. (%) | |
| Cisgender male | 165 (92.7) |
| Cisgender female | 3 (1.7) |
| Transgender female | 2 (1.1) |
| Non-binary | 5 (2.8) |
| Gender non-conforming | 3 (1.7) |
| Sexual orientation, No. (%) | |
| Gay/homosexual | 146 (82.0) |
| Heterosexual | 9 (5.1) |
| Bisexual | 16 (9.0) |
| Pansexual | 4 (2.3) |
| Other | 2 (1.1) |
| Annual household income, No. (%) | |
| No income | 3 (1.7) |
| $1–24,999 | 6 (3.4) |
| $25,000–34,999 | 6 (3.4) |
| $35,000–49,999 | 8 (4.5) |
| $50,000–69,999 | 33 (18.5) |
| $70,000–99,999 | 35 (19.7) |
| $100,000–149,000 | 42 (23.6) |
| $150,000 or higher | 35 (19.7) |
| Educational attainment, No. (%) | |
| Some high school, no diploma | 4 (2.3) |
| High school graduate | 7 (3.9) |
| Some college credit, no degree | 37 (20.8) |
| Trade school/technical college/vocational training | 3 (1.7) |
| Associate’s degree | 4 (2.3) |
| Bachelor’s degree | 55 (30.9) |
| Master’s degree | 51 (28.7) |
| Professional degree | 4 (2.3) |
| Doctorate degree | 12 (6.7) |
| Health Factors | |
| Sexual activity in previous 30 days, No. (%) | |
| Yes | 160 (89.9) |
| No | 15 (8.4) |
| Exchange sex, No. (%) | |
| Yes | 7 (3.9) |
| No | 171 (96.0) |
| Regular attending large gatherings (including sex parties, sex clubs, and dance clubs), No. (%) | |
| Yes | 52 (29.2) |
| No | 124 (69.7) |
| Attended large gatherings (including sex parties, sex clubs, and dance clubs) in previous 30 days, No. (%) | |
| Yes | 55 (30.9) |
| No | 121 (68.0) |
| Weakened immune system, No. (%) | |
| Yes | 63 (35.4) |
| No | 115 (64.6) |
| Received at least one dose of COVID-19 vaccine, No. (%) | |
| Yes | 170 (95.5) |
| No | 8 (4.5) |
| Received COVID-19 booster, No. (%) | |
| Yes | 142 (79.8) |
| No | 36 (20.2) |
| Mpox-specific questions | |
| Risk perception | |
| I worry about getting mpox, No. (%) | |
| None of the time | 7 (3.9) |
| Rarely | 21 (11.8) |
| Some of the time | 63 (35.4) |
| A lot of the time | 42 (23.6) |
| All of the time | 44 (24.7) |
| I think my chances of getting infected with mpox are, No. (%): | |
| Zero | 5 (2.8) |
| Almost zero | 9 (5.1) |
| Small | 46 (25.8) |
| Moderate | 70 (39.3) |
| Large | 35 (19.7) |
| Very Large | 13 (7.3) |
| I am sure I will NOT get infected with mpox, No. (%) | |
| Strongly agree | 8 (4.5) |
| Agree | 21 (11.8) |
| Neither agree nor disagree | 91 (51.1) |
| Disagree | 39 (21.9) |
| Strongly disagree | 18 (10.1) |
| Anticipated stigma | |
| The LGBT community would think less of me if they found out I got mpox, No. (%) | |
| Strongly agree | 29 (16.3) |
| Agree | 22 (12.4) |
| Neither agree nor disagree | 59 (33.2) |
| Disagree | 37 (20.8) |
| Strongly disagree | 23 (12.9) |
| My friends would think less of me if they found out I got mpox, No. (%) | |
| Strongly agree | 11 (6.2) |
| Agree | 13 (7.3) |
| Neither agree nor disagree | 53 (29.8) |
| Disagree | 53 (29.8) |
| Strongly disagree | 41 (23.0) |
| My sexual partners would think less of me if they found out I got mpox, No. (%) | |
| Strongly agree | 27 (15.2) |
| Agree | 29 (16.3) |
| Neither agree nor disagree | 44 (24.7) |
| Disagree | 37 (20.8) |
| Strongly disagree | 33 (18.5) |
| My family would think less of me if they found out I got mpox, No. (%) | |
| Strongly agree | 18 (10.1) |
| Agree | 28 (15.7) |
| Neither agree nor disagree | 41 (23.0) |
| Disagree | 43 (24.2) |
| Strongly disagree | 41 (23.0) |
| If I got mpox, I would feel a need to hide that from other people, No. (%) | |
| Strongly agree | 41 (23.0) |
| Agree | 34 (19.1) |
| Neither agree nor disagree | 39 (21.9) |
| Disagree | 26 (14.6) |
| Strongly disagree | 31 (17.4) |
| People would avoid me if they found out I got mpox, No. (%) | |
| Strongly agree | 63 (35.4) |
| Agree | 49 (27.5) |
| Neither agree nor disagree | 38 (21.4) |
| Disagree | 11 (6.2) |
| Strongly disagree | 9 (5.1) |
| People would blame me if they found out I got mpox, No. (%) | |
| Strongly agree | 27 (15.2) |
| Agree | 36 (20.2) |
| Neither agree nor disagree | 60 (33.7) |
| Disagree | 29 (16.3) |
| Strongly disagree | 18 (10.1) |
| People would assume I was gay or bisexual if they found out I got mpox, No. (%) | |
| Strongly agree | 50 (28.1) |
| Agree | 36 (20.2) |
| Neither agree nor disagree | 55 (30.9) |
| Disagree | 10 (5.6) |
| Strongly disagree | 19 (10.7) |
| People would assume I slept around if they found out I got mpox, No. (%) | |
| Strongly agree | 48 (27.0) |
| Agree | 44 (24.7) |
| Neither agree nor disagree | 45 (25.3) |
| Disagree | 13 (7.3) |
| Strongly disagree | 20 (11.2) |
| Composite stigma score | 25.9 (8.6) |
| Attitudes towards mpox | |
| Mpox is a “gay disease,” No. (%) | |
| Strongly agree | 7 (3.9) |
| Agree | 3 (1.7) |
| Neither agree nor disagree | 33 (18.5) |
| Disagree | 25 (14.0) |
| Strongly disagree | 101 (56.7) |
| Mpox mostly affects people who have multiple sex partners in a short period of time, No. (%) | |
| Strongly agree | 13 (7.3) |
| Agree | 18 (10.1) |
| Neither agree nor disagree | 63 (35.4) |
| Disagree | 25 (14.0) |
| Strongly disagree | 51 (28.7) |
| Mpox was a government-made virus, No. (%) | |
| Strongly agree | 10 (5.6) |
| Agree | 15 (8.4) |
| Neither agree nor disagree | 56 (31.5) |
| Disagree | 39 (21.9) |
| Strongly disagree | 52 (29.2) |
| Mpox was made in a lab, No. (%) | |
| Strongly agree | 10 (5.6) |
| Agree | 17 (9.6) |
| Neither agree nor disagree | 58 (32.6) |
| Disagree | 35 (19.7) |
| Strongly disagree | 51 (28.7) |
| Mpox has been around for over 60 years, No. (%) | |
| Strongly agree | 27 (15.2) |
| Agree | 49 (27.5) |
| Neither agree nor disagree | 77 (43.3) |
| Disagree | 6 (3.4) |
| Strongly disagree | 10 (5.6) |
| Mpox does not really exist, No. (%) | |
| Strongly agree | 5 (2.8) |
| Agree | 3 (1.7) |
| Neither agree nor disagree | 25 (14.0) |
| Disagree | 37 (20.8) |
| Strongly disagree | 100 (56.2) |
| A lot of information about mpox is being held back from the public, No. (%) | |
| Strongly agree | 25 (14.0) |
| Agree | 27 (15.2) |
| Neither agree nor disagree | 71 (39.9) |
| Disagree | 33 (18.5) |
| Strongly disagree | 14 (7.9) |
| Mpox is a real public health threat, No. (%) | |
| Strongly agree | 87 (48.9) |
| Agree | 50 (28.1) |
| Neither agree nor disagree | 22 (12.4) |
| Disagree | 3 (1.7) |
| Strongly disagree | 9 (5.1) |
| People who take the mpox vaccine are human guinea pigs for the government, No. (%) | |
| Strongly agree | 6 (3.4) |
| Agree | 4 (2.3) |
| Neither agree nor disagree | 51 (28.7) |
| Disagree | 40 (22.5) |
| Strongly disagree | 70 (39.3) |
| Public health officials and the government are telling the truth about mpox, No. (%) | |
| Strongly agree | 17 (9.6) |
| Agree | 49 (27.5) |
| Neither agree nor disagree | 79 (44.4) |
| Disagree | 14 (7.9) |
| Strongly disagree | 12 (6.7) |
Additionally, 84% reported being worried about contracting MPV, and 66% believed their chances of getting MPV were moderate to very large. A significant proportion of respondents (13–31%) believed various people in their lives (friends, family, sexual partners, and larger LGBT community) would think less of them if they found out they had contracted the MPV. Furthermore, 35% believed they would be blamed, and 51% believed others would assume they were sexually promiscuous if they acquired MPV. While respondents were early adopters of the MPV vaccine, they still held some skepticism and possible conspiracy theories about the current MPV outbreak. Specifically, 48% were neutral or agreed that that MPV was intentionally made in a laboratory, and 29% believed that information about MPV was being held back from the public.
Discussion
We found that study participants had high socioeconomic status, high levels of anticipated MPV stigma, and were relatively skeptic about MPV. This is the first known empirical study of demographic characteristics and health beliefs of SMM recipients of the MPV vaccine in the U.S. Our findings illuminate the need for more public education about MPV that is rooted in scientific evidence [8]. Also, concerns about MPV and MPV vaccines can be addressed by engaging members of most-affected communities (Black and Hispanic SMM) in the development and dissemination of campaigns to boost confidence in the effectiveness and safety of the vaccine.
We demonstrated how a partnership between a nonprofit and government agency can facilitate quick and effective dissemination of a community intervention in a relatively low-cost manner. In a short amount of time, we successfully planned and implemented a vaccination effort in response to a quickly escalating public health emergency that is primarily affecting Black SMM. The nonprofit organization utilized existing staff to promote these vaccination clinics, and the health department deployed existing clinical staff to administer vaccines. With little to no monetary expenses, the initiative vaccinated almost 200 individuals who were vulnerable to MPV infection within the span of 2 months. We believe this initiative can be scaled to have a streamlined and singular registration process, more convenient clinic hours (evening and weekend), and include health department staff that reflect the target community. However, updated policies and additional resources on all government levels are critical to expanding these programs. Social inequalities and disproportionate access to healthcare services, especially how they manifest for racial, ethnic, and sexual minority communities, are the major diving forces of health disparities and inequities [9]. The disproportionate burden of HIV, COVID-19, and MPV on racial and sexual minority communities is further evidence for the need for equitable access to healthcare services for historically marginalized groups [9, 10].
This study has several limitations. The cross-sectional design limits our ability to draw causal inferences. In addition, all the measures relied on participant recall/self-report, which may have contributed to social desirability bias. Our study sample was recruited via social media and recruitment of clients who had received service at the nonprofit organization, limiting our ability to generalize our findings to Black SMM outside of these social networks. Additionally, our sample was skewed towards higher socioeconomic status Black SMM, which is not a representative sample of entire Black SMM community. Despite these limitations, our study is the first to examine characteristics of Black SMM who received a first dose of the MPV vaccine through a community vaccination initiative.
In conclusion, we found that study participants had high socioeconomic status and high levels of anticipated MPV stigma and were relatively skeptic about MPV. We believe that evidence-based and culturally relevant health interventions are needed to ensure optimal MPV vaccination rates among Black SMM. Actively engaging key opinion leaders within the Black SMM community, nonprofit organizations, faith-based organizations, social media influencers, and other trusted information sources in the designing and implementation of a MPV vaccination program and campaign is pivotal to closing the observed racial gap in MPV vaccination among SMM in the U.S.
Acknowledgements
We would like to acknowledge all the participants who graciously completed our survey. We alsothank the staff and administrators of the DC Department of Health and Prince George’s County Health Department. Lastly,we acknowledge grant funding from ViiV Healthcare and Gilead Sciences to support our efforts in addressing the mpox epidemic. Neither funder had any input in the designing of the study.
Data availability
Deidentified data is available for additional analysis and requests should be sent to corresponding author.
Footnotes
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References
- 1.Philpott D. Epidemiologic and clinical characteristics of monkeypox cases—United States. MMWR. Morbidity and Mortality Weekly Report. 2022;2022:71. doi: 10.15585/mmwr.mm7132e3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Thornhill JP et al. Monkeypox virus infection in humans across 16 countries—April–June 2022. N Eng J Med. 2022. [DOI] [PubMed]
- 3.Minhaj FS, et al. Monkeypox outbreak—nine states, May 2022. Morb Mortal Wkly Rep. 2022;71(23):764. doi: 10.15585/mmwr.mm7123e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Miller MJ. Severe monkeypox in hospitalized patients—United States, August 10–October 10, 2022. MMWR. Morb Mortal Wkly Rep. 2022;71 [DOI] [PMC free article] [PubMed]
- 5.Delaney KP. Strategies adopted by gay, bisexual, and other men who have sex with men to prevent monkeypox virus transmission—United States, August 2022. MMWR. Morb Mortal Wkly Rep. 2022;71. [DOI] [PMC free article] [PubMed]
- 6.O’Shea J. Interim guidance for prevention and treatment of monkeypox in persons with HIV infection—United States, August 2022. MMWR. Morb Mortal Wkly Rep. 2022;71 [DOI] [PMC free article] [PubMed]
- 7.Payne AB. Incidence of monkeypox among unvaccinated persons compared with persons receiving≥ 1 JYNNEOS vaccine dose—32 US jurisdictions, July 31–September 3, 2022. MMWR. Morb Mortal Wkly Rep. 2022;71 [DOI] [PMC free article] [PubMed]
- 8.März JW, Holm S, Biller-Andorno N. Monkeypox, stigma and public health. Lancet Reg Health Eur 2022;23. [DOI] [PMC free article] [PubMed]
- 9.Rodriguez-Diaz CE, et al. From COVID-19 to monkeypox: unlearned lessons for Black, Latino, and other men with HIV who have sex with men. Am J Public Health. 2022;112(11):1567–1571. doi: 10.2105/AJPH.2022.307093. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gonsalves GS, Mayer K, Beyrer C. Déjà vu all over again? Emergent monkeypox, delayed responses, and stigmatized populations. J Urban Health. 2022;99(4):603–606. doi: 10.1007/s11524-022-00671-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Data Availability Statement
Deidentified data is available for additional analysis and requests should be sent to corresponding author.