On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox (MPX) outbreak to be a public health emergency. The Centers for Disease Control and Prevention (CDC) released data on national-level MPX cases reported in the U.S through July 22, including demographic information where available. These data show that, in addition to nearly all MPX cases reported being among men (99%) reporting recent male-to-male sexual or close intimate contact (94%), there are also racial and ethnic disparities, with Black and Hispanic people bearing a disproportionate burden of cases to date. While the national data by race/ethnicity have not been updated since the CDC release, a small number of states, as well as some local jurisdictions, are reporting race/ethnicity data on MPX cases and vaccinations and these data show a similar disproportionate impact. Moreover, the very limited data available to date on vaccinations also suggest that Black and Hispanic people are receiving smaller shares of vaccinations despite accounting for larger shares of cases.
National Data on MPX Cases by Race/Ethnicity
Data from 43 states, DC, and Puerto Rico show that Black people made up 26% of MPX cases compared to 12% of the population, and Hispanic people accounted for 28% of cases versus 19% of the population. Data were not separately reported for American Indian and Alaska Native (AIAN) or Native Hawaiian or Other Pacific Islander (NHOPI) people. CDC notes that areas with high numbers of cases that did not submit case reports are more racially and ethnically diverse. As such, the reported data may understate disparities. Moreover, the share of cases among Black people has risen in recent weeks, suggesting widening disparities for this group.
To date, race and ethnicity data are missing for the majority of MPX cases at the federal level. CDC reports a total of 2,891 cases through July 22 in the 43 reporting states and DC and Puerto Rico. Case reports with at least some demographic data were available for 1,195 or 41% of these cases, but only 1,095 or 38% of cases had race/ethnicity reported. Cases have continued to climb since the report, with CDC reporting over 14,000 cases as of August 18, 2022.
State and Local Data on MPX Cases and Vaccinations by Race/ Ethnicity
Similar to national data, the limited state data available to date suggest Black and Hispanic people are accounting for disproportionate shares of MPX cases. As of August 22nd, 2022, nine states (California, Colorado, Georgia, Louisiana, New Jersey, New York, North Carolina, Oregon, and Tennessee), and Washington D.C are reporting MPX cases by race/ethnicity. While these states report race/ethnicity of MPX cases and vaccines, they vary in their racial/ethnic categorizations, making it challenging to compare data across jurisdictions. Still, these data raise early concerns about disparities for Black and Hispanic people. The proportion of MPX cases among Black and Hispanic people is higher than their share of the total population in most reporting states (Table1). For example, in Georgia, Black people account for over 80% of cases but less than a third of the population, and in Oregon, Hispanic people account for 28% of cases versus 13% of the population. White people account for a smaller share of cases than their share of the population in most of the states reporting data. Asian people make up a smaller share of cases than their share of the total population in all reporting states.
Four states (Colorado, Georgia, New Jersey, and North Carolina) and Washington D.C. are reporting MPX vaccination data by race and/or ethnicity, which show that Black people are receiving smaller shares of vaccinations compared to their share of cases. For example, in DC, Black people have received 22% vaccines, while they account for 36% of cases. In contrast, White people have received 63% of vaccinations but account for 42% of cases. In Georgia, Black people have received less than half of vaccinations, while they make up 80% of cases. Conversely, White people have received 44% of vaccinations and make up 14% of cases. And, in North Carolina, a quarter (25%) of vaccinations have gone to Black people although they account for nearly three-quarters of cases (73%), while over two-thirds (69%) of vaccinations have been received by White people who account for 20% of cases. Data are mixed for Hispanic people with them receiving a smaller share of vaccinations compared to their share of cases in Colorado (11% of vaccinations vs. 37% of cases) and New Jersey (25% of vaccinations vs. 40% of cases), but a similar or higher share in Georgia (8% of both vaccinations and cases) and North Carolina (8% of vaccinations vs. 4% of cases).
While this analysis did not include a comprehensive assessment of data being reported at the local level, we did assess data from five cities (Chicago, Houston, Los Angeles, New York City, and Philadelphia) for which the federal government is providing direct MPX vaccine allotments. All five of these cities, except Houston, were reporting MPX cases data by race and/or ethnicity, with Philadelphia and New York City also reporting MPX vaccination data by race/ethnicity as of August 19, 2022 (Table 2). Similar to the state data, for cities reporting both MPX vaccination and cases data, Black people are receiving a smaller share of vaccinations compared to their shares of cases while White people are receiving similar to, or higher shares of vaccinations compared to their share of cases. The city data also show Hispanic people receiving a lower share of vaccinations compared to their share of cases. For example, New York City reports that Black and Hispanic people account for 29% and 34% of MPX cases, respectively, while they have received 12%, and 23% of vaccines. Conversely, White people in New York City account for 32% of MPX cases yet make up nearly half (46%) of MPX vaccine recipients. Similarly, in Philadelphia, Black people make up more than half of MPX cases (57%), yet only account for 23% of MPX vaccine recipients and Hispanic people make up 15% of cases but represent 12% of vaccine recipients. In contrast, White people account for 28% of MPX cases and make up 57% of vaccine recipients.
Overall, it remains challenging to draw strong conclusions about racial equity in MPX cases and vaccinations due to the dearth of comprehensive data, inconsistency in reporting, and the lack of disaggregated data for smaller racial/ethnic groups, particularly NHOPI people. As the COVID-19 pandemic highlighted, having comprehensive data disaggregated by race/ethnicity is fundamental for identifying and addressing disparities.
Although limited, these early data indicate significant and potential growing racial and ethnic disparities in MPX cases and vaccination uptake, highlighting the importance of centering intersectional equity in MPX response efforts, including prevention, testing, and treatment, from the outset. Moreover, addressing challenges that include homophobia, stigma, and discrimination will be key given the disproportionate impacts among men who have sex with other men. Underlying structural inequities place people of color at increased risk for public health threats, as was seen in COVID-19 and as is beginning to be observed amid the MPX outbreak. Early and intentional efforts will be key to minimizing and preventing disparities going forward amid the MPX outbreak and for future public health threats.