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caption: A health professional prepares a dose of a Monkeypox vaccine at the Edison municipal vaccination centre in Paris Wednesday July 27, 2022. Public health officials warn that moves by rich countries to buy large quantities of monkeypox vaccine, while declining to share doses with Africa, could leave millions of people unprotected against a more dangerous version of the disease and risk continued spillovers of the virus into humans.
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A health professional prepares a dose of a Monkeypox vaccine at the Edison municipal vaccination centre in Paris Wednesday July 27, 2022. Public health officials warn that moves by rich countries to buy large quantities of monkeypox vaccine, while declining to share doses with Africa, could leave millions of people unprotected against a more dangerous version of the disease and risk continued spillovers of the virus into humans.
Credit: Alain Jocard, Pool via AP

'Another kind of homophobia:' Critics say King County's monkeypox vaccine criteria are intrusive

On Friday morning, Oscar and Darrick were among the first early-birds waiting in line outside King County’s sexual health clinic at Harborview to try to get the monkeypox vaccine.

“People around us are getting sick,” Oscar said. “We are hearing that friends of friends or ‘Hey, yeah, my friend just got the monkeypox.’ So when it starts hitting close to home, you kind of want to get the vaccine.”

“It’s gross-looking; I hear they’re very painful; they hurt; they can get infected,” said Darrick, Oscar's husband. “And so I just want to protect myself against that.”

The couple, who asked to only use their first names for privacy reasons, said they got to the clinic early so they could avoid long lines, and so Darrick could get to work almost on time.

Anyone can contract monkeypox, but the current outbreak is spreading primarily among gay men.

The supply of monkeypox vaccines from the federal government is limited: So far, King County has received 9,160 doses of the monkeypox vaccine, which is only 11% of the 80,000 doses county officials say are needed to vaccinate everyone at highest risk.

To try to make sure those scarce doses are reaching those most at risk of contracting the virus, King County put detailed eligibility requirements in place. But critics of the county’s approach say it’s not working as intended and might actually be doing harm.

In King County, those currently eligible for the vaccine include a subset of men or transgender people who have sex with men: such as those who’ve had more than 10 sexual partners in the past three months, those who’ve used meth in the past month, or who meet certain other criteria. People who’ve had sexual or close contact with someone who tested positive for monkeypox can also get the vaccine.

The way those eligibility requirements are being rolled out might actually be creating problems, said Bekah Telew, the co-executive director of Seattle’s LGBTQ+ Center.

That’s because, when folks come in for a vaccine, the provider asks them to sign paperwork verifying their eligibility — that they’ve had 10 sexual partners in the past three months, for example, or that they’ve had syphilis or gonorrhea in the past year.

“It seems like something that would just create another barrier for folks who may identify in the eligible categories, but wouldn’t be comfortable putting that on paper,” Telew said.

Keletso Makofane, a social network epidemiologist at Harvard, agrees that the county’s approach is inadvisable.

“It is intrusive, and it also reveals a kind of callousness with respect to the meaning of sex, the meanings that people attach to sex,” he said. “To act as if you can just get this information as if these folks are robots who have no shame and no fear, who do not have a desire to keep some things private — to not accommodate that humanity that gay men have around our lives is another kind of homophobia.”

County officials said the goal of the eligibility requirements is to ensure that the people who most need the vaccine get it first, instead of the people with the most privilege. They said a first-come, first-served approach would mean that people with, say, flexible work schedules and a pre-existing relationship with a primary care provider would get the vaccine first.

Just as in the rollout of the Covid vaccine, the stringent eligibility criteria are only expected to be in place for a short time.

“We’re trying to be a little bit more targeted in who we’re giving it to in this initial phase,” said Dr. Matthew Golden, the director of the sexual health clinic as well as the county’s HIV/STD program. Golden is helping lead the county’s monkeypox response. “As we get more vaccine, we expect to change what those criteria will be.”

Telew said she agrees with the county’s aims but that the approach isn’t working as officials intended.

“Unfortunately, I think what we’re seeing is that folks who are more comfortable navigating systems — because of the many privileges that folks may hold — are going to get the vaccines regardless,” she said.

Telew and Makofane agree that instead of writing and trying to enforce stringent eligibility requirements, a community-based approach would work better: setting up pop-up clinics at places where gay, bisexual, and transgender men already gather and feel comfortable.

A spokesperson said King County’s public health agency has used a number of strategies to reach the people at highest risk for exposure to the monkeypox virus and who might have limited access to the vaccine, including distributing the vaccine to community-based organizations and businesses and doing targeted outreach through UW Medicine.

The county has also held two pop-up vaccine events on weekends, where 1,200 people were vaccinated, and it plans to hold more pop-up clinics as soon as it has more vaccines on hand.

Also, the county's vaccine supply might stretch slightly further than anticipated, because some providers have started using a new vaccine administration technique that allows each vial to vaccinate three to four people instead of just one.

As people wait for vaccines, Makofane said there are steps they can take to reduce their risk of contracting monkeypox. They can reduce their number of sexual partners, choose a couple of stable partners and only have sex with them for the time being, and talk to them about what risks they’re taking and how many people they’re having sex with.

Also, he said, people who are going to be out in tight, crowded spaces, rubbing against other people, can reduce their risk of contracting the virus by wearing long sleeves.

He said using a condom can reduce the risk of transmission during sex, although monkeypox can also be transmitted through kissing and skin-to-skin contact.

Makofane also expressed frustration over the current state of vaccine access. He said it didn’t have to be this way, with people waiting weeks or months for the vaccine as the outbreak continues to grow. He said it was a failure of the federal government.

“The reason that people are scrambling for vaccine or are lining up very early in the morning for vaccine is not … that there is some kind of global shortage,” he said. “It’s that the people in charge of bringing vaccine over [to the US] did not decide to bring in as much vaccine as we needed.”

All that can be done at the local level is “set up systems that afford us a little dignity,” he said. “And they’ve failed to do that, by and large.”