July 14, 2022 – People with monkeypox can face a wide variety of symptoms, from minor skin lesions to severe, debilitating pain. Experts don’t yet have a reliable way to predict who will have the most severe symptoms.
There is an antiviral treatment, tecovirimat (TPOXX), but it is currently only available from the national strategic stockpile. FDA approves tecovirimat for treatment smallpox In 2018, there were fears that it could one day be used as a bioterrorism weapon.
Local health departments are working with the CDC and the U.S. Department of Health and Human Services to apply for tecovirimat through a complex 120-page protocol. Meanwhile, global monkeypox cases have risen to more than 11,000, according to the U.S. Centers for Disease Control and Prevention.
In the U.S. alone, cases have now surpassed 1,000, according to the CDC.
While monkeypox is a global concern, some parts of the United States, such as New York City, are experiencing larger outbreaks.
“As of yesterday, New York City alone had as many as 336 cases — that’s essentially triple the number of cases over the past week,” Mary Foote, MD, told a news conference sponsored by the Society for Infectious Diseases of the United States society.
“It is very clear that we do not believe this count [reflects] The real burden of disease. There are a lot of cases that go undiagnosed,” said Foote, medical director of the Office of Emergency Preparedness and Response at the New York City Department of Health and Mental Hygiene.
“We do think it’s a really exponential increase in cases that will probably continue for some time,” she said.
Experts say these soaring case numbers are the result of a slow and inadequate response to the outbreak.
Amesh Adalja, MD, senior scholar at the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, said: “If this is a post-COVID trial run to see if we’re better off, I don’t think that’s going to be the case. Good,” said in an interview in Baltimore. “The CDC response leaves a lot to be desired.”
The slow response to growing monkeypox cases is all the more puzzling because we already have all the tools we need to control the spread, Adalja said. “This should be a home run after COVID-19: a disease that’s not very easily spread, and we have a vaccine, an antiviral drug, and a diagnostic test that already exists,” he said.
Access to treatment can be challenging
Health officials in New York require treatment for about 20 to 25 percent of monkeypox patients who meet specific guidelines.
But the problem is that the drug can only be prescribed through a cumbersome new process called the Expanded Access Investigational New Drug Program.
“Completing all of this paperwork is complex…and time-consuming,” Foote said.
Because of these requirements, primarily state health departments and large academic health systems have the resources to apply through this protocol.
Additionally, Foote estimates that it may take 1.5 to 3 hours for a patient visit to initiate monkeypox treatment, based on all forms and management requirements. “In a busy community clinic, urgent care center or emergency department, where most patients are seen, it’s almost impossible to implement.”
What’s more, tecovirimat has not been tested in humans.
“You can’t do a randomized controlled trial on smallpox or monkeypox for obvious reasons, so it’s based on an animal model,” Foote said. But animal evidence suggests 90 to 100 percent effectiveness in preventing deaths.
Human data on tecovirimat are limited to a few case reports, but so far the signs are positive.
“Interestingly, the clinical response was excellent,” Foote said. “Many patients reported significant improvement in their symptoms in just a few days.”
She said patients appeared to tolerate the drug well, with some headaches and nausea, but no serious side effects were reported.
“Extreme pain” and other symptoms
A lot of doctors learned in medical school that monkeypox is a mild disease that goes away on its own,” and a lot of people say so break out Same thing,” Foote said. “But the reality is that a lot of people with this virus are really suffering, and some may actually be at risk for permanent damage and scarring.
“We’ve seen many people with symptoms so severe that they can’t go to the toilet, urinate or eat without excruciating pain,” she said.
Lilian Abbo, MD, who spoke at the news conference, said monkeypox awareness needs to be raised among patients and providers. Many infected individuals jump from one clinical setting to another before being diagnosed.
Foote agreed. “I’m really shocked how many of these patients are struggling to get the care they need to treat these symptoms — having to go back and forth between clinics, hospitals and urgent care centers — and never be referred to us,” Foote said.
Risk may spread
To date, most monkeypox cases reported to the CDC have occurred in men who have sex with men. “It’s a very savvy community that’s very good at defending itself,” Foote said. “They literally stood up and said, ‘Hey, you need to take this seriously.'”
Abbo said monkeypox has spread beyond the community.
“It feels a bit like HIV The epidemic has begun. I don’t want to create stigma on MSM – we’ve seen it spread among women, and it’s been reported among children in other countries. “
It’s an infectious disease that spreads through close contact, said Abo, deputy chief medical officer for infectious diseases at the Jackson Health System in South Florida.
“We need to take care of the entire population,” she said. Even if it starts with one group, “it spreads to other groups.”
“I don’t want to create fear. I just want to create awareness so we can control it, stop the spread, and focus our attention on prevention,” she said.
Testing is also cumbersome
Access to testing has also been challenging, Abbo said. Photographs of monkeypox lesions are sometimes required for authorized testing, and “after multiple layers and phone calls, it can take up to 8 hours for approval.”
In addition to testing by public health authorities, commercial labs began offering monkeypox testing last week, but that comes at a cost, Abbo said. She estimates the cost of each commercial test to be $90 to $100.
“We’re also trying to build internal testing,” she said.
Some universities have already done so, but they face challenges due to supply chain shortages.
Monkeypox testing is now available from Aegis Sciences, LabCorp, Mayo Clinic Laboratories and Quest Diagnostics. Tests need to be ordered by a health care provider; patients cannot go to the lab on their own to request a test. Each company has a designated laboratory nationwide where all samples can be sent.
“This is not an urgent enough response to the need to contain this virus,” said Dr. Jennifer Nuzzo, director of the Center for Epidemiology at Brown University’s School of Public Health in Providence, Rhode Island.
Vaccine demand exceeds supply
Vaccination can also help prevent monkeypox infection, or, if given early enough, can prevent severe disease in people who are already infected with monkeypox. But experts say there are challenges there too.
The New York City Department of Health is pioneering expanded vaccine protection for people at high risk of monkeypox exposure.
“And the demand has been very very high – This time is unstoppable. Supply is limited nationwide,” Foote said.
Health officials in New York and elsewhere are working with federal partners, clinics and community health organizations to provide vaccines to at-risk groups in an equitable manner, she said.
Treating people with monkeypox also has a higher risk of infection, Abbo said. Many people are asking about vaccinating health care workers, she said. “We’re constantly exposed, examining patients.”
If or when such categories or guidelines are created, health care workers could end up being classified as high risk, Abbo said. This strategy can also help get scarce resources to the right places.
More testing is needed to mitigate the spread of monkeypox before a vaccine becomes more available. “We really need a strategy to make sure anyone who needs a test can get it as easily as possible,” Nuzzo said, “because right now, with a lack of vaccines and treatments, that’s our main intervention: testing people so that They can isolate and stay at home as long as they are contagious.”
Abbo also noted that health care workers were already feeling the pressure to manage COVID-19 before the monkeypox outbreak.
“It’s also the exhaustion of nurses, doctors, lab technicians, and everyone who has been working nonstop for the past 2 years to deal with the COVID pandemic. Now, we must continue to focus on COVID and this new outbreak.
“Please understand that we appreciate what the government has done,” Abo said, “but we do need help with treatment and rapid diagnosis.”
Asked if infectious disease outbreaks are becoming more common, Foote said yes.
“We know outbreaks are becoming more frequent. There’s a huge body of public health literature looking at why,” she said.
“We’re definitely seeing more frequent outbreaks.”