Nov 05, 2023

Chicago's mpox control strategy is tested as cases return before Pride

CHICAGO — The purple sandwich boards scattered throughout the historic hotel hosting the annual International Mr. Leather convention bore a stark warning: "MPOX ISN’T GONE."

Health officials and LGBTQ+ organizations treated the convention as an opening salvo in the race to stave off another outbreak of the virus that ripped through the gay community and infected more than 30,000 Americans last year. They sought to vaccinate attendees and raise awareness at the event, one of the first large gay gatherings to kick off a summer of Pride festivities and travel — and with it, sexual activity that drives mpox transmission.

Chicago has recorded 31 infections in the last five weeks, raising alarms because two-thirds of the cases were in fully vaccinated people. And the leather convention, drawing thousands to celebrate the sexual subculture over Memorial Day Weekend, risked further spread to travelers from around the world.

"Any inaction on our part would be catastrophic," said Antonio V. King, the LGBTQ+ health and outreach director for the Chicago Department of Public Health.

Public health officials are monitoring whether Chicago represents an isolated incident or marks the start of a second summer wave. The coming weeks will either reveal the resilience of their vaccine-centric campaign to bring last year's outbreak under control, or offer a humbling reminder that viruses are formidable and unpredictable foes.

How to protect yourself against a possible mpox resurgence

About a quarter of people considered at risk for contracting mpox are fully vaccinated, according to the Centers for Disease Control and Prevention, although the rates are far higher in major cities that saw the largest outbreaks. Health officials worry low immunity in some swaths of the country and people letting their guard down because they think mpox has vanished could spark a resurgence.

"No one at this point is resting on their laurels," said Demetre Daskalakis, who leads the White House response to mpox, formerly named monkeypox. "People are concerned what we are seeing in Chicago could happen in other places."

It's difficult to sustain public interest in health threats, especially when gay Americans faced three consecutive summers upended by covid and then mpox. The current national tally of mpox cases is small, with 81 people infected since April, a slight uptick following a winter decline. More cases could be going undetected because attention to mpox has waned and some infections manifest as inconspicuous bumps. Full protection from vaccines take six weeks to kick in, so health officials need to act before a spike.

On the front lines to prevent another wave, workers from Howard Brown Health manned a booth to tout vaccines at an entrance of the convention's leather market, between speedo-clad young men promoting an app for casual sex and vendors hawking mesh tank-tops.

Employees of Howard Brown, which serves Chicago's LGBTQ+ community, asked attendees who stopped by for free condoms and lube whether they were up to date on their mpox vaccine, a two-shot regimen. To their surprise, nearly everyone said they were. So many people asked whether they should get a booster shot that a supervisor posted laminated cards noting third doses are not recommended. One worker who spent ten minutes walking around the hotel to advertise a mobile vaccine clinic could not find a single unvaccinated person.

That offered hope for quashing another outbreak.

"There is this preconceived notion that most people that belong to this sort of community don't really take too much caution when it comes to sex," said Ivan Capifali-Cartagena, a bilingual outreach health educator at Howard Brown, after a full day of talking to people who stopped by his booth. "That camaraderie, looking out for one another, that in and of itself was pretty satisfying to me."

For many gay men, the trauma of last summer's mpox outbreak is seared into memory. It created chaos and fear in a season embraced as a time for gay joy. Men who contracted mpox were forced to quarantine for weeks, losing income and facing stigma and ridicule. Others put their sex lives on hold for fear of infection.

Experts credit the gay community for taking mpox seriously and playing a key role in nearly vanquishing the virus through behavioral change and vaccination last year. Now, convention attendees were alert to its return.

How the mpox outbreak revealed a path for quelling viruses

One man walking through the leather market mentioned the Chicago cases to a friend, fretting that even more were probably going undetected. Another told a health worker that he had seen a tweet from a fully-vaccinated porn star who contracted a mild case with a subtle lesion on his hand, questioning the official tally. "If there's one cockroach, there's 100 more," he said.

And many considered the risks of mpox before coming to the convention, where people feel liberated to wear leather harnesses, masks and full-body latex or rubber suits and have casual sex after-hours without judgment.

Ajmal Millar, a Chicago artist who partied with a leather club for men of color, posted on Facebook that mpox is back and people should get vaccinated and be careful who they choose as sex partners. He and other members of his club worried Black men would again bear the brunt of another outbreak with vaccines harder to access in majority Black neighborhoods and stigma dissuading discussion about the virus.

In Charlotte, a gay Black man's crusades to protect his community from mpox

Millar, 36, described the toll of mpox in his South Side community as something out of a horror movie: People developing marks on their faces, some unable to go to the bathroom without intense pain and friends disappearing for weeks on end without explanation. He received the first dose of his vaccine late last summer. As a Black man, he said he had misgivings about returning for a second dose as the mpox wave receded because he distrusted the medical establishment that has historically mistreated African Americans.

But the recent rise in Chicago cases swayed him to get a second dose and push his friends to take the virus seriously, too.

"Let's not allow these things to deplete us in a way that we just are just sitting ducks," Millar said, following a health discussion hosted by the leather club in its hotel suite. "Let's make sure we’re taking care of ourselves … and make sure we’re being that friend that is going to make those uncomfortable posts or have those uncomfortable conversations during dinner or cocktail hour."

Even with convention attendees largely vaccinated, there's still potential for spread. The vaccines do not guarantee protection.

Studies last year estimate that two doses of the Jynneos vaccine is 66 to 86 percent effective in preventing mpox, with lower protection after just one dose. They do not answer the crucial question of how long protection lasts. Health officials are examining data from Los Angeles and D.C. to assess whether immunity is waning and if booster shots are warranted.

Some attendees remain unvaccinated because they faced difficulty getting shots last year.

While shopping at the leather market, Daniel Williams, a 30-year-old adult performer, said he worries about contracting mpox. But he did not get vaccinated in his hometown of D.C. last summer because he wasn't getting out as much due to health issues and had heard about long lines to get shots. He knows cases are rising again and an infection could put him out of work.

Ultimately, he decided to record sex scenes during the convention with people he trusted and skipped sex parties, hoping he would not contract the virus.

"When you’re here and you see all these people having fun, the fear of missing out kicks in," Williams said, "and you kind of stop paying attention to it."

Inside America's mpox crisis - and the mistakes that made it worse

Despite breakthrough cases, Chicago's recent mpox uptick also offers hope that the vaccines are working as intended. No other community has reported a significant increase. The Chicago cases are mild with smaller lesions. Weekly new cases have stayed steady instead of increasing exponentially, suggesting the virus is hitting a wall and will not spark an explosion of cases.

"The absence of a sharp rise of cases that you typically see in an outbreak is reassuring. It suggests that there's some immunity or protection at the population level," said Jeffrey Klausner, an infectious-disease specialist at the Keck School of Medicine of University of Southern California who has researched mpox. "I don't expect that there's going to be anything like what we saw last summer."

The Centers for Disease Control and Prevention released models in May predicting that cities with large gay populations including D.C., New York City and San Francisco have enough immunity due to vaccination and past infection to drastically reduce the risk of resurgence. Other metropolitan areas face elevated risks for resurgence because of low levels of immunity, including Atlanta, Dallas and Houston.

After advertising free vaccines at a van parked outside the hotel and talking to hundreds of attendees, health workers vaccinated 37 people at International Mr. Leather. The shots would not confer full protection for sexual encounters during the weekend.

Many attendees had struggled to get shots in their hometowns.

Philip Rice figured the three-hour drive from his home in rural Michigan to the nearest vaccination site wasn't worth it last year because there weren't many cases in his region and he counted on the epidemic eventually ending. As he prepared for his annual trip to the leather convention, he searched "Is monkeypox over?" on Google to find news of cases climbing in Chicago. Then, he Googled vaccine sites near the convention and figured one shot would be better than none even if he can't get a second shot back home.

"I’m hoping that everybody gets vaccinated and that this kind of second wave that we’re worried about right now ends up being much smaller," said Rice, 34, after getting his shot.

Mpox response marred by inequitable access to protection

At his husband's prodding, Andy Tracy, 56, of Tulsa, went to get his vaccine after noticing signs about mpox posted around the hotel.

"Down in Oklahoma, they don't have signs like that. And it's very hard to get monkeypox vaccination," said Tracy, a nurse who said he couldn't find time to get a shot through public health agencies. "The red states are a lot less interested. To them, everything is like a liberal conspiracy."

As the second day of the convention came to an end, Howard Brown workers felt optimistic about the months ahead.

"Our community has a history of dealing with outbreaks," said Javier Chapa, outreach coordinator for Howard Brown. "Seeing everyone at the festival just being really informed and very adamant and enthusiastic about vaccinations just really gives me hope that we will continue to show up for each other."