Towards equitable and sustainable vaccination against mpox in Los Angeles County

The mission of the Los Angeles County Department of Public Health (LAC DPH) is to protect health, prevent disease, and promote the health and well-being of the over 10 million County residents, with a focus on advancing health equity. In 2020, the Latino/x population represented the largest population group (49%), followed by White (28%), Asian (15%), and Black/African American populations (8%). Native Hawaiians and Pacific Islanders (NHPI) and American Indians and Alaska Natives (AIAN) represented less than 1% of the total County population.

On May 19, 2022, the first case of mpox (formally known as Monkeypox) was diagnosed in Los Angeles County leading to a targeted JYNNEOS vaccine distribution strategy to contain the mpox outbreak with limited vaccine supply from the US Government (USG). As more JYNNEOS vaccine became available through Phases 2, 3, and 4 of the National JYNNEOS Vaccine Strategy, LAC DPH was able to expand vaccine eligibility to include those groups that were disproportionally affected by disease including any man or transgender person who has sex with men or transgender persons;  persons with diagnosed HIV and sexually transmitted infections (STI), persons experiencing homelessness who engaged in high-risk behavior; persons who engaged in commercial and/or transactional sex; sexual partners of people in any of the eligibility groups; and eventually any person who anticipated being in any of the eligibility groups.

Between May 27, 2022, through September 27, 2022, across the four phases of the National JYNNEOS Vaccine Strategy, Los Angeles County received a total of 73,864 vials of JYNNEOS vaccine, representing approximately 196,162 doses available to vaccinate the County's at-risk population.

From the beginning of the mpox outbreak, LAC DPH understood the critical role that community-based clinics would play in ensuring sustainable access to and uptake of JYNNEOS vaccine for residents at highest risk for mpox. Community-based clinics are trusted organizations that provide clinical care for the most vulnerable populations in the County, and they were the first to enlist as mpox vaccine providers. They also played a key role in advocating for more vaccine supply for the County when the federal supply could not meet demand.

Our initial vaccine allocation was distributed to 12 high volume providers in LA County that were HIV PrEP Centers of Excellence. These providers were requested to begin offering vaccine to their patients at highest risk for mpox, including those who were diagnosed with early syphilis or rectal gonorrhea in the last 3 months. The number of community providers was then expanded to include all Ryan White Clinics and other strategic partners who served the at-risk population, with over 64 community-based health care providers. As vaccine demand and supply increased and to promote equitable access to the vaccine, eligibility was expanded to include communities with fewer health affirming resources, persons living with diagnosed HIV (PLWDH), persons experiencing homelessness, people living in congregate setting (e.g., substance abuse treatment centers, correctional settings, congregate housing, or dormitories), and additional sites were added including LACDPH points of dispensing (PODS) in the community and strategically located pop-up vaccine clinics with a mobile vaccine unit.

While community-based clinics reflect a sustainable and equitable model for ensuring that the communities at-risk for mpox can access JYNNEOS vaccine, the success of vaccine administration in these settings requires time, training, and resources to ensure vaccine distribution and administration can be integrated into routine clinical care. As the pace of the outbreak and vaccine demand quickly increased in early July, Public Health was able to step in to supplement the efforts of community-based clinics to meet vaccine demand by providing mass vaccinating sites, including 4 POD locations across the County and pop-up mobile vaccine clinics and events.

To date, there are currently 124 mpox vaccination sites in Los Angeles County that have resulted in an estimated 116,071 vaccine administrations in the community for 73,345 persons.  At least half of these vaccinating sites are supported by our community-based clinics in all areas of the County. With these numbers, we estimate that approximately 50% of the at-risk community has received at least one dose of JYNNEOS vaccine to date. Given the clear evidence that the JYNNEOS vaccine provides strong protection against mpox infection, this level of mpox vaccination coverage in the at-risk population likely played a role in reaching the current low level of transmission in the County.

Though vaccine demand has decreased with waning transmission, community-based clinics have demonstrated that they are nimble to changes in guidance on vaccine eligibility and administration. As of mid-December 2022, community-based clinics are now administering the highest number of vaccine doses each week compared with other vaccination sites (e.g., Public Health, pharmacies, and hospital sites). They continue to vaccinate under-immunized residents each week and have demonstrated higher vaccination coverage in overburdened and under-represented racial and ethnic groups compared with other vaccine providers. Key to the success of these community-based clinics is that they are trusted with community members and have the ability to integrate mpox vaccinations into routine clinical services for the community.

Mpox vaccination remains a key strategy to prevent infections with mpox. Engagement with community providers increased the proportion of vaccine administered to those disproportionally affected. A community-driven partnership with vaccine providers across public and private health care providers is needed to respond effectively and equitably to an outbreak.

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 17^th, to 7,022 doses administered during the week of July 24^th when the was portal went live.

On August 1^st, 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 14^th, 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 14^th; 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.

The role of LAC DPH in the mpox outbreak has been to coordinate across internal teams to support the various aspects of the response. The main teams have included the Acute Communicable Disease Control Program (case and contact confirmation, surveillance, and data reporting), Community Field Services (case and contact follow-up), Vaccine Preventable Disease Control Program (vaccination and vaccine data reporting), and the Division of HIV and STD Program (community partnerships, community advocacy, clinical consult for testing, vaccination, and treatment). Costs associated with the activities related to the County's mpox response are estimated at 5 million dollars. These funds have supported case and contact investigations, including isolation housing for cases; partnerships with community-based organizations and community clinics to support vaccine event planning, staffing outreach efforts, training, education, material development, and supplies; communication plans; mobile vaccine clinics in the community; surveillance, data management, reporting, and informatics.

With respect to vaccination, the role of the vaccine program was to establish and expand the mpox vaccine provider network to offer vaccine to residents who were at risk for mpox across; ensure that vaccine was ordered, received, and delivered to vaccine providers; communicate regular vaccine updates to providers and the public regarding vaccine availability, vaccine eligibility criteria, and vaccine administration trends; manage vaccine supply to ensure that providers were demonstrating progress in vaccination and eligible residents had access to vaccine; and manage the collection, processing, and reporting of vaccine administration data.

The vaccine program provided oversight on vaccine administration across the 124 vaccine provider sites. These sites consisted of public health vaccinating sites, including Points of dispending sites (PODS) which served as mass vaccination sites leading up to the peak of the outbreak and Public Health Centers; community clinic sites, pharmacy sites, hospital sites, and mobile vaccine sites. At the onset of the outbreak when community sites were slow to ramp up vaccine administration, the vaccine program was able to expand vaccine access through public health PODS and other public vaccinating sites, including pop-up vaccine sites at the epicenter of the outbreak and in underserved areas. Together, all vaccine providers worked hand in hand to help fill in gaps in vaccine access and administration.

Above all, the vaccine program relied on the trusted relationships that the Division of HIV and STD Programs (DHSP) had established with their HIV and STI provider network, namely HIV PrEP Centers of Excellence, STI Clinics, and Ryan White Providers, to quickly offer vaccine to their highest risk patients. In addition, routine informational events were essential to communicate vaccine availability and eligibility updates. These events ranged from weekly meetings with mpox vaccine providers, bi-weekly meetings with DHSP community stakeholders which included clinical providers and community members from the Latino/x, Black/African American, and Transgender communities, and in-person community events and townhalls to answer questions on the vaccine, address community concerns and misinformation.

From May 27, 2022, to December 18, 2022, a total of 116,071 doses of JYNNEOS vaccine were administered to at-risk residents in LA County. These doses represented 74,345 persons who had received at least 1 dose of JYNNEOS vaccine in Los Angeles County and 41,726 persons who were fully vaccinated with the 2-dose series. It is estimated that  approximately 50% of the at-risk population has been vaccinated with 1 dose of JYNNEOS and approximately 30% of this population is fully vaccinated. In the week ending December 18, 2022, there were 3 mpox cases in LA County, representing the lowest weekly count of mpox cases since the onset of the outbreak.

Among persons vaccinated with at least 1 dose of vaccine, 84% identified as male, 72% identified as gay, 9% identified as bisexual, 39% were White, 32% were Latino/x, 10% were Asian, and 9% were Black/African American. Nearly one-third lived in the least healthy neighborhoods, while 17% lived in the healthiest neighborhoods.

Overall vaccination rates improved with expanding vaccine eligibility, extending the vaccine provider network, and implementation of the online vaccine registration portal. However, rapid expansion of vaccine with higher demand than supply led to disproportionate access among some race/ethnicity groups and other vulnerable populations.

At the beginning of the outbreak, when LA County first expanded vaccine eligibility using Phase 1 vaccine, 65% of first doses administered were among individuals who identified as White, 16% were among Latino/x, and 4% were among Black/African Americans, reflecting wide disparities in vaccine equity across race/ethnicity. Vaccine utilization among Latino/x and Black/African Americans increased over time and by the week ending December 18, 2022, 37% of first doses administered were among Latino/x, 29% were among Whites, and 13% were among Black/African Americans.

When examining the breakdown of vaccine doses administered in LA County by the type of vaccine provider (i.e., public health sites, community clinics, pharmacy sites, and hospital sites), we found that community clinics administered a higher percentage of mpox vaccine to Black/African American and Latino/x residents compared with Public Health sites. This finding supports that community-based clinics do a much better job at communicating with and vaccinating the most vulnerable residents in LA County. They have trusted relationships with their clinic populations and serve as important ambassadors for impacted community members during public health emergencies. Although it may take time to fully integrate new public health interventions into routine clinical practice, they are key to sustaining community interventions in the long-term.  

Given their essential partnership with LAC DPH in responding to public health emergencies, it is important that community-based providers are supported through advocacy of community driven policies and investments when meeting with elected officials, sector-specific partners and other decision makers. This includes support for swift allocation of resources and funding for highly impacted groups already burdened by stigmatization and a history of government inaction; clear reimbursement pathways for testing, vaccination, and education conducted by community-based entities; competitive pricing of vaccines that help prevent diseases that can spread through close intimate contact for entities that primarily serve highly impacted groups including Federally Qualified Health Centers and the Ryan White Program; a comprehensive approach to health to best serve marginalized communities including promoting linkage to primary care and vaccination against HPV, meningitis, monkeypox, COVID-19, and flu; robust data collection infrastructure, requirements, and enforcement that facilitates timely and transparent public health surveillance and reporting; and continuous investments in community entities as essential partners in the public health implementation.

During the COVID-19 outbreak, due to difficulties with cold chain requirements, an already overburdened health delivery infrastructure, and a complicated tiered vaccine roll out strategy, LAC DPH became the largest vaccine provider in Los Angeles County and regular health care providers were slowly onboarded as vaccine providers over the period of months.  In contrast, with the mpox vaccine response, LAC DPH quickly created, expanded and maintained a robust vaccine provider network to distribute and administer mpox vaccines.  These providers were already trusted entities in their communities and could address disproportionality in vaccine administration by targeting those at highest risk.  Public health role consisted of delivering the vaccine to their sites, communicating updates regarding vaccine administration, vaccine eligibility and outbreak trends, and providing pop-up clinics at events and locations where there was not adequate vaccine access. Establishing relationships with a diverse vaccine provider network is key to the sustainability for vaccine administration during vaccine preventable disease outbreaks and other public health interventions. Local, State, and Federal entities much also continue to provide up-to-date and trustworthy communication that reduces stigma about risk, transmission, and prevention, as well as engage community leaders and providers as overall vaccine fatigue poses a challenge.

Public Health continues to work directly with community providers that serve highly impacted residents to inform the development and implementation of strategies to improve mpox-related outcomes in highly impacted groups of residents.