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While looking for a place to get vaccinated against monkeypox in August, Jack Feng of Baltimore looked to the city health department to try and schedule a shot. Case counts in the state and country were rising, and Feng wanted to be part of the solution and protect himself against the infectious disease.

To his dismay, the health department and a private partner had limited doses in their possession, and Feng, a public health researcher and a member of the LGBTQ+ community, could not get an appointment. He also faulted the state and city health department for not immediately launching a pre-registration website, call line or public service announcement campaign to help people learn more about the outbreak.

Feng asked himself: Was it worth leaving the state for someplace where shots were more plentiful? He wound up traveling to New York for his first dose.

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“I kind of gave up on Baltimore; things were too slow, we were so behind,” said Feng, 25, who received his second dose in Los Angeles during a scheduled trip. He considers himself privileged for being able to make such flexible plans but knows many can’t afford alternatives.

Feng and others wanted to know: Why did Maryland’s response to monkeypox seem to lag behind that of other jurisdictions, especially in neighboring areas such as Washington, D.C.?

D.C. health officials have vaccinated people against monkeypox at a rate at least 56 times higher than Maryland, a Baltimore Banner data analysis data found. While D.C.’s per capita infection rate has been about twice as high as Baltimore’s, there are now more new cases per person in Baltimore.

The response has been picking up. Maryland health officials widened the vaccine eligibility criteria last month from those who had potentially been exposed to monkeypox in the prior two weeks to anyone who has had multiple or unknown sexual partners in the past two weeks, or any potential exposure. Health officials also have been able to expand the number of doses available per vial by changing the way they vaccinate, from subcutaneously, which means under the skin, to between the layers of skin.

A data dashboard launched in August shows the vaccination rate has increased with these changes. But the statewide rate still lags well behind D.C., and the Maryland data dashboard doesn’t say who is getting doses or where they live. It’s not clear if officials are addressing Baltimore’s outsized need.

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So, why the difference?

Public health experts, Maryland lawmakers and city officials acknowledged the state’s shortcomings in its monkeypox response but said they didn’t have enough data or direct knowledge to explain exactly why D.C. had vaccinated so many more people. Some reasons have been explored.

At a virtual community town hall last month, Peter G. DeMartino, director of the Infectious Disease Prevention and Health Services Bureau at the Maryland Department of Health, linked the disparity to D.C. having more infections earlier on and having only one health agency, a contrast to Maryland’s system with local health departments and a state health agency.

“They have a different distribution mechanism and they got more product,” DeMartino said. “D.C. is a single jurisdiction, we are 24 with a very different mechanism of administration of public health in general. They were better able to launch a more sustained effort earlier on because they had a much more significant outbreak earlier.”

Public health experts said Maryland’s response in many ways mirrored that of the federal government. While human monkeypox has been spreading since at least May, the World Health Organization did not declare it a global public health emergency until July. President Joe Biden’s administration declared a U.S. public health emergency in August.

“It reflects how poor our systems are nationally,” said Dr. Joshua M. Sharfstein, a former city health commissioner and state health secretary. “This is not easy public health work; you have to reach people who may not be in regular touch with public health professionals, and I think what different health agencies are learning is that information and vaccines need to go out where people who are high risk are. That requires good relationships and extra staff, but there’s been no extra funding from Congress on this.”

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Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, said it wasn’t clear why D.C. has outpaced Maryland to this degree or why Maryland received the initial small volume it did. He said it would make sense for such decisions to be made more transparently to avoid confusion.

There have been more than 25,800 confirmed monkeypox cases across the country, according to data from the U.S. Centers for Disease Control and Prevention, and Maryland is listed among states with the highest infection counts, along with Illinois, New York, Pennsylvania and several others. But the dashboard does not include data showing states’ cases over time or an equation for vaccine allocation, which can help the public assess their level of risk.

Sharfstein and others said the federal government may have acted diligently to allocate more vaccine to D.C. in the beginning if more cases per person had been detected there. He said D.C.’s vaccination numbers — 36,163 total, according to the D.C. Health website — appear “very aggressive” compared to other states and jurisdictions.

“Monkeypox surged, and D.C. responded,” Sharfstein said. “What I’m missing in Maryland is how many new cases there are over time. Are things … getting better in Baltimore and Maryland?”

The D.C. and Maryland data dashboards do not show how infection rates have changed over time, but The Banner used internet archives to access past versions of the data. This analysis shows rates continue to rise steadily in Baltimore as they slowed in D.C. during a similar time period.

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Nationally, the seven-day average of reported cases peaked in early August before trending downward, CDC data shows. In Maryland, the infection rate rose from 30 cases per 100,000 residents before Sept. 9 to 35 cases per 100,000 residents on Sept. 23. That infection rate of 5 people per 100,000 was higher than D.C.’s during a similar time frame. D.C.’s infection rate was about 3 per 100,000 residents between Sept. 13 and Sept. 27.

Chase Cook, a Maryland Department of Health spokesman, directed a reporter in late September to the health department’s website in response to a series of questions about the virus and the state’s response. He said at the time that Maryland’s preregistration system logged about 2,800 people seeking to be immunized, and officials had vaccinated well above that amount.

‘Limited by funding forces, to be honest’

Baltimore, which has an outsized concentration of residents living with HIV and other sexually transmitted infections — a population that has been overrepresented in monkeypox case counts, according to the CDC — received only 200 doses of vaccine in the first round. Baltimore health officials said they are meeting the city’s needs with what limited financial resources and personnel they have.

“The state, like us, is limited by funding forces, to be honest. Not having a defined funding source to support resources is challenging,” Baltimore Health Commissioner Dr. Letitia Dzirasa said. “Grant funds are so prescriptive. To pivot quickly and support something like this is a challenge at the local and state level. I don’t know if that’s the state’s fault.”

Dzirasa said monkeypox so far has primarily affected men who have sex with men and transgender people. For now, it seems contained in those groups, she said. The caveat is that Baltimore is seeing more women with monkeypox, making up 8% of all infections; nationally, women make up about 5% of cases.

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Dzirasa said monkeypox, though severe, doesn’t require the same degree of response as other, deadlier diseases, such as COVID-19, which could also explain the state’s response.

“[With COVID-19], if the health care system couldn’t handle the demand, there would be more preventable mortality,” Dzirasa said. “We have to acknowledge that this is different. We don’t want to do this overall, broad messaging, because we really are seeing this relatively limited to a specific population.”

Dzirasa also said education may be just as important to fighting monkeypox as vaccinations, and Maryland and Baltimore’s response to monkeypox can’t be judged by immunizations alone.

‘Chicken and egg’

In July, Tom Carpino, an epidemiologist and graduate student at Hopkins’ public health school, co-wrote a letter with Feng to city and state officials calling on them to not only increase vaccine supply but also to increase the volume of resources on outreach, communication and education to empower communities.

The letter noted the discrepancy between Baltimore and D.C.’s vaccine numbers and said Baltimore could be uniquely poised to use its expansive understanding of health disparities against human monkeypox.

Frustratingly, Carpino said, he still found it “almost impossible” to get a vaccine in Baltimore and didn’t feel the letter deeply resonated with state and city officials. He said he knew of few people who got vaccinated in the city. And he felt the state had minimized the risk of exposure to other communities outside of those in LGBTQ+ circles, such as sex workers or people who engage in sex as a form of survival.

He said while there’s been progress in getting more people vaccinated, he fears state officials abandoned basic public health lessons in a moment of need.

Maryland state Sen. Clarence Lam, a physician who represents parts of Baltimore and Howard counties, said the monkeypox response has been lacking, “all up and down levels of the government.”

There wasn’t enough applied from the pandemic, he said, such as making tests more widely available, breaking down bureaucratic barriers and paying attention to who gets vaccinated when.

“There’s a little chicken-and-egg dynamic here: there isn’t the broad concern we saw with COVID; elected leaders aren’t responding because there’s not the same level of concern; agencies aren’t treating this as a priority; and because there’s not that level of activity, the press is probably not covering it to the degree it requires, as well,” Lam said.

Elected officials running for election or reelection, especially in competitive races, may also be hesitant to bring up monkeypox, he added.

“Every elected official wants to focus on the positive things they’ve done, and monkeypox doesn’t seem to have captured the public’s attention, and there hasn’t been enough success there to be able to point to,” Lam said. “Even among elected officials, many want to move on from the constant health crises that we’re seeing.”

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