• There have been over 2,500 monkeypox cases reported in the U.S.
  • Many people report difficulty in getting tested and few vaccines are available.
  • Healthline asked three infectious disease experts how they think the response to monkeypox is going, and what the biggest hurdles to containing this disease are.

There are 2,592 U.S. monkeypox cases in the U.S., with New York, California, and Illinois among states hit hardest, according to the most recent data from the Centers for Disease Control and Prevention (CDC).

On Sunday, former FDA Commissioner Dr. Scott Gottlieb told NBC’s Face the Nation that we’re on the cusp of monkeypox becoming an endemic virus.

Healthline asked three infectious disease experts how they think the response to monkeypox is going, and what the biggest hurdles to containing this disease are. These are their responses.

Eric Cioe Pena, MD, director of Global Health for Northwell Health in New York

Miriam Smith, MD, chief of infectious disease, at Long Island Jewish Forest Hills in Queens, New York

Supriya Narasimhan, MD, Division Chief, Infectious Diseases, Hospital Epidemiologist and Medical Director of Infection Prevention, Santa Clara Valley Medical Center

Pena: We have learned that it likely originated from a traveler to Europe, and has been circulating in a community of men who have sex with men at raves or parties. It is contagious with close contact.

Smith: Monkeypox, which had been endemic to Africa, is spreading globally through networks of men having sex with men. The prodrome (early signs) include fever, adenopathy (swollen glands), headache, muscle aches, and rash.

The rash usually starts on the face or oral cavity and progresses through synchronized stages with concentration on the face and extremities.

The infection has generally been mild and self-limited with no reported deaths to date.

Some patients, however, have reported a more severe course.

The virus is transmitted by close physical contact with an individual who is infected, primarily through skin-to-skin contact from individuals with active skin lesions although respiratory droplets or oral fluids are potential sources of spread.

Narasimhan: Monkeypox has taken us by surprise.

It was formerly only noted to be transmitted among close family contacts or from animals to humans however the current outbreak is spreading via transmission predominantly among [men who have sex with men] MSM through close sexual contact.

Due to this pattern of transmission, most patients have painful genital lesions including penile lesions, perianal lesions, and proctitis. Most cases have been mild and self-limited, and have not required hospitalization.

Pena: It has been frustrating. Testing hasn’t been widely available; vaccination of close contacts or people with risk factors was slow to get ramped up.

Smith: The NYC Department of Health has had a variable response to the outbreak.

Some members of the health department have cautioned at-risk individuals to temporarily reduce sexual activity. Other members of the DOH are concerned about stigmatizing potentially at-risk individuals with respect to sexual behavior.

Antivirals and vaccine are becoming more readily available.

Narasimhan: I think there is room for improvement in the monkeypox response.

Firstly, it is being messaged as a predominantly sexually transmitted infection but it is important for public to know that anyone can get this to close personal contact.

Secondly, vaccine distribution for post-exposure prophylaxis to sexual contacts of known cases and for pre-exposure prophylaxis of high-risk individuals needs to be ramped up in a very short timeframe to curtail this outbreak.

Testing for monkeypox is only available in select labs and requires that providers fill out multiple forms. While commercial labs are now making testing available, we need testing to be easily available with a rapid turnaround time for quick diagnosis, isolation, and treatment.

Lastly, currently, the treatment of monkeypox is an investigational new drug called tecovirimat or TPOXX. Because it is currently listed as an IND (investigational new drug), obtaining the drug and prescribing it is onerous, and there are multiple forms that need to be filled out.

Making this process significantly simpler will help providers as the number of cases increase.

Pena: Resources. This is much easier to contain than COVID. We need to ramp up testing and we should be able to wipe this out.

Smith: Having a uniform, evidence-based message from the DOH to individuals at risk as well as information disseminated to practitioners are very important.

At this time, patients with suspected monkeypox are reported by their providers to local departments of health. Specimens for viral testing are sent to designated labs and may be confirmed by the CDC, all of which is time-consuming but vital to the diagnosis and management.

Narasimhan: Availability of adequate vaccine and therapeutics, access to testing, public awareness and concern, [and] addressing the stigma, as transmission is mainly due to close contact during sex.

Pena: Not effective because of limited doses of vaccine, limited points of vaccination and poor contact tracing.

Smith: Awareness of mode of transmission, and increased availability of vaccine and treatment should help to reduce the spread.

Narasimhan: Ring vaccination efforts (where vaccines are given to people exposed to monkeypox) to prevent spread has been challenging, because several patients meet their sexual contacts via dating apps and tracking these contacts is extremely difficult.

Vaccination efforts in Santa Clara County are just starting to be ramped up, [but] the supply of vaccine is very limited at this point which is the rate-limiting factor.

I appreciate that the CDC is making efforts to increase both vaccine supply and distribution.

Pena: This should end. If it becomes endemic, it’s a failure of public health.

Smith: We do not know whether this will end or become endemic at this time. Vigilance, identification of infected individuals, and prevention or treatment, are drivers of reducing the spread of this virus.

Narasimhan: It is too early to say at this time. I think much will depend upon our ability to ramp up testing, treatment and vaccination.

Pena: Vaccination, knowledge of symptoms and quick presentation and isolation.

Smith: Avoid close contact with an individual who has been diagnosed with this virus, consider vaccination of individuals at risk, [and] continue to track this outbreak with attention to identification of individuals and reduction of spread.

Narasimhan: This is predominantly a disease spread by close contact although aerosolized secretions can also cause droplet/airborne transmission.

Good hand hygiene is very important in preventing spread of the disease. Avoiding crowded settings such as raves or parties in enclosed areas where there is minimal clothing and direct, personal, often skin-to-skin contact with others is recommended. Patients who are suspected to have monkeypox should avoid close contact including sexual contact and seek medical care. Mask wearing will also help minimize spread of the disease.


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