State Action on Monkeypox: A Q&A with North Carolina’s Susan Kansagra

State Health Policy Leadership Health Equity

More than 22,000 cases of monkeypox have now been reported across the United States. Last month, the US Department of Health and Human Services declared monkeypox a public health emergency, mobilizing new resources for states. The announcement followed emergency declarations by New York, Illinois, and California.

Monkeypox is caused by infection with a virus in the same family as smallpox, but it causes milder symptoms and is usually not fatal. The virus is less transmissible than COVID—it is spread through intimate contact—and can be managed by existing vaccines. Yet the rapid spread of the disease in the US this summer, particularly among men who have sex with men, placed new demands on state and local health departments. Supplies of Jynneos, the only FDA-approved vaccine for monkeypox, continue to be limited.

Susan Kansagra, MD, North Carolina’s State Health Officer and Director of the North Carolina Division of Public Health, spoke with the Milbank Memorial Fund about North Carolina’s coordinated monkeypox public health response and her advice for state officials.

How is North Carolina’s Division of Public Health mitigating the spread of monkeypox?

In North Carolina, nearly all cases are in men who have sex with men (MSM), and 70% of those cases have been in Black men. A part of our monkeypox response strategy is to be transparent about the demographics in our cases, so that we can focus on populations at the highest risk. That’s why we published the nation’s first equity report in August, highlighting this disparity and creating collective accountability for closing those disparities. This equity data has centered our communication and outreach efforts for the impacted communities, particularly the Black MSM community. We’ve been working closely with community organizations serving Black MSM and the LGBTQ+ community, HIV providers, local health departments, and others to make testing and vaccines as easy as possible to access.

For testing, we’ve been educating the public on the signs and symptoms of monkeypox and encouraging anyone with clinically consistent symptoms to get tested. We’ve held town halls with LGBTQ+ organizations and webinars for providers and have also placed paid social media ads on dating apps and other websites. We’re also sharing this information with community health workers and community-based organizations, who are, in turn, reaching many others. We’ve been fortunate that there has been plenty of testing capacity from the beginning.

We’re also working on making sure vaccines reach the highest-risk populations. In North Carolina, a quarter of vaccines go to Black individuals, while nearly 70% of cases are in Black MSM. Nationally, only 10% of vaccines are going to Black individuals. Our vaccine equity efforts build off our work with COVID, where we collaborated with trusted messengers to share information and ensure vaccine locations were accessible. We launched Healthier Together, a public-private partnership of community-based organizations that helped conduct outreach and connect people to wraparound resources to get vaccinated for COVID, and we are now working on monkeypox [vaccination] as well. In addition, our local health departments are working on the ground to provide vaccinations at events and venues that reach Black MSM.

States and cities such as California and New York City have declared a ‘state of emergency’ as they do not have an adequate supply of vaccines, testing resources, and access to treatment. Do you anticipate that North Carolina will do something similar? What would be the threshold for such an action?

We declared a North Carolina state of emergency for COVID that recently ended. At this moment, we do not see the need to declare such an emergency for monkeypox because we have implemented a lot of the infrastructure needed to respond.

There has been some flexibility for federal COVID funds to be used for monkeypox. Our greatest need is funding to support vaccinators. In the fall, there will be a higher demand for COVID boosters in addition to monkeypox vaccines. We need funding to support additional vaccinators across our state, and Federal Emergency Management Administration (FEMA) reimbursement for monkeypox response would help meet this need.

Students are already heading back to school. Are there resources or guidance for colleges, universities, and K-12 schools regarding monkeypox prevention/mitigation?

We work closely with our K-12 and higher education partners in North Carolina. It’s important to remember that monkeypox is more complicated to spread than COVID, so the overall risk in a K-12 school setting is low. Monkeypox transmission spreads with close, skin-to-skin contact, which could be sexual or non-sexual, and is different from COVID. The Centers for Disease Control and Prevention has provided guidance for schools and institutions of higher education that we have been sharing. We have focused on ensuring the school community knows how to access testing. We have also been working with health centers at colleges and universities, including historically black colleges and universities, to enroll as vaccine providers.

What can state and county leaders do to learn from, engage with, and communicate with people currently at high risk (e.g., gay, bisexual, and men who have sex with men), with the specific intent of avoiding stigma, discrimination, and failures of the past?

One of the best communication methods is to involve trusted partners and messengers from the community. Here in NC, we have been hosting town halls with LGBTQ+ organizations, placing social media ads on dating sites that reach MSM, and ensuring vaccines are available at events and venues MSM attend. For example, in Charlotte, home to the epicenter of North Carolina’s monkeypox virus, we worked closely with the local health department, which sent vaccinators to events for black MSM and worked with Pride organizers to make vaccines accessible.

In Washington, DC, and New York City, monkeypox vaccination appointments were being scheduled through an online portal, resulting in a disproportionate number of vaccines being distributed to people of higher socio-economic status. How can state and local public health clinics work to prioritize underserved individuals?

Offering vaccines efficiently and equitably for high-priority populations without increasing stigma has been particularly challenging given the eligibility criteria initially required individuals to identify as MSM with multiple or anonymous sexual partners. Ensuring the process of getting vaccinated is as easy as possible and protects privacy is of the utmost importance. It may be more comfortable for some people to get the vaccination as part of routine care, and in the same way as they would for any other health problem, so no one knows why they’re in the waiting room. Other individuals may feel more comfortable attending an event geared solely for monkeypox vaccination. We encouraged providers to offer as many options as possible for individuals to get vaccinated, including online and phone scheduling, routine clinical appointments, and special vaccine events. We also urged providers to avoid asking a list of eligibility questions and ask, “considering all of the criteria, are you eligible?” We wanted our monkeypox approach to respect privacy and prevent further stigma.

What does the spread of monkeypox say about the state of public health in the US?

The monkeypox response reminds us yet again about the need for critical public health infrastructure investments across the country. Every person in America should be served by a public health infrastructure supported at the federal, state, and local levels. For decades, we have not, as a country, invested in this public health infrastructure, and that makes us vulnerable to current and future public health threats. We saw that with COVID, and indeed there was a lot of funding poured out for COVID, but now it’s not as easy to translate that into the monkeypox response. As a country, we need investment in foundational public health capabilities, including communication, community partnership development, data gathering, and preparedness capabilities. I hope this is another opportunity to remind our national policymakers of the importance of having a public health infrastructure across the country and investing, particularly, in the workforce. Across the country, over 40,000 jobs were lost in public health in the past decade.

What words of encouragement do you have for state and county officials working tirelessly to curb the spread of Monkeypox?

It has been a challenging few years, and as we go into this response, much of what came up during COVID is coming back. Taking time to appreciate our gains, the resiliency of our workforce, and ensuring we care for each other is essential. We’ve tried to ensure that folks get time off, that no one “worries alone,” and we keep a long-term perspective in managing the response. You can only take care of others if you take care of yourself too.

I thank all the other folks across the country who are in the same boat, working as hard as we are. I’ve never been prouder of our public health community.