Most Mpox deaths in the United States have occurred in black men with advanced HIV

Most mpox-associated deaths have occurred in black, cisgender men HIV or AIDS who reported recent sexual contact with another man, according to the latest CDC report Morbidity and Mortality Weekly Report.

Between May 10, 2022 and March 7, 2023, a total of 30,235 confirmed and probable cases of mpox were reported in the United States. During this period, 38 mpox-associated deaths were recorded in the country, which equates to 1.3 mpox-associated deaths per 1000 cases.

The number of deaths in the United States alone accounts for nearly a third of mpox-related deaths worldwide, with more than 87,000 cases in 110 countries and 120 deaths at the time of writing, according to the World Health Organization.

The CDC has received reports of 52 total deaths in the United States among people with confirmed or probable mpox, 38 of which were classified as associated with mpox. Three deaths have been confirmed not to be associated with mpox and 11 deaths are still under investigation.

Of the 38 people who died from mpox in the United States, 87% were black, followed by whites (8%) and Latinos (5%), compared to 33% of those who survived and recovered from mpox. All but 2 of the deceased were cisgender men, 1 being a cisgender woman and 1 a transgender woman. The CDC also reported that nearly half (47%) of those who died resided in southern states, compared to 39.4% of survivors in the region.

“Gender and racial disparities in mpox-associated deaths align with previous reports, in which most patients hospitalized with severe manifestations of mpox were black males with uncontrolled HIV and racial disparities and ethnic parallels in HIV infection and mortality,” the authors said. “In 2020, 75% of all-cause deaths among HIV-positive adults occurred in men, of which 39% were black men. Disparities and barriers are apparent at all levels of HIV care, including recognition of HIV risk, access to testing, access to and receipt of pre-exposure prophylaxis and ART [antiretroviral therapy].”

Of the 10 deceased individuals for whom recent sexual or intimate contact information was available, 9 had had sexual or intimate contact with cisgender men in the 3 weeks prior to symptom onset. Additionally, 2 of the deceased had been in close contact with people with mpox, but not through sexual activity, but rather sharing a bed or caring for a family member, and 5 of the 11 decedents with available housing data experienced homelessness.

HIV infection was more common in the deceased than in the survivors, as indicated by available information for 87% of the deceased and 45% of the survivors, with an HIV prevalence of 93.9% and 38.3 %, respectively. Of the 24 HIV-positive decedents for whom information is available, all had very advanced HIV or AIDS, all but one having a CD4 count below 50. Two other decedents were immunocompromised for other reasons, one suffering from diabetic ketoacidosis and the other having recently undergone a kidney transplant complicated by acute rejection.

Of 25 people living with HIV, only 2 reported taking ART before being diagnosed with mpox, and HIV was not well controlled in one of those who died. ART was started for 19 of the 20 deceased people who were not already receiving it, including 1 who was diagnosed with HIV just 5 days after being diagnosed with mpox.

One decedent refused treatment for advanced HIV, and antiretroviral therapy status was unknown for three of the 25 decedents with HIV. ART was delayed or interrupted for 7 people who died due to clinicians’ concerns about immune reconstitution inflammatory syndrome (IRIS), a hyperinflammatory response that can occur in HIV-infected patients within the first 6 months of ART .

Current methods of preventing mpox deaths include integrated screening, diagnosis and early treatment of mpox and HIV, and ensuring equitable access to both mpox and HIV prevention and treatments such as ART.

Clinicians elected not to administer mpox treatment to 2 of the deceased. In one case, this was due to concerns about the contraindication related to other comorbidities, and in the other, the deceased was already on ART for HIV with an undetectable viral load at the time of the initial assessment for mpox care. A month later, the latter deceased was found dead during a health check, showing diffuse lesions indicative of mpox. In addition, 7 of the 27 deceased refused therapeutic or intravenous medications or left the hospital against medical advice during their clinical treatment.

The median age (IQR) at death was 34 (22-58) years and the median time from symptom onset to death was 68 (50-86) days, with mpox cases peaking at summer 2022 while deaths peaked in fall to early winter 2022. Of the 38 mpox-associated deaths in the CDC report, 25 (65.8%) occurred between October and November 2022. The number of cases and deaths has dropped significantly since then.

According to the authors, the findings of this report further underscore the importance of combining prevention, testing and treatment for sexually associated infections such as mpox and HIV.

“Equitable access to prevention, treatment, initiation and maintenance of care for mpox and HIV should be a priority, especially among black men and others at risk of sexually associated infections” , the authors pointed out. “These findings underscore previous recommendations that providers offer HIV testing to all patients with probable or confirmed mpox and consider early treatment directed at mpox in highly immunocompromised patients. mpox and boosting immune function may also reduce mortality from severe mpox.

Reference

Riser AP, Hanley A, Cima M, et al. Epidemiological and clinical characteristics of mpox-associated deaths – United States, May 10, 2022–March 7, 2023. MMWR Morb Mortal Wkly Rep. 2023;72:404–410. doi:10.15585/mmwr.mm7215a5