In the City and State, Monkeypox is a Public Health Emergency

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Brian Lehrer: Brian Lehrer on WNYC. If you haven't heard this yet, in the last few days, New York City and New York State have both now declared the monkeypox virus a public health emergency. Once the epicenter of the coronavirus pandemic and earlier of HIV/AIDS, New York City is now the epicenter of the monkeypox outbreak in this country. In the city, there's been a more than threefold increase in cases over the past two weeks according to reporting from Gothamist. This is likely an undercount because there remains a lack of testing capacity. How does this public health emergency declaration change things?

What's changed and what hasn't in the care that monkeypox patients are receiving and how our public health officials messaging against the stigma while prioritizing care for the populations that have so far been disproportionately affected by the virus queer man? With me now for an update on the monkeypox virus and the official public health response are Joseph Osmundson, a microbiologist, activist, and writer with a PhD in Molecular Biophysics, and author of the recently published Virology: Essays for the Living, the Dead, and the Small Things in Between.

We also have Jay Varma, physician and epidemiologist, director of the Cornell Center for Pandemic Prevention and Response, and professor of Population Health Sciences at Weill Cornell Medicine. Hi, Dr. Osmundson, Dr. Varma, great to have you both back with us on WNYC.

Joseph Osmundson: Thank you so much for having us.

Jay Varma: Thank you.

Brian Lehrer: Dr. Varma, so what does the public health emergency declaration actually changed with respect to the response of both city and state governments?

Jay Varma: The reason a government does this is really basically for three reasons, and that's true both for here in New York City, as well as in New York State. The first is it allows the city to expedite anything it needs related to staff, stuff, or space. If they need to hire somebody quicker, they can bypass a lot of standard procedures, and they can contract for other services. The second thing it does is it allows either the Commissioner of Health or the mayor himself to issue an executive order that may bypass existing laws.

Like during COVID, for example, you saw that during limiting hours or capacity of certain facilities. The third thing it does is raise political awareness. It gets people like WNYC and other people to talk about monkeypox, which is really, absolutely critical in terms of raising awareness both among people at risk, as well as among medical providers.

Brian Lehrer: Most known cases in the state, we should say, are in the five boroughs. Why then, Dr. Varma, did the state declare monkeypox a public health emergency before the city did?

Jay Varma: Well, the city and state have both different authorities as well as different capacity to deal with certain issues. For example, the state regulates hospitals and all healthcare facilities, like nursing homes. There may be situations in which the state needs to have this declaration as well if it wants to issue specific guidance or requirements at that level. The second issue is, of course, there's a lot of inequity in New York State itself.

There's a lot of counties outside of New York City that have nowhere near the capacity to deliver vaccines or conduct testing without reach, simply because they don't have the staff. This would allow the state to also help address those counties which may have the absolute number of cases may be quite small, but it represents a large burden that their health department can't meet.

Brian Lehrer: Listeners, we're going to open up the phones for your participation in this conversation about monkeypox, now officially declared a public health emergency at the New York City level and New York State level. First of all, if you've actually had monkeypox, you want to help us report this story by telling us what you've gone through or are going through or how you managed or managing, and how you cope with a stigma if that's part of it for you, as well as the effects of the virus physically. 212-433-WNYC, 212-433-9692.

I feel like a lot of the conversation in the media about monkeypox so far has been with public health officials and experts like our guests, and they obviously need to be on and impart their knowledge. We also need to hear the voices of people who are experiencing this firsthand. We need to hear community voices. We need to hear individual voices. If you've had monkeypox or even if you know somebody who's had monkeypox, help us report this story. Tell us what you or the person you know has been going through.

How did you manage the physical symptoms? Is there a stigma element that you want to talk about? 212-433-WNYC, 433-9692, or tweet @BrianLehrer. Beyond that, we can just take your monkeypox questions for Joseph Osmundson, again, a microbiologist, activist, and writer with a PhD in Molecular Biophysics, and Jay Varma, physician and epidemiologist, Director of the Cornell Center for Pandemic Prevention and Response, and Professor of Population Health Sciences at Weill Cornell Medicine.

212-433-WNYC, 212-433-9692, your experiences and questions are invited. Dr. Osmundson, is the evidence still indicating that most monkeypox cases are spread by close personal skin-to-skin contact?

Joseph Osmundson: Yes, that is absolutely right. I am both [chuckles] a scientist and also a community member. Many people I know are dealing with monkeypox directly or have been exposed, and I've had to try to find vaccinations to prevent, hopefully, than getting the illness. Really, New York City and New York State are doing the right thing, but New York City and State cannot procure a vaccine. They do not control the national stockpile. They are not the CDC that says how many pages of paperwork a physician has to fill out in order to get someone treatment. They really have no control in terms of regulating the tests for this virus.

We are really arguing that the federal government who has the most control in New York but also nationwide, that they need to understand finally that this is a public health emergency, and that when the federal government follows New York City and State in that declaration will hopefully open up new pathways to test and make treatment, and hopefully, also vaccination be so much easier because on the ground, people are still not able to access treatment, and they are not able to access vaccination. Most spread, yes, it's still occurring, we think through very extended skin-to-skin personal contact.

We can't ask people to not have skin-to-skin contact for weeks and months. People need the tools that the government has actually to keep them safer when they have that type of interaction.

Brian Lehrer: Well, is there a safe skin-to-skin contact, or safer skin-to-skin contact in the context of monkeypox?

Joseph Osmundson: Of course, we are giving people all of the information that we can in terms of risk reduction and safer interactions, both sexual interactions and non-sexual interactions. We're talking about, at the circuit party, instead of going shirtless, maybe wear a shirt, minimize how much skin you have available. Interacting with people sexually on a webcam is the safest way to interact. Then there's gradations all the way down.

The most risky type of in-person interaction is with lots of people and lots of skin touching. Yes, we are asking people to be mindful of risk awareness around the behaviors that just like with COVID and with HIV, they're steps individuals can take, but we know based on public health, that asking people to do those harm reduction steps over and over and over again is very limited, and people are beautifully imperfect. We need tools and redundancies such that a human being's imperfection it does not land them with a virus.

Brian Lehrer: Let's take a phone call from Jack in Brooklyn, who says he recently recovered from a case. Hi, Jack, you're on WNYC. We really appreciate you calling in.

Jack: Hi, Brian, my pleasure. I think you're totally right in saying that hearing voices is important right now. I definitely experienced some excruciating pain, a bit of stigma even within my friend group. I know that right now, the largest piece of recovering and putting together a health plan has been a network of gay friends messaging about vaccine availability, messaging which doctors might be more helpful to get TPOXX medication.

I'm really grateful for my social sphere because it was incredibly painful. I had to talk to you a ton of different doctors about pain medication and exactly what I was going through. There was a different diagnosis going on, and it was just a really confusing time. It seems like it sprung up from nowhere, even though we have a lot of models to base things off of in recent history.

Brian Lehrer: When you say different diagnoses going on. Were you first diagnosed with something else, and then you had to go to another doctor to confirm that it was monkeypox or something like that?

Jack: I know a number of my friends initially were told that perhaps they were experiencing a herpes outbreak. They were prescribed things like Valtrex and then overnight that turned into a monkeypox diagnosis. Doctor is saying, "I think this might be herpes. Never mind, I think this sounds more like monkeypox."

Brian Lehrer: When you talked about suffering some stigma even in your friend's group, can you talk as it might be useful for people to hear a little bit of how that played out?

Jack: Sure. It was just about once I was in the clear, once doctors say once lesions fall off, scab over, and you have new skin growth. I personally only had one pox on my entire body and once that went away, I was able to go socialize and things. I experienced some, maybe a bit of judgment in my reentry to socialization, which was painful and confusing. I think that we need to do our best to educate, just like we had to do with COVID not so long ago, to make sure that we know the facts that doctors are putting out there so that we can minimize all of that judgment and not make our friends feel any particular way about reentering into social situations.

Brian Lehrer: Jack, we really appreciate your voice. Thank you very much for calling on, and be well. Here's another caller who says he's just recovering from monkeypox, Ed in the Bronx. Ed, you're on WNYC. Thank you so much for calling in. Hi, there.

Ed: Hi, how are you?

Brian Lehrer: Good. How are you?

Ed: Finally recovering. It's been a rough two weeks, partly because of the limited access or the difficulty in accessing the anti-viral TPOXX, which could have probably shortened my recovery. It wasn't until I actually got the TPOXX last week that I saw a significant improvement within 36 hours of severe pain that I was experiencing for some of the pox and the lesions had gone away. Had I gotten this much sooner, knowing that I was exposed to monkeypox and knowing that I had monkeypox, I think me and many people out there could have just passed through this much quicker.

Brian Lehrer: What was the cause for the delay in your case, if you can say? Was it that your doctor didn't know about it? Was it the supply wasn't available? Can you say?

Ed: Well, it's a combination of a lot of issues. It's a combination of this is something new for a lot of doctors. A lot of doctors are not equipped. A lot of medical officers aren't equipped to handle the amount of paperwork that was required up until a little less than two weeks ago when you can now do it at the back end instead of the front end to get someone approved with medication. There were a lot of roadblocks because this is just not having the capacity to dedicate so much time to fill out the paperwork.

We were relegated to places like Callen-Lorde and Columbia University, where they do have the capacity to handle the paperwork, but at the same time, they were being flooded by people trying to get access to medication so they were delayed left and right. Another thing that I want to add is that the government really dropped the ball on this. We knew that the first cases were popping in May.

Why did it take so long for them to begin releasing significant amounts of the vaccine to the general population that was being impacted? We knew that that was happening, and then here we are now. There's a lot of suffering being with government neglect.

Brian Lehrer: Ed, I appreciate your voice. Thank you very much for sharing your story and your critique of how the government has handled it as well. Dr. Varma, let me ask you about one of the things that the first caller said. Well, actually, let me ask you about something that the second caller said about the 36-hour vast improvement time from the time that he was prescribed the medication. Is that your experience? Talk about the effectiveness of the particular medication. Are there multiple medications? What's the best course of treatment if somebody discovers that they have monkeypox?

Jay Varma: Brian, thank you for raising that. Thank you to Ed and Jack for sharing their stories. It takes strength and courage to acknowledge the suffering you've been through. We really appreciate that as public health people. The drug that your second caller was referencing, the chemical name is tecovirimat, but the common name is TPOXX. It's actually a really interesting story.

I'll tell it very quickly because it's relevant to the issue here, which is actually that the US government in 2001 because it was concerned about the potential risk of a smallpox bioterrorism attack mobilized all parts of government, the NIH, the CDC, and Department of Defense to find a drug that could be used to treat smallpox because there was never a drug discovered before for this.

They developed TPOXX, which because smallpox and monkeypox are very similar works, very well for monkeypox. Now because of shortsightedness at that time, the US government approved it only for the treatment of smallpox even though it was demonstrated in their animal models to be very effective against monkeypox. As a result, CDC is the only agency that can release the drug and is releasing it with all this paperwork required. Many of us, Joe, myself, and tremendous community activists have worked to expedite that.

We don't have a really good randomized trial, which is the gold standard. One group has monkeypox and gets the drug. Another group has monkeypox and doesn't get the drug. There's a lot of data from animal models and now from patient experience indicating first that the drug is safe, and it has very few side effects. Second of all, that you can see this very dramatic reduction in pain and discomfort and rapid removal of these lesions very quickly.

That's particularly important not just because it reduces suffering, but it also reduces the time that people need to isolate. It's both good for the patient as well as good for our society because it gets people out and about much faster. We're hopeful that there's going to be both good research on this, but also really just expanded compassionate use.

Brian Lehrer: Dr. Osmundson, to one of the things the first caller was talking about, the wariness of his friends to interact in certain ways after he was recovered. Can you talk about the timeline of recovery and immunity? We know with coronavirus, in general, once you've had it and in the immediate period after you've recovered from it, you're pretty safe to interact with other people, both for yourself and for them. What's the case with monkeypox?

Joseph Osmundson: First, I just I want to echo Jay's comment about Ed and Jack. The thing that I heard from those callers was what we saw with HIV, what we're seeing again now, where a community is being impacted, and they feel left behind, and they become experts at their own health. Hearing Ed and Jack talk, I was hearing specific nods to changes in CDC protocols about TPOXX. As an activist, we've been following but patients have had to become experts at that level in order to advocate for care for themselves. It gives me immense pride in my community but it also makes me so scared and worried that not everyone has the time and capacity to have to do that to get a drug to ease their suffering.

I have immense pride for my community at the moment. This is a really long isolation. As Dr. Varma said, folks need to isolate when they're infectious, and that can be for weeks. That's another thing at a public health emergency at the federal level can do is mobilize funds to help people support people, get the emotional, practical, and financial needs met so they can properly isolate to prevent ongoing spread. Once you're cleared by your doctor and you have that good skin growing underneath the lesions, you are the most immune person in the North American continent to this virus.

In a way, we had this framework shift around HIV in the last decade where we learned through amazing science that someone who was HIV positive and undetectable actually is the safest sex partner in terms of HIV transmission. They cannot transmit HIV, whereas if you think you're having sex with someone who's HIV negative, they might not know their status, et cetera. Someone who has just recovered from monkeypox is the most immune, "safest", the best--

Brian Lehrer: Good to know. Is there a test to determine that somebody is clear, or is it like a negative COVID test?

Joseph Osmundson: There isn't. We have a huge runway ahead of us in terms of diagnostics. The only diagnostics available now are on open lesions. Frankly, just because someone has the DNA in their saliva does not mean they're infectious. Again, this virus was ignored from 1970 until now. These fundamental virological questions, is there live virus in saliva? Is there DNA in saliva? What is the pathway to recovery? What are the exact and the totality? We don't really understand if saliva and respiratory droplets play a significant role or not, and why do we not understand that?

Because until recently, this virus impacted people in a place that we could ignore and forget about and think that it wouldn't impact us, and we could ignore also the suffering of the people in the endemic region. We're seeing just the global costs of ignoring a preventable infectious disease anywhere on this planet.

Brian Lehrer: Kevin, in Queens, you're on WNYC. Hi, Kevin.

Kevin: Hi. I just had a question about how the vaccine eligibility criteria are slated to change under the emergency order and just to comment on, I think, how restrictive that the criteria have been so far. I think currently, you need to be a man who have sex with men, with multiple sex partners in the past, I don't know two weeks or something, to be eligible to receive a vaccine. I feel that such a very ham-fisted policy decision that leads to some of the stigmas that we're talking about and really doesn't give me that much faith and the government's ability to make this epidemic different from what we call it [unintelligible 00:21:35].

Brian Lehrer: Well, Dr. Varma, do you want to confirm or refute those eligibility criteria as Kevin laid them out and comment?

Jay Varma: Yes. First comment was about whether the eligibility criteria will change. I don't think they will for the near future. Really, right now, there's just simply not enough supply to meet the demand. The priority at the federal government level, in addition to getting more supply, is to make sure it gets delivered to the people at highest risk. We know right now that the highest risk group is gay men and people in their sexual networks. That's been loosely defined or written definition is multiple or anonymous sex partners in the last 14 days. I would say that, that people are just self-attesting to what the risk is.

I wouldn't encourage people to come out there and claim there because it is unethical that the claim that you're at higher risk than you are, but there is some nuance in what it means to be at risk. What is the definition of multiple-sex partners, for example, but right now, it is really a priority that that group maintained the priority for getting vaccinated. Then the only other group that's recommended to get vaccinated is people who are known close contacts. Let's say you're a household member of somebody who's in one of those high-risk groups and has gotten monkeypox.

Brian Lehrer: Few more minutes with Dr. Varma and Dr. Osmundson on what it means that New York City and New York State have declared monkeypox an official public health emergency and with your monkeypox questions and anecdotes, generally. Alex in Manhattan, you're on WNYC. Hi, Alex.

Alex: Hi, there. Thanks for this conversation. It's been actually incredibly enlightening. I do have a question. Should gyms or athletic facilities that have a lot of sports with close contact like wrestling or jiu-jitsu or any of those kinds of sports be taking monkeypox more seriously? I think, for context, this isn't being talked about or taking very seriously at all in the circles and I'm curious if it should be.

Brian Lehrer: Dr. Varma, should it be?

Jay Varma: At this time, the number of people with monkeypox, even though it has grown substantially, is not a level where I would say that all gyms need to be implementing immediate precautions related to monkeypox. Now that said, the caller is highlighting an important consideration and this is very relevant for back-to-college and university settings as well too. We know that diseases that transmit by skin-to-skin contact such as MRSA, a skin infection, you have outbreaks in places where people are in close contact like gyms, wrestling teams, et cetera.

It wouldn't surprise me if there ended up being some infections that end up being transmitted through gyms and saunas and other places like that. I do think that gyms and saunas and places like that should be thinking about what their protocols are going to be for the near future. There's always a benefit to having enhanced cleaning of surfaces in those places, but I don't feel like there needs to be specific warnings or business restrictions at this time on those places.

Brian Lehrer: Related question from a listener on Twitter says how long does the monkeypox virus live on surfaces like doorknobs or grocery packages and products or hotel linen? Dr. Varma, I'll stay with you for that. If it does even live on all of those surfaces that the tweeter referenced?

Jay Varma: Yes, this is an important question we don't know the exact answer to, but I'll tell you what we do know and then I'd be happy to see Joe, since he's a basic scientist and works on these viruses, maybe chime in as well. What we do know is that this virus can survive on the surfaces around a patient, and particularly on the clothing, towels, linens, et cetera that a person uses.

This is based on epidemiologic investigations in Central and West Africa, where the disease has historically been localized to, but we don't know, because those studies were never done in exhaustive detail to figure out how long it survives. It's particularly challenging even if you can detect the virus on a surface to know is it actually infectious to other people? A lot of people were asking the same questions, for example, about COVID.

The current recommendation is that any surfaces that you use in your home or any utensils should be washed thoroughly. You can use a dilute bleach, or you can use an alcohol-based solution or even just vigorous rubbing with hot soap and water, and that your linens and things should be washed in a washing machine. If it's a proper washing machine that should disinfect them, but we don't really know the answer, whether it's hours or days that you're at risk of getting an infection if none of those surfaces are cleaned. [crosstalk]

Brian Lehrer: Did you want to add anything, Dr. Osmundson?

Joseph Osmundson: Yes, I do. It's remarkable how little we know. Pox viruses are robust viruses. Unlike COVID, where we really thought it might play a role, and it turns out largely no, here's a virus where epidemiologically we know that surfaces can play a role. Thinking about very early on in COVID, I think in March, a preprint came out on the SARS-CoV-2, which was a novel virus, did not exist on the planet before the six months prior to the pandemic showing the durability of the virus on different surfaces for different amounts of time using really good virological methods.

We still don't have that for this virus that's been described in humans since 1970. I just cannot help but believe that's because largely the people impacted before now were in Central and West Africa, and the people largely being impacted now are queer men in our sexual network. The WHO said, the panel that recommended against declaring this public health emergency of international concern, literally said, "Oh, it's just affecting gay men, and therefore, it's not yet an emergency." Before it was just affecting people in Central and West Africa, and therefore it's not an emergency. This affects what virological questions we ask and answer.

How has no one published the surface durability of this virus using best virological practice? It astonishes me the lack of basic neurological knowledge we have, and I cannot help but believe it's because of the communities largely impacted so far.

Brian Lehrer: Lastly, Dr. Osmundson, let's talk about the public health messaging here for just a second. That is so far, how are public health officials weighing the need for destigmatizing responses, and how do you recommend that they do while also recognizing that certain groups have been disproportionately affected by monkeypox? Even the term men who have sex with men sounds sort of clunky plus it could lead to some missed diagnoses because some trans and non-binary folks aren't really included in it.

In fact, I'll also read a tweet that just came in from a listener who says to not forget the transgender, gender non-conforming, or gender non-binary people are also eligible for the monkeypox vaccine, not just men. Dr. Osmundson, how do they strike the balance? How should they strike the balance?

Joseph Osmundson: We're talking about behaviors and risk, not identities. You'll notice Jay and I have not been saying men who have sex with men. We've been saying gay men, or queer people, and our sexual network which better describes the lay of the land. When I open up Grindr on my phone, I don't just see men. I see people of different genders, and increasingly so. That is something my community is really proud of.

I think we've been doing better on and the public health community needs to catch up to where we're at and make sure that trans women and non-binary people know that they have access to vaccine, and when they go try to get vaccine, that they do not have any [chuckles] issues in that line or with their healthcare provider. Look, the messaging here is so difficult, and we are in a world with increased institutional homophobia and transphobia. We see legislative pushbacks on our ability to exist in public in many places.

At the same time, my community's health is the first thing on my mind. I'm not worried about not being honest with my community about different risk factors because of what some a fascist Republican type pushback against queer people's ability to exist. We need to be very clear and honest and direct for community by community. That's why I'm so glad we've heard from me and the other callers who are in the community affected. We need to be left to talk to our community about what's risk.

Then the other thing is our government needs to show up because we have need. People wanted to get vaccinated before Pride, and the federal government did not let that happen. Gay folks are not driving this epidemic, a global lack of access to healthcare is driving this epidemic, and we need to be very clear that gay sex is the thing that has always existed and will always exist. People deserve the tools to enjoy the type of sex that they like without risk of infectious disease. We have those tools with this epidemic, and it is a crime that people have not been able to access those tools.

Brian Lehrer: I said that was going to be the last question, but some tweets have just come in that I want to reference because I think they're interesting and important. Someone writes, "While vaccination appointments are extremely limited in New York City, neighboring county health departments have vaccine clinics with minimal waiting times." If that's true, posted by somebody who's tweeting as "fam doc" as in family doctor, that's good information for people. Dr. Varma, one for you from a listener who asks is it-- oops. Here it is--

Joseph Osmundson: Can I hop in on the previous question just really quick?

Brian Lehrer: Yes, you may.

Joseph Osmundson: That is true. We've seen Westchester County and places on Long Island have vaccine appointments when no one could get them in New York. The question is who in New York City has the privilege, the access, the ability to take off work, to get up to Westchester, to pay for the Long Island Rail Road, to pay for the cab to the county health place, and to actually access that vaccine. We know that that's true, but that really disproportionately helps a certain type of person.

Brian Lehrer: Dr. Varma, listener writes, "I am a licensed massage therapist in Manhattan. I am up to my elbows in multiple naked people five days a week. Why is the monkeypox vaccine not available to those in my profession?"

Jay Varma: It's an important question. It also relates to why the monkeypox vaccine isn't being provided recently to healthcare workers as well. Normally, when we have a new infectious disease, when we have a new outbreak of a disease, healthcare workers are at high risk, and they often get prioritized as well. The reason is fundamentally because there just isn't enough supply. If there was enough supply, then people who come into close skin-to-skin contact potentially with monkeypox patient should be eligible. Fundamentally, it's a supply question then when you look at, okay, we have a limited supply, who do we prioritize it to? We have to go with what we know.

The reality is both here in the United States and globally, this outbreak is so tightly linked right now to gay men and their sexual health networks, as well as their household contacts. That is where the limited supply has to go. It's not just, but that's what we're left with.

Brian Lehrer: 10 seconds, how will we get to sufficient supply for everybody who wants one?

Jay Varma: It's going to take some time. This is a vaccine that is not grown very quickly, and the US fell behind on it. It's one of the reasons I would really push for people to also understand the purpose of screening, how to look at your skin, educate yourself, and also try to access testing whenever possible because we're going to be in this for some time.

Brian Lehrer: Jay Varma, physician and epidemiologist, director of the Cornell Center for Pandemic Prevention and Response, and professor of Population Health Sciences at Weill Cornell Medicine, and Joseph Osmundson, microbiologist, activist, writer, the PhD in Molecular Biophysics. Wait, I'm going to find your book title again because how could I let you go without one more time citing your book title. It's Virology: Essays for the Living, the Dead, and the Small Things in Between. Unforgettable. Doctors, thank you very much.

Joseph Osmundson: Thank you so much for having us.

Jay Varma: Thank you very much.

 

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