Stay Ready II: MPX Safety Alert
Clover Barnes: They are people who have either had skin to skin contact with someone diagnosed with MPX or cases where, for example, a child was in daycare with another child who had MPX. “Close contact” is a term we use to identify people who have been exposed to the disease, so we can vaccinate those who have been exposed.
Dr. Gajjala: Yes, it is mostly transmitted through skin-to-skin contact, though there is a very small chance of getting it through aerosol transmissions if you are within 6 feet of an infected person for about an hour or so without any mask or eyeglass protection, and this would be considered a high-risk contact. We don’t have exact information the way we do about COVID, but this is what we have seen so far.
Clover Barnes: In the make-up of the monkeypox virus, it is most similar to smallpox out of all the viruses in the orthopox family. It is the closest thing we have seen to smallpox, which is why we are using the smallpox vaccines and treatments for infected individuals, and they have been successful. We are using what we know about smallpox when trying to understand more about monkeypox and determine the best public health guidance.
Clover Barnes: Right now, I send the invitations to providers.
Clover Barnes: With the limited amount of vaccines we have been given, we have to prioritize the groups that are most likely to get MPX. This does not mean that you will not be able to get it forever, but we have to first stop the spread among the most affected communities. For example, when we had our first MPX case in May, our cases were doubling every two days. If we had 10 cases on Tuesday, we would have 20 cases on Thursday, then 40 cases on Saturday, and they were all in the same type of population. We had to take the step in prioritizing that population because that is where all the infections were. Now that there is more availability, you will be able to get your vaccine appointments right away.
Clover Barnes: We advise anybody with dirty sheets or towels, etc. to fold these materials over and roll them in to keep whatever is inside those sheets or towels inside. They should put them straight in the washer instead of placing them in hampers or mix it with other materials, and it should be washed with hot water. The disinfection for hard surfaces is a lot like COVID, so it’s your everyday routine of using Clorox, Lysol, or wipes to clean surfaces.
Clover Barnes: We have not seen instances with anything other than skin-to-skin, intimate contact. However, we do not want to say it is spread through sexual contact because you could get it from having skin-to-skin contact without having sex. We also have not seen any cases where it has been spread through the debris of the MPX sores, but we do know that other jurisdictions have reported those types of cases.
Clover Barnes: We have seen the same stigma from the HIV epidemic, and what we have learned is that the stigma does not help anybody. It keeps people from getting treatment and being fully engaged in the healthcare system and being virally suppressed sooner than they would be. We have been trying to remove this stigma by just focusing on the science. The science says that this certain demographic is getting it most than any other demographic in DC. That doesn’t make this demographic any different than any other demographic. It could have been women, children, or any other demographic because all of us have skin.
Clover Barnes: We have seen some cases in children within the District. One case was actually not a resident but was here on holiday from another country. They were exposed in a different country but was diagnosed while here in DC. They have since recovered and have gone home. We do have a child that is a DC resident that recently tested positive, and the parents are positive as well. It does present the same way: fever, malaise, body aches, and the sores. So far, the children have not had any adverse reactions or more severe course than any of the adults We have given them the medication right away, which shortens the course of the infection, but the doses have to be titrated for the small children.
Clover Barnes: We can typically get the TPOXX medication to a provider within 3 days. We typically deliver during Tuesdays and Thursdays, but if there is an emergency room, we do make special deliveries. We do ask that providers request more than the number of cases they have because it is not as limited as a resource compared to the vaccines. We recommend that student health centers in universities keep a stock of the medication, so you can immediately administer it to students.
Clover Barnes: We have not seen a variant at this point. To my knowledge, in the past, we have not had any cases of MPX outbreaks in the US, but it has been endemic in Africa for a while. They are trying to gather information from the knowledge they have about it in Africa, though <<this version of the virus>> is a bit different from the virus in Africa. There are different “clades” of MPX: a West African clade and a Central African clade. What we have is the West African clade, which is less severe and so far, less lethal. The Central African clade seems to be more virulent, meaning people get sicker or have greater consequences. We have not seen that clade in the US or any of the other countries that are experiencing MPX at this time.
Dr. Gajjala: The Western clade is the same clade that we see in the outbreak. I think it is a little different because the transmission mode is different than the past. In the past, it was usually transmitted through skin-to-skin contact and through aerosolization. Now, it is more transmitted through sexual contact because the rash is more localized in the genital and rectal areas compared to before. Usually, the rash is supposed to start from the mouth and face, then it goes down to the arms and feet. This time in the cases that we see, the rashes are in the genital and rectal areas and do not spread throughout the rest of the body. We do not know why this is, but I think it is likely because of the route of contact.
Clover Barnes: Also in Africa, they believe it started from eating meat from an animal infected with MPX, so that is another difference there, as well.
Clover Barnes: The CDC is saying that there is some immunity, but they don’t know how much at this point since they are studying that now. They do say that if you have not had a smallpox vaccine in the past 30 years and are from a high-risk population, you should get the MPX vaccine.
Clover Barnes: About every three weeks, we have pop-up clinics within homeless shelters to make sure we are vaccinating them from MPX. We also have guidance that we have given to those entities with congregate settings in how they can best protect themselves and their residents, all based on CDC guidance.
Clover Barnes: So far, we have had 4 women test positive for MPX, but 98% of the cases are still among men. We have seen cases in transgender women and a transgender, non-binary man. This is what we have seen so far, but this could change because everybody has skin and that is how it is transmitted. Because the scabs tend to flake, we have to be very careful because those scabs are still contagious.
The original criteria for getting the MPX vaccine was that you were gay, bisexual, or same gender-loving man who have sex with men, a sex worker or somebody who exchanges sex for any need or want, or work in areas like a sauna or other places where sexual activities occur. They then added transgender woman to that list who have sex with men. They prioritize those who have sex with more than 2 partners within 14 days at the very beginning, but that was changed to include those who have sex with multiple partners at any time. Again, this guideline has now changed to include anybody in the District who works or receives healthcare services, are university students, or anybody of any gender who have multiple sex partners. All of these people can get a MPX vaccine, though they have to self-report (without any verifications needed) in order to receive them either as a walk-in or a scheduled appointment.
Clover Barnes: The only test we have is to swab the rash itself. If you develop a rash that is unusual to you, you need to see your primary care provider or go to urgent care. If there is pain, go to the emergency room. However, you have to have a rash for them to test you for MPX.
Clover Barnes: Our state epidemiologist just had a meeting with all the universities to protect students coming back to campus. We are looking for those with a rash so they can be tested and isolated as soon as possible.
Clover Barnes: There is a quarantine period, which is until the MPX heals. It is contagious until the new layer of skin has formed. This can be a long time if you have a lot of pox, which is why we want people to take TPOXX right away so that your course is shortened. It could take as long as 4 weeks for your skin to heal.
Clover Barnes: We have not seen any significant side effects from the vaccines, especially when they were given subcutaneously. Now that it is intradermal, like a TB test, we have seen some redness and bruising at the injection site. If you have a skin condition like eczema, you are required to have the vaccine injected subcutaneously.
Bring the Noise: Event Questions
Dr. Yolandra Hancock: With each new variant or version of COVID, it becomes even more infectious to the point now that BA.5 is as infectious as measles, which is the most infectious disease in the planet. We know that BA.5 escapes the immune protection that any previous COVID-19 infection provided. You can still get COVID even if you just had it two months ago.
As of now, the BA.5 subvariant, which comes from the Omicron variant, is the most dominant variant, making up 77.9% of COVID cases. For more information on variants, please visit these websites.
Tracking SARS-CoV-2 variants (who.int)
Studies are showing that “South Africa’s BA.4 and BA.5 wave led to a similar rate of hospitalization but slightly lower death rate when compared with the country’s earlier Omicron wave. Both Omicron surges proved much milder, in terms of hospitalizations and deaths, than the country’s ferocious Delta wave.”
What Omicron’s BA.4 and BA.5 variants mean for the pandemic (nature.com)
You can protect yourself by continuing to take the same precautions: wearing your mask, social distancing, gathering outdoors, staying updated with COVID-vaccine shots, and isolating when exposed to COVID-19 or have COVID-19 symptoms.
Dr. Yolandra Hancock: There have not been enough conversations about the aerosolization of COVID, meaning when someone with COVID coughs in the air we breathe, it would still be in the air 30 minutes later. This is why we still always recommend to wear masks when in indoor, crowded environments.
Dr. Yolandra Hancock: The vaccine was not originally designed to prevent you from getting COVID—that was a bonus, but it was designed to keep you from getting critically ill and dying. In addition, getting the vaccine lowers your risk of developing long COVID. Studies show that 10-30% of those who are unvaccinated got long COVID after their infection, while only 0.5-5% of those who were vaccinated got long COVID.
Dr. Yolandra Hancock: The data shows that if you are vaccinated, you are less likely to be hospitalized and die from COVID.
Dr. Tracy Faulkner: The vaccine is not enough. We still have to use what I call the three W’s:
- Watch your distance (6 feet)
- Wash your hands (20 seconds minimum, soap and water)
- Wear your mask (n95 gives the best protection)
Whether or not you should get the vaccine is a choice. We do have evidence that the COVID vaccine helps in preventing severe disease. For example, President Biden contracted the virus even with the vaccine, but his symptoms may not be as severe as someone who has not had the vaccine, have not been fully vaccinated, or have had the booster. There is a rising trend in cases, and from what I’ve seen, it is mostly among individuals who have chosen not to receive the vaccine.
There is no definitive answer. As of now, we must learn to live with the new normal and minimize our risk of getting the infection. This includes washing our hands often, wearing a mask and distancing when in indoor, crowded spaces, holding gatherings outdoors, isolating when we feel symptoms or are exposed to COVID, and staying updated on our COVID vaccines.
Dr. Yolandra Hancock: Here’s an example. The rain is COVID, and an umbrella is vaccination protection. Right now, with the BA.5 subvariant, if you are fully vaccinated without boosters and wear a mask, it’s like having one of those cheap, flimsy umbrellas in the pouring rain. If you have a booster, it’s like having a Totes umbrella. When you have the second booster, it’s like having those dome, plastic umbrellas that comes all the way down to your waist, but even with that, you will still get wet from all the rain. However, these are all meant to decrease your risk of acquiring COVID and the severity of COVID illness.
The timing and amount of booster shots you can receive depends on your age, vaccine types administered during your primary series, and if you are immunocompromised. A breakdown of CDC’s booster guidelines can be found here.
Dr. Tracy Faulkner: The recommendation is not as such right now, but I do foresee that this will become a part of a schedule as many vaccines are.
The best way to know whether you got sick or infected by COVID-19 is by testing. If you have COVID-19 symptoms, OR if you were in a high-risk situation OR if you were exposed to someone who tested positive, test as soon as possible. If you were exposed to someone with COVID-19, test at least 5 days after your contact with them.
According to the CDC, symptoms usually appear 2-14 days after exposure to the virus.
Dr. Yolandra Hancock: It certainly is concerning to me that coming out of the pandemic there weren’t any basic public health procedures/polices/practices that school systems and municipalities could follow. When places don’t have procedures because the government has decided that we don’t need any public health policy or procedure, it is up to us individually to put policies and procedures in place. If there are no policies in place, we know that people won’t do it. What I would say is to still have your little one wear a mask, especially if the numbers are up. An N95 or KN95 mask is best.
Dr. Yolandra Hancock: We need to remain vigilant about washing our hands and wearing our masks. In the fall, the FDA has approved a vaccine with an Omicron-specific component, so we can have better protection against the variants.
Dr. Yolandra Hancock: COVID will likely remain endemic in our society, similar to the influenza, the common cold, strep, and other respiratory infections. We must minimize our risk and decrease the spread as a community because COVID is very much still with us.
Dr. Tracy Faulkner: There is a drug called Paxlovid and it has to be taken within 5 days of symptoms or a positive test. Molnupiravir is also available but is not as popular.
Dr. Yolandra Hancock: Paxlovid is indicated for people 12 and older and greater than 50kg in weight. Currently, there is not any pill treatment available for children under 12 years of age. If you are on a cholesterol lowering medication, a blood thinner, or an immunosuppressant, Paxlovid can interfere with the levels of those drugs. Because of these factors, it is critical to talk to a healthcare provider and be knowledgeable on your other medications to avoid any complications.
The reason you do not hear about Molnupiravir often is because of concerns with teratogenicity, which is the ability to cause deformity in fetal tissue. So, if you are pregnant or likely to get pregnant, you would need to be concerned about the medication’s impact. Studies in animals have also shown a degree of carcinogenicity, which is the ability to produce cancer.
Dr. Yolandra Hancock: When the pandemic first began, a common misconception was that Black people were not contracting the virus. Once the peak began around March <2020>, we began seeing Black people being disproportionally affected due to health and income disparities that already existed. Housing, transportation, healthcare access, etc., has made it more difficult for black people to achieve healthy lifestyles. Black people’s increased risk of contracting COVID and developing complications is really a reflection of the systems already in place.
We certainly need more conversations around systemic issues and health disparities. The media likes to show that the reason for health disparities is simply ignorance, but it is more than that. Unless we address the system in which we live—food insecurity, housing insecurity, income inequality, availability of healthy food options, healthcare being a business rather than a human right—we will continue to feed into the health inequities because the decisions that we make are based on the resources we have available. What I would also have to say is look at your own food. Are you at Popeye’s, or making your own chicken? Coming down to it, some of the differences in life expectancy within African Americans is systemic, and some of it is individual choice. This is what we should talk through in our communities.
Dr. Tracy Faulkner: Yes, I do believe that a lot of this comes from managed care. While a lot of doctors want to spend as much time with their patients, they are often restricted by insurance companies. They would definitely have better relationships with their patients if they did not have time or policy restrictions.
Dr. Yolandra Hancock: Part of the “death of medicine” was the introduction of managed care organizations, which was designed to control costs. I left academic medicine because I knew that I couldn’t see a patient in 15 minutes. With private practice, I get to create space for patients to have the time they deserve. The challenge is that it costs me.
Regarding building trust in patient-doctor relationships, there are several studies that show building trust improves health outcomes within African-Americans:
Trust in African Americans’ Healthcare Experiences – PubMed (nih.gov)
Here is an article that explains the importance of trust in the doctor-patient relationship among minority populations:
Distrust of Medical System and Minority Health Care (webmd.com)
| Beliefs | Facts |
| COVID can be a major problem/be fatal for people who are not vaccinated and have significant pre-existing health issue. | Many studies show that having pre-existing conditions like obesity, high-blood pressure, diabetes, etc. are risk factors for severe or fatal outcomes from COVID-19. In addition, those who are unvaccinated make up the majority of those who have severe/fatal COVID outcomes. |
| I believe the pandemic was preventable. | Yes, with the right infrastructure, it could have been prevented, but there were delays in our emergency public health response |
| Variants of COVID are here to stay. | The variants are labeled as “being monitored,” “of concern,” or “of interest.” Right now, all COVID variants are at least being monitored, with some variants of concern circulating around. It seems that COVID will be endemic, so it will be here to stay. |
| I believe COVID is manmade. | There is certainly information circulating that COVID was made in a lab as a weapon; however, there is no significant evidence to confirm this. |
| There is no cure. | For most cases, people recover from COVID-19 within a few weeks because their immune system (increased with vaccination) overcomes the infection. |
| With the assistance of a natural dietary supplement coupled with the vaccine, we can resist breakthrough and rebound. | If you are not getting enough of the essential nutrients, vitamins, and minerals, dietary supplements may help boost your immune system and reduce COVID-19 symptoms. |
| I believe that if every single person were to be vaccinated and boosted against the virus that it could curve and even lower it. | Yes, studies are showing that being vaccinated and boosted reduces the spread of COVID-19. |
| It affects everyone differently. | COVID-19 does affect people differently. We see, even from the beginning, that some people show a range of different symptoms while others have none. Some develop long COVID and present with disabilities that they never had before. In addition, socioeconomic factors also play a role in COVID-19 disproportionately affecting minority communities. |
| It’s become a new normal. | Because COVID-19 is becoming endemic, these protective measures must now be part of our lifestyles as we navigate through the new normal. |
| It can come back even if you have had it before or been vaccinated. | Yes, there have been breakthrough cases among those who have gotten COVID or have been vaccinated, especially with the Omicron variants becoming increasingly transmissible. |
| The vaccine is a cure. | The vaccine acts as a prevention measure to lower your risk of severe COVID-19 illness. Once someone has COVID-19, healthcare professionals use COVID-19 medications such as Paxlovid to treat patients’ symptoms and kill the virus rather than the vaccine. |
| COVID vaccine does NOT affect my fertility. | Yes, there is increasing evidence showing that COVID-19 vaccines do not cause infertility. It must be noted, however that COVID-19 infection can affect male fertility. |
| You will not die if you have the COVID vaccination when you contract it again. | While the COVID-19 vaccines lower your risk of getting severe/fatal outcomes, there are still a small number of fully vaccinated people who have died from COVID-19. This is why we must continue to take precautions such as wearing masks, distancing, isolating, watching our symptoms, and seeking help from a medical professional when necessary. |
| COVID virus has been around for a long time. COVID-19 and its newer forms are new. | Yes, coronaviruses have been around for centuries, though commonly found in animals. Some coronaviruses have caused outbreaks in humans, such as SARS and MERS, which had higher mortality rates. SARS-CoV-2 is the coronavirus that causes COVID-19 and is continually mutating to increase its ability to infect hosts like us. |
| COVID/Omicron DOESN’T function like a natural virus. Its molecular size(structure) gets smaller with every new variant. | While there are some similarities with other viruses, SARS-CoV-2 has been less predictable, and its mutations have made it harder to combat the virus. The molecular structure changes but is not necessariy smaller. As we are learning more, we also have to adjust public health guidelines to reflect the most recent scientific evidence. |
| Not being vaccinated isn’t that big of a thing when there have been one million plus people dying from the virus. | While the new variants have made COVID much more transmissible and escape the immune systems of those who have previously been infected or are fully-vaccinated/boosted, there is still a lot of evidence to prove that the vaccines lowers your risk of getting severely-ill or dying from COVID-19 and lowers your risk of developing long COVID. |
| It’s still a risk in many ways. | Yes, with emerging research about long COVID, we are seeing that COVID-19 is more than just the flu-like symptoms. The virus also attacks the vulnerable parts of your body, impacts the tissues in your blood vessels, causes inflammation in your brain cells, and more. There have been some patients who had no medical conditions before COVID, but after infection, they now present with diabetes or neurological conditions. |
| It’s manageable at home. | If you have a mild case of COVID-19, which is likely the case for most people, then you can certainly manage your symptoms at home as long as you make sure to eat nutritious foods, get lots of rest and hydration, and take over-the-counter medications as needed. However, for older adults and those with chronic conditions, it is advisable that you seek help from your healthcare provider. If you have emergency warning signs or your symptoms are getting worse, please seek medical attention as soon as possible. |
Long COVID and vaccination
Kuodi et al. https://www.medrxiv.org/content/10.1101/2022.01.05.22268800v2.full-text
Ayoubknai et al. https://www.bmj.com/content/377/bmj-2021-069676
Booster guidelines
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html
Variants of Concern
https://www.yalemedicine.org/news/covid-19-variants-of-concern-omicron
https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html
Masking
How well do face masks protect against COVID-19? – Mayo Clinic
Face masks help prevent COVID-19 spread. Here’s how. | Ohio State Medical Center (osu.edu)