In two short months, more than 18,000 cases of monkeypox (MPV) and five deaths have been reported across the globe. This is a rapidly evolving situation, but clearly a public health crisis. While one takes hold (MPV) we concurrently fight another pandemic (COVID-19), so it’s tempting to compare the diseases and our responses. There are certainly similarities, but there are key differences, too.
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."
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.
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.
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.
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.
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.
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
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.
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?
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.
Isn't the relevant comparison two pandemics vs one? Or even "concurrent global public health crisis and pandemic" vs "pandemic"?
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.