Getting Mpox Treatment to Patients: Los Angeles County's Hub-and-Spoke Network, 2022–2023

In May 2022, clade II mpox — long endemic in West and Central Africa — spread into a widespread outbreak, and the United States declared a public health emergency in August 2022. The first-line treatment for severe mpox, or for patients at risk of severe disease, is tecovirimat, an antiviral originally developed for smallpox. Patients received it under an expanded access investigational new drug (IND) protocol held by CDC, with eligibility rules that changed as the outbreak went on, and supplies came from the Strategic National Stockpile through state and local health departments.

Los Angeles County — 10 million people across 4,058 square miles — was an epicenter of the U.S. outbreak at its peak, with the most mpox cases in California: 39% of the state's reported cases by January 30, 2023. A report in CDC's MMWR described how the county's Department of Public Health got the drug to patients.

Building the network

The county didn't start from scratch. It reused the medical countermeasure distribution networks already set up under two emergency programs, the Public Health Emergency Preparedness Program and the Hospital Preparedness Program.

• Hubs. The department recruited providers experienced in distributing medical countermeasures, choosing them for location, closeness to patients, number of providers, patient volume and extended opening hours. By August 1, 2022, there were 44 hubs: 23 community clinics, 11 hospitals and 10 independent pharmacies.
• Spokes. The hubs supplied 456 affiliated sites, whose health workers were trained to order the drug from their hub, complete the IND paperwork and give the treatment.
• Hospitals. Each of the county's Disaster Resource Center hospitals held one intravenous course and twenty oral courses to pass on, on demand, to nearby general hospitals.
• Support. The department stored the stockpile supply at its own warehouse, filled hub orders by clinical volume and inventory, reviewed reports weekly to decide where to send more drug and training, and offered consultation to providers at any hour. Patients with no regular provider, or none willing to treat them, got help finding care, and public health nurses followed up every case.

Tecovirimat hub and spoke sites, Los Angeles County, June 2022–January 2023 (CDC).

Who was treated, and where

From June 2022 through January 2023, the county recorded 2,281 patients with mpox, and about one third of them — 735 — received tecovirimat.

• Most treatment happened outside hospitals: 685 patients (93%) were outpatients and 48 (7%) inpatients. Only 7 (1%) received the drug intravenously; the rest took it by mouth.
• Treatment followed the epidemic curve. Confirmed cases peaked in late July 2022, and treatment peaked in August, when 423 patients (58%) were treated.
• The patients: where gender was known, nearly all identified as male (659, 90% of all treated patients). The median age was 38 (range 9–79). Half (375, 51%) reported HIV infection.
• Why they were treated: lesions in places where they might cause serious complications (75%), pain (55%), and a weakened immune system that raised the risk of severe illness (31%). One patient was pregnant. Nearly half (333, 45%) had 10 to 100 lesions.

Patients with mpox who did and did not receive tecovirimat, by week, June 2022–January 2023 (CDC).

How fast it reached people

For the 525 treated patients (71%) whose records could be matched to surveillance data, the median time from specimen collection (or presumed diagnosis) to receiving the drug was 2 days (interquartile range 0–5), and it did not change from month to month. Patients who waited for laboratory confirmation got it in a median of 4 days; those treated on clinical suspicion alone got it the same day. Three of those treated without confirmation later tested negative. Local public health and commercial laboratories took about 2 and 3 days, respectively, to return results. Among matched patients, 47 (9%) were hospitalized and two died.

What it showed

• Clinics and pharmacies matter in an emergency. Preparedness planning for handing out countermeasures has focused on hospitals, yet here roughly two thirds of treated patients got the drug at clinics and pharmacies — a strategy built on the COVID-19 vaccine rollout.
• Local data kept supply ahead of demand. Combining intake forms with provider inventories and case trends let the department spot shortages and restock before gaps opened.
• More patients were treated than nationally — about a third in the county against 23% nationwide. National data may be underreported; county patients may also have been sicker or had better access. Training aimed to balance access against overuse that could breed drug resistance, but some treatment may still have been unnecessary.

Limits

About 29% of treated patients could not be matched to surveillance records, which could push the time-to-treatment estimate either way. And because intake forms were filed only at the start of treatment, with no report at the end and no agreed measure of success, the county could not judge how much the network reduced illness or death.

The authors recommend that local health departments build clinics and pharmacies into preparedness plans, collect local data to find gaps in access, and measure the additional administrative costs of a countermeasure program, such as training, staff hours, storage and support for partners.

Sources

• O'Neil MJ, Archer R, Danza P, et al. "Successful Distribution of Tecovirimat During the Peak of the Mpox Outbreak — Los Angeles County, June 2022–January 2023," MMWR Vol. 73, No. 24, CDC; a work of the United States government in the public domain. The report gives the share of patients treated as 32% in its results and 33% in its discussion, so this page says "about one third"; and its counts of confirmed versus empirically treated patients (307, 63%, and 155, 37%, of 485) do not add up, so those shares are not stated.