Ring Vaccination Won’t Stop Monkeypox. Can Montreal?
The WHO may soon declare a global emergency. Montreal has abandoned ring vaccination. In the U.S., we’re counting on ring-vaxing and ‘trust.’ Data and history suggest neither will work.
[Update: on June 23, New York City followed Montreal’s example and began offering Jynneos vaccine to gay men who have had multiple or anonymous sex partners in the last 14 days.]
On Thursday, the World Health Organization will convene a panel of experts to decide whether to declare the epidemic a PHEIC: a “public health emergency of international concern.”
The disease is not spreading as fast as a respiratory virus like Covid can, but for a sexually transmitted pathogen, it’s a jackrabbit. It was only one month ago, on May 16, that Spain, Portugal and Britain had a mere handful of cases; now it’s an incipient pandemic.
But when public health officials realized that most victims were gay males, they got a case of the vapors. For fear of stigma, they began discussing the outbreak in cautious, oblique, academic ways, as in this recent article in the Annals of Internal Medicine by the C.D.C.’s top experts on MSM sex.
Actually, at the moment it looks as if only some limited subgroups of gay men are at the highest risk. If officials were more open about approaching those subgroups directly and more aggressive about vaccinating them immediately, they might be able to corral this epidemic before it’s out of control.
But that’s not what’s happening, except in Canada. [Update June 21: and now Britain. 2d Update June 23: And now New York City.] More below.
Epidemics usually start — or accelerate — by ricocheting through small networks. If you hope to stop one, you must identify the network, alert it, and aggressively fight the disease within it before that network intersects with others and the pathogen finds new pathways and accelerants.
For example: Measles has never been called a “Jewish disease,” but the 2018-2019 outbreak in Israel, England and New York was almost entirely within ultra-Orthodox neighborhoods. And not whole neighborhoods, just small pockets of vaccine resisters. The vast majority of Orthodox Jews do vaccinate their kids (as leading rabbis have for centuries demanded they do). Despite fears of stigma and anti-Semitism — some of which came true — health officials confronted the outbreak honestly and stopped it with vaccine, which required both polite persuasion and threats to shutter yeshivas and impose $1,000 fines.
Maybe a better example: There is no group that is less marginalized and better exemplifies white privilege than skiers, right? Well, guess what: skiers helped spread Covid. A timely crackdown on skiers might have saved some lives in our Mountain States. Last winter, Italy, France and Austria actually did crack down on skiers, telling them that, if they couldn’t prove they were vaccinated, they could stay out of the Alps.
It’s not personal. It’s public health.
Some officials — and the reporters quoting them — are still mouthing optimistic platitudes like: “We can still contain this.” “Contact tracing and ring vaccination will work.” “Above all, we must avoid stigma.”
I think they’re wrong on all three counts.
First, on stigma: Implying that all gay men are at risk is inaccurate.
Case reports and foreign media coverage suggests that almost all the early cases were within small subsets of gay men: the BDSM/leather/fetish/rough subset and the party-n-play/chemsex subset. Transmission leapfrogged from country to country because some men can afford to fly from events like the Darklands festival in Antwerp (motto: “Are You Ready to Go Deep?”) to the International Mr. Leather Conference in Chicago (where submissives competed to be “International Mr. Bootblack”). They go specifically to have sex with many other men. Behavior at those venues can be very high-risk: Men jam-packing dance floors wearing just jockstraps or harnesses. Pants with back zips for public sex. Fetishes like fisting, urine, puppy play and whips. Amphetamines to keep up the energy. Viagra to keep up the erections. And lots of alcohol.
Take a look at the detailed investigation by Britain’s Health Security Agency into the first 336 cases there. Of the men willing to answer questions about their sex habits, 44 percent reported more than 10 sex partners in the previous three months; the same amount reported group sex within the previous three weeks. That’s unusual behavior — except in tiny subsets of all gay men.
(Believe it or not, the phenomenon of one person having sex with many others is known to epidemiologists as a “heavy-tailed sexual network.” And these are the people we’re trusting to come up with new names?)
(And, while we’re at it, would a more accurate new name like “pouched rat-pox” really be an improvement over “monkeypox”? Whom does “chickenpox” stigmatize? Can we move on from this renaming fetish?)
Amphetamines, alcohol and testosterone all promote careless behavior. Historically, there has been a lot of STI transmission within these relatively small networks: H.I.V., oral and anal syphilis, drug-resistant gonorrhea, chlamydia, hepatitis and MRSA.
So why would anyone say that contact tracing will work?
Tracing hospital transmission is easy — you know who touched a patient. But in a dark sauna? A sweaty rave? At an orgy? Who gathers names, cell numbers and email addresses? And any contact-tracer will tell you that many men won’t cooperate. For the British investigation cited above, contact-tracers tried to interview 82 infected men; almost half refused to participate or had no information to offer.
When contact-tracing stumbles, ring vaccination fails. Ring vaccination will not work against monkeypox. It’s been the policy for a month now and the epidemic is expanding.
[Ring vaccination is vaccinating the “ring” of contacts around each known case of a disease. Mass vaccination is vaccinating everyone. What I’m describing is a middle path, sometimes called “targeted vaccination”: vaccinating everyone in the high-risk group. In this case, not all men who have sex with men — but men who have sex with multiple men, or even close bare-skin contact with multiple men.
[I hear from sources that the C.D.C. is debating doing this — but trying to decide whether the ACAM2000 vaccine is safe enough to use, because there isn’t enough Jynneos right now.]
I imagine the real reason experts don’t want to discuss subgroups is that they reinforce the stereotype that all gay sex is kinky and all gay men are sluts. It’s not and they’re not. Some heterosexuals (male and female) are sluts, almost all heterosexuals sometimes do stupid things like have sex while drunk. And if kissing turns out to transmit monkeypox, we’re in trouble. Even Stanford University has a century-old group-kissing tradition.
Heterosexuals are not in the network of monkeypox infection yet. But they’re not immune.
“In the 1980’s, we had H.I.V. outbreaks among ‘swingers,’ even here in Minnesota,” said Michael T. Osterholm, an expert on disease transmission who was for many years that state’s chief epidemiologist. He described whole hotels rented out by swingers clubs, with people running down for an STI test before switching rooms. “I’d never equate swingers with all heterosexuals, but you get these foci of transmission, and you have to address them.”
The important thing is neither to gawk nor to moralize, but to either stop the highest-risk behavior or offer the cure — as rapidly as possible.
This is a lesson we already learned with PrEP. Some doctors opposed it, saying men would stop using condoms and rates of syphilis and gonorrhea would go up. They were right — men did stop and the rates did go up. But those diseases are curable, and rates of H.I.V., which is not, plummeted.
We learned it before in the 1960’s, with The Pill. Some doctors opposed it, saying women would have more premarital sex and get more venereal diseases. Yes, women had more sex and got more diseases. But we didn’t withdraw The Pill. It was a vaccine against a bigger problem: unwanted pregnancies. We even no longer stigmatize women who use it as sluts. Times change.
The “mildness” of this strain made it more transmissible. It has a short prodrome (the fever/aches/swollen-gland stage that resembles a cold), then often mouth sores, then a few pox that resemble acne, then more pox but not always in obvious places like the face and hands. Therefore, it’s easy to not realize you have it — and relatively easy to conceal if you do. That’s a dangerous mix. And it’s looking as if transmission can occur for many days before a case is caught.
So, as Dr. Jay Varma of Cornell observed a week ago, by the time most men get diagnosed “it’s a bit too late to vaccinate your contacts and even your contacts of contacts.”
Thus far, no one outside of Africa has died. But some victims have found it painful and disfiguring and some are sick enough to be hospitalized. As the virus spreads away from its current victims — mostly healthy young men — outcomes might get worse.
As the authors of the AIM piece point out, MRSA —sometimes a “flesh-eating bacteria” — moved from a gay subgroup to wider gay male circles and then to prisoners and then athletes. Why did it stop there? Maybe fewer drug users but no one is sure. There’s no guarantee where this outbreak will stop.
The best hope for monkeypox to die out by itself in a heterosexual population is that most women are, in epi-speak, less “heavy-tailed” than men (i.e., smarter about anonymous sex). But that’s hardly a foolproof firewall. There are already examples of monkeypox infecting women: the wife and baby of a Nigerian man in Liverpool, a nurse in Newcastle, a sex worker in Mexico, one percent of the current British cases.
If left unchecked, the virus might wend its way through various sub-groups and hit the networks that HSV-2, mononucleosis and meningitis B transmit readily through — young, sexually active people including high school and college students. Will it ultimately be as rare in them as syphilis or as common as herpes? We can’t know yet.
Yes, stigma is bad. But epidemics are worse. And, frankly, you can’t prevent stigma with pious tut-tutting or official name changes. Bigots will be bigots. You can call it SARS-CoV-2 instead of “a new coronavirus in Wuhan,” but bigots will still call it “the China virus,” leading to attacks on Asian women in NYC. Stopping epidemics is more important than greenwashing them. If Wuhan had not held its brief initial coverup, if it had moved faster just a week earlier than it did, it might have quenched its small seafood-market-focused outbreak. There would have been no pandemic — and no anti-Asian violence here.
Montreal — Canada’s epicenter — is trying to move fast. It abandoned ring vaccination a week ago and is offering vaccine to any gay man who has had two or more recent casual sex partners, or plans to during Pride, or who sells sex or who works at GBTQ events where sex takes place. Men who already have symptoms aren’t even eligible; for them it’s too late for vaccine to do any good.
Quebec alone has ordered 40,000 doses.
Luckily for Montreal, its Pride events aren’t till early August. Pride Vancouver and Pride Ottawa are also late summer.
But Pride Toronto is on now. It may become the next epicenter. (Just this past Saturday, Toronto adopted Montreal’s targeted-vaccination policy.)
[2d Update: as of Thursday June 23, New York City followed Canada’s too. It offered vaccine — at the Chelsea Clinic only — to gay men who had sex with multiple partners or anonymous partners in the last 14 days.]
New York Pride will crest with next Sunday’s parade but events are already in full swing.
So what is New York City — home to what is arguably the world’s biggest Pride celebration — doing to prevent super-spreading?
According to The New York Times, there are educational messages on the gay dating app Grindr and on NYC Pride’s Instagram account. A sex-party organizer will “ask invitees to check themselves for lesions” before coming.
Will any of that work?
History says no.
H.I.V. was “discovered” in 1981; by 1983, it was clear it was a virus and condoms blocked it. From 1983 to 1996, with no cure and no vaccine, official U.S. policy (to the extent that there was any) was based on education and trust. Men were advised to “know their status” and trusted to tell the truth and use condoms. There was an unofficial “100%” campaign — if 100 percent of men used condoms 100 percent of the time, the epidemic would stop dead.
Here’s how that worked:
Since the infection-to-death interval is 10 years or less, if “trust” had worked, that death line would have started dropping by the late 1980’s. Instead, it kept climbing until 1996, when antiretroviral triple therapy was introduced. (Triple therapy prevented both death and transmission by lowering viral loads.)
Studies and interviews during that era showed that many men avoided learning their status. Many admitting lying about being infected before engaging in bareback sex. Men don’t like condoms, and horny men — straight or gay — will say anything to not ruin the big moment.
And many kept engaging in multi-partner drug-fueled sex in full knowledge that it might kill them. Assuming that people are always altruistic — or even sensible — is a losing public health policy.
Super-spreading events might be avoided if all sex-party organizers like the one cited by the Times were to say: “You will be checked for lesions before you enter.”
Does that seem outrageous? Absurd?
Yes, it would be intrusive, but it is part of how the porn film industry kept its sets mostly STI-free for years, even though the actors didn’t use condoms. Every actor had to be tested for H.I.V., syphilis, gonorrhea and chlamydia every two weeks by an industry-run lab. Then, before each day’s shooting, they had to take down their pants and let a producer check their genitals, mouths and hands for sores.
Do I think party organizers will have bouncers with flashlights doing that? Unfortunately, not likely.
Do I think they will play it safe and cancel the parties? Again, not likely; $50 entry fees plus bar alcohol means they will make a lot of money.
(On the other hand, the city health department could ban such parties and compensate the sponsors. This is a grotesque analogy, but when government veterinary health authorities order farmers to cull their herds to stop outbreaks, they compensate them for the lost income.)
If the private sector were to be unleashed, there could soon be a rapid test, which might be a game-changer. Maybe one will arrive by late July for Up Your Alley, or late September for the Folsom Street Fair.
Suppose we did try to follow Montreal’s example and vaccinate all high-risk men. Would there be enough vaccine?
Enough ACAM2000, certainly. The Strategic National Stockpile is said to contain 100 million doses. It would be necessary to test men for HIV and screen them for eczema and immune-suppression. But, with some effort, that’s absolutely doable. It would be a lot less effort and money than dealing with an outbreak of many thousands of cases in a few months.
Enough of the much safer Jynneos vaccine? Alas, not immediately. The 72,000 doses now on hand will go fast just to protect health care workers in STI clinics, for futile attempts at ring vaccination, and so on. Up to 1 million doses are stockpiled but not yet all ready to inject.
So right now, I fear this could be contained, but won’t be — unless the vaccination net gets bigger.
I’d love to be proved wrong.