Three pressing questions about Monkeypox: distribution, vaccination, treatment

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

On Thursday, New York State and San Francisco declared their own emergencies. But even as the national number approaches 5,000 and experts warn that containment is slipping, federal health officials have not followed suit.

One reason: Unlike the coronavirus, this virus is a known enemy, officials say. Doctors understand how it spreads and there are already tests, vaccines and treatments.

But for scientists, the increasing research paints a more complicated and challenging picture. The virus remains a mystery in a number of important ways, not exactly behaving in ways that researchers have seen during sporadic outbreaks in African countries.

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

At the start of the outbreak, health officials claimed the virus spread through respiratory droplets released when an infected person coughed or sneered, and through close contact with pus-filled skin lesions or bedding and other contaminated material.

That was all true. But it may not be the whole picture.

According to the Centers for Disease Control and Prevention, more than 99 percent of people infected so far are men who got the virus through intimate contact with other men. As of July 25, only 13 women and two young children had been diagnosed with monkey pox.

Researchers have found the virus in saliva, urine, feces and semen. It’s unclear whether those fluids could be contagious and, in particular, whether the virus could be transmitted during sex by means other than close skin-to-skin contact. But its distribution pattern so far, through sexual networks, has left researchers questioning.

However, it is clear that monkey pox 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 clothing or a cursory interaction with an infected person, as some social media posts have suggested.

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

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

In the outbreak outside Africa, many patients have no fever or respiratory symptoms at all, and the rash is often limited to a few lesions in the genital or rectal area, which can be easily mistaken for various sexually transmitted diseases.

Britain 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 presentation of the disease in Western countries may accurately reflect the natural course of the virus.

Jynneos, the safer of two monkeypox vaccines, is made by Bavarian Nordic, a small company in Denmark. Stocks are severely limited and the Biden administration moved slowly to obtain additional doses as the virus spread.

Now federal officials have ordered nearly seven million doses, which will arrive in batches in the coming months. So far, the administration has shipped about 320,000 doses to states. The Food and Drug Administration said on Wednesday it had approved another 800,000 doses, but it was unclear when they would be handed out.

Jynneos is believed to be administered in two doses 28 days apart. But some cities, including Washington and New York City, are holding back on second doses until more become available, following a strategy adopted by Britain and Canada.

Federal health officials have advised against delaying second doses. But in studies, a single dose of Jynneos has been shown to be protective for up to two years. If that real-world finding is true, delaying additional shots could help officials contain the outbreak by immunizing more Americans.

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

There may not be much choice as eligibility grows and more risky people look for shots. Some jurisdictions have already expanded the groups eligible for immunization to include sex workers, patients at sexual health clinics and clinicians and other workers who may be exposed to the virus on the job.

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 injection because she sometimes has sex with men at high risk of monkeypox infection. No one doubted her suitability. “They weren’t weird about that at all — it was a very smooth process,” she said.

Due to its deficiency, the vaccine is only offered as a preventive measure, although it can reduce symptoms if given within a few days of exposure.

David Baldwin, 45, a music professor in New York, was only eligible for vaccination because doctors didn’t believe he was already infected. (His first symptom was rectal pain.) “As a result, I think I never developed 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 only limited data on its use in humans.

Supply is not a problem: the national stock contains about 1.7 million doses. Still, getting the drug has been difficult, and that has led to ambiguities about how well and for whom the drug works, even as the number of cases increases.

Because tecovirimat is not specifically approved for the treatment of monkeypox, it can only be prescribed through a cumbersome “investigation drug protocol” that until recently required doctors to send detailed reports to the CDC, a diary kept by patients to record their progress. and take pictures of the lesions.

With so many hurdles, many clinics didn’t offer tecovirimat at all; even doctors in well-funded institutions managed to treat only two or three patients a day.

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

As he waited in seclusion for the drug, three new lesions emerged on his back. “It’s like getting your sentence extended,” he said.

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

Due to such delays, the CDC has relaxed the rules for accessing tecovirimat. The agency now requires fewer patient visits, samples and forms and allows physicians to virtually assess patients.

Wider use should help scientists and health officials gain a better understanding of the drug’s efficacy. The new requirements will help the CDC “determine whether and how well this drug works for monkeypox patients,” noted Kristen Nordlund, a spokeswoman for the agency.

The National Institute of Allergy and Infectious Diseases plans a clinical trial of tecovirimat in adults with monkeypox infection, including people with HIV, possibly starting this fall. The agency is working with Siga Technologies, which manufactures the drug, on another trial in the Democratic Republic of Congo, where the virus is a long-standing scourge, also expected to begin this fall.

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