We included all NYC residents who had a positive nonvariola orthopoxvirus (probable case) or mpox (confirmed case) test reported to DOHMH during May 19–October 29, 2022. We collected data on age, gender, race/ethnicity, sexual orientation, and residential addresses during standardized interviews. We obtained tecovirimat treatment data from provider reports via a mandatory REDCap survey and from partner pharmacy dispensing records. We matched cases with treatment data by using names, dates of birth, and postal (ZIP) codes. For persons treated before their first positive test, we used the treatment date instead of diagnosis date. We excluded persons who were treated but never had a reported positive test.

We calculated descriptive statistics for selected demographic characteristics (Table), both overall and according to treatment status. We assessed differences by using χ² tests or t-tests. We included unknown values as separate categories under race/ethnicity and sexual orientation. We calculated cumulative changes in percentages of tecovirimat-treated persons in 2-week intervals according to race/ethnicity and neighborhood poverty level (defined as the percentage of residents in the patient’s ZIP code living below the federal poverty level according to the American Community Survey [https://www.census.gov]). We categorized neighborhoods into 4 groups: low poverty, <10%; medium, 10%–19.9%; high, 20%–29.9%; and very high, >30%. We performed analyses by using SAS version 9.4 (SAS Institute, https://www.sas.com) and R version 4.2.3 (The R Project for Statistical Computing, https://www.r-project.org). We considered a p value <0.05 statistically significant. DOHMH’s Institutional Review Board deemed this evaluation to be public health surveillance.

Mpox was diagnosed for 3,740 persons during the study period. Most mpox-positive persons were 25–44 years of age (74.7%); men (94.2%); lesbian, gay, bisexual, or queer (64.4%); Hispanic/Latino or Black/African American (61.8%); and lived in medium- or high-poverty neighborhoods (66.6%) (Table). A total of 1,213 (32.4%) persons were treated. Compared with untreated persons, a larger percentage of treated persons were lesbian, gay, bisexual, or queer (70.7% vs. 61.4%) and White (27.1% vs. 20.5%); a smaller percentage of treated persons were of unknown race/ethnicity (8.8% vs. 11.0%) or resided in Queens (11.5% vs. 18.1%) (Table).

Figure

Figure. Comparisons of cumulative percentages of persons with mpox treated with tecovirimat during 2-week intervals in study of racial and socioeconomic equity of tecovirimat treatment during 2022 mpox emergency, New York...

By October 29, 2022, the percentage of treated persons was highest among those identifying as White (38.8%), then Black/African American (31.3%), Hispanic/Latino (31.0%), Asian/Pacific Islander/other (30.1%), and unknown race/ethnicity (27.7%) (Appendix Table). Percentages of treated persons were similar (30.6%–33.9%) across neighborhood poverty levels (Appendix Table). Percentages of treated persons increased initially for all racial/ethnic groups, stabilizing by late July 2022, except for White persons, among whom percentages increased an additional month before stabilizing (Figure). In all but one 2-week interval, percentages of tecovirimat-treated White persons were higher than all other groups. The increasing trend was generally consistent across neighborhood poverty levels (Figure).

During our evaluation period, 32.4% of persons in NYC with reported mpox were treated with tecovirimat, compared with <20% nationally (10). The increasing percentages of treated persons during the outbreak was likely related to advocacy by and peer support from affected communities (11), increased prescriber familiarity with tecovirimat, and iterative revisions to the EA-IND protocol that reduced provider administrative requirements. The higher percentage of persons treated in NYC and our finding that treatment did not substantially vary by neighborhood poverty level might be attributable to the free, at-home delivery approach to tecovirimat distribution, which eliminated pharmacy access as a barrier. DOHMH also established a team to recruit and support providers to prescribe tecovirimat under the EA-IND protocol. Safety net health systems and federally qualified health centers were chosen for early outreach and technical assistance to improve access for underinsured and uninsured patients. In addition, the DOHMH team connected patients to available prescribers, if their initial providers were unable to meet EA-IND requirements.

Although percentages of tecovirimat-treated persons increased over time across all racial/ethnic groups, inequities existed. When we evaluated the cumulative percentages of treated persons in each racial/ethnic category, none approached that of White persons (≈31% for other groups vs. 38.8% for White persons) (Figure). Racial inequities and, specifically, lower percentages of treated Black/African American and Hispanic/Latino persons were foreseeable, because similar patterns have been observed for other medical countermeasures (e.g., mpox vaccines, COVID-19 antivirals, and HIV treatment) (5,12,13). Stigma from healthcare providers experienced by Black gay and bisexual men is a known barrier to sex-related healthcare access (14). Furthermore, the regulatory obligations of the EA-IND process limited the number of tecovirimat prescribers, which might have disproportionately affected Black and Hispanic/Latino communities. For example, DOHMH sexual health clinics, safety-net providers of services for Black and Hispanic/Latino men who have sex with men, did not prescribe tecovirimat until mid-September 2022 because of regulatory issues. In addition, insurance coverage inequities are a major barrier to accessing primary care (15), including mpox testing and treatment. No comprehensive data source identifies healthcare providers serving specific race/ethnicity groups, making interventions to increase equitable access to mpox countermeasures imprecise.

The first limitation of our study is that univariate analysis cannot capture all factors affecting treatment, such as differences in eligibility, healthcare access, and provider prescribing. Second, tecovirimat data were not available if the prescriber did not complete the online form when the drug was prescribed through a clinical trial beginning in mid-September 2022 or was dispensed from an inpatient pharmacy (e.g., some hospitalized patients). Lack of tecovirimat treatment data might have caused treatment undercounting, but we expect minimal effect because crossover between the trial recruitment period and our evaluation was brief, and the reporting form was mandatory for all prescribers.

In conclusion, our findings indicate racial inequity in tecovirimat treatment in NYC during the 2022 mpox emergency. Future responses to public health emergencies must prioritize institutional and structural racism mitigation from the outset to build more resilient communities and healthcare delivery systems. Additional analyses of factors (e.g., clinical characteristics, acceptability of treatment, detailed sociodemographic information) should be prioritized to assess the extent and effect of race/ethnicity on mpox treatment distribution and to inform future efforts to achieve equitable medical countermeasure access. Having comprehensive data for race/ethnicity of populations served by healthcare providers/networks and for characteristics of persons receiving medical countermeasures is critical for improving equity in emergency preparedness and response. Although neither dataset is sufficient to overcome institutional or structural racism, the alternative, a reactive approach, will inevitably perpetuate entrenched inequities.