Progress Toward Equitable Mpox Vaccination Coverage: A Shortfall Analysis — United States, May 2022–April 2023

Abstract

More than 30,000 monkeypox (mpox) cases were reported in the United States during the 2022 multinational outbreak; cases disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Substantial racial and ethnic disparities in incidence were also reported (1). The national mpox vaccination strategy* emphasizes that efforts to administer the JYNNEOS mpox vaccine should be focused among the populations at elevated risk for exposure to mpox (2). During May 2022-April 2023, a total of 748,329 first JYNNEOS vaccine doses (of the two recommended) were administered in the United States. † During the initial months of the outbreak, lower vaccination coverage rates among racial and ethnic minority groups were reported (1,3); however, after implementation of initiatives developed to expand access to mpox vaccination, § coverage among racial and ethnic minority groups increased (1,4). A shortfall analysis was conducted to examine whether the increase in mpox vaccination coverage was equitable across all racial and ethnic groups (5). Shortfall was defined as the percentage of the vaccine-eligible population that did not receive the vaccine (i.e., 100% minus the percentage of the eligible population that did receive a first dose). Monthly mpox vaccination shortfalls were calculated and were stratified by race and ethnicity; monthly percent reductions in shortfall were also calculated compared with the preceding month's shortfall (6). The mpox vaccination shortfall decreased among all racial and ethnic groups during May 2022-April 2023; however, based on analysis of vaccine administration data with race and ethnicity reported, 66.0% of vaccine-eligible persons remained unvaccinated at the end of this period. The shortfall was largest among non-Hispanic Black or African American (Black) (77.9%) and non-Hispanic American Indian or Alaska Native (AI/AN) (74.5%) persons, followed by non-Hispanic White (White) (66.6%) and Hispanic or Latino (Hispanic) (63.0%) persons, and was lowest among non-Hispanic Asian (Asian) (38.5%) and non-Hispanic Native Hawaiian and other Pacific Islander (NH/OPI) (43.7%) persons. The largest percentage decreases in the shortfall were achieved during August (17.7%) and September (8.5%). However, during these * https://www.cdc.gov/poxvirus/mpox/interim-considerations/overview.html (Accessed May 11, 2023). † https://www.cdc.gov/poxvirus/mpox/response/2022/vaccines_data.html (Accessed May 14, 2023). § https://www.cdc.gov/poxvirus/mpox/health-departments/vaccine-equity-pilot.html months, smaller percentage decreases were achieved among Black persons (12.2% and 4.9%, respectively), highlighting the need for a focus on equity for the entirety of a public health response. Achieving equitable progress in JYNNEOS vaccination coverage will require substantial decreases in shortfalls among Black and AI/AN persons. Shortfall analysis, an approach that focuses on the percentage of persons who have not achieved a certain health outcome (5), was used to quantify progress in mpox vaccination overall and by racial and ethnic groups. Unlike many conventional disparity measures that compare the rate of a particular health outcome in racial and ethnic minority groups with the rate of another group, such as the group with most favorable rate or the overall population (7), shortfall analysis does not require a comparison group. Thus, the shortfall analysis can quantify progress in mpox vaccination coverage for any given racial or ethnic group without regard to changes in vaccination coverage in a comparison group. Further, comparisons of shortfalls across racial and ethnic groups can help to determine if progress in mpox vaccination coverage is equitable. Shortfall in mpox vaccination was calculated as 100% minus the percentage of the eligible population that received a first dose of mpox vaccine; thus, the shortfall measure reflects the deficit in the percentage of vaccinated persons in the eligible population from 100% coverage. Shortfalls, and decreases in shortfalls (measured as a percentage), were calculated at monthly intervals during May 2022-April 2023 for each racial and ethnic group (6). A reduction in shortfall indicates progress specific to an individual racial and ethnic group without the need for a reference group, because the reference point is 100% coverage (6). Shortfall analyses have been used for measuring progress for a range of health outcomes, such as increases in life expectancies (6). Data on the number of persons aged ≥13 years among seven racial and ethnic groups ¶ who received a first dose of mpox vaccine were obtained from case surveillance reports submitted to CDC by 49 states, the District of Columbia, and Puerto Rico, during May 2022-April 2023.** The size of ¶ Persons who indicated Hispanic ethnicity, regardless of race, were categorized as Hispanic. AI/AN, Asian, Black, NH/OPI, White, or Multiple race (more than one race category selected) or other persons were categorized as non-Hispanic. Persons with missing data on ethnicity or race were categorized as missing or unknown and not included in this analysis. ** Data from Vermont were not included in the analysis because vaccination data stratified by race and ethnicity were not reported.