Clade I Mpox Emerges as Public Health Capacity Collapses

Between October 14 and October 17, 2025, three California residents were confirmed with Clade I mpox, all requiring hospitalization, none vaccinated, none with international travel history. These represent the first known cases of community transmission of Clade I within the United States. The strain demonstrates case fatality rates of 3-10.6% compared to less than 0.2% for the Clade II virus that spread in 2022. All three cases occurred in Southern California. Health officials have found no epidemiological connections between them.

This was predictable. In May 2023, the Community Access National Network (CANN) cautioned against premature declarations of victory over mpox, warned that insufficient vaccine coverage among marginalized communities risked endemic transmission, and urged public health agencies to take community reports seriously rather than "paternalistically denying the potential or possibility of new outbreaks or breakthrough cases." Two and a half years later, the infrastructure to respond to those warnings has been systematically dismantled precisely when the more dangerous strain has arrived.

What We Failed to Build

Only 21-23% of at-risk populations nationally have received the full two-dose JYNNEOS vaccine series. This means 66-78% remain unvaccinated against a virus now spreading domestically. Even California, ranked third nationally with 43% of at-risk populations fully vaccinated, leaves more than half of vulnerable people unprotected. None of the three confirmed Clade I cases had been vaccinated.

The racial disparities are unchanged from 2022. As of April 2023, 77.9% of Black people in vaccine-eligible populations remained unvaccinated, despite experiencing mpox incidence 5.8 times higher than White people during the August 2022 peak. The vaccination-to-case ratio during the 2022 outbreak tells the story precisely: for every mpox case in a White male, 43 White males were vaccinated. For Black males, 9 were vaccinated per case. For Hispanic males, 17 per case.

JYNNEOS was added to CDC immunization schedules in October 2023. Most health plans have been required to cover vaccination without cost-sharing since January 1, 2025. Access improved. Utilization did not. Dr. Peter Chin-Hong of UCSF explained the gap: "They might have gotten the first shot back in 2022 when everyone was afraid, and people knew a lot of people who had it." As mpox faded from headlines, vaccination rates declined. Series completion rates remain at 64.5% in California. The consequence is massive population vulnerability to a virus significantly more dangerous than the 2022 strain, spreading now in the communities with the lowest vaccination coverage.

What We Are Dismantling

The federal government shutdown that began October 1, 2025, continues through October 22, now the second-longest in modern U.S. history. Only 37% of CDC staff continue working. Disease surveillance analysis has halted for certain diseases. Guidance to state and local health departments has been suspended. Communication lines are severely limited.

On October 10, approximately 600 CDC workers were cut when 1,300 employees received Reduction in Force (RIF) notices. These targeted staff in infectious disease programs, Laboratory Leadership Service, the CDC Library, chronic disease programs, global health initiatives, and health statistics. The entire CDC Washington Office was eliminated, destroying the agency's Congressional liaison capacity. Dr. John Brooks, former CDC Division of HIV Prevention official, explained the significance: "CDC has worked directly with Congress for decades to help constituents by providing data, expertise and insight when needed. These firings mean Congress no longer has a means of direct access to the agency it funds when it needs information or briefings."

This followed March 2025 HHS restructuring under Secretary Robert F. Kennedy Jr. that eliminated approximately 3,000 CDC positions, a 25% workforce reduction. The Morbidity and Mortality Weekly Report (MMWR) failed to publish for the first time in its 60-year history. Dr. Karen Remley, former CDC official and Virginia health commissioner, described the practical impact: "Sometimes that help might be sending some people to help you investigate this. Sometimes that might be talking to somebody who's the world's expert on a specific type of infection or exposure. Now, there's nobody to answer the phone."

The California Department of Public Health acknowledged: "The department continues to work with available staff at CDC, but the recent federal government shutdown and other actions at the federal level have added a layer of uncertainty to the current work environment." Joseph Osmundson, Clinical Associate Professor of Biology at NYU, stated it plainly: "The infrastructure we built during the 2022 outbreak has just been eviscerated. The very things we need to understand if we have a problem now, and if we will have a problem in the future, are being systematically dismantled."

What We Refused to Fix

Provider knowledge gaps documented in 2022 persist unchanged. A Johns Hopkins study analyzing 1,024 mpox tests across different clinical settings found anogenital examination performed in only 44.5% of emergency department visits and 40.4% of primary care visits, compared to 82.4% in infectious disease clinics. An HIV activist in New York's Hell's Kitchen reported in early 2023: "A number of my friends, as well as myself, if I'm being honest, have reported that their physicians are both unaware that reinfection with MPV [MPOX Virus] is possible and that infections can still occur in people who have been fully vaccinated, and as a result of their knowledge gap are refusing to test MPV lesions."

Spanish-language materials were not available until August 2022, three months into the outbreak. Technology-dependent scheduling systems requiring monitoring of health department social media accounts favored digitally connected populations. Uninsured patients were vaccinated significantly later than privately insured patients, 83 days versus 41 days. Three years later, these barriers remain unaddressed.

The vaccination disparities - 77.9% of Black people unvaccinated, 9 vaccinated per case compared to 43 per case for White people - reflect structural access failures compounded by medical mistrust rooted in documented sterilization programs, non-consensual experimentation, and systemic racism in healthcare delivery. As CANN documented in 2022, these historical harms manifest in current provider interactions: "Moral judgments are made, stories get told, patients are admonished and made to feel ashamed. The impacts of these behaviors, both short-term and long-term, can lead to patients refusing to seek testing or treatment." The barriers are known. The solutions are known. We have chosen not to implement them.

What Works and What We Abandoned

Community-based vaccination programs work. CDC's Mpox Vaccine Equity Pilot Program launched in September 2022 received 35 vaccination project proposals, with 22 completed projects administering 25,675 vaccine doses at targeted locations including Pride events and sexual health clinics. The program partnered with community-based organizations serving gay, bisexual, and other men who have sex with men and transgender people, used trusted messengers, and eliminated eligibility documentation barriers. It was proven effective. It was never scaled to address the 66-78% of at-risk populations who remain unvaccinated.

No real-world effectiveness data exists for JYNNEOS against Clade I. The vaccine is expected to provide protection based on its mechanism and animal studies showing 100% protective efficacy against death. But antibody levels wane significantly 6-12 months post-vaccination, dropping to levels at 12 months comparable to peak single-dose levels. Whether booster doses might be needed remains unresolved. CDC currently does not recommend third doses.

Epidemiological models suggest vaccination coverage above 50% is needed to prevent mpox outbreaks in high-risk populations. California's 43% falls short. Most states are far below that threshold. As CANN wrote in 2023: "If we are ever going to eradicate MPV in the United States, we are going to have to do a significantly better job of getting vaccine supplies to those most likely to be impacted and do a better job of overcoming the cultural and hesitancy barriers that exist in those communities."

The recommendations are unchanged because the problems are unchanged. Increase investments in mobile, pop-up, and community-based healthcare delivery. Provide culturally competent care that meets people where they are. Address provider knowledge gaps through comprehensive education. Eliminate technology-dependent barriers to vaccine access. Collect complete demographic data to track and address disparities. Hold health departments accountable for being "responsive, creative, and careful as community members and advocates identify potential cases and outbreaks."

The Choice We Face

These are early days of this outbreak. But the October 2025 California cases represent something no other country has reported: Clade I mpox transmission without international travel links. Sweden, United Kingdom, Germany, Thailand, Australia all successfully prevented community transmission when they detected imported cases through rapid surveillance, contact tracing, and adequate public health capacity. No wider community transmission occurred in any of these countries.

The California cases emerged during a 22-day federal shutdown, with CDC operating at 37% staffing. State health departments report "nobody to answer the phone" when they need federal expertise. Whether this degraded capacity contributed to these cases spreading undetected, or whether it will hamper efforts to contain them, remains to be seen.

Whether California can contain these three cases depends on rapidly closing vaccination gaps in communities with lowest coverage and highest risk, restoring adequate federal public health capacity to support state and local response, and implementing the equity-centered strategies that worked in 2022 but were never sustained. The infrastructure to accomplish these goals did exist.

Three cases with no identified connections between them and no clear source of transmission suggests either multiple introductions or undetected spread. The systems that failed to prevent these cases being the first domestic transmissions must now prove they can contain them. The question is whether they still have the capacity to do so.