Data Lead Equity Approach to Containing the Spread of Mpox

Dallas County Health and Human Services (DCHHS) serves as the Local Health Department for a diverse population of over 2.6 million people. DCHHS reported the first case of Mpox in Texas on June 6^, 2022. Throughout the Mpox epidemic, Dallas County reported the highest number of Mpox cases in Texas accounting for nearly 30% of all Mpox cases in the state.

DCHHS leveraged technology systems developed during COVID to rapidly respond to the Mpox outbreak. DCHHS quickly expanded our Salesforce Platform to include Mpox response activities. DCHHS can now receive electronic reports of Mpox positive cases from the DCHHS Lab, the Texas Department of State Health Services (DSHS), and commercial labs. DCHHS also updated the Salesforce Platform to monitor close contacts by sending an automated daily text message to contacts for 21 days with a survey to help them monitor and report symptoms.

DCHHS used data to target messaging and education to communities at the highest risk of becoming infected with Mpox and utilized partnerships developed during COVID to expand the reach of our messaging. DCHHS successfully used geographic hot-spot maps of COVID cases to target COVID outreach and vaccination clinics to high-risk communities.

DCHHS leveraged community partnerships developed during COVID to quickly distribute the JYNNEOS vaccine to eligible populations. During COVID, DCHHS purchased the Luminare Vaccine Administration software to coordinate large scale vaccination operations. DCHHS worked with Luminare to update our system to include the JYNNEOS vaccine, allowing DCHHS to stand up a high-volume drive thru vaccination site in ten days.

DCHHS leveraged our community partners to quickly distribute the JYNNEOS vaccine to over a dozen community providers, focusing on providers who primarily serve the target population. For example, DCHHS worked with our Ryan White Division and our Ending the HIV Epidemic teams to coordinate with providers who serve people living with HIV. These community partners were able to administer over 14,200 doses of the JYNNEOS vaccine to eligible populations.

Dallas County Health and Human Services (DCHHS) serves as the Local Health Department for a diverse population of over 2.6 million people. The target population for the Mpox response equity strategies included the racial and ethnic groups who experienced higher rates of disease throughout the COVID-19 epidemic. As of January 4, 2023, Dallas County reported 853 cases of Mpox, which accounts for nearly 30% of all Texas Mpox cases (2,882 Mpox cases identified in Texas according to the CDC to date). The CDC identifies gay, bisexual, and other men who have sex with men as the populations at the highest risk of Mpox infection. Black and Hispanic residents accounted for 60% of Mpox cases in Dallas County, and 70% of cases were identified in people under 40 years old.  

Accordingly, DCHHS identified the following target populations for Mpox response efforts:

• Men (cisgender and transgender) and transwomen 18 and older who have sex with men who have multiple or anonymous sex partners or who routinely meet partners through an online website, digital application ("app"), or social event, such as a bar or party.
• Persons 18 years of age or older who were diagnosed with HIV, chlamydia, gonorrhea or early syphilis within the past 12 months or are on HIV pre-exposure prophylaxis (PrEP).

Root causes that existed to challenge Mpox response activities included mistrust in government due to initial poor response to the AIDs epidemic in the 1980s, stigmatization of the LGBTQ community, and transportation barriers and related issues for accessing care. DCHHS utilized existing community relationships established through our Ryan White Division and EHE Division, as well as the new community partnerships established by our Community Outreach Team and Immunizations Division during COVID, to engage community champions and partners in the shared objective to reduce disease and improve quality of life within the population groups and neighborhoods.

DCHHS reported the first case of Mpox in Texas on June 6^, 2022. At the onset of the outbreak, the DCHHS Communicable Disease and Epidemiology division implemented enhanced surveillance measures to identify cases of Mpox in Dallas County quickly. These measures include providing education and outreach to clinicians, evaluating persons with suspicion of Mpox and providing guidance, monitoring contacts of confirmed cases for symptom development, and referring exposed peresons to testing and vaccination resources.

DCHHS leveraged the case investigation tools developed during COVID to get rapid, real-time electronic lab and hospital case reports. Using COVID funding, DCHHS developed our Salesforce Platform to create a master data engine that is the central point for the automatic ingestion of COVID lab, hospital, vaccination, and other data. The system allows for the automated deduplication, matching and merging of case information to create a golden case record,” eliminating the manual integration processes and improving data quality and timeliness.

At the onset of the Mpox outbreak, DCHHS quickly expanded our Salesforce Platform to include Mpox response activities. DCHHS can now receive electronic reports of Mpox positive cases from the DCHHS Lab, the Texas Department of State Health Services (DSHS), and commercial labs. DCHHS also updated the Salesforce Platform to monitor close contacts by sending an automated daily text message to contacts for 21 days with a survey to help them monitor and report symptoms.

DCHHS used data to target messaging and education to communities at the highest risk of becoming infected with Mpox and utilized partnerships developed during COVID to expand the reach of our messaging. DCHHS successfully used geographic hot-spot maps of COVID cases to target COVID outreach and vaccination clinics to high-risk communities. DCHHS followed this practice in our Mpox response by developing geographic hot-spot maps of Mpox cases to target Mpox outreach and vaccination clinics to high-risk communities. Using these maps, DCHHS identified the Oak Lawn neighborhood in the City of Dallas as the area with the highest infection rate and sent our Community Outreach Team to educate local businesses and community-based organizations in the area, hanging flyers with education materials, mitigation best practices and contact information for Mpox testing and vaccination resources. During this time, the Community Outreach Team developed partnerships with local businesses enabling DCHHS to host community vaccination clinics in the Oak Lawn neighborhood at local LGBTQ bars as vaccine became more readily available.

DCHHS also used this data to monitor the trends in new cases and update response activities accordingly. For example, early case data trends showed that Mpox cases in Dallas County were occurring in younger men who have sex with men (MSM), so DCHHS worked with our media company to target media efforts towards men who have sex with men aged 15-45. DCHHS and our media campaign utilized focus groups made up pf people within the target population to develop the concepts and creatives for our website and media campaign. Based on these focus groups, we developed a website with vibrant colors and messaging that stood out to younger MSM populations, located here: Monkeypox (MPV) (mpvdallascounty.com). Additionally, DCHHS and our media company leveraged existing partnerships and best practices developed with our Ending the HIV Epidemic media campaign to ensure our communication campaigns were reaching the target population. For instance, DCHHS had our media company place educational ads on dating sites used predominately by men who have sex with men.

Finally, DCHHS leveraged community partnerships developed during COVID to quickly distribute the JYNNEOS vaccine to eligible populations. During COVID, DCHHS purchased the Luminare Vaccine Administration software to coordinate large scale vaccination operations. DCHHS worked with Luminare to update our system to include the JYNNEOS vaccine, allowing DCHHS to stand up a high-volume drive thru vaccination site in ten days. The Luminare system was used to schedule appointments sending a text and email to people on the waitlist with a link for them to schedule their appointment. DCHHS is sent out appointment invitations in batches several times a day, as needed, to ensure all appointment slots were filled for each day. The Luminare system was also used to register people on-site when they arrived for their appointment, fill out all required documentation, automatically send the information to the Texas Immunization Registry, and send out reminders for second doses.

DCHHS leveraged our community partners to quickly distribute the JYNNEOS vaccine to over a dozen community providers, focusing on providers who primarily serve the target population. For example, DCHHS worked with our Ryan White Division and our Ending the HIV Epidemic teams to coordinate with providers who serve people living with HIV. Some of the community partners we worked with to distribute the JYNNEOS vaccine include Prism Health, Abounding Prosperity, Aids Healthcare Foundation, and the Center for Health Empowerment. These community partners were able to administer over 14,200 doses of the JYNNEOS vaccine to eligible populations.

DCHHS' response efforts to Mpox are evidence-based, applying guidelines and strategies created for COVID-19 including:

1. The Community Guide: Vaccination Programs: Community-based Interventions Implemented in Combination.  The Community Preventive Services Task Force (CPSTF) recommends using a combination of community-based interventions to increase vaccination rates in targeted populations. Interventions may aim to increase community demand, enhance access to vaccination services, or reduce missed opportunities by vaccination providers.” Source: https://www.thecommunityguide.org/findings/vaccination-programs-community-based-interventions-implemented-combination
2. CDC: Ways Health Departments Can Help Increase COVID-19 Vaccinations. Discusses strategies and resources for LHDs to generate demand for vaccination, building trust, addressing misinformation, and tailoring messages. Explicitly discusses reaching people where they live, work, learn, pray, play, and gather. Source: https://www.cdc.gov/vaccines/covid-19/health-departments/generate-vaccinations

The goal of our Mpox response activities was to contain the spread of Mpox disease in high risk communities through access to education, testing, and vaccination. The objectives include:

1) Promote protective/mitigation behaviors in targeted communities

2) Promote awareness of testing and vaccination resources to high-risk populations

3) Reduce barriers to vaccination for eligible populations

To achieve these objectives, DCHHS used data to target messaging and education to communities at the highest risk of becoming infected with Mpox and utilize partnerships developed during COVID-19 to expand the reach of our messaging. DCHHS successfully used geographic hot-spot maps of COVID-19 cases to target COVID-19 outreach and vaccination clinics to high-risk communities. DCHHS followed this practice in our Mpox response by developing geographic hot-spot maps of Mpox cases to target Mpox outreach and vaccination clinics to high-risk communities. Using these maps, DCHHS identified the Oak Lawn neighborhood in the City of Dallas as the area with the highest infection rate and sent our Community Outreach Team to educate local businesses and community-based organizations in the area, hanging flyers with education materials, mitigation best practices and contact information for Mpox testing and vaccination resources.

During this time, the Community Outreach Team developed partnerships with local businesses enabling DCHHS to host community vaccination clinics in the Oak Lawn neighborhood at local LGBTQ bars as vaccine became more readily available. For instance, the Community Outreach Team developed a relationship with the owner of a popular LGBTQ bar named Station 4 while canvasing the Oak Lawn neighborhood. DCHHS in partnership with Nomi Health hosted 4 community vaccination clinics at Station 4, vaccinating our maximum limit of 200 people per clinic. The success of these clinics was due to Station 4 promoting the vaccination clinic via email to their client listserv and the pre-established trust that the owner of Station 4 has with members of the LGBTQ community.  

DCHHS also leveraged our community partners to quickly distribute the JYNNEOS vaccine to over a dozen community providers, focusing on providers who primarily serve the target population. For example, DCHHS worked with our Ryan White Division and our Ending the HIV Epidemic teams to coordinate with providers who serve people living with HIV. Some of the community partners we worked with to distribute the JYNNEOS vaccine include Prism Health, Abounding Prosperity, Aids Healthcare Foundation, and the Center for Health Empowerment. These community partners were able to administer over 14,200 doses of the JYNNEOS vaccine to eligible populations.

Additional steps taken to ensure equitable, meaningful and representative collaboration included regular communications and conversations with target populations. These conversations occurred in LGBTQ businesses, community-based organizations serving the LGBTQ community, and in community zoom meetings organized by local elected officials and community based social service organizations. The feedback received from residents informed the development of communication tools and messages.

Mpox response activities began in early June when the first case was reported in Dallas County. Press releases announcing the case along with educational flyers were sent to the media, providers, community partners, and DCHHS divisions who work closely with the target population for further distribution. During the initial response the focus was on the rapid dissemination of information related to mitigation measures and testing resources. Over the next 6 weeks as cases increased and vaccine became available, the focus shifted to providing information on vaccine eligibility and resources to high-risk communities.

Containment of the spread of Mpox has been successful in Dallas County. Over the last 14 days (December 22, 2022 to January 5, 2023), DCHHS has reported no new cases of Mpox infection. This success was possible due to the education, outreach, and rapid vaccination of high-risk populations. Reducing barriers to vaccination was possible through establishing vaccine clinics with trusted partners, reducing location barriers by hosting community clinics, and offering vaccine during evening hours and on weekends.

Primary Data: Vaccination data was obtained from the Texas Immunization Registry and weekly vaccination reports submitted by community providers to the DCHHS Immunizations Division.

From July 2022 to December 2022, community partners administered over 14,200 doses of the JYNNEOS vaccine to eligible populations while DCHHS administered over 3,000 doses. Contributing to these numbers were 15 locations, including 12 permanent vaccination sites and 3 community pop-up clinic sites. DCHHS implemented a bi-lingual call center to make appointments for people at multiple sites.

Mpox case investigations and case counts were initiated from lab reports received from state electronic lab reporting, local LRN results, and electronic case reports from hospital systems.

DCHHS and our media campaign utilized focus groups made up pf people within the target population to develop the concepts and creatives for our website and media campaign. To evaluate our media campaign, DCHHS staff met weekly with our media company to review the KPIs for the media campaign including people reached and the number of clicks on the vaccination appointment scheduler.  

DCHHS leveraged the lessons learned during the COVID-19 pandemic to rapidly respond to the Mpox epidemic. The approach used to contain the spread of Mpox in Dallas County will be used as a model for future public health emergencies, as well as to improve routine public health activities. For example, DCHHS has already developed and implemented a Salesforce module for Ebola in less than two weeks as a proof of concept to demonstrate how Salesforce can be rapidly stood up in response to emerging public health issues.

DCHHS is also working with the State Health Department (DSHS) on direct electronic case reporting from the Salesforce system to the National Electronic Disease Surveillance System (NEDSS).  DCHHS has been making good progress working with Tarrant County Health Department, Houston Health Department, and DSHS on standardized data collection, which will be used to convert from paper to full electronic reporting. DCHHS is also almost complete with the mapping of an additional 80 reportable conditions and is currently working on Salesforce integration.

Additionally, DCHHS has learned that strong relationships with community partners are necessary to successfully respond to any future public health emergency. Utilizing community partners and private vendors gave us the ability to increase our vaccine response efforts and build trusting community relationships simultaneously. These partnerships also allowed us to expand our vaccine response while still working on our normal health department practices.