As Covid-19 continues its vexing mutations, monkeypox has proved to be the next medical challenge, having been declared a public health emergency by the World Health Organization and the United States government, as well as New York state. (The U.S. leads the world with 9,492 cases, 2,104 of them in New York state. Of those in New York, all are in New York City except for 53 in Westchester County and one in Ulster County. Connecticut has 49 cases statewide.)
This virus, which is related to smallpox but not anywhere near as lethal, originated with rodents in Central and West Africa, where the first human cases were documented in 1970. (It is called monkeypox, because it was first identified as a disease in laboratory monkeys in Copenhagen, Denmark, in 1958.)
While the numbers may not seem that alarming, particularly when compared to Covid, monkeypox has like Covid and HIV/AIDS found itself at the intersection of public health and politics because of whom it has infected and the American government”™s slow response to address it.
“The vast majority of those who”™ve been diagnosed to date with human monkeypox virus are self-identifying men who have sex with men,” Jason Zucker, M.D., said in a recent Zoom presentation on the disease. Zucker, an infectious diseases specialist at NewYork-Presbyterian/Columbia University Irving Medical Center and assistant professor of medicine at Columbia Vagelos College of Physicians and Surgeons, added, “This is likely due to shared sexual networks”¦. But just like other diseases, there”™s no reason it can”™t spread to other communities via sexual or other close contact.”
Indeed, he said that while the disease has a low hospitalization and mortality rate ”“ 10 deaths in almost 27,000 cases in more than 80 countries ”“ “it is believed to be more severe in children under 8 and may lead to worse outcomes in pregnant women. For these reasons we all have to pay attention and remain vigilant.”
Symptoms include fever, chills, fatigue, muscle aches and swollen lymph nodes. Within five days, patients can develop a rash anywhere on the body that looks like pimples or blisters. In this outbreak, there are fewer flu-like symptoms, Zucker said, and more of a concentration of swollen lymph nodes and excruciatingly painful pustules in the mouth, groin and rectal area, making it a challenge to swallow or go to the bathroom. These lesions are transmitted through direct skin-to-skin contact, though the disease can be transmitted in other ways, such as through infected bed linen and clothing. (It does not spread like Covid through airborne means.)
Monkeypox virus is what Zucker called “a long disease,” with an incubation period of five to 21 days. “Patients are no longer considered infectious after their sores have scabbed over, those scabs have fallen off and new skin has grown in its place. This process can take up to four weeks.”
In New York City, once again the epicenter of an infectious disease outbreak, Zucker said those with symptoms are being told to see a health-care provider for testing, faster than going to an emergency room, and treatment, which centers on pain management and the investigational drug tecovirimat (TPOXX) for those with severe disease. The vaccine being used, which takes two to three weeks to guard against monkeypox, is the smallpox vaccine JYNNEOS. However, testing has been slow to roll out, getting a prescription for TPOXX, not yet approved by the U.S. Food & Drug Administration (FDA), has been a bureaucratic nightmare of paperwork and the vaccine is in short supply, thanks to the U.S. allowing a stockpile of 20 million doses to expire and a slow ramp up of production to replenish our reserve. According to an NPR report, 1.6 to 1.7 million people in the U.S. are considered at highest risk for the disease, but only about 1.1 million vaccine doses have been available, and you need two. Of those doses, about 670,000 have been shipped to the states.
This has proved unsurprising to the LGBTQ community, which sees in monkeypox a not-so-distant mirror of the 1980s AIDS debacle when the Reagan administration appeared to be indifferent. The Biden Administration ”“ which has appointed Robert Fenton, formerly of the Federal Emergency Management Agency (FEMA), as monkeypox response coordinator ”“ has introduced a new way of injecting the drug, between layers of skin rather than into the fat, thus cutting the dosage to a fifth without losing efficacy. (Those at risk will still need two doses.)
“I can”™t emphasize enough that we have to eliminate any stigma associated with monkeypox virus,” said Zucker, who treats people with HIV. “I would say that one of my biggest surprises has been how much stigma and shame is associated with this diagnosis. There”™s even a heavier stigma around this disease.” The stigma has led to violence as two men in Washington D.C. were attacked Aug. 7 by assailants using homophobic slurs and referencing monkeypox. Add to the stigma that patients must isolate for up to a month, which can affect mental health.
“It”™s important that we are all cognizant of this, that we all work together to reduce stigma and that we offer patients mental health and other supportive resources after their diagnosis,” Zucker added. “Eliminating the stigma and supporting patients is the only way to ensure that patients present for care and receive the care they need.”
This is not the United States”™ first encounter with monkeypox. A 2003, 71 cases in the Midwest were traced to Gambian pouched rats imported by an exotic animal distributor in Texas. What is different now is that many people who were inoculated against smallpox as children and young adults have died off. (The U.S. stopped smallpox vaccination in 1972 after the disease was eliminated in this country.)
The thinking is that those inoculated against smallpox might provide some kind of herd immunity. But the jury is still out on whether those inoculated decades ago have any protection against the monkeypox virus.
What is certain, Zucker said, is the need to pull together: “This is a public health crisis and we all have a role to play in eliminating stigma as a barrier for testing and treatment.”
