The Fading of the Mpox Outbreak Among Men Who Have Sex With Men: A Mathematical Modelling Study

Background In the Netherlands, the number of mpox cases started declining before mpox vaccination was initiated. Most cases were men who have sex with men (MSM). We investigated whether the decline in mpox could be attributed to infection-induced immunity or behavioral adaptations.Methods We developed a transmission model and accounted for possible behavioral adaptations: fewer casual partners and shorter time until MSM with mpox refrain from sexual contacts.Results Without behavioral adaptations, the peak in modelled cases matched observations, but the decline was less steep than observed. With behavioral adaptations in the model, we found a decline of 16%-18% in numbers of casual partners in June and 13%-22% in July 2022. Model results showed a halving of the time before refraining from sex. When mpox vaccination started, 57% of MSM with very high sexual activity in the model had been infected. Model scenarios revealed that the outbreak could have waned by November 2022 even without vaccination.Conclusions The limited duration of the mpox outbreak in the Netherlands can be ascribed primarily to infection-induced immunity among MSM with high sexual activity levels. The decline was accelerated by behavioral adaptations. Immunity among those most sexually active is essential to impede mpox resurgence. Modelling study shows that the decline in mpox cases among MSM in the Netherlands was primarily due to infection-induced immunity among those with high sexual activity levels and accelerated by behavioral adaptions. The outbreak could have faded even without vaccination.