Dr. Bobby Kelly, a family physician at an LGBTQ+ health center on the Seacoast, cares a lot about public health. Last year, he even sent out a COVID-19-themed Christmas card featuring a photo of him giving the coronavirus vaccine to his husband.
Lately, Kelly says another public health emergency has been top of mind: monkeypox.
While monkeypox can infect anyone, the vast majority of cases confirmed through July 2022 were reported among men who had recent sexual or intimate contact with men, according to the Centers for Disease Control and Prevention. And that, Kelly said, has triggered a lot of fears among his patients — especially those who lived through the HIV/AIDs crisis.
“Hearing the messaging and the media, they were sort of being retraumatized,” Kelly said.
New Hampshire has so far seen significantly fewer confirmed monkeypox cases than other states, with 15 total as of Aug. 16. But as case counts across the country grew, so did frustrations among local patients who wondered what was being done to protect Granite Staters against the virus.
“A lot of my patients have been sharing that they're going on vacation to other states and have been seeing other [vaccine] clinics,” Kelly said.
Kelly’s patients weren’t the only ones who felt like they were in the dark. In recent weeks, providers that are typically on the front lines of public health outreach — including local health departments and other reproductive health clinics — also told NHPR they weren’t sure what their role in New Hampshire’s monkeypox response would look like. Many said they were awaiting further guidance from the state.
But in the last week, more than a month after health officials identified the first local patient with the virus, New Hampshire’s plan for monkeypox has started to come into clearer focus. The Department of Human Services rolled out an initial list of clinics where eligible Granite Staters can get vaccinated on Monday evening. And on Wednesday, Dartmouth Health kicked off a three part monkeypox educational program for health providers, where state officials and other medical professionals shared details information about testing and screening protocols.
While monkeypox presents and spreads differently than COVID-19, state and local health officials said they’re trying to draw on lessons learned through the coronavirus pandemic to inform how they approach prevention, testing, vaccination, education and more.
“One of the similarities with COVID, as with monkeypox, is that it is dynamic,” said Director of New Hampshire's Division of Public Health Services Patricia Tilley. “The response is evolving.”
At the same time, with that ever changing landscape, some said it’s been challenging to calibrate the level of urgency when there are still comparably few cases and some unknowns about the virus — and since the funding that supported many of the prevention efforts around COVID-19 just isn’t there.
Think you might be eligible for a monkeypox vaccine? Read the state’s official guidelines here.
An emerging vaccine rollout
Tilley, New Hampshire’s public health director, knows the state is behind others when it comes to its monkeypox vaccination rollout. With fewer cases and fewer identifiable communities of high-risk populations, she said New Hampshire hasn’t received as many vaccines from the federal government as other parts of the country.
“It's tough when we've had limited supplies of vaccines,” she said. “New Hampshire is not New York City. It's not San Francisco. And so our rollout is a little bit slower.”
But Tilley said New Hampshire is trying to learn from what’s worked — and what hasn’t — in other parts of the country. They’re also trying to be intentional, she said, about how they structure the vaccine rollout.
Instead of starting with the kind of large public clinics that were available in the early days of the COVID-19 vaccine rollout, Tilley said New Hampshire health officials are prioritizing smaller, more intimate clinics that give patients more opportunities to ask questions and talk with healthcare providers. Local patients looking for the monkeypox vaccine can either ask their primary care provider for a referral or call a monkeypox vaccine clinic directly.
As of early August, the federal government has set aside over 1,400 doses of the monkeypox vaccine for New Hampshire; thanks to recent changes meant to stretch that limited vaccine supply further, the state estimates it will be able to extend that supply five times more than originally planned. But it’s not clear how long those doses will last, and state officials expect additional doses from the federal government won't come for another few months.
“We're unclear what that exact demand is going to be in the community,” said Tilley. “We've certainly been taking calls and our office, but that call volume is nothing like COVID was in those early days.”
Tilley said the state has limited demographic data on the local LGBTQ+ population and not everyone in that community is eligible, making it difficult to estimate what demand will look like under current vaccine guidelines.
“If someone is in a monogamous relationship,” Tilley explained, “it does not appear that those folks are at higher risk right now.”
One potential indicator of vaccine demand is the number of Granite Staters on HIV prevention medication. Men who have sex with men, who also take this medication, are among the groups currently eligible for the vaccine in New Hampshire. As of 2020, the CDC reported 646 people age 16 or older were taking HIV prevention medication statewide, though it's not clear how many people in that group would be eligible given the criteria the state has outlined.
But Scott Cloutier, who serves as the communications director for Queen City Pride in Manchester and helps run a Facebook group for gay men in New Hampshire, thinks demand for the vaccine could be higher than health officials realize — especially as the rollout continues and eligibility broadens further.
“As soon as there’s a vaccine program, they’re all jumping on it,” he said of the 2,500 members in his Facebook group.
Cloutier also said there’s a broader demand for more queer spaces in New Hampshire. Just because LGBTQ+ communities aren’t as visible here as they might be in other states or cities, he said, doesn’t mean they’re not present.
“People put their blinders on, to not see things that they don't necessarily need to pay attention to,” Cloutier said. “We actually have an incredibly large community just in Manchester.”
While vaccines are one key part of the state’s monkeypox response, public health officials say — as with COVID-19 — testing is also critical.
State health officials say any healthcare provider should have the capacity to test patients for monkeypox. The process involves swabbing the patient and sending the specimen to the state’s public health lab or a private lab.
On a call with health providers last week, State Epidemiologist Dr. Ben Chan said there is no shortage of testing resources for monkeypox.
“Testing is not a limiting factor here,” he said. “From the time that we receive the specimen, we will turn around results generally within 24 hours.”
Still, some local providers told NHPR in recent weeks that they weren’t fully confident about their testing capacity. Several health centers said they are offering testing but expressed hesitation about publicizing that information in a news story because they weren’t sure they could handle a large influx of patients. Another provider said they were sending patients to a local urgent care clinic for testing until they received more guidance on how to safely handle it on their own.
Lack of funding poses some challenges
New Hampshire’s response to the COVID-19 pandemic relied heavily on funding from the federal government. But thus far, the state hasn’t received any extra money to help pay for testing, vaccination or other public health activities related to monkeypox.
While the federal government provided monkeypox vaccine doses to New Hampshire and other states, it didn’t offer any extra financial support to stand up vaccine clinics or other distribution efforts. That’s a departure not just from their approach during the COVID-19 pandemic, Tilley said, but also in response to Ebola and Zika viruses.
The state is also not offering any funding to local health providers distributing the monkeypox vaccine. And recently, New Hampshire’s Executive Council blocked funding for three reproductive health centers that would have supported programs to test for viruses like monkeypox. The Republican councilors who objected to the funding cited concerns about sending money to reproductive health centers that provide abortions, despite assurances that the money would not be used for that purpose.
“Those three providers in particular have strong relationships in the communities that will likely be most impacted by monkeypox,” Tilley said of the clinics that were denied additional funding. “Those providers are still seeing patients every day. But without additional resources, it will be difficult for them to open the doors wide open and take all comers in a timely way.”
Given these financial constraints, Tilley said she understands why only a small group of clinics have stepped forward so far to help administer the monkeypox vaccine.
“Our health centers are strapped,” she said.
COVID-19 exacerbated staffing shortages across the healthcare industry, and many providers are dealing with a backlog in care people put off during the pandemic. Several health centers contacted by NHPR said they would be interested in offering the vaccine to existing patients but worried about their capacity to host larger public clinics.
At this point, there’s also no targeted state or federal funding to support a broad public health campaign to inform people about the vaccine, or counter misinformation or stigma. But that hasn’t deterred some local health workers from trying to educate their communities.
Flavia Martin, a public health nurse with the Nashua Division of Public Health and Community Services, says she’s been trying to spread the word about the monkeypox vaccine as much as she can — including at the city’s weekly Sexual Wellness clinics.
“I had the conversation with a client that came in,” she said. “This was not something that was even on their radar, but I just brought it up with them.”
Kris van Bergen, with the North Country Health Consortium, said her organization is focused on sharing safe and accurate messaging around monkeypox.
“We're wanting to be very careful to not inadvertently create stigma around the gay community,” van Bergen said, “and to also make sure that all citizens understand that they face risk for monkeypox and take the necessary precautions.”
Other local health officials echoed those concerns about avoiding stigma around the virus. For that reason, many said they’re trying to refer to the virus as MPX or MPV in place of a name that can conjure racist and misleading stereotypes.
Earlier this year, a group of scientists also called on global health authorities to change the name of the virus, saying: “In the context of the current global outbreak, continued reference to, and nomenclature of this virus being African is not only inaccurate but is also discriminatory and stigmatizing.” Last month, the World Health Organization said it is also exploring a new name.
Here in New Hampshire, Scott Cloutier has also been thinking a lot about the stigma attached to the virus. He said it’s important to be honest about who’s most impacted by monkeypox and to recognize the virus is disproportionately affecting LGBTQ+ communities. At the same time, Cloutier said, it’s important not to stigmatize those communities as a whole, which is what he feels has been happening.
“Everybody has this picture in their mind of what a healthy relationship is,” he said. “And I think some people in the LGBT community just experiment and experience things in a much different way… like not everybody wants to be monogamous and married to one person or sexually active with one person.”
Monkeypox resources in N.H.
- The New Hampshire Department of Health and Human Services has put together an FAQ page, which includes information about symptoms and what to do if you have a virus.
- Dartmouth Health is operating a hotline to help point people toward resources and answer questions. The number is 603-650-1818.
- If you don't have a primary care provider and think you might have the virus, you can get in touch with a state public health nurse by calling 603-271-4496.
