The first US case of monkeypox was confirmed in Massachusetts in May, and now there are at least 1,972 cases across 44 states, Puerto Rico, and the District of Columbia.
As the virus spreads across the country and the world, social media is rife with posts about lack of access to testing, vaccines, and healthcare providers who take monkeypox symptoms seriously. While it’s enough to give you COVID déjà vu, public health experts emphasized that there are significant differences between monkeypox and the ongoing coronavirus pandemic — monkeypox is not a new virus and there are existing vaccines.
“We’re all emerging from the last several years of COVID, exhausted and frustrated by the lessons that we all had to learn from that,” said Dr. Jennifer McQuiston, who has been heading up the CDC’s response to the monkeypox outbreak. “I can tell you the CDC has been working from the very first day when the very first [monkeypox] case was reported here in the United States.”
That said, monkeypox vaccine and testing woes are a whole new genre of tweet. In one viral TikTok, Halle, 24, from Pennsylvania, posted that despite experiencing what looked like monkeypox symptoms, she could not find anyone to test her despite making multiple calls and doctor visits. (After five days, she was finally seen by a Pittsburgh clinic called Central Outreach Wellness Center.)
People are tweeting about sharing special tricks to grapple with overloaded websites, waiting in lines for as long as eight hours, spotting privileged white people who seemed to be able to snag appointments in lower-income neighborhoods, and being turned away when the clinic ran out of shots. A current viral Twitter trend follows the format “the most exclusive and hottest new club seems to be the monkeypox vaccine line.”
Despite the posts, the federal government, public health agencies, and healthcare providers are working to get this outbreak in check. David C. Harvey, executive director of the National Coalition of STD Directors, has been critical of the federal response until recently.
“We have been concerned about monkeypox from day one,” Harvey said. “I will say that we have made progress in the last two weeks. The administration deserves credit for that. The White House, HHS, and CDC people are working very, very hard to ramp up the response to monkeypox.”
The CDC expects rising cases in the coming weeks on account of enhanced reporting protocols and presumed exposures with positive cases. Here is an update on the current status of this outbreak, including information about how to protect yourself from monkeypox, what to do if you have symptoms or think you have been exposed, and where to look for information on vaccine distribution in your area.
Monkeypox is not a new virus.
Monkeypox was initially discovered in 1958 at an animal facility in Denmark and first observed in the Democratic Republic of Congo in 1970. It is considered endemic in some countries in Central and Western Africa. Outbreaks have occurred outside of these regions in the past, including one in the United States in 2003 that originated from pet prairie dogs and resulted in 47 cases across six states.
There is typically an incubation period of one to two weeks, though it can take up to 21 days for infected individuals to develop symptoms. These may include fever, headaches, body aches, swollen lymph nodes, chills, and exhaustion. One to three days later, it’s common for people to develop a rash and raised pocklike lesions, and the monkeypox symptoms can persist for up to a month.
Monkeypox is included in the orthopoxvirus genus, the same one as smallpox, although monkeypox tends to be much milder. While it can be potentially life-threatening, particularly in children or people who are immunocompromised (3% to 6% of people with monkeypox can die of the infection), the strain of the virus currently spreading appears to be milder, similar to the one endemic to West Africa. (A more dangerous strain of monkeypox is endemic to Central Africa.)
McQuiston said the CDC has been monitoring monkeypox and preparing for a potential outbreak of a virus of this nature for years.
“Monkeypox is not COVID. It is not a brand-new disease. We’ve been working on it for decades,” she said. “We had a stockpile of vaccine in the event of an outbreak, we had therapeutics that were also stockpiled, and we had studies happening in parts of the world where monkeypox normally occurs and spreads to see how these vaccines work.”
Two monkeypox vaccines are currently approved in the US, Jynneos and ACAM2000, which both can be given to prevent serious complications in people who have already been exposed to the virus.
ACAM2000 contains live replicating vaccinia virus, which is a pox virus that generally doesn’t cause serious illness in humans unless they are immunocompromised. That means the injection site creates a small lesion that itself could be contagious for a vaccinia infection. Patients must take care not to touch the injection site and keep it covered with a bandage until it is fully healed. Because of the lower risk of side effects, Jynneos is the vaccine being administered to protect against monkeypox.
McQuiston said she is not currently aware of any facilities administering ACAM2000 at this time.
“ACAM2000 is maybe not the first vaccine people would automatically reach for, but it’s a good vaccine. It provides very strong protection against the pox viruses, like monkeypox,” she said. “And it is available in the strategic national stockpile, if states wanted to offer it and if they could make sure patients were educated about taking care of that site so they didn’t spread it further.”
ACAM2000 vaccines are not recommended for everyone, particularly for the immunocompromised.
The vaccine supply is limited, but help is on the way.
Studies have shown that individuals fully vaccinated for monkeypox are protected from potential infection 85% of the time. The vaccines have also been shown to reduce the severity of infections in those who have already been exposed. Supplies are currently limited, so the CDC has been “focused on post-exposure prophylaxis,” McQuiston said, meaning only giving the vaccine to people with a known monkeypox exposure. Some localities are also offering the vaccine to individuals they consider to have a higher profile of risk.
All vaccination efforts are being handled at the local level with each state rationing its supply to areas it deems most in need. Consult the website of your county or city health department to see if they are publishing any information about vaccinations in your area.
If you live in a more rural area and want to get the vaccine, you may currently need to travel to a larger city. Check with your state health department to see if they are publishing information about the localities to which they have distributed vaccines.
Since vaccination efforts have ramped up, some have reported long lines and crashing websites. The CDC said that most of the national stockpile is composed of the less desirable ACAM2000 shot, and the agency fully acknowledges that public demand has far exceeded the supply of the preferred Jynneos vaccine, of which the nation had only 3,000 doses in May. That supply increased to 72,000 by the end of May and over 300,000 by July 15. It is working to procure a supply of 786,000 more doses by the end of July from a facility in Denmark, and this month, it placed two orders for a total of an additional 5 million Jynneos shots. In total, the US is currently expecting 7 million Jynneos doses to be delivered by mid-2023.
Full vaccination for monkeypox requires two shots, but some areas are prioritizing single doses to save supplies.
The CDC has been firm that monkeypox vaccination is a two-shot procedure, with the second injection occurring 28 days after the first. An individual is considered fully vaccinated two weeks after their second dose. Nevertheless, some local health departments, including New York City’s, have chosen to disregard this directive in favor of rationing supplies with a single-shot policy. McQuiston worries that this will only create public confusion.
“One of our concerns with vaccine campaigns offering only the first dose of vaccine is that it could give people a false sense of security,” she said. “We’re just not sure that a single dose will give people the protection they might think they have.”
Challenges with testing are being addressed with increased access to commercial labs.
Technical issues in the healthcare system have limited the testing options to certain facilities and prevented some healthcare providers from using their preferred laboratories for monkeypox testing, McQuiston said.
“I know some physicians really did not want to use that network, and they cried out for a different type of testing system. And CDC has listened to that,” McQuiston said. “We’ve worked really hard to stand up commercial laboratories that can offer FDA-approved tests, and those labs are now live and testing.”
With the additional capacity of these four commercial laboratories, the US has increased testing abilities from 6,000 tests per week to 70,000, which the CDC says far exceeds the current demand.
Donald Nardelli, a registered nurse at Pittsburgh’s Central Wellness Outreach, would like to see a way for his clinic to reduce the amount of time it takes to get results.
“The turnaround time on testing is an issue,” he said. “I would love to have a PCR test right in my office, so I can tell you in a matter of minutes.”
Currently, his clinic’s average wait period for results is about three days.
Initial clusters have been mostly among gay men, but everyone should educate themselves about monkeypox.
Most of the cases for which the CDC currently has demographical data represent gay men or men who have sex with men. As such, initial campaigns have been largely focused on the appropriate information channels and community resources to reach these individuals, like STI clinics focused on servicing LGBTQ+ patients. These STI clinics have been leading the early frontlines of the fight against monkeypox in the United States.
One of these STI clinics is Pittsburgh’s Central Wellness Outreach Center, where the viral TikToker Halle spoke about finally receiving care. Nardelli said Halle’s story is fairly common for their facility.
“Patients come to us and are frustrated because they might have been to one or two other places, and their symptoms might have been minimized for whatever reason. And we try not to do that, especially with this,” he said. “With this, we’ve learned that something very minimal can turn out to be a positive case. We’ve already seen that a few times. Someone may be presenting with just one or two small spots, and it turns out positive.”
Nardelli thinks the campaign to get the word out to gay men has been successful, but he would like to see an expansion of messaging to reach other people who may be at risk for monkeypox.
“I think we’re doing a very good job within this community spreading the word to one another,” Nardelli said. “I think it is certainly time to broaden that horizon so people outside of the LGBTQ+ community don’t minimize their symptoms and delay care.”
Currently, the main method of protection is vigilance.
Monkeypox is spread via close contact with infected individuals and materials they have come into contact with, including specifically any direct touching of rashes or lesions, or the inhalation of respiratory droplets.
Close contact refers not only to sex, but also to cuddling, kissing, and even dancing at parties where to skin-to-skin touching can occur. For the most protection from monkeypox, experts recommend mitigating risk by avoiding or limiting these activities for now. As with COVID, masks can also serve as protection.
The CDC recommends that people not share towels or sheets with infected individuals, but its guidelines do not address any high-touch public spaces, like buses or gyms. McQuiston said the agency’s data show that monkeypox’s fomites — or objects that might help aid transmission of an infectious organism — tend to be limited to items of a personal nature.
“Towels and sheets are mentioned because those are items that could be shared in close scenarios, and people might be rubbing their bodies and mucosal surfaces with those things,” she said. “We have seen no evidence that things like gym equipment are promoting spread.”
The experts we spoke to also recommended that you ask any potential partners if they have recently had any rashes or lesions on their body.
If you are experiencing monkeypox symptoms, particularly a rash, stay at home except to get tested, cover your lesions, and avoid skin-to-skin contact with others.
There is a therapeutic medication available, but access is complicated.
Most people who have contracted monkeypox during this outbreak have had relatively mild symptoms. Those who experience more extreme illness may have a resource available to them through a new drug called TPOXX (tecovirimat), which is currently only available through an investigational new drug permit. Nardelli said the program is too complicated and that his patients have found the requirements to be overwhelming.
“It’s a big commitment to start taking this medicine, if you even meet the qualifications — 48 to 54 days of regular office visits, interviews, assessments,” he said. “That’s a lot to commit to all at once.”
No one knows for sure what’s next.
The World Health Organization’s monkeypox emergency panel is set to reconvene on July 21. They will vote once again on whether they are labeling monkeypox as a public health emergency of international concern. The agency defines this designation as “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.” In a meeting held on June 25, the agency said the outbreak did not qualify. At that time, the case count was about 3,000 worldwide, compared with 13,340 now. This figure includes 13,100 cases from 63 countries that have not historically reported monkeypox. More than half of these infections are from three countries, Spain with 2,835, the United States with 1,972, and Germany with 1,924. The United Kingdom is fourth in reported cases with 1,856 and Canada is seventh with 539.
The time for this disease continues to be pivotal, and no one knows if monkeypox will become a major worldwide crisis or whether it will become endemic in other countries as it is in Africa. (In some African countries, it circulates in rodent populations, which occasionally gives rise to outbreaks in humans, which is something to be wary of given the prairie dog outbreak in 2003.)
McQuiston said that she and her colleagues do not know what is going to happen, but they are dedicated to doing all they can to keep things under control.
“That sometimes wakes me up in the middle of the night, and I think a lot about it, and we certainly talk about it here,” she said. “We don’t yet have a sense of exactly where this may go.” ●
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