Three urgent questions about monkeypox: spread, vaccination, treatment

Monkeypox, once a relatively obscure virus endemic to Africa, has grown into a global threat, infecting more than 20,000 people in 75 countries and forcing the World Health Organization to declare a global public health emergency.

On Thursday, New York State and San Francisco declared their own states of emergency. But even as the national tally approaches 5,000 cases and experts warn that containment is easing, federal health officials have not followed suit.

One reason: This virus — unlike the coronavirus — is a known enemy, officials say. Doctors understand how it spreads, and tests, vaccines, and treatments already exist.

But for scientists, the accumulating research presents a more complicated and challenging picture. The virus remains somewhat of a mystery and doesn’t behave exactly like researchers have seen in sporadic outbreaks in African countries.

Scientists are trying to answer three questions in particular that will determine how quickly – if stopped at all – monkeypox can be stopped.

At the beginning of the outbreak, health officials claimed the virus was spread through respiratory droplets released when an infected person coughs or sneezes and through close contact with pus-filled skin lesions or bedding and other contaminated materials.

All of that was true. But it may not be the whole picture.

According to the Centers for Disease Control and Prevention, more than 99 percent of those infected to date are men who contracted the virus through intimate contact with other men. As of July 25, only 13 women and two small children had been diagnosed with monkeypox.

Researchers have found the virus in saliva, urine, feces and semen. It’s unclear whether these fluids can be infectious, and specifically whether the virus can be transmitted during sex other than through close skin-to-skin contact. But the pattern of distribution so far along sexual networks has given researchers pause for thought.

However, it is clear that monkeypox does not spread easily and has not yet spread to the rest of the population. For example, the average person is not at risk from store-bought clothes or from a cursory interaction with an infected person, as some social media posts suggest.

According to the CDC, people without symptoms cannot spread monkeypox. But at least one study has detected the virus in men who have had no symptoms. The pattern of symptoms also differs from that seen in previous outbreaks.

In Africa, some people became ill after touching infected animals, consuming bushmeat, or using medicines made from the animals. They often got fever and body aches, followed by a characteristic rash first on the face, palms and feet and then all over the body. Infants and pregnant women appeared to be at the highest risk for severe symptoms.

In the outbreak outside Africa, many patients have no fever or difficulty breathing at all, and the rash is often limited to a few genital or rectal lesions that can easily be mistaken for various sexually transmitted infections.

The UK has now changed its official description of monkeypox to include lesions in the mouth and anal or rectal pain and bleeding. Some scientists have speculated that the depiction of the disease in Western countries may accurately reflect the natural history of the virus.

Jynneos, the safer of two monkeypox vaccines, is made by Bavarian Nordic, a small company in Denmark. Supplies were severely restricted, and the Biden administration was slow to move to get additional doses as the virus spread.

Now federal officials have ordered nearly seven million doses, which will arrive in batches over the next few months. So far, the government has shipped about 320,000 doses to states. The Food and Drug Administration said Wednesday it had approved an additional 800,000 doses, but it was unclear when they would be distributed.

Jynneos is to be given in two doses 28 days apart. However, some cities, including Washington and New York City, are holding back second cans until more are available, mimicking a strategy adopted by Britain and Canada.

Federal health officials have advised against postponing second doses. But in studies, a single shot of Jynneos seems to protect for up to two years. If this finding is true in the real world, delaying additional vaccinations may help officials contain the outbreak by getting more Americans vaccinated.

Britain withheld second doses of the Covid vaccine early in the pandemic when supplies were low, noted Tinglong Dai, a vaccine supply expert at Johns Hopkins University. “The benefit of prioritizing the first doses outweighs the risk,” he said.

There may not be much choice as permission expands and more vulnerable people seek recordings. Some jurisdictions have already expanded vaccine-eligible groups to include sex workers, sexual health clinic patients, and clinicians and other workers who may be exposed to the virus at work.

In Rhode Island, Emily Rogers, a 29-year-old medical anthropologist, said she could call the local health department and get an appointment “very, very quickly.”

Ms Rogers qualified for the shot because she sometimes has sex with men who are at high risk of monkeypox infection. No one questioned their suitability. “They weren’t weird about it at all — it was a very smooth process,” she said.

Because of the shortage, the vaccine is only offered as a preventive measure, although it can relieve symptoms if given within days of exposure.

David Baldwin, 45, a music professor in New York, only qualified for the vaccine because doctors didn’t believe he was already infected. (His first symptom was rectal pain.) “As a result, I don’t think I’ve ever developed any lesions on my body,” he said.

In 2018, the FDA approved a drug to treat smallpox called Tecovirimat, or TPOXX, based on data from animal studies. There are limited data on human use.

Supply isn’t a problem: the national stockpile holds about 1.7 million doses. However, the drug has been difficult to obtain and this has led to a lack of clarity about how well and for whom the drug works, even as case numbers are rising.

Because tecovirimate isn’t specifically approved to treat monkeypox, it can only be prescribed through a cumbersome “investigation protocol,” which until recently required doctors to provide the CDC with detailed reports, a diary kept by patients to track their progress, and photos send the lesions.

With so many hurdles, many clinics did not offer Tecovirimat at all; Even doctors in well-funded facilities managed to treat only two or three patients a day.

Nephi Niven Stogner, 39, sought help for monkeypox symptoms on July 8. He was in excruciating pain and tried to get tecovirimat, but was told that others were sicker and needed it more.

While waiting for the drug in isolation, three new lesions appeared on his back. “It’s like getting your sentence extended,” he said.

Mr Stogner finally got his first dose on July 21st. Within 24 hours, “his lesions went from swollen and red to flat, dark patches,” he said.

Such delays prompted the CDC to relax rules on access to Tecovirimat. The agency now requires fewer patient visits, samples and forms, and allows physicians to assess patients virtually.

Wider application should mean that scientists and public health officials gain a better understanding of the drug’s effectiveness. The new requirements will help the CDC “determine whether and how well this drug works in monkeypox patients,” noted Kristen Nordlund, a spokesman for the agency.

The National Institute of Allergy and Infectious Diseases is planning a clinical trial of tecovirimat in adults infected with monkeypox, including people with HIV, that could begin this fall. The agency is collaborating with Siga Technologies, the maker of the drug, on another trial in the Democratic Republic of Congo, where the virus has long been a scourge and is also expected to start this fall.

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