While Debby Birx worked in the Army with Redfield, my impression of him has never been much better than "ideologue". When he took over CDC, the organization hemorrhaged experienced people who could have retired years before but were the basis for a lot of the good science. But it's not all Redfield's fault, although he didn't start turning the response around until it was obvious he couldn't ignore any longer, nor accept political direction. The directorship at CDC was transitioned to a political appointment over 20 years ago. It needs to go back to a professionally derived position. That could restore some confidence and autonomy to the group.
I learned, in the initial days of the AIDS outbreak that it was dangerous to claim, as a lot of us did, that, "This is only a disease of gay men." I'm concerned that we have to raise the alarm that there can and will be spill-over into the general population, as we saw with HIV. I remember the day we shifted from no precautions to universal precautions to enter a patient room (and at one point, to enter an entire ICU in my hospital) after one of our providers suffered a needle stick and became ill (no, it wasn't a short time... but with a doc in the ICU who wasn't a gay man, it started changing the complexion of the disease for us. The spill-over for HIV/AIDS wasn't immediate, but did occur.
Solely identifying MPV as a MSM disease will diminish the awareness in the rest of the population. I suspect there's already community cases that have escaped that subgroup (we know of 2 kids and a pregnant woman; how many more?) but since we're not up to speed on testing (again but it's better handled this time) it'll take a bit to establish R(0) and the initial case load.
Disagree in a friendly way. Public distrust of authority and "experts" has always been a continuing bass note in American thought. Nothing new there. We Americans cherish anti-intellectualism like very few other industrialized countries. When it comes down to it, even hard data is put through that filter.
Hi Larry, My perception is that there is a sizable segment of the population that is inclined to distrust the medical establishment no matter how perfectly the latter perform or whether damning revelations are publicized or not. I think the term was "medical tyranny." I tend to trust authority, but not require of it perfection.
But don't let the perfect be the enemy of the good. As Lucillius said, "O quantum est in rebus inane.". What folly there is in human affairs. All our endeavors have a certain ramshackle, improvisatory aspect to them..public health is no exception!
There were, indeed, political decisions made. Some were made at CDC, but most were make at a higher level and promulgated by CDC and FDA. Hahn at FDA had a stellar record before taking a politicized job. He bowed to pressure several times but usually corrected pretty quickly. Redfield was, in my opinion, a somewhat bigger problem, but again, when Nancy Messonnier was thrown under the bus for stating the obvious (at least to those studying the pandemic already) Redfield failed to protect her and went along with sidelining her permanently.
What we needed to do was communicate the science in a manner that was unambiguous and understandable, but... both are hard, and the first is almost impossible when the mis-/disinformation process is already in full swing. You might find https://www.newyorker.com/magazine/2021/01/04/the-plague-year an interesting read.
It would appear that now there is a better understanding how political the past 2 years have been. You appear to know more
About what is happening in the trenches while common folks saw and see that science is not taking a priority.
My fear and YLE clearly articulate that peoples feelings are invoked in MP.
For me this is over reach.
Smoke cigarettes is as dangerous and as avoidable as MP. In fact M0 is more avoidable than quitting smoking since it’s a chemical dependance not a voluntary act.
In the past medical treatments were attempting to stop the cause instead of mitigate the effect.
I take issue with the presentation of MP as anything but what is so far presents as - a STD in the gay community. In fact,a good case can be made that if it spread to the whole population that it incubated in the gay community due to dangerous behaviors not happenstance. That’s as of today.
Stigma ? Worrying about stigma or
Dead people? apparently much of the public health officials are worried about stigma. (BTW this political sensitivity is destroying our military- recruitment is down 40% this year)
I've had a clinical background at several levels, so I should know more about what's happening in the trenches. And over my career(s) I've met some people who are influential today, so I often get their impressions early on.
Science is, indeed, taking a priority when we attempt to deal with this new emergency as best we can. One of the shortfalls is, indeed, political. We need more vaccines in this country and in the hands of health departments and providers. But the stores of MPV vaccine are relatively small overall, and that's political as well. Countries in Africa generally fall into the middle- or low-income range. It is incumbent on wealthier countries to assist with treating and preventing communicable diseases if for no other reason than self-preservation. That both recognized strains of MPV, one with a 10% mortality, are considered endemic in Africa only highlights that it's probably time to address this disease with a massive vaccination program there. And had we paid attention over the last 20 years we'd not be having this discussion because the wealthier nations, assuming cooler heads prevailed, would have accomplished this.
Peoples' feelings are involved, and like the original presentation of HIV/AIDS, people are likely to go, "STD for Gay Men", and promptly ignore it. That's MY fear.
For a variety of reasons, and assuming your premise that MPV infection is solely an STD, your analogy vice smoking is flawed. A chemical dependence is no less a driving force than the need in humans for physical intimacy. What we don't know is if barrier protection is effective (I suspect not), because that would be a good way to mitigate the impact.
We treat to mitigate as well as prevent. That's been the case for a long time, although I could reasonably argue insurance companies are less interested in preventative care than treating preventable diseases. That's a discussion for another time. However, I can assure you that counseling on abstinence, reducing partner count, and use of barrier protection are ongoing in an attempt to slow this process.
We keep coming back to "a STD in the gay community". HIV remains a worldwide problem regardless of sexual orientation. It's somewhat less prominent in the heterosexual community in the US, but this is a pretty small planet: We have to think outside of our little political enclave. It IS a problem in other areas of the world in other communities than solely the gay community. We've seen population outbreaks before. HIV/AIDS was first seen in the same community but since we couldn't SEE a virus we had a difficult starting point and plenty of bacterial confounders. The 1918 Flu outbreak was first seen in this country in Ft Riley, KS, if I recall correctly (at least en masse); note that it was called the "Spanish Flu" because Spain didn't hide statistics, while the US was worried about having the enemy learn of all the ill troops on our side and take advantage of the situation. Zika was first identified in Brazil, then Haiti.
We worry about stigma because stigmatized people will also be subject to poorer care to treat disease, and this creates an environment where, without appropriate care a disease can worsen underserved or perhaps stigmatized individual who was likely immunocompromised and thus didn't clear the original viral infection but was a fertile ground for modifications and substitutions, especially if they were reinfected before clearing the active virus.
And: Military recruiting is, indeed, down. But civilian unemployment is significantly lower, at least among those seeking jobs (and Veterans are likely to be in that group). We just ended a "war" and Congress determined the need for troops was significantly lower than before, so we entered a Reduction In Force period. The Services are offering bonuses to retain and recruit, now, because they have to compete with the private sector, and as the needs of the service are shifting, they need smarter, better and brighter folks: The same people business is recruiting, often with higher wages and better schedules (although it's really hard to beat MTF and Tricare for benefits).
You and I look at this through different lenses. I am, by nature, a pessimist: I look for what can go wrong, because I suspect it will, but then work hard to mitigate or prevent the adverse outcomes. You'll have to determine what your life view is. For me, expecting the worst and planning for it, while seen as odd by someone who hasn't seen what I've seen is odd, but overall, the people I've cared for benefited from such planning on my part.
And why do “ stigmatized people will also be subject to poorer care to treat disease,”?
I suggest that not know if condoms help is a serious failing of the healthcare community.
I would strongly disagree about smoking and sex. Smoking is chemical dependency and sex with multiple partners that is high risk for spreading a virus is downright selfish. Physical intimacy with multiple partners is as strong a need a chemical dependency is, on the face of it all, political pandering. Is that now a new conatituoright?
Back to not know if a condom protects - there is no excuse. You should be more outraged At that than no money for a
Vaccine. Mitigating the disease ( wear a mask and stand 6ft apart) should be more important than treating it.
Not wanting To mitigate MP is likely the
Politics. We wore useles masks and still require them in some schools today, that we know are ineffective.
Sorry - it’s all political pandering by the public health officials and in some way, you too appear, to tacitly support risky behavior as a need instead of a danger. I just don’t get it.
Thanks for the update. And, I look forward to your take on the vaccine round-table. But without funding, where does this go?
I'm concerned that we're looking at a longer-standing outbreak (recall this is a 2018-2019 trigger event) that went unnoticed in Europe and the US (or... worldwide). The latest manifestation is in the MSM population, but that could well be artifact. I had a discussion with our clinicians, most in primary care, and until the news started frequent discussions, they were unaware of the potential in the US and would not have had it on the differential diagnosis. When we add in the atypical presentation now being seen, that of a single lesion (often a genital lesion at this time), identifying it, and swabbing and sending the swab for viral culture would have been unlikely until the last 60 days or so in this country. Africa is different as it's endemic, highlighting the failure of the world to maintain adequate smallpox and monkeypox vaccinations.
There is ample evidence there is a respiratory component to transmission, during the prodromal phase when viral symptoms are the key feature, with a direct contact issue when lesions form.
This isn't as readily transmissible and the CFR is much lower than SARS-CoV-2, but identification of the problem has come very late and we're playing catch-up. I suspect we're 15x underreported, due to clinician unawareness and lack of test facilities.
While this has been seen and documented by CDC and WHO as a MSM issue, the potential for cross-over into the mainstream population remains present. I'm seeing the media hype, and for that matter CDC's focus on the MSM population as very similar to what I saw with AIDS decades ago.
I can see the kids' ages keeping them away from high-touch surfaces, and certainly the level of virons needed for infection may need to be looked at more though they say they went beyond known threshold, but what about this new paper? There are cleaning approaches most learned during the beginning of SARS-CoV-2 which may be useful in homes where someone is ill with monkeypox.
QUOTED SECTION
Of the 42 samples collected, 37 (88.1%) were confirmed as positive for MPXV DNA via RT-qPCR with crossing threshold (Ct) values ranging from 22.6 to 38.1 (Table 1). All 21 samples collected from the patient's single-room residence were positive for MPXV DNA including 14 samples with Ct values of less than 30.0 inferring a high level of contamination. Five of the six samples collected from the sibling's single-room accommodation were also positive for MPXV DNA; however, Ct values were much higher in positive samples ranging from 30.5 to 35.3 inferring a lower degree of contamination. MPXV DNA was also frequently identified in both bathroom facilities (5/8 samples positive with Ct values ranging from 29.9 to 33.5) and from door handles, light switches and bannisters in the landing area (6/7 samples positives with Ct values ranging from 28.1 to 38.1). These results show widespread MPXV DNA contamination not only in the patient's main residence but also in locations in which they spent less time including high-touchpoint areas such as door handles and light switches.
Thank you so much for this clear, concise information! My 13 yo daughter was asking me about monkeypox the other day. I've shared with her what you've said previously, and this newsletter made things even more clear. We appreciate your work so much!
Do we have definitive evidence that MPX does not spread through the air?
I've seen some documentation from the Global Alliance for Vaccines and Immunisation (GAVI) and the International Conservation and Education Fund (INCEF) that indicates there's still _at least_ a discussion about whether MPX can spread through the air.
"Currently, monkeypox can also spread through large respiratory droplets that can’t travel far in the air, but there have been suggestions that the virus may have evolved to become more easily airborne – similarly to the way that SARS-CoV-2 was not believed to have been airborne until studies proved that in some situations it could be. “It’s too early to say categorically that monkeypox is airborne, so we need to be careful,” [Dr Adesola Yinka-Ogunleye] says."
"Rodents don't suffer from the disease but they serve as a reservoir ... Rodents frequently enter houses in the villages. If they sneeze near sleeping people, those people can be contaminated by inhaling small, fine droplets containing the virus." Dr Jean Vivien Mombouli, Directeur de la Recherhe et de la Production, Laboratoire National de Sante Publique
Quote from INCEF video (time-stamped near mention of rodents expelling airborne droplets containing the virus ) = https://youtu.be/x6jWz8a9Rzs?t=243
And here's an excerpt from a pre-print titled "Air and surface sampling for monkeypox virus in UK hospitals"
"Findings We identified widespread surface contamination (66 positive out of 73 samples) in occupied patient rooms (MPXV DNA Ct values 24·7-38·6), on healthcare worker personal protective equipment after use, and in doffing areas (Ct 26·3-34·3). Five out of fifteen air samples taken were positive. Significantly, three of four air samples collected during a bed linen change in one patient’s room were positive (Ct 32·7-35·8). Replication-competent virus was identified in two of four samples selected for viral isolation, including from air samples collected during the bed linen change."
This has come up and it's believed that it can be spread primarily as a large-droplet transmission vector (if at all). The close contact time I recall seeing is 3 hours.
The error with SARS was the mental model used for transmission was tuberculosis, which has been judged to be a large-droplet phenomenon. Until now. In the last 6 months, the potential that tuberculosis could be spread by fine-droplet aerosol has been discussed more thoroughly.
The rodent vector in this country could well be pets in the not too distant future. Someone's gerbil or hamster is infected. It could potentially infect room mates and visitors, and if it got loose, could infect other rodents.
I edited my original post to include the following.
And here's an excerpt from a pre-print titled "Air and surface sampling for monkeypox virus in UK hospitals"
"Findings We identified widespread surface contamination (66 positive out of 73 samples) in occupied patient rooms (MPXV DNA Ct values 24·7-38·6), on healthcare worker personal protective equipment after use, and in doffing areas (Ct 26·3-34·3). Five out of fifteen air samples taken were positive. Significantly, three of four air samples collected during a bed linen change in one patient’s room were positive (Ct 32·7-35·8). Replication-competent virus was identified in two of four samples selected for viral isolation, including from air samples collected during the bed linen change."
You're correct to point out the nuance. I'm still concerned. In my original post, I cited documentation from African doctors who spoke about the potential of airborne transmission. Taking that with the pre-print, I worry that our public communication is so focused on talking about risk from person-to-person contact that we're ignoring other risks.
I don't think we're prioritizing. So much of the public discourse about MPX keeps framing it as basically an STI that only impacts MSM. It's neither of those things.
I think it is fair to say that MSM happen to be most acutely impacted right now. It is appropriate to focus medical outreach, intervention, and support on the MSM community. Accompanying that, we should get communication about the broader risks or MPX including all the possible ways it can spread (from most likely to less likely) so that people can make informed decisions for their health and safety (and so that bad actors don't get empowered to vomit misinformation and homophobia).
Maybe it's just my perspective from my own corner of the world. But so far, I don't think we're prioritizing. I think we're toeing the line of marginalizing and ignoring. At any rate, I hope things don't get worse and that they get better instead.
Hopefully, we make all the right moves to control MPX while also finally doing something to get COVID-19 under control. I am really hoping for a better world.
Thanks for dealing with difficult topics at a time when one of the only things that can be counted on to happen is change. With human over-population leading to more incursions into wild areas which had previously been pristine and not often traversed, coupled with high speed travel all over the globe, the chances of a disease which had once been localized making it into a major population center and taking off is higher than ever. Meanwhile, some major advances have woven together into new modes of care and medical understanding so how to tackle those emerging diseases as well as already known ones is also rapidly changing. I think that a lot of people do not realize that the data is not static.
On that regard, if you would enjoy something which may be potentially cheering:
Replicating RNA Vaccine Generates Unexpected Immune Response Against CCHFV in Mice
Crimean-Congo hemorrhagic fever virus has about a 30% death rate in people and there is no way to treat it, just to tackle symptoms, so if this pans out in humans as well then it will be wonderful. The vaccine worked much better than expected in the mice and did so with one small dose.
You covered an enormous amount of ground in your report. Where to start? Worst of times best of times in our public health infrastructure. Need more funding stat. Numbers of new cases could explode in the U.S. by late next week to six figures and still an undercount. I hope I'm wrong but we're in fairly early stage and growth is not linear now. People will continue to turn blind eyes: wrongly using lethality as a metric, and s NIMG attitude. Continuing roadblocks from anti-vaxxers and anti public health folks. Usual mess.
Can't say I disagree with you that when politics enters the picture it usually isn't to anyone's long term benefit. But PC isn't the bogeyman in public health that it's often made out to be. We learned with Covid that there were underserved BIPOC communities, etc. So good mixed with the bad as usual.
It's hardly an issue of political correctness, although Osterholm (UMn) wants to emphasize the risk to the MSM subgroup. That group's already aware of it. I'm much more worried that, by overemphasizing that aspect, others will decide there's no risk to the rest of the community and will avoid precautions.
One consideration is the lack of vaccine doses. We're missing about 90% of the on-hand doses we need at this point. For the cases we know about. I suspect, thanks to a lack of testing, we have yet to understand the degree of community spread. Also, this virus isn't presenting in the same manner it has in the past. In the MSM community, (and speaking relative to the clinical evaluations) there's discussion that it's been seen and diagnosed for some time as one of the more common STDs. Often, only a single lesion has presented. A single lesion on a hand or arm might well go unnoticed and serve as a vector for more dissemination. Also, during the early onset of illness, "viral" symptoms predominate, and the virus can spread by air. At this time, the current thought is large-droplet transmission as we know fomite transmission is viable. The prolonged contact time I've seen so far is 3 hours (vs 15 min for COVID).
While we have not seen the spillover, it may have simply not been recognized. This was a discussion we had in my organization 2 weeks ago: How many would have recognized and had a high index of suspicion for MPV 3 months ago? The answer: None of us. But since we're all also engaged in public health work, our index of suspicion is now elevated. CDC and all the primary care organizations are trying to get more info out to increase awareness.
Sadly, Mr. Reines's comment seems to be an indication of how the right wing intends to weaponize this issue. Just as they have done with SARS-Cov-2 and attempted to do with Ebola. SS, DD.
"Political correctness appears to be costing lives not more vaccines..." It may appear to you that way, and I have a pretty good idea why. But in reality, no.
But, of course, this is how I expect the far right to approach this: blame it all on the LGBTQ community, spread anti-vaccine lies and then, when the problem gets worse, use that as an excuse to persecute the LGBTQ community.
Find or create a problem, do everything you can to make it worse, and then blame it on Democrats, liberals, gays, lesbians, environmentalists, scientists, educators, Muslims, BLM, "antifa," and miscellaneous other bogeymen, real or imagined.
Huh - its clear by the YLE article that this is happening -
QUOTE
But resources, vaccine messaging, and education need to be laser focused on the MSM network. However, we cannot pigeonhole ourselves to this group, because we need to prevent stigma and because the situation may change. That’s challenging to communicate. UNQUOTE
Preventing Stigma is not a reason to avoid addressing any issue at all.
Actually, no, nothing in that quote indicates that "Political correctness appears to be costing lives not more vaccines..." We know where the majority of the cases are showing up right now. This was initially true of HIV infection as well, and for the same reason: sexual contact is an important means of transmission. Gay men were the proverbial canaries in the coal mine on that one. It looks like they might be again.
So, yeah, we need to make sure that the word gets out to the most vulnerable population. But we need to do it in a way that insures that people like you won't see it as a political weapon and decide that this is just a gay male issue and ignore the reality of how it can be spread. Just as the right wing did with HIV. And we all know how well that worked out.
Here's the CDC article linked from Dr. Jetelina's article the goes into more details on transmission methods: https://www.cdc.gov/poxvirus/monkeypox/transmission.html You will note that any close physical contact will do it.
Another difference: it seems with MPX, the vaccine is effective both before and *after* exposure (highlighting importance of contact tracing), whereas with Covid, the vaccine is only effective *before* exposure.
How so, if most of them have never before been exposed to monkeypox? I'm not speculating that they are spreading cow pox from the live vaccine, but that today, they are being exposed to monkey pox, and, due to prior vaccination, having an extremely mild case that they don't notice, but that's contagious.
Essentially, in all documented cases, vaccination for orthopoxvirus with the vaccines currently or historically available has been completely neutalizing/sterilizing. This virus changes very little, although there's some interesting evidence of base substitutions due to interaction with the human immune system. The implications of this remain to be discerned.
I read an article about the possibility of using Janneos as an intradermal vaccine to stretch it out. As an intradermal vaccine, we would get about 5x the coverage with what we currently have because it requires a smaller dose than a muscular injection does. Do you have any further information or input on this?
I have a question about intranasal vaccines. I already know that testing has to be done differently on those of us who have had extensive sinus surgery or have had basal brain surgery because the risk of perforation is too great, so we have to have throat tests (which involve a different pH). Should a difference in effectiveness of intranasal vaccines be expected by those who have had extensive sinus surgery?
BTW, there IS a lollypop style test for young children (under development?) according to a European friend in public health, but I appear to have misplaced that reference. My apologies. A quick search find this:
Apropos the deja vu some of us are feeling with monkeypox and the HIV years, suppose a large church-owned hospital system (and there are many such) decides that they shall neither test nor treat hMPX patients because the latter offend their religious beliefs?
In the Reagan era this would have been impossible with the liberal majorities present on the Court back then. The Federalist Society had just been formed and the legal climate was so different. Public health does not operate in a vacuum. The legal environment is very important and sad to say is much worse now than it was in 1982 with the current Court.
Yes. The proportionality test, just like the Lemon test, is a bit shaky and certainly the case will come up for reexamination sooner or later. Most likely sooner. But in W. O V Quine's, famous image, there are a lot of fat men jammed up in the appellate doorway awaiting "corrective" review. The conservative faction, nursing their long grievances, are entering their promised land with this Court.
YLE - thanks for the update-
Monkeypox is another health concern that the health officials are destroying public trust in our institutions.
We have learned from Dr Brix that the CDC COVID response was politics over science. Data was manipulated.
Now public health officials are worried about stigmatizing a group over avoiding spreading a disease.
The real epidemic is how the Global Health and US Health officials are eroding all public trust.
While Debby Birx worked in the Army with Redfield, my impression of him has never been much better than "ideologue". When he took over CDC, the organization hemorrhaged experienced people who could have retired years before but were the basis for a lot of the good science. But it's not all Redfield's fault, although he didn't start turning the response around until it was obvious he couldn't ignore any longer, nor accept political direction. The directorship at CDC was transitioned to a political appointment over 20 years ago. It needs to go back to a professionally derived position. That could restore some confidence and autonomy to the group.
I learned, in the initial days of the AIDS outbreak that it was dangerous to claim, as a lot of us did, that, "This is only a disease of gay men." I'm concerned that we have to raise the alarm that there can and will be spill-over into the general population, as we saw with HIV. I remember the day we shifted from no precautions to universal precautions to enter a patient room (and at one point, to enter an entire ICU in my hospital) after one of our providers suffered a needle stick and became ill (no, it wasn't a short time... but with a doc in the ICU who wasn't a gay man, it started changing the complexion of the disease for us. The spill-over for HIV/AIDS wasn't immediate, but did occur.
Solely identifying MPV as a MSM disease will diminish the awareness in the rest of the population. I suspect there's already community cases that have escaped that subgroup (we know of 2 kids and a pregnant woman; how many more?) but since we're not up to speed on testing (again but it's better handled this time) it'll take a bit to establish R(0) and the initial case load.
Couldn't agree more as they say..
Disagree in a friendly way. Public distrust of authority and "experts" has always been a continuing bass note in American thought. Nothing new there. We Americans cherish anti-intellectualism like very few other industrialized countries. When it comes down to it, even hard data is put through that filter.
Dont you think that during the pandemic decisions were made for political reasons not scientific reasons is eroding the trust at breakneck speed?
Dr. Brix admitted to manipulated data and false statements (ie the vaccine will stop you from getting it? OR flatten the curve in 2 weeks)
Hi Larry, My perception is that there is a sizable segment of the population that is inclined to distrust the medical establishment no matter how perfectly the latter perform or whether damning revelations are publicized or not. I think the term was "medical tyranny." I tend to trust authority, but not require of it perfection.
Agreed - but as in all aspects of our lives, do not give people ammunition...
i like to think we should try to be so good they can not ignore you...
But don't let the perfect be the enemy of the good. As Lucillius said, "O quantum est in rebus inane.". What folly there is in human affairs. All our endeavors have a certain ramshackle, improvisatory aspect to them..public health is no exception!
There were, indeed, political decisions made. Some were made at CDC, but most were make at a higher level and promulgated by CDC and FDA. Hahn at FDA had a stellar record before taking a politicized job. He bowed to pressure several times but usually corrected pretty quickly. Redfield was, in my opinion, a somewhat bigger problem, but again, when Nancy Messonnier was thrown under the bus for stating the obvious (at least to those studying the pandemic already) Redfield failed to protect her and went along with sidelining her permanently.
What we needed to do was communicate the science in a manner that was unambiguous and understandable, but... both are hard, and the first is almost impossible when the mis-/disinformation process is already in full swing. You might find https://www.newyorker.com/magazine/2021/01/04/the-plague-year an interesting read.
We had a conversation in the past.
It would appear that now there is a better understanding how political the past 2 years have been. You appear to know more
About what is happening in the trenches while common folks saw and see that science is not taking a priority.
My fear and YLE clearly articulate that peoples feelings are invoked in MP.
For me this is over reach.
Smoke cigarettes is as dangerous and as avoidable as MP. In fact M0 is more avoidable than quitting smoking since it’s a chemical dependance not a voluntary act.
In the past medical treatments were attempting to stop the cause instead of mitigate the effect.
I take issue with the presentation of MP as anything but what is so far presents as - a STD in the gay community. In fact,a good case can be made that if it spread to the whole population that it incubated in the gay community due to dangerous behaviors not happenstance. That’s as of today.
Stigma ? Worrying about stigma or
Dead people? apparently much of the public health officials are worried about stigma. (BTW this political sensitivity is destroying our military- recruitment is down 40% this year)
And so it goes.
I've had a clinical background at several levels, so I should know more about what's happening in the trenches. And over my career(s) I've met some people who are influential today, so I often get their impressions early on.
Science is, indeed, taking a priority when we attempt to deal with this new emergency as best we can. One of the shortfalls is, indeed, political. We need more vaccines in this country and in the hands of health departments and providers. But the stores of MPV vaccine are relatively small overall, and that's political as well. Countries in Africa generally fall into the middle- or low-income range. It is incumbent on wealthier countries to assist with treating and preventing communicable diseases if for no other reason than self-preservation. That both recognized strains of MPV, one with a 10% mortality, are considered endemic in Africa only highlights that it's probably time to address this disease with a massive vaccination program there. And had we paid attention over the last 20 years we'd not be having this discussion because the wealthier nations, assuming cooler heads prevailed, would have accomplished this.
Peoples' feelings are involved, and like the original presentation of HIV/AIDS, people are likely to go, "STD for Gay Men", and promptly ignore it. That's MY fear.
For a variety of reasons, and assuming your premise that MPV infection is solely an STD, your analogy vice smoking is flawed. A chemical dependence is no less a driving force than the need in humans for physical intimacy. What we don't know is if barrier protection is effective (I suspect not), because that would be a good way to mitigate the impact.
We treat to mitigate as well as prevent. That's been the case for a long time, although I could reasonably argue insurance companies are less interested in preventative care than treating preventable diseases. That's a discussion for another time. However, I can assure you that counseling on abstinence, reducing partner count, and use of barrier protection are ongoing in an attempt to slow this process.
We keep coming back to "a STD in the gay community". HIV remains a worldwide problem regardless of sexual orientation. It's somewhat less prominent in the heterosexual community in the US, but this is a pretty small planet: We have to think outside of our little political enclave. It IS a problem in other areas of the world in other communities than solely the gay community. We've seen population outbreaks before. HIV/AIDS was first seen in the same community but since we couldn't SEE a virus we had a difficult starting point and plenty of bacterial confounders. The 1918 Flu outbreak was first seen in this country in Ft Riley, KS, if I recall correctly (at least en masse); note that it was called the "Spanish Flu" because Spain didn't hide statistics, while the US was worried about having the enemy learn of all the ill troops on our side and take advantage of the situation. Zika was first identified in Brazil, then Haiti.
We worry about stigma because stigmatized people will also be subject to poorer care to treat disease, and this creates an environment where, without appropriate care a disease can worsen underserved or perhaps stigmatized individual who was likely immunocompromised and thus didn't clear the original viral infection but was a fertile ground for modifications and substitutions, especially if they were reinfected before clearing the active virus.
And: Military recruiting is, indeed, down. But civilian unemployment is significantly lower, at least among those seeking jobs (and Veterans are likely to be in that group). We just ended a "war" and Congress determined the need for troops was significantly lower than before, so we entered a Reduction In Force period. The Services are offering bonuses to retain and recruit, now, because they have to compete with the private sector, and as the needs of the service are shifting, they need smarter, better and brighter folks: The same people business is recruiting, often with higher wages and better schedules (although it's really hard to beat MTF and Tricare for benefits).
You and I look at this through different lenses. I am, by nature, a pessimist: I look for what can go wrong, because I suspect it will, but then work hard to mitigate or prevent the adverse outcomes. You'll have to determine what your life view is. For me, expecting the worst and planning for it, while seen as odd by someone who hasn't seen what I've seen is odd, but overall, the people I've cared for benefited from such planning on my part.
And why do “ stigmatized people will also be subject to poorer care to treat disease,”?
I suggest that not know if condoms help is a serious failing of the healthcare community.
I would strongly disagree about smoking and sex. Smoking is chemical dependency and sex with multiple partners that is high risk for spreading a virus is downright selfish. Physical intimacy with multiple partners is as strong a need a chemical dependency is, on the face of it all, political pandering. Is that now a new conatituoright?
Back to not know if a condom protects - there is no excuse. You should be more outraged At that than no money for a
Vaccine. Mitigating the disease ( wear a mask and stand 6ft apart) should be more important than treating it.
Not wanting To mitigate MP is likely the
Politics. We wore useles masks and still require them in some schools today, that we know are ineffective.
Sorry - it’s all political pandering by the public health officials and in some way, you too appear, to tacitly support risky behavior as a need instead of a danger. I just don’t get it.
Katelyn,
Thanks for the update. And, I look forward to your take on the vaccine round-table. But without funding, where does this go?
I'm concerned that we're looking at a longer-standing outbreak (recall this is a 2018-2019 trigger event) that went unnoticed in Europe and the US (or... worldwide). The latest manifestation is in the MSM population, but that could well be artifact. I had a discussion with our clinicians, most in primary care, and until the news started frequent discussions, they were unaware of the potential in the US and would not have had it on the differential diagnosis. When we add in the atypical presentation now being seen, that of a single lesion (often a genital lesion at this time), identifying it, and swabbing and sending the swab for viral culture would have been unlikely until the last 60 days or so in this country. Africa is different as it's endemic, highlighting the failure of the world to maintain adequate smallpox and monkeypox vaccinations.
There is ample evidence there is a respiratory component to transmission, during the prodromal phase when viral symptoms are the key feature, with a direct contact issue when lesions form.
This isn't as readily transmissible and the CFR is much lower than SARS-CoV-2, but identification of the problem has come very late and we're playing catch-up. I suspect we're 15x underreported, due to clinician unawareness and lack of test facilities.
While this has been seen and documented by CDC and WHO as a MSM issue, the potential for cross-over into the mainstream population remains present. I'm seeing the media hype, and for that matter CDC's focus on the MSM population as very similar to what I saw with AIDS decades ago.
Yes it reminds me of that time also. Plus ça change...
I can see the kids' ages keeping them away from high-touch surfaces, and certainly the level of virons needed for infection may need to be looked at more though they say they went beyond known threshold, but what about this new paper? There are cleaning approaches most learned during the beginning of SARS-CoV-2 which may be useful in homes where someone is ill with monkeypox.
QUOTED SECTION
Of the 42 samples collected, 37 (88.1%) were confirmed as positive for MPXV DNA via RT-qPCR with crossing threshold (Ct) values ranging from 22.6 to 38.1 (Table 1). All 21 samples collected from the patient's single-room residence were positive for MPXV DNA including 14 samples with Ct values of less than 30.0 inferring a high level of contamination. Five of the six samples collected from the sibling's single-room accommodation were also positive for MPXV DNA; however, Ct values were much higher in positive samples ranging from 30.5 to 35.3 inferring a lower degree of contamination. MPXV DNA was also frequently identified in both bathroom facilities (5/8 samples positive with Ct values ranging from 29.9 to 33.5) and from door handles, light switches and bannisters in the landing area (6/7 samples positives with Ct values ranging from 28.1 to 38.1). These results show widespread MPXV DNA contamination not only in the patient's main residence but also in locations in which they spent less time including high-touchpoint areas such as door handles and light switches.
END QUOTE
https://sfamjournals.onlinelibrary.wiley.com/doi/10.1111/1462-2920.16129
Infection-competent monkeypox virus contamination identified in domestic settings following an imported case of monkeypox into the UK
Thank you so much for this clear, concise information! My 13 yo daughter was asking me about monkeypox the other day. I've shared with her what you've said previously, and this newsletter made things even more clear. We appreciate your work so much!
Do we have definitive evidence that MPX does not spread through the air?
I've seen some documentation from the Global Alliance for Vaccines and Immunisation (GAVI) and the International Conservation and Education Fund (INCEF) that indicates there's still _at least_ a discussion about whether MPX can spread through the air.
"Currently, monkeypox can also spread through large respiratory droplets that can’t travel far in the air, but there have been suggestions that the virus may have evolved to become more easily airborne – similarly to the way that SARS-CoV-2 was not believed to have been airborne until studies proved that in some situations it could be. “It’s too early to say categorically that monkeypox is airborne, so we need to be careful,” [Dr Adesola Yinka-Ogunleye] says."
Quote from GAVI article: https://www.gavi.org/vaccineswork/how-african-scientific-sleuths-spotted-signs-monkeypox-could-become-global-problem
"Rodents don't suffer from the disease but they serve as a reservoir ... Rodents frequently enter houses in the villages. If they sneeze near sleeping people, those people can be contaminated by inhaling small, fine droplets containing the virus." Dr Jean Vivien Mombouli, Directeur de la Recherhe et de la Production, Laboratoire National de Sante Publique
Quote from INCEF video (time-stamped near mention of rodents expelling airborne droplets containing the virus ) = https://youtu.be/x6jWz8a9Rzs?t=243
And here's an excerpt from a pre-print titled "Air and surface sampling for monkeypox virus in UK hospitals"
"Findings We identified widespread surface contamination (66 positive out of 73 samples) in occupied patient rooms (MPXV DNA Ct values 24·7-38·6), on healthcare worker personal protective equipment after use, and in doffing areas (Ct 26·3-34·3). Five out of fifteen air samples taken were positive. Significantly, three of four air samples collected during a bed linen change in one patient’s room were positive (Ct 32·7-35·8). Replication-competent virus was identified in two of four samples selected for viral isolation, including from air samples collected during the bed linen change."
Link to pre-print = https://www.medrxiv.org/content/10.1101/2022.07.21.22277864v1
This has come up and it's believed that it can be spread primarily as a large-droplet transmission vector (if at all). The close contact time I recall seeing is 3 hours.
The error with SARS was the mental model used for transmission was tuberculosis, which has been judged to be a large-droplet phenomenon. Until now. In the last 6 months, the potential that tuberculosis could be spread by fine-droplet aerosol has been discussed more thoroughly.
The rodent vector in this country could well be pets in the not too distant future. Someone's gerbil or hamster is infected. It could potentially infect room mates and visitors, and if it got loose, could infect other rodents.
I edited my original post to include the following.
And here's an excerpt from a pre-print titled "Air and surface sampling for monkeypox virus in UK hospitals"
"Findings We identified widespread surface contamination (66 positive out of 73 samples) in occupied patient rooms (MPXV DNA Ct values 24·7-38·6), on healthcare worker personal protective equipment after use, and in doffing areas (Ct 26·3-34·3). Five out of fifteen air samples taken were positive. Significantly, three of four air samples collected during a bed linen change in one patient’s room were positive (Ct 32·7-35·8). Replication-competent virus was identified in two of four samples selected for viral isolation, including from air samples collected during the bed linen change."
Link to pre-print = https://www.medrxiv.org/content/10.1101/2022.07.21.22277864v1
You're correct to point out the nuance. I'm still concerned. In my original post, I cited documentation from African doctors who spoke about the potential of airborne transmission. Taking that with the pre-print, I worry that our public communication is so focused on talking about risk from person-to-person contact that we're ignoring other risks.
We're not forgetting other risks, and pointing them out is a good thing, but we ARE prioritizing the risks.
I don't think we're prioritizing. So much of the public discourse about MPX keeps framing it as basically an STI that only impacts MSM. It's neither of those things.
I think it is fair to say that MSM happen to be most acutely impacted right now. It is appropriate to focus medical outreach, intervention, and support on the MSM community. Accompanying that, we should get communication about the broader risks or MPX including all the possible ways it can spread (from most likely to less likely) so that people can make informed decisions for their health and safety (and so that bad actors don't get empowered to vomit misinformation and homophobia).
Maybe it's just my perspective from my own corner of the world. But so far, I don't think we're prioritizing. I think we're toeing the line of marginalizing and ignoring. At any rate, I hope things don't get worse and that they get better instead.
Hopefully, we make all the right moves to control MPX while also finally doing something to get COVID-19 under control. I am really hoping for a better world.
Thanks for dealing with difficult topics at a time when one of the only things that can be counted on to happen is change. With human over-population leading to more incursions into wild areas which had previously been pristine and not often traversed, coupled with high speed travel all over the globe, the chances of a disease which had once been localized making it into a major population center and taking off is higher than ever. Meanwhile, some major advances have woven together into new modes of care and medical understanding so how to tackle those emerging diseases as well as already known ones is also rapidly changing. I think that a lot of people do not realize that the data is not static.
On that regard, if you would enjoy something which may be potentially cheering:
https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(22)00369-3/fulltext
Replicating RNA Vaccine Generates Unexpected Immune Response Against CCHFV in Mice
Crimean-Congo hemorrhagic fever virus has about a 30% death rate in people and there is no way to treat it, just to tackle symptoms, so if this pans out in humans as well then it will be wonderful. The vaccine worked much better than expected in the mice and did so with one small dose.
You covered an enormous amount of ground in your report. Where to start? Worst of times best of times in our public health infrastructure. Need more funding stat. Numbers of new cases could explode in the U.S. by late next week to six figures and still an undercount. I hope I'm wrong but we're in fairly early stage and growth is not linear now. People will continue to turn blind eyes: wrongly using lethality as a metric, and s NIMG attitude. Continuing roadblocks from anti-vaxxers and anti public health folks. Usual mess.
Michael - Do you think that addressing the problem head on would benefit everyone and save lives?
Political correctness appears to be costing lives not more vaccines...
An ounce of prevention is worth a pound of cure - Benjamin Franklin
Can't say I disagree with you that when politics enters the picture it usually isn't to anyone's long term benefit. But PC isn't the bogeyman in public health that it's often made out to be. We learned with Covid that there were underserved BIPOC communities, etc. So good mixed with the bad as usual.
It's hardly an issue of political correctness, although Osterholm (UMn) wants to emphasize the risk to the MSM subgroup. That group's already aware of it. I'm much more worried that, by overemphasizing that aspect, others will decide there's no risk to the rest of the community and will avoid precautions.
One consideration is the lack of vaccine doses. We're missing about 90% of the on-hand doses we need at this point. For the cases we know about. I suspect, thanks to a lack of testing, we have yet to understand the degree of community spread. Also, this virus isn't presenting in the same manner it has in the past. In the MSM community, (and speaking relative to the clinical evaluations) there's discussion that it's been seen and diagnosed for some time as one of the more common STDs. Often, only a single lesion has presented. A single lesion on a hand or arm might well go unnoticed and serve as a vector for more dissemination. Also, during the early onset of illness, "viral" symptoms predominate, and the virus can spread by air. At this time, the current thought is large-droplet transmission as we know fomite transmission is viable. The prolonged contact time I've seen so far is 3 hours (vs 15 min for COVID).
While we have not seen the spillover, it may have simply not been recognized. This was a discussion we had in my organization 2 weeks ago: How many would have recognized and had a high index of suspicion for MPV 3 months ago? The answer: None of us. But since we're all also engaged in public health work, our index of suspicion is now elevated. CDC and all the primary care organizations are trying to get more info out to increase awareness.
Sadly, Mr. Reines's comment seems to be an indication of how the right wing intends to weaponize this issue. Just as they have done with SARS-Cov-2 and attempted to do with Ebola. SS, DD.
"Political correctness appears to be costing lives not more vaccines..." It may appear to you that way, and I have a pretty good idea why. But in reality, no.
But, of course, this is how I expect the far right to approach this: blame it all on the LGBTQ community, spread anti-vaccine lies and then, when the problem gets worse, use that as an excuse to persecute the LGBTQ community.
Find or create a problem, do everything you can to make it worse, and then blame it on Democrats, liberals, gays, lesbians, environmentalists, scientists, educators, Muslims, BLM, "antifa," and miscellaneous other bogeymen, real or imagined.
Also Her Emails and Hunter Biden's Laptop.
SS,DD.
Huh - its clear by the YLE article that this is happening -
QUOTE
But resources, vaccine messaging, and education need to be laser focused on the MSM network. However, we cannot pigeonhole ourselves to this group, because we need to prevent stigma and because the situation may change. That’s challenging to communicate. UNQUOTE
Preventing Stigma is not a reason to avoid addressing any issue at all.
See the data.
Actually, no, nothing in that quote indicates that "Political correctness appears to be costing lives not more vaccines..." We know where the majority of the cases are showing up right now. This was initially true of HIV infection as well, and for the same reason: sexual contact is an important means of transmission. Gay men were the proverbial canaries in the coal mine on that one. It looks like they might be again.
So, yeah, we need to make sure that the word gets out to the most vulnerable population. But we need to do it in a way that insures that people like you won't see it as a political weapon and decide that this is just a gay male issue and ignore the reality of how it can be spread. Just as the right wing did with HIV. And we all know how well that worked out.
Here's the CDC article linked from Dr. Jetelina's article the goes into more details on transmission methods: https://www.cdc.gov/poxvirus/monkeypox/transmission.html You will note that any close physical contact will do it.
Does anyone know the case fatality rate for MPX?
Another difference: it seems with MPX, the vaccine is effective both before and *after* exposure (highlighting importance of contact tracing), whereas with Covid, the vaccine is only effective *before* exposure.
Is it possibly that some older people, who were vaccinated decades ago, are spreading monkeypox asymptomatically?
Unlikely. That transmission mode would have been exhausted long ago.
How so, if most of them have never before been exposed to monkeypox? I'm not speculating that they are spreading cow pox from the live vaccine, but that today, they are being exposed to monkey pox, and, due to prior vaccination, having an extremely mild case that they don't notice, but that's contagious.
There's no evidence of this, and the article says as much. I have to wonder why you are bringing this up.
Essentially, in all documented cases, vaccination for orthopoxvirus with the vaccines currently or historically available has been completely neutalizing/sterilizing. This virus changes very little, although there's some interesting evidence of base substitutions due to interaction with the human immune system. The implications of this remain to be discerned.
Are environmental stability (bad) and long term sterilizing immunity (good) two sides of the same coin?
I read an article about the possibility of using Janneos as an intradermal vaccine to stretch it out. As an intradermal vaccine, we would get about 5x the coverage with what we currently have because it requires a smaller dose than a muscular injection does. Do you have any further information or input on this?
It will be interesting to see what non-affiliated researchers think of Bharat Biotech's testing done on its announced intranasal vaccine:
https://www.thehindu.com/news/national/bharat-biotech-expects-regulators-nod-for-intranasal-covid-19-vaccine-this-month/article65714909.ece
I have a question about intranasal vaccines. I already know that testing has to be done differently on those of us who have had extensive sinus surgery or have had basal brain surgery because the risk of perforation is too great, so we have to have throat tests (which involve a different pH). Should a difference in effectiveness of intranasal vaccines be expected by those who have had extensive sinus surgery?
BTW, there IS a lollypop style test for young children (under development?) according to a European friend in public health, but I appear to have misplaced that reference. My apologies. A quick search find this:
https://www.youtube.com/watch?v=ZS_kQdnUK_o
but I can not recall offhand if that is what he was referring to.
I forgot to include this ref about the risks of nasal swab tests for some of us:
https://news.uthscsa.edu/covid-19-nasal-swab-test-may-not-be-best-for-those-whove-had-sinus-surgery/
Isn't the relevant comparison two pandemics vs one? Or even "concurrent global public health crisis and pandemic" vs "pandemic"?
And I might add: the two public health crises are disturbingly complementary:
Monkeypox - not airborne, stable on surfaces
Covid - airborne, but doesn't last on surfaces
Vulnerable populations:
Monkeypox - children
Covid - older adults
Apropos the deja vu some of us are feeling with monkeypox and the HIV years, suppose a large church-owned hospital system (and there are many such) decides that they shall neither test nor treat hMPX patients because the latter offend their religious beliefs?
In the Reagan era this would have been impossible with the liberal majorities present on the Court back then. The Federalist Society had just been formed and the legal climate was so different. Public health does not operate in a vacuum. The legal environment is very important and sad to say is much worse now than it was in 1982 with the current Court.
Sigh. I fear that SCOTUS wouldn't hesitate to overturn Jacobson vs Massachusetts given the right case
Yes. The proportionality test, just like the Lemon test, is a bit shaky and certainly the case will come up for reexamination sooner or later. Most likely sooner. But in W. O V Quine's, famous image, there are a lot of fat men jammed up in the appellate doorway awaiting "corrective" review. The conservative faction, nursing their long grievances, are entering their promised land with this Court.
Yup.
Been too busy to look at the medcram. Thanks for reposting.