The ongoing monkeypox outbreak has slowed dramatically in the United States and Europe after peaking in late summer, but health officials and advocates say it’s too soon to declare victory. Centers for Disease Control and Prevention (CDC) director Rochelle Walensky, MD, says she is “cautiously optimistic,” but adds, “we are not done with this fight.”


The United Kingdom, which saw the first cases of this outbreak in May, was also the first to report that it had peaked. The same pattern repeated itself in the U.S. and Europe as countries and cities with early surges recorded declines. In late August, the World Health Organization reported that new cases had fallen by 21% worldwide. But while New York City, Chicago and San Francisco, among others, saw large drops, smaller U.S. cities, rural areas and countries in Latin America continued to see rising case numbers.


Five months into the outbreak, monkeypox still overwhelmingly affects men who have sex with men; cases among women and children remain uncommon. Like HIV, monkeypox has shifted toward communities of color and the South. About 40% of people with monkeypox are living with HIV. Black and Latino men now account for around two thirds of cases nationwide, but they have not received their fair share of vaccines.


The overall decline in new cases is attributable to multiple factors, including sexually active gay men developing immunity after infection and the rollout of vaccines. According to a preliminary CDC analysis, vaccinated men were 14 times less likely to contract monkeypox than eligible men who were not vaccinated. Behavior change also plays a key role: A CDC survey found that half of gay men had made changes, such as having fewer sex partners.


Early adopters in large cities lined up throughout the summer to score scarce shots, but efforts are now focused on getting vaccines to others at risk, including people who may not identify as gay and those who are not connected to sexual health services. “Now we really have the hard part of the job to do,” says deputy national monkeypox response coordinator Demetre Daskalakis, MD.


Some health experts think monkeypox could be nearly eliminated in the U.S. and Europe, but others predict it will continue to circulate at a low level indefinitely, especially in vulnerable communities. Some fear it could become endemic, as it is in African countries that have dealt with monkeypox for decades but do not have access to vaccines or treatments.