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Monkeypox

Monkeypox outbreak debacle: “Failure to communicate & vaccinate”

“The question is when will we ever learn that a small investment in prevention & surveillance is worth a pound of cure?”

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Los Angeles Blade graphic via Microsoft Bing of the global Monkeypox outbreak as extrapolated from CDC data & WHO data

LOS ANGELES – Directly linked as the epi-centres for the outbreak of the current global Monkeypox virus, which occurred in the latter part of May this year, were a Gay Pride event in the Spanish Canary Islands, the Darklands fetish festival in Antwerp, Belgium, and raves in Berlin, Germany and Madrid, Spain.

The common denominator for all of those persons affected by the viral outbreak was that they were gay or bisexual men. The number of the first recorded cases was less than ten individuals infected per event, but since then the number has grown exponentially and spread rapidly. As of July 19, 2022 globally there are 14, 511 cases in over 70 countries according to the latest data from the World Health Organization, (WHO).

In the United States on July 19, 2022, according to the Centers for Disease Control and Prevention‘s National Center for Emerging and Zoonotic Infectious Diseases the case count was 2,108.

Leading the number of cases were New York with 581, California with 267, Illinois with 200, Florida with 180, Georgia with 132, and the District of Columbia with 126. CDC reported that the metropolitan areas of New York City, San Francisco, Los Angeles, Chicago, Miami-Dade, Atlanta plus Washington D.C. with their high concentrated populations of gay and bisexual men accounted for the majority of the case counts.

While the primary transmission is intimate bodily or personal contact such as a kiss, WHO clinical researchers were able to determine that in numerous cases in Europe the viral DNA was detected in seminal analysis defining sexual transmission as another means of infection.

The Blade communicated with Dr. David Heymann, an American infectious disease epidemiologist and public health expert, based in London, UK who was formerly Executive Director of WHO’s communicable diseases cluster. Heymann pointed out that “We know monkeypox can spread when there is close contact with the lesions of someone who is infected, and it looks like sexual contact has now amplified that transmission.”

Last week, WHO Director-General Tedros Adhanom Ghebreyesus told reporters that the U.N. agency will reconvene a meeting of the committee that will advise on declaring the outbreak a global health emergency this week when it meets in Geneva, Switzerland on Thursday.

Ghebreyesus also pointed out that a lack of testing meant that there were likely many more cases going unreported. “I continue to be concerned by the scale and spread of the virus across the world,” the Director-General said.

In the U.S. CDC Director Rochelle Walensky told reporters late last week in a virtual press briefing that five commercial laboratory companies would soon begin offering monkeypox testing.

“The ability of commercial laboratories to test for monkeypox is an important pillar in our comprehensive strategy to combat this disease,” said Walensky. “This will not only increase testing capacity but also make it more convenient for providers and patients to access tests by using existing provider-to-laboratory networks.”

The CDC Director said that the Mayo Clinic Laboratories has begun testing for monkeypox using CDC’s orthopoxvirus test, which detects most non-smallpox related orthopoxviruses, including monkeypox. On Monday of this week, the CDC announced that Sonic Healthcare USA (Sonic) will also begin testing for monkeypox using CDC’s orthopoxvirus test.

Photo Credit: CDC

Monkeypox overview:

  • Monkeypox is a viral infection that can cause a flu-like illness and characteristic rash. The pathogen that causes this infection is an Orthopoxvirus, “the same genus as the virus that causes smallpox,” according to MDH, though it is “less severe.” The rash can develop into fluid-filled bumps that eventually scab over. The illness can last three to four weeks.
  • Monkeypox is a bit of a misnomer. It doesn’t mainly occur in monkeys. Rodents are the likeliest source, but the virus can leap to other species, including humans. Those who are infected can transmit it to other people. Before now, monkeypox infections have mainly occurred in some African countries.
  • Severe illness can occur, but perspective is crucial. Global health officials list the case fatality ratio at 3-6%, which may reflect a lack of access to medical care in countries where monkeypox is endemic. The WHO said no deaths had been reported in the 2022 outbreak outside of Africa. In addition, the current outbreak appears to be caused by a monkeypox “clade,” or strain, less likely to cause severe illness.
  • Two critical things to know about the rash: As more people are infected, we are learning that the rash can be “very, very painful,” though, in others, it might not be very noticeable, health officials said. In addition, people remain infectious until scabs heal and healthy new skin appears. People should be off work and take other precautions until they heal.
  • How monkeypox spreads in humans: “Direct contact with body fluids or skin lesions (i.e., skin-to-skin contact) is the most common mode of human-to-human transmission,” state health officials advise. “Transmission via respiratory particles can also occur but usually require prolonged face-to-face contact.” To be even clearer: Sexual activity provides a setting where this contact can occur, facilitating viral spread. Transmission can also occur if someone wears or uses an infected person’s clothing, bedding or towels. While anyone can get monkeypox, risk increases with “multiple or anonymous sex partners,” according to the CDC.
  • Time frame from exposure to symptoms: Twelve days is often when people start feeling sick after becoming infected, but symptoms could appear anywhere from five days to 21 days afterward.
  • A vaccine and antivirals are available: Health officials said the vaccine could “actually stop the disease” if given within four days of exposure. It can still mitigate the illness if given up to 14 days later. Prescription drugs such as TPOXX (tecovirimat) may also be beneficial.

As the outbreak rolled on in June and into early July criticism and questions begun to be raised over vaccines and testing. In New York City, an Out gay medical resident and PhD candidate Lala Tanmoy (Tom) Das noted in an op-ed written for CNN:

“The demand outpacing supply is a problem we could have prevented; demand was and is largely predictable as cases in the US are still mostly limited to men who have sex with men (MSM) — many of whom self-identify as gay, bisexual or transgender. And studies consistently show that LGBTQ individuals are much more likely to get vaccinated than our heterosexual peers — including getting the Covid-19 vaccine.”

Bavarian Nordic company headquarters in the Hellerup suburb of Copenhagen, Demark
(Photo Credit: Bavarian Nordic)

The JYNNEOS Smallpox (Monkeypox) Vaccine is manufactured solely by the Danish Bavarian Nordic A/S company in Denmark. Since 2010, The company has manufactured its liquid-frozen MVA-BN smallpox vaccine and has supplied doses to the U.S. Strategic National Stockpile (SNS) for emergency use.

However there has been greater demand than supply. The United States has distributed about 156,000 monkeypox vaccine doses nationwide, including more than 100,000 doses in just the past week. The CDC Director noted “We are actively working to increase supply… update our strategy to make sure we are using our current supply strategically,” she said.

Part of the problem was that the U.S. Food & Drug Administration, (FDA) was slow in signing off on approval of a facility “We were beginning the process of pre-positioning those doses in the US, but they will be available pending the FDA clearance of the facility expected by the end of July,” Walensky said.

Political leadership was quick to point out that the Federal response was anemic and lacking impetus. California State Senator Scott Wiener blasted federal agencies over the apparent lack of preparedness and the recent lessons gained from the coronavirus pandemic.

“We need to be very clear where the responsibility lies for this completely avoidable situation: the federal government. As far back as 2010, public health experts were warning that it was inevitable that monkeypox would spread beyond West Africa. And in 2019, the FDA approved a safe and effective monkeypox vaccine. Yet, the United States government ordered a mere 56,000 vaccine doses (enough for 28,000 people) for the national vaccine stockpile and failed to order the millions of doses that should have been ordered in preparation for an inevitable outbreak. … We need an enormous amount of additional vaccine doses, and we need it immediately. The federal government’s failures are threatening to deeply harm our community. Once we move past this emergency, we need accountability for these failures — failures that put people’s lives and health in jeopardy.” 

In a letter sent to U.S. Health and Human Services Secretary Xavier Becerra on Tuesday, U.S. Representative Adam B. Schiff (D-CA28), who represents portions of Los Angeles including the city’s traditionally LGBTQ+ neighborhoods,  expressed serious concerns regarding the federal response.

The demand for monkeypox vaccinations across the country far outweighs supply, with members of at-risk communities reportedly being turned away at vaccination sites due to limited supply. Public health experts estimate that confirmed cases reported by the Centers for Disease Control and Prevention (CDC) vastly underrepresents the true number of cases due to limited access to testing. I am deeply concerned that the approximately 7 million doses of the JYNNEOS vaccine acquired by the United States will not meet the sky-rocketing demand,” Schiff wrote.

The current supply of the two-dose vaccine regimen accounts for only 3.5 million residents in the United States. With some shipments of the vaccine not expected to arrive until well into 2023, the current federal vaccination strategy falls short in terms of supply and timeliness. I urge HHS, in coordination with the Food and Drug Administration (FDA) and the Biomedical Advanced Research and Development Authority (BARDA), to draw upon lessons learned during the Covid-19 pandemic and use the full power of the executive branch to increase manufacturing and distribution of the JYNNEOS vaccine across the country as quickly as possible.”

The other considerations being overlooked say LGBTQ+ health care advocates and political leaders are the confusing and somewhat impossible labyrinthic requirements for getting a vaccine.

There is also a lack of a unified approach to containment and prevention. Rep. Schiff warned that more needed to be done:

I strongly encourage HHS to develop and implement a comprehensive, long-term strategy to combat the spread of the monkeypox virus in the United States. Sky-rocketing cases and limited vaccination supply world-wide suggests that the monkeypox virus will continue to spread for years to come, if not indefinitely. The HIV crisis and Covid-19 pandemic have demonstrated it is critical that public health officials be forward-thinking in combatting the spread of viral infections – particularly in instances when marginalized communities, such as the LGBTQ+ community, are hardest-hit. It is imperative that HHS consider, develop, and implement a public health strategy that will ensure access to monkeypox testing, vaccination, treatment, and provider education for years to come.”

The AIDS Healthcare Foundation’s President Michael Weinstein in a press conference last week said that “regardless of what term is used by WHO, monkeypox is a pandemic. …the effort at every level of government is failing to address it.”

Rick Zbur, the former Executive Director of Equality California also agreed with Weinstein’s assessment especially as far as the response by the Los Angeles Department of Public Health,(LADPH) in dealing with the building crisis.

“[LADPH] has been making it difficult to obtain the vaccine – let alone information. There’s no human interface just the 211 system which leads into a confusing set of menus and then nothing clearly labeled as monkeypox related,” Zbur said. ” If you do get through to a human then you may end up waiting six hours on hold- in some cases literally,” he added.

The other issue is that the LADPH has focused on its own system of clinics and appointment sites that exclude for the most part the neighborhoods of Los Angeles where the LGBTQ+ community lives- especially those most affected, gay, bisexual and Trans Angelenos.

“The people affected are in Silver Lake through Hollywood into West Hollywood and Downtown LA,” Zbur said. Yet one of the clinic locations is in Santa Clarita which is not accessible by transit systems and is a long commute, not to mention hardly a center for the LGBTQ+ population. “There aren’t walk-in clinics for testing and then there are up to 2 hour potential travel times for some LGBTQ+ people,” Zbur pointed out.

AHF’s Weinstein argued that the current monkeypox spread is part of the country’s larger failure to prevent and treat STIs, and that many individuals who test positive for monkeypox also test positive for other STIs.

“The question that I keep coming back to is when will we ever learn that a small investment in prevention and surveillance is worth a pound of cure?” Weinstein said. “We need to put the public back in public health.”

Zbur, Weinsten, and Weiner all pointed out that historically because of the HIV/AIDS pandemic the LGBTQ+ community already had the resources and clinical healthcare infrastructure in place to best serve the very community that is disproportionately affected by the outbreak.

Zbur noted that while unlike the HIV/AIDS pandemic there is a vaccine, the lackluster response by government especially that while the agencies like LADPH may see their distribution and testing as equity driven, the truth is that with the central community affected being the LGBTQ+ community their response is mismatched with the reality of the outbreak.

“This is a disruption of normal lives for our community- for entering into intimate relationships or even attending events shirtless or in a tank-top,” Zbur said. LADPH and others need to refocus and take into account our community, and more so where our community actually lives,” he added.

Eligibility and vaccine distribution also needs to be better thought out Zbur said, a point stressed by Dr. Lala Tanmoy (Tom) Dasin his op-ed to CNN.

We also need to supplement the current approach in many cities of first-come-first-served, online-only scheduling portals with pre-registration (like Washington, DC is doing) and walk-in options. As we witnessed with the Covid-19 vaccine rollout, the online, first-come-first-served system disadvantages anyone who has work or other obligations that prevent them from getting online the minute appointments are released, as well as people with unstable housing who don’t often have access to digital technology.

In terms of information, AHF noted:

  1. The Los Angeles County Department of Public Health should conduct twice weekly public briefings outlining the number of new cases and where they are occurring.                                                  
  2. Warnings to the gay and bisexual male population should be launched online, in newspapers and in outdoor advertising advising men to watch for symptoms; avoid group sexual situations; consult a doctor if you have symptoms indicative of monkeypox, and isolate if you are diagnosed.
  3. Require signs to be posted in commercial sex venues and via banner or other ads on hookup applications.
  4. Lobby the federal government to supply vaccine on an emergency basis.  
  5. Regularly engage community partners to assist the Department of Public Health in prevention, testing, vaccination and treatment of monkeypox.
  6. Engage universities to initiate studies to determine the changed characteristics of monkeypox in the current pandemic.
Monkeypox victim (Photo courtesy of the Ministry of Health of Argentina)

On Tuesday the LADPH released its latest updates:

With the arrival of an additional 9,000 JYNNEOS doses late last week and an additional 7,000 doses arriving later this week, the Los Angeles County Department of Public Health (Public Health) is expanding eligibility for the monkeypox vaccine to include additional residents at higher risk of exposure.  

Beginning tomorrow, Wednesday, July 20, monkeypox vaccine will be available for gay men, bisexual men, men having sex with men, and transgender persons who:

  • Were diagnosed with gonorrhea or early syphilis within the past 12 months; or
  • Are on HIV pre-exposure prophylaxis (PrEP); or
  • Attended or worked at a commercial sex venue or other venue where they had anonymous sex or sex with multiple partners (e.g., saunas, bathhouses, sex clubs, sex party) within past 21 days.

Residents who fall under these eligibility requirements can get vaccinated several ways:

  1. Contacting their doctor or healthcare provider to find out if they are a monkeypox vaccine provider. If they are a vaccine provider, eligible residents can request an appointment with their provider to get vaccinated. Providers that are registered to administered vaccine may also reach out to patients who are thought to be eligible to invite them to get vaccinated.
  2. Visiting a Public Monkeypox vaccine location with their ID and provide one of the following:
    1. Proof of gonorrhea or early syphilis infection in the last 12 months in the form of a lab report (the proof can be shown from your phone, including a screenshot of the result or within a patient portal; OR
    2. monkeypox provider attestation form completed by your doctor; OR
  3. Being invited to get vaccinated after receiving a text message with their name from the Los Angeles County Department of Public Health.

Residents who meet any of the eligibility criteria can fill out a sign-up form by visiting ph.lacounty.gov/monkeypoxsignup and providing their name, date of birth, and eligibility information to get on a list to receive vaccine if they meet the eligibility criteria and vaccine is available. Residents can also indicate locations that are most convenient for them to get vaccinated.

Those without access to the internet or needing help with registration, can call 2-1-1 for assistance.

Public Health will continue to provide monkeypox vaccines by invitation only to the following persons identified through public health investigation, including:

  • Persons confirmed by Public Health to have had high- or intermediate-risk contact with someone with monkeypox, as defined by CDC.
  • Persons who attended an event or venue where there was high risk of exposure to an individual(s) with confirmed monkeypox virus through skin-to-skin or sexual contact. Public Health will work with event/venue organizers to identify persons who may have been present and at risk of exposure while at the venue.

Public Health or clinic partners will directly communicate to those identified as being close contacts to a confirmed case to provide details on how and where to access the JYNNEOS vaccine.

For more information, please visit: http://publichealth.lacounty.gov/monkeypox/    

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Monkeypox

LA County Public Health expands Monkeypox vaccination eligibility

Eligible residents can go to a Public vaccinating site or visit Myturn.ca.gov to find other vaccinating sites near you

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Photo Credit: County of Los Angeles

LOS ANGELES – The Los Angeles County Department of Public Health has expanded eligibility to the monkeypox vaccine to closely align with the Centers for Disease Control and Prevention’s recent expansion, which includes persons in select occupational groups whose jobs may expose them to orthopoxviruses (such as monkeypox).

Monkeypox vaccine will be available to residents who self-attest to being in the following groups:

  • Gay, bisexual or other men who have sex with men or transgender people who have sex with men or other transgender people
  • Persons of any gender or sexual orientation who engage in commercial and/or transactional sex
  • Persons living with HIV, especially persons with uncontrolled or advanced HIV disease
  • Persons who had skin-to-skin or intimate contact with someone with suspected or confirmed monkeypox, including those who have not yet been confirmed by Public Health
  • (NEW) Sexual partners of people in any of the above groups
  • (NEW) People who anticipate being in any of the above groups

Monkeypox vaccine is also available for persons in select occupational groups whose may be exposed to orthopoxviruses including:

  • Research laboratory personnel working with orthopoxviruses
  • Clinical laboratory personnel performing diagnostic testing for orthopoxviruses
  • Designated public health response team members
  • Health care personnel who administer ACAM2000 (Smallpox [Vaccinia] Vaccine)
  • Designated health care workers who care for persons with suspected or confirmed orthopoxvirus infections, including clinicians and environmental services personnel

Note that the risk of monkeypox transmission remains very low for health care workers if appropriate personal protective equipment is worn and other infection control practices are followed.

Eligible residents can go to a Public vaccinating site or visit Myturn.ca.gov to find other vaccinating sites near you.

Residents do not need to show ID in order to get a vaccine at sites run by Public Health. However, because residents may need to show vaccination record and ID if you travel or visit certain venues, it is recommended that when getting a vaccine that residents provide the name that is on their ID.

Residents who met prior eligibility criteria can still get vaccinated (see below for prior criteria).

Gay or bisexual men or transgender people who:

  • Had multiple or anonymous sex partners in the past 14 days
  • Had skin-to-skin or intimate contact with persons at venues or events in the past 14 days
  • Had a history of early syphilis or gonorrhea in the past 12 months
  • Are on HIV pre-exposure prophylaxis (PrEP)
  • Had anonymous sex or sex with multiple partners in the past 21 days in a commercial sex venue or other venue.

Residents who have monkeypox symptoms or are currently under isolation for monkeypox, should not come to the vaccination clinics or walk-up sites. If residents think they have monkeypox, they should speak with a provider and get tested. If residents do not have a provider, residents can call the Public Health Call Center for more information on monkeypox, including general information, testing, treatment, and vaccines at (833) 540-0473 (open 7 days a week 8am – 8:30pm).

For more information, please visit: http://publichealth.lacounty.gov/monkeypox/.   

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Monkeypox

Los Angeles County Supervisors approve sick leave for monkeypox

Both coronavirus and the monkeypox outbreak has disproportionately affected essential workers, who are predominantly Black and Latino

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The Los Angeles County Board of Supervisors meeting room (Photo Credit: County of Los Angeles)

LOS ANGELES – The Los Angeles County Board of Supervisors unanimously passed a motion Tuesday, sponsored by Supervisors Hilda Solis and Sheila Kuehl, which directs County attorneys to report back to the board in three weeks on how the County could implement a paid sick leave policy for people who contract monkeypox, or other new and emerging infectious diseases.

The Board also is urging California Governor Gavin Newsom to extend the state’s coronavirus supplemental paid sick leave by signing the AB-152 COVID-19 relief leave bill.

Supervisor Solis prior to the vote pointed out that both coronavirus pandemic and the monkeypox outbreak has disproportionately affected essential workers, who are predominantly Black and Latino.

Solis further noted that without a form of paid sick leave, are in most cases, unable to take the recommended five to 10 days to isolate for COVID-19 — much less the two to four weeks needed to isolate for the duration of a monkeypox diagnosis as recommended by the Centers for Disease Control and Prevention as well as the County Dept. of Public Health .

During a monkeypox townhall hosted by the Blade in East Los Angeles last week, which was also attended by Supervisor Solis, Sherrill Brown, M.D, AltaMed’s Medical Director of Infection Prevention, in her presentation noted the need for economic relief.

In her practice treating primarily Latino monkeypox cases at AltaMed clinics in Los Angeles and Orange Counties, she told the townhall attendees she was hearing some of her patients were having difficulty with the required isolation protocols because of their economic needs.

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Monkeypox

Unvaccinated 14 times more likely to contract monkeypox

Racial disparities persist in new cases of monkeypox as Black & Latino people are overrepresented in the numbers

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White House Monkeypox Response Team and Public Health Officials (Screenshot/YouTube)

WASHINGTON – U.S. health officials are celebrating preliminary data on the vaccine used in the monkeypox outbreak, which has led them to conclude eligible persons who didn’t get a shot were 14 times more likely to become infected than those who are vaccinated.

The new data, as described by health officials on the White House monkeypox task force during a call with reporters on Wednesday, comes as the overall number of new cases of monkeypox is in sharp decline, although considerable racial disparities persist in the remaining cases as Black and Latino people are overrepresented in the numbers.

Rochelle Walensky, director of the Centers for Disease Control & Prevention, said during the conference call the preliminary data — collected from 32 states between July 2022 and September 2022 — provides an early shapshot of the effectiveness of the vaccine and cause for optimism on the path forward.

“These new data provide us with a level of cautious optimism that the vaccine is working as intended,” Walkensky said. “These early findings and similar results from studies and other countries suggest even one dose of the monkeypox vaccine offers at least some initial protection against infection.”

Walensky during the conference call admitted the data is incomplete in numerous ways. For example, the data is based on information on individuals who have obtained only the first shot as opposed to both shots in the two-shot vaccination process. (The data showing positive results from individuals who have only one shot contradicts previous warnings from the same U.S. health officials that one shot of the monkeypox vaccine was insufficient.)

The data also makes no distinction between individuals who have obtained a shot through subcutaneous injection, a more traditional approach to vaccine administration, as opposed to intradermal injection, which is a newer approach adopted in the U.S. guidance amid the early vaccine shortage. Skeptics of the new approach have said data is limited to support the idea the intradermal injection is effective, particularly among immunocompromised people with HIV who have been at higher risk of contracting monkeypox.

Not enumerated as part of the data were underlying numbers leading health officials to conclude the unvaccinated were 14 times more likely to contract monkeypox as opposed to those with a shot, as well as any limiting principle on the definition of eligible persons. Also unclear from the data is whether individual practices in sexual behavior had any role in the results.

Despite the positive data on the monkeypox vaccine based on one shot, U.S. health officials warned during the conference call the two-shot approach to vaccine administration is consistent with their guidance and more effective.

Demetre Daskalakis, the Biden administration’s face of LGBTQ outreach for monkeypox and deputy coordinator for the White House monkeypox task force, made the case that for individuals at risk obtaining a second dose is “really important.”

“So we see some response after the first [shot] in the laboratory, but the really high responses that we want to really get — that you know, level 10 forcefield as opposed to the level five forcefield — doesn’t happen until the second dose,” Daskalakis said. “So the important message is this just tells us to keep on trucking forward because we need that second dose at arms that people haven’t gotten the first should start their series of two vaccines.”

Also during the call, health officials said they would be expanding opportunities for vaccines as pre exposure prophylaxis, as opposed to practices in certain regions granting vaccines in their limited supply to individuals who meet certain criteria or have had risk of exposure.

The Centers of Disease Control & Prevention, officials said, is also updating its guidance to allow injection of the vaccines in places other than a patient’s arm.

Daskalakis said fear of stigma about getting a noticeable shot in the forearm after obtaining a monkeypox vaccine was a key part of the decision to issue the new guidance on implementation.

“Many jurisdictions and advocates have told us that some people declined vaccine to monkeypox because of the stigma associated with the visible but temporary mark often left on their forearm,” Daskalakis said. “New guidance from CDC allows people who don’t want to risk a visible mark on their forearm to offer a vaccine on their skin by their shoulder or their upper back. Those are areas more frequently covered by clothes.”

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