Monkeypox update

[0:00:23]

RICK WEISS: Hello, everyone, and welcome to SciLine’s media briefing on monkeypox. I’m SciLine’s director, Rick Weiss. For those of you who are not familiar with us at SciLine, we are a philanthropically funded, editorially independent, free service for journalists and scientists based at the nonprofit American Association for the Advancement of Science. Our mission is pretty simple. It’s just to make it easier for reporters like you to get more scientifically validated evidence into your news stories, whether those stories are about science per se or are stories about local events that could be strengthened with the inclusion of some science. Among other things, we offer a free matching service that connects you one-on-one to scientists who are both deeply knowledgeable and are excellent communicators. We connect you to these scientists on deadline or as needed. All you need to do is go to sciline.org, click on I need an expert, and while you’re there, you can check out our other helpful reporting resources.

A couple of quick logistical details before we start. We have three panelists with us today who are going to make short presentations of about five to seven minutes each before we open things up for Q&A. To enter a question during or after these presentations, just hover over the bottom of the Zoom window, select Q&A, enter your name, news outlet and your question, and if you want to pose your question to a specific panelist, be sure to note that. A full video of this briefing should be available on our website by tomorrow and a timestamped transcript within a day or so after that. But if you would like a raw copy of the recording more immediately, just submit a request with your name and email in the Q&A box, and we can send you a link to the video by the end of today. You can also use the Q&A box to alert SciLine staff of any technical difficulties.

I’m not going to give full introductions to our speakers. Their bios are on the SciLine website. I just want to tell you that we will hear first from Dr. Anne Rimoin, a professor of epidemiology at the University of California Los Angeles Fielding School of Public Health and the Geffen School of Medicine, who will provide some monkeypox history up to this most recent U.S. outbreak. Next, we’re going to hear from Dr. Inger Damon, director of CDC’s Division of High Consequence Pathogens and Pathology, who will share what we know about the current outbreak of monkeypox in the United States, including symptoms, treatment options and where things seem to be going. And third, we’re going to hear from Dr. Amira Roess, a professor of global health and epidemiology at George Mason University’s College of Health and Human Services, who will talk about the public health response to monkeypox with some particular attention to lessons learned from COVID-19 and how public health communications from officials and from media like you can help to control the spread and impact of this outbreak. With that, let’s just skip right over to you, Dr. Rimoin.

[0:03:27]

ANNE RIMOIN: OK. Well, thank you so much. I’m going to share my screen now and go into presenter mode. Here we go. Where is it? Hold on. It’s this one. Aha, here we go. Share. And now I will also go to—here we go. OK. Can you just see my screen here? Just…

[0:04:01]

RICK WEISS: Looks good. Perfect.

[0:04:03]

ANNE RIMOIN: OK. Well, as you said, I’m a professor in the department of epidemiology at the UCLA Fielding School of Public Health. And I am going to talk to you just a little bit about the history of monkeypox and just what we know. I should just make it clear I’ve been working on monkeypox in [the  Democratic Republic of the Congo] since the early 2000s, and so that’s where my area of expertise really lies. I’m just going to give you a little bit of background. So, first of all, monkeypox was—really, was first discovered in monkeys—in a colony of monkeys that was being used for research in Denmark. Despite being named monkeypox, the virus is likely more of a rodent pox, although the species is quite wide. And Dr. Damon’s group has actually done a lot of work on the host range, and she may be able to answer more questions about that. The first case of human monkeypox was discovered in a 9-month-old child unvaccinated against smallpox in 1970 in Basankusu in DRC. And this was happening at the end of the smallpox eradication campaign when all cases of rash illness were being investigated. What they realized was this was actually not a case of smallpox but a case of monkeypox.

Now, I always like to show these photos because what you see here is the photos of what monkeypox looks like versus what smallpox looks like and why it was so complicated to be able to see that this was a case of monkeypox versus smallpox. They look almost identical, except that monkeypox has a very characteristic swelling of the lymph nodes—this lymphadenopathy, which you can see in this upper left photo here. But the very kind of—the photo in the middle is a child with monkeypox. The photo then to the left is a child with smallpox. So, you can see how similar they look and why it was very complicated to be able to distinguish the difference. Smallpox was eradicated in 1980, and this was one of the greatest achievements of public health. But as a result, we stopped vaccinating against smallpox. And therefore, we started to see a lot of—then what was—what happened over time is the population no longer had vaccine-induced immunity to smallpox. The WHO was aware of this, and so they started disease surveillance. What they found in the early ’70s was a few cases of monkeypox, mostly in what’s now known as DRC but what was in then-Zaire. In the 1980s, at the end of the smallpox eradication campaign, there was a very intensified disease surveillance program from ’81 to ’86, where cases—they had a very intensified disease surveillance program. And they found approximately 338 cases, thereabouts, of monkeypox. They were able to do detailed analysis of this. But you have to remember that if smallpox vaccination really ended somewhere between ’80 and ’82 in DRC, the vast majority of the population was still—had immunity to the virus. And so, we had to—you know, what we know was limited.

Now, you can see here in this timeline that we’ve seen sporadic cases. We saw sporadic cases here and there. And we really only saw most of them in DRC and Central Africa, with a few cases in West Africa. We did have cases of monkeypox occur in the United States in 2003. And Dr. Damon and her team really led this, so she’ll be able to tell you more about that. But that was really the first time we saw monkeypox outside of Africa. My team did active disease surveillance in DRC between 2000—in the—early 2000’s. And from a specific period from 2005 to 2007, we really documented a large rise in the incidence of monkeypox. And it was very clear, based on our data, that it really had to do with smallpox providing long-term protective immunity, but those individuals now no longer immune were then getting monkeypox. You know, the question was—is, how much of this rise was real? Was it just because we were looking for it? And you have to remember, compared to the data in the 1980s, those data were so—you know, they had a lot more resources. We were doing this in a very, very kind of resource-poor setting and in a limited area. So, there were probably a lot more cases than we found. You know, disease surveillance in low-resource settings is very complicated for a variety of reasons. And so, what we know about monkeypox in those settings, you know, is hard. One of the big questions was, how much of this was human-to-human transmission? How much of this was animal-to-human transmission? And this was something we really did need to think about over time.

You know, monkeypox has increased in terms of number of cases over the years. In 2017, there were cases of monkeypox in Nigeria. And that was the first time it had been seen in at least 30 to 40 years. So, this was very unique. Again, I think it’s Dr. Damon’s team that’s done a lot of work related to this. And so I think that, you know, that’s going to be a big clue to what we see today. But I think the keys here are monkeypox cases have been increasing. We’ve seen this in DRC. We’ve seen this now in Nigeria. We see cases reported in many countries in West and Central Africa now, through WHO. We know that this is something that has been continuing to increase. We started to see importation of cases, first from the Gambian rats in 2003. And then over time between 2018 and 2021, we saw more and more of these imported cases. And I think that that’s really the key where we are today in 2022, that we now know that there have been cases that have been spread globally. And I believe that Dr. Damon and Dr. Roess will be able to then take us from there.

[0:11:06]

RICK WEISS: Great. Thank you very much, Dr. Rimoin. And I’ll let you pick it up, Dr. Damon.

[0:11:16]

INGER DAMON: OK. Coming off mute and trying to share my screen, so let me know if you can see it.

[0:11:23]

RICK WEISS: Looks good.

[0:11:23]

INGER DAMON: Super. Great. Well, hello, all and thanks for joining all of us today. It’s a pleasure to be on a panel with Dr. Rimoin and Dr. Roess, who I’ve known for many years. I’m Inger Damon. I’m director of CDC’s Division of High-Consequence Pathogens and Pathology and happy and pleased to be participating in the panel today. So, our current monkeypox outbreak, in the United States, at least, began with a traveler returning to Massachusetts from Canada on the 17 of May. CDC began working with state and local jurisdictions on an emergency response and activated under our incident management system for monkeypox on the 23 of May. We now have over a hundred cases, and I think we are up to over 20 states or localities at this point in time. We’ll update our website later today with the specific numbers.

So, I’ve been asked to explain the signs and symptoms and clinical manifestations of the disease, as well as the treatment options and vaccines against monkeypox, including their availability. So, let’s begin with the symptoms and clinical manifestations of monkeypox. Dr. Rimoin showed some pretty dramatic pictures of generalized rash in children and adults, and that’s classically what we anticipate monkeypox to be. And as you’re looking at the images here, you’ll see that they look a little bit different than the slides that Dr. Rimoin showed. So, in people, the signs and symptoms of monkeypox are classically described as being similar to but milder than the symptoms of smallpox. And so, Dr. Rimoin also pointed out the challenges in the ’70s of really differentiating this new—what turned out to be a new disease from an old disease known as smallpox caused by the related virus, variola virus. Monkeypox is classically described in patients from the DRC, in that same study that Dr. Rimoin mentioned in terms of the active case ascertainment and follow-up in—from 1981 to 1986—begins with fever, headache, muscle aches and exhaustion, so very classic prodromal symptoms that were described with smallpox and a lot of other illnesses.

The main differences between the symptoms of smallpox and monkeypox is that monkeypox causes lymph nodes to swell while smallpox does not. The incubation period for this classic description of monkeypox—so the time from infection to the onset of any symptoms—is roughly one to two weeks. Within one to three days, sometimes longer, after the appearance of fever, the patient develops a rash, often beginning on the face and then spreading to other parts of the body. In the U.S. in 2003, as Dr. Rimoin pointed out, a different type of monkeypox was introduced into the United States, which led to our understanding of two genetically and clinically different clades of virus. U.S. case patients were less ill than those in the DRC study from ’81 to ’86. Now, there could be a lot of reasons for that. When age-matched and assessed for prior smallpox vaccination, which can prevent disease or make disease less severe, as discussed by Dr. Rimoin, the 2003 disease introduced into the U.S. by a consignment of African rodents captured in Ghana and imported to the United States for the exotic pet trade was less severe both in rash burden, disease severity. So, there were no fatalities in the U.S. outbreak, which has 47 probable and confirmed cases with a case fatality rate, mostly in young children from the DRC studies, but about 10 to 11% in that 1981 to 1986 material. So—and so I think what you’re seeing here in this image is some of the even milder disease lesions that we’re seeing currently in this outbreak in—after May of 2022 in the United States. There’s been some differences in the way symptoms have presented and progressed in this outbreak compared with what we’ve previously seen in other monkeypox outbreaks.

Similar to what was reported by Nigerian scientists evaluating 40 hospitalized Nigerian monkeypox patients from 2017 to 2019, all patients in the current U.S. monkeypox outbreak in 2022 have experienced a rash, but the lesions have been scattered or localized to a specific body site rather than diffuse and have not generally involved the face or the extremities, specifically palms of the hands or the soles of the feet. In some cases, the rash has started in the genital and anal areas, and sometimes does not spread to other parts of the body. Additionally, sometimes common early symptoms like fever and body aches are mild or even nonexistent before the initial rash appears. The clinical presentation of monkeypox may be similar to some sexually transmitted infections, such as syphilis or herpes. And the genetic sequences of the viruses we’re currently seeing in the United States show that these monkeypox viruses are somewhat related but very—from—related to viruses seen previously from Nigeria and very different from viruses sequenced from patients in the Democratic Republic of Congo.

So, what types of treatments and prevention measures do we have? So, moving to this, the U.S. has resources needed to respond to monkeypox in this country. Work on the smallpox preparedness efforts over the last 20 years have really enabled preparedness for monkeypox with the related viral illness. It’s not a new disease, as we pointed out. It was introduced into the United States in 2003, and that outbreak led to the development of a lot of the diagnostic tools that are currently being used in the Laboratory Response Network to support diagnosis. We have two preventative vaccines and two antiviral treatments that can be used. One of the vaccines, the trade name JYNNEOS here, is approved for the prevention of monkeypox disease in adults 18 years of age and older. It’s a two-dose vaccine. The other, ACAM2000, can be used under an expanded access protocol for post-exposure prophylaxis of monkeypox. It’s a one-dose vaccine, but as a live virus vaccine in distinction to JYNNEOS, it can be associated with a greater frequency of adverse events.

So, most often, people who are infected with monkeypox virus recover fully within two to four weeks without the need for any specific treatment. In certain circumstances, it may be recommended to use vaccine after close contact with someone who has monkeypox based on the assessment of the person’s risk for developing monkeypox and use of the vaccine in these post-exposure mechanisms similar to what’s done with rabies virus, where vaccines and immunoglobulin in that case can be used post-exposure to prevent disease. CDC consults with state health departments on when it’s appropriate to offer vaccine based on circumstances around cases and contacts, and we have a lot of information up on our website.

The antiviral drug known as tecovirimat, or TPOXX here on the slide, was developed to fight smallpox. But we can use it to treat monkeypox during an outbreak, again, under special approval by the FDA. In addition to tecovirimat, two other drugs may be useful against monkeypox. One is known as trade name Tembexa now and the other is vaccinia immune globulin, with the latter—is licensed by the FDA for the treatment of complications due to the live virus vaccinia virus vaccination or smallpox vaccine. Regarding supply, the Strategic National Stockpile, SNS, originally called the National Pharmaceutical Stockpile, is the United States’ national repository of antibiotics, vaccines, chemical antidotes, antitoxins and more. And that includes both JYNNEOS and ACAM2000 as well as some Tecovirimat.

So, this is a picture of what the JYNNEOS label looks like. So, this is actually the IMVAMUNE product, which is the European licensed product, and it is FDA approved for smallpox and monkeypox in adults 18 years or older at high risk for smallpox or monkeypox. It’s made with a nonreplicating virus which is safer for some populations. As of the 14 of June, there are more than 72,000 single doses of JYNNEOS in its immediate inventory. Last week, an additional order was placed by the U.S. government to increase manufacturing and receive another half million liquid frozen doses. ACAM2000 is an older vaccine developed for use against smallpox. Clinical trials to show equivalency to the prior smallpox vaccine known in the United States—and Dryvax were conducted between 2002 and 2004. It’s effective against monkeypox. It can cause serious side effects as it is a live virus vaccine. It cannot be used for people with severely weakened immune systems or some skin conditions known as atopic dermatitis. The Strategic National Stockpile has more than a hundred million doses of this vaccine available.

Tecovirimat—and so this is an image of the pill—is an FDA-approved antiviral to treat smallpox disease in adults and pediatric patients who weigh at least 6.6 pounds. It’s approved for use in both oral capsule as well as an intravenous formulation. The SNS has a supply of the drug, which can be used to treat individuals with monkeypox. So, the SNS in coordination with CDC responds to requests from a number of different jurisdictions for the vaccines and treatments to support those affected by monkeypox disease. And we continue to work with jurisdictions to support their response. So, lastly, vaccinia immune globulin is licensed by the Food and Drug Administration for treatment of smallpox vaccine or vaccinia virus vaccination complications such as eczema vaccinatum, progressive vaccinia and aberrant infections caused by the virus. CDC has an emergency access investigational new drug protocol, which allows us to use the product in critically ill, hospitalized patients infected with other related orthopox viruses such as monkeypox virus. So, I’ll stop here—save time to hear your questions. And I believe we go to our next speaker.

[0:22:45]

RICK WEISS: Great. Thank you very much. And over to you, Dr. Roess.

[0:22:49]

AMIRA ROESS: OK. Thank you for including me in this panel. I will just share my screen here. OK. So, today what I’d like to do is talk a bit about the U.S. public health response challenges and some similarities to what we’ve been seeing with COVID-19. So, just first, one of the similarities is that both of these are what we call zoonotic diseases. Typically, there is an animal reservoir or an animal host. A human who comes into contact with that animal will become exposed, infected. Then that human who’s infected will go on to infect other people. So, COVID-19 is the disease caused by the novel virus SARS-CoV-2. It was a new virus. We hadn’t seen it before. And so, there was a delay in reporting. Monkeypox, on the other hand, we’ve known about, as the previous two speakers have said, for quite some time. But especially in Western countries, it tends to be underappreciated. Medical students will hear about it. Sometimes, you know, residents will hear about it but in passing. They don’t expect to see this, you know, in the West. So, when COVID-19 emerged, you know, it was at a time when, in the U.S. especially, there was a lot of anti-globalization rhetoric, a lot of, you know, talk about disengaging from the WHO. Globally, there was this rise in nationalism. Many countries had very conservative individuals who were running for office or who were in office. And one way that we saw this anti-globalization manifest itself when we talk about COVID-19 was in this idea of vaccine nationalism—that every country that could afford it, you know, was talking about stockpiling the vaccine. And so, it’s important to sort of recognize that this is the backdrop of the monkeypox pandemic.

And interestingly, while there’s been this talk about vaccine nationalism and a little bit of talk in social media about this, at the same time, there’s a minority—a very vocal minority—of individuals who are strongly anti-vaccine, anti-science. And I emphasize that it turns out that it is a minority of the general U.S. population that have this anti-vaccine sentiment. However, it is gradually increasing, and this is of concern. When COVID-19 emerged and evolved, there was a very heavy politicalization of the virus, of anything to do with mitigation strategies—from vaccines, to masking, to movement restrictions or mandates. And that is still on the minds of many individuals that we deal with in the U.S.

In addition, with monkeypox, we have a real concern over possibly stigmatizing monkeypox because there are so many individuals who are MSM—or men who have sex with men—who are involved in the pandemic right now, or at least in the early cases. This is also concerning when you are thinking about monkeypox cases in conservative areas or conservative countries. When COVID-19 emerged, one of the challenges that we had in response was that we were dealing with a very under-resourced public health infrastructure here in the U.S. In 2008, when I worked at the CDC under Dr. Damon’s group on monkeypox, one thing that we dealt with was the Great Recession, and it had a very direct impact on a lot of our colleagues who worked at local or state health departments. You know, they were told, hey, you know, you have to go home because you’re being furloughed. One day a week, many health departments—local health departments—ended up furloughing individuals. They were told, you know, you’re not going to get paid for that time, so don’t come in. But, of course, you know, the ethos of outbreak investigators and public health workers is that if there is an outbreak or an emergency, they will come in, and they will volunteer anyway. So, here you could see, over time, what happened to our infrastructure here in the U.S.

And actually, let me just remove this so that you could see the full slide. So, here you could see the number of public health workers really started to decline significantly at the beginning of the Great Recession, and a lot of us—right?—have been really concerned about this. So, COVID-19 hit, and we were, you know, really dealing with an all-time low of public health workers. In the U.S., we’ve also been seeing this gradual decrease in funding for public health emergency preparedness over time—a pretty significant decrease, unlike some of our counterparts in Western Europe. And what we tend to do in the U.S. is we put in an influx of funding to respond to outbreaks. And that is more of the response side and not the preparedness side. So, one thing that we’re seeing with COVID-19 is we had to very quickly scale up contact tracing. And there was a lot of work to find people who would be willing to work hourly or as contractors for the health departments. And we even had different organizations send volunteers. Public health programs or public health schools—they sent individuals to the local health department to serve as volunteer contact tracers. And what you’re seeing now in this report that just came out is that now that the COVID-19 emergency has expired, we’ve seen a significant decrease or, you know, reduction in staffing of contact tracers. The states that are in blue, which are, you know, the majority of states here—along here—they’ve really seen a significant reduction in their contact tracing infrastructure. And this is at a time when we have monkeypox emerging, when we have hepatitis in pediatric populations also, you know, causing a burden on some of our public health staff. And there has been a lot of talk about using contact tracing apps to automate contact tracing. But, you know, one of the challenges here in the U.S. is that oftentimes we think that we can implement a technology, and it’s really a tool. These apps are really a tool, but they’re not solutions.

So, some other things that, you know, we’re seeing—I mentioned the anti-science, anti-vaccine backdrop. So, when the pandemic hit and the politicalization of the vaccine was evident, a lot of us started to be very concerned that, you know, we’re just going to end up seeing an increase in vaccine hesitancy and anti-vax sentiment. And while it is still a minority of the population that feels this way, it has been increasing steadily. And, you know, one of the fears is that we’re just going to continue to see this increase in vaccine hesitancy and, along with it, an increase in what were once preventable diseases. You know, one of the paradigms of public health is that when things work out, it’s quiet. You don’t see measles deaths. You don’t see infants dying of preventable illnesses, diarrheal diseases. And so, what ends up happening here in the U.S. is that we start to take funding away from public health infrastructure, from our public works infrastructure, because it’s silent, right? We don’t think that, you know, we really need to keep on supporting this. And that’s a real problem. You know, at the same time, some of what we’re seeing in the U.S. is that there is a record number of immune-compromised and medically vulnerable Americans who are at risk for having, like we saw, severe illness from COVID-19. Same thing with monkeypox and other emerging zoonotic diseases. As we have more individuals who have immune-compromising conditions—who are on chemotherapy, for example—you know, they are going to be vulnerable to these infectious diseases. And so, we really need to think carefully about how to improve our messaging so that we can do the best that we can to protect our fellow Americans here.

You know, one thing that has been promising in a lot of our research and in the research that has been done by our peers is that, you know, most Americans still report high levels of trust when it comes to their own medical care providers. And that’s very important because that means that there is still a chance that the medical care providers, the health care providers, could work directly with their patients to provide adequate information and health education when it comes to mitigation strategies—wearing masks, you know, getting vaccinated.

One thing that, you know, I think we have to be very cognizant about, like the other two speakers said—historically, most monkeypox cases were among individuals who handled infected animals. And it often spread to family members and health care workers. This outbreak of monkeypox is a little bit different because you’re seeing a lot of spread, and it’s possibly been spreading for a while among men who have sex with men. Now, something to keep in mind here is that in the U.S., MSM are significantly more engaged with the health care sector than other populations. And so, you know, this is good because it allows us an opportunity to work closely with MSM populations on health campaigns. And we have some really good examples of very effective grassroots health campaigns, even with COVID-19, when you had individuals really leading contact tracing among MSM populations when there were some large outbreaks in 2021. I mentioned the contact tracing apps. You know, again, these could be very useful tools to help us as we try to address emerging outbreaks—not just monkeypox, but other future outbreaks. But one of the issues is that we have to be really aware of the privacy concerns of Americans and what that means for the use and the effectiveness of these contact tracing apps. They are—you know, they’re just not the solution that a lot of individuals were hoping that they would be here in the U.S.

Another big concern that a lot of us are really paying a lot of attention to these days is, you know, what about this idea of maybe an animal reservoir becoming established here in the U.S. for monkeypox? In the 2002 outbreak—and Dr. Damon can tell you more about this—prairie dogs became infected, but we never really saw monkeypox becoming established in the prairie dog population in the wild here in the U.S. And so, a lot more work has to be done in this area. And I think we also need to spend a lot more time really thinking through what support we provide our public health and our health care providers, both in terms of infrastructure, workforce development and so forth. So, with that, I will stop so that there could be time for questions. Thank you.

[0:35:24]

RICK WEISS: Great. Thanks, Dr. Roess. We do have a lot of questions coming in, so I’m going to start going through them. And I’ll ask our panelists to try to give complete but relatively brief answers so that we can get through as many questions as we can. The first one—and I’ll remind folks, it’s the Q&A icon at the bottom of your screens if you’d like to submit a question. First one here is from Kathiann Kowalski, who is a freelance journalist. If the smallpox vaccine, in fact, protects against monkeypox—which I’ve heard—does this mean that older people who probably got the smallpox vaccine are likely to be protected, or will they probably need booster shots? Also, are younger adults and kids likely to be more vulnerable? Dr. Damon, I might throw that to you for starters.

[0:36:14]

INGER DAMON: OK. Great. Yeah, so I think Dr. Rimoin did a nice job showing you what information we may be able to glean from DRC. So, I think, as she pointed out, the 1981 to 1986 case series were identified. There were a number of individuals who’d been vaccinated three to 19 years previously. And they appeared—when they were household contacts of cases, they appeared to be protected by their prior vaccination. And I think, as you saw from Dr. Rimoin’s data, that when you go out to 2005 and the studies that were undertaken in DRC, you no longer seem to see the protection of that prior vaccination, which would at that point have been at a far greater time period. So, I think—we certainly think that prior vaccination may have some benefit, but I don’t think we would think it would be completely protective at this point in time. I think younger age populations were the population groups where we saw some of the more significant adverse events from the fully replicative smallpox vaccines, so it’s really trying to screen and understand risk benefit ratio. At this point, as Dr. Roess mentioned, predominantly, we’re seeing a subpopulation being affected where we’re really trying to work with them so they better understand risks here and approaches to protect themselves in terms of this male-to-male sex or community of individuals who have male-to-male sexual activities.

[0:38:02]

RICK WEISS: Great. We have a question here that sort of follows on that. And maybe this would be for you, Dr. Roess, as you were talking about this. This is from Cindy Goodman from the South Florida Sun-Sentinel. I’ve heard that the virus can be found in sperm. Can it be spread that way through sex? Is it actually an STD or is it a physical contact that just happens during sex?

[0:38:26]

AMIRA ROESS: Now, I saw those reports as well. I think what we typically see is that it is the close contact that’s really spreading the virus, right? So, when people have sex, they’re in close physical contact. And I think there is some more work being done to understand the levels that are found in semen, you know, if they are enough to be infectious. And perhaps Dr. Damon could comment on what is known about this topic as well.

[0:38:56]

INGER DAMON: Yeah. So, I think, you know, we—I think we are looking carefully at that data as it rolls in. And so, I really appreciate people sharing the information. To date, what we’ve seen is virus in semen is evidence of DNA in semen. There’s been one study, the German study, where they tried to culture virus from semen, and they were unable to culture it. But that was one case—patient. So, this is, as Dr. Roess mentions, clearly, close contact will transmit the virus. Is there, you know, a specific role of semen here? I think these are the kinds of questions we’ll need to ask through natural history studies and engage those who have disease to help support these studies so we can better understand the potential role of infectiousness here. But the data we’ve seen so far has all been from individuals who have active rash lesions. So, differentiating the contribution of the two is difficult.

[0:40:01]

RICK WEISS: An important distinction there, though. It’s one thing to find DNA from a virus in semen or anywhere in the body. It’s another thing to say there are actually active viruses there. DNA gets around. So, that’s very helpful. Thanks. A question here from actually a number of reporters—Tina Hesman Saey at Science News, Margaret Nicklas—freelancer in Texas, and others. Have there been any changes to the virus that would account for its spread to so many people compared to its behavior in Africa? Dr. Rimoin, I’m not sure if you’ve tracked those kinds of changes from your experience in Africa or if that belongs somewhere else.

[0:40:39]

ANNE RIMOIN: Well, my team has not actually done that work. That’s really the work that Dr. Damon’s team has done. So, I’m going to let her discuss that, because she also really understands the West African clade, which is what we’re discussing here, versus the Congo basin clade, which has really been what I’ve worked on.

[0:40:57]

INGER DAMON: Yeah. So, that’s a great question. We’ve been working with Nigerian scientists from the Nigerian Centers for Disease Control for a number of years now and are beginning to get to work with them to post sequences from viruses seen in Nigeria, and then also working as quickly as possible to get virus sequences from viruses that were seen in the United States since 2022 as well as from importation of disease into the United States in two cases from 2021. And so, the observations we’ve made—and so we’ve been working with Bette Korber as well as analysis of the sequences from Portugal and Spain, Belgium, a couple other places that have been looked at in virological.org. And so, Andrew Rambaut has been a big discussant on this. There does appear to be sort of one of these innate immune response editing factors that we’re seeing have a role in what we’re seeing in the change in the genetic structure of these viruses since 2017. First sequences were published in Nigeria. The significance here isn’t really known. You can look at a couple genes of the virus that are changed by maybe one amino acid. I think it’s really understanding this in the greater context of the epidemiology and the disease ecology studies that will help us better understand the virus changes that we’re seeing.

[0:42:47]

RICK WEISS: Question here, again, from multiple reporters—Lena Sun at The Washington Post, Denise Roland—Wall Street Journal, and others—what consideration is being given to pre-exposure prophylaxis to high-risk people such as health care personnel, laboratory personnel, men who have sex with men? In the U.K., apparently, the health department announced today that they would do some of that with high-risk individuals. We had a related question about, you know, were our vaccines actually totally effective in preventing disease? I think, Dr. Rimoin, you said that the evidence was that vaccines did work when used in Africa? Maybe that would be first to clarify and then over to either Amira or Inger to talk about what the policy change might be here in terms of protective prophylactic use.

[0:43:38]

ANNE RIMOIN: So, what I can tell you is that from our studies that were back in the early 2000s, mid-2000s, what we did see is that smallpox vaccine did appear to be—provide some sort of protective effect. And our analysis of the 2005 to 2007 data suggested that monkeypox was still providing somewhere in the range of the—80 to 85% protective—seemed to be protective against infection with monkeypox. So, you know, what does this mean in the context of today? We don’t know. And in DRC, you know, there have been some studies that Dr. Damon has been involved in where they’ve been working with the vaccine. But, you know, we haven’t seen smallpox vaccine or any orthopox virus vaccine be used in broad with, you know, strokes for places where monkeypox is endemic.

[0:44:48]

RICK WEISS: And Dr. Roess or Dr. Damon, anything to say about prophylactic use here in this country? Is it on the books?

[0:44:59]

INGER DAMON: OK. I’ll take that one on. So, I think currently the recommendations—we’ve been working with the Advisory Committee on Immunization Practices to look to provide recommendations for people who are at operation—at occupational risk of disease. And both ACAM2000, which is the replicative vaccine, and JYNNEOS, which is the essentially non-replicative vaccine—and so the JYNNEOS recommendations recently came out there. We are advocating right now for sort of what we call, really, vaccination of those who may have had high-risk exposure—so a post-exposure prophylaxis. I think broader use of pre-exposure prophylaxis in health care workers will be something that we discuss in terms of other—are there other operational controls that can be used to prevent disease? And I think the issue of how to make sure that we’re appropriately working and thinking through any additional efforts beyond post-exposure prophylaxis for the communities that we’re certainly—that we’re seeing affected right now, we’re working through some of the logistics of what we would need to consider there and would definitely have—had not seen it was posted yet today. But we were aware that the U.K. guidance would be becoming available today.

[0:46:38]

RICK WEISS: Dr. Roess, did you want to add to that?

[0:46:40]

AMIRA ROESS: In some countries they are really actively looking for high-risk populations, contacts of those infected, contacts of those contacts. And they are looking at providing vaccination for those high-risk populations. And like Dr. Damon said in the U.S.—right?—they’re considering vaccinating the health care providers who are at high risk, and that’s being done in several other countries as well. It is a logical strategy, given what we know about how vaccines work and given the smallpox experience, as well as, you know, a lot of the monkeypox experience that others have reported around the world. So, I think we will see more countries releasing updates to their strategies.

[0:47:34]

RICK WEISS: And related to that, from Max Kozlov at Nature magazine, what does the early epidemiological data say about how effective ring vaccination strategy has been, given that it relies on rapid testing and contact tracing? I’m not sure if that’s what you were talking about, Dr. Damon, for the current approach, or is that a little—something a little different?

[0:47:53]

INGER DAMON: Yeah. So, I think we’re trying to collect that efficacy data. And I—we’re actively trying to understand just who all has been vaccinated with the JYNNEOS—or, sorry, the JYNNEOS vaccine that has been distributed. We know the distribution numbers yet, but we’re still working with our partners and state and local health departments to understand the specifics of how product was used. So hopefully, we’ll have more information on that. As well as I think it’s a—you know, the issue really is what is the efficacy of the contact identification and their follow-up? And if that is a challenge—and we’re certainly hearing in some areas that it is a challenge—then it does mean that we need to refocus in terms of what needs to be done. So, it’s—more information is needed, and it’s definitely something that is being followed up on.

[0:48:57]

RICK WEISS: Question again from several reporters—there’s a few variants of this, but at what point would this constitute a public health emergency? I think, Dr. Roess, you might have even used the word pandemic. I think some people would like to know whether this is an outbreak or a pandemic or something else. And if the WHO determines on Thursday that monkeypox is a public health emergency of international concern, what difference would that make?

[0:49:28]

AMIRA ROESS: Right. So, generally, when the WHO declares that something is a public health emergency of international concern, that means that they could then mobilize certain reporting structures. There is the international health regulations that we rely on. One hundred and ninety-six countries and counting have signed on to that. So, when something is declared a public health emergency of international concern, the WHO can ask countries some very specific questions about cases that they may have seen. Resources could be mobilized, and that is a very important step for, you know, getting a pandemic—I don’t want to say under control, but basically, in responding to a pandemic, we do need more resources, especially in some of the low- and middle-income countries.

[0:50:27]

RICK WEISS: Question here from Mauricio Chamberlin from TEGNA VERIFY program—

what are the most common misconceptions or false rumors about monkeypox that reporters should be aware of? Anything you folks can point to that reporters should be careful about in particular?

[0:50:48]

ANNE RIMOIN: I can start. I mean, I think Dr. Roess and Dr. Damon have all said this, too. You know, monkeypox is not a disease that targets any group in particular. This is a disease that spreads, you know, as we understand it, through close contact. And I think that, you know, it’s really important for everyone just to remember that just because it’s spreading efficiently right now through one network doesn’t mean that it can’t spread through any network. It’s really a function of close contact in global. And we’ll learn more about the very specifics in this new iteration. I think it’s also really important to understand—and this is what I was trying to get at with Dr. Damon, Dr. Roess—we’ve all said, you know, what we understand about monkeypox in particular is about—is really based on the data that we have from this case series in the ’80s, from these kind of small, targeted studies that we have. But they’re in a very different context than we’re seeing today. And, you know, as the epidemiologic and ecologic landscape changes both in host countries and globally with trade, travel, you know, changes in patterns, you know, we’re—we probably will learn things about this virus that we just don’t understand. I think it’s reasonable. You know, we know what we know today. We’ll learn a lot more in this new context. And I think we all are just trying to make it clear, here’s what we know so far. There could be something that this virus is just spreading the way that it spreads, and now it has some runway to do so. And I think that that’s really the key here, is that, you know, we—what we know is from a very different context. And we’re going to learn a lot as we go forward.

[0:52:39]

RICK WEISS: Thank you. Wonderful. Anything to add there?

[0:52:42]

INGER DAMON: Sure. I’ll add a little bit. I mean, I think it’s also—it’s really stepping back, and, as both Dr. Rimoin and Dr. Roess have emphasized, it’s really understanding the basics of what we know of this virus and then appreciating the unknowns but being accurate in terms of, you know, what we tell people. And so, I think for us, the recent issue that maybe has come up is the concern based on our experience with COVID for the last two years of what is the mechanism of spread, using the words airborne, and is airborne transmission possible with monkeypox? I think what we know about this disease is that viruses certainly shed in the skin. So, you have skin lesions, scabs as the skin lesions resolve. You see evidence of virus being shed in the throat, and so you can find it in saliva. And again, close contact and contact with—close contact with those respiratoria salivary secretions likely transmit disease. So, in certain circumstances, you can generate aerosols. For instance, in the hospital situation, in there, there may be a concern of more of a—you know, a—and, you know, a finer particle transmission that may happen. But in general, the mechanism of transmission is close contact. And I think that’s—that direct contact with rash lesions or direct contact with material that is contaminated with that virus is an important message.

[0:54:27]

AMIRA ROESS: And I would emphasize exactly, you know, what Dr. Damon said, that it is the close physical contact that we’re concerned about here. And, you know, I just keep thinking back to some of the initial cases, even the 2003 outbreak here in the U.S., the cases in, you know, parts of Western and Central Africa, it was individuals who came into close contact with the infected animal, and then it was their close contacts—usually family members—and then the health care workers. And when we are, you know, looking at this outbreak, it just so happens that that close physical contact was among MSM. And, you know, we want to be very clear that it doesn’t mean that this is only going to spread among MSM. And I think there is—we have to be very careful with the messaging on this. It is not just going to be an issue for MSM, you know, because that kind of makes everybody else complacent. And then it will also create a lot of—like a spiral effect in other—especially in countries where, you know, people are reticent to go into health care—to go talk to their health care provider about their behaviors because they’re afraid of stigma, right? So, we want to be very careful here. And then, you know, I think back to a lot of the research that we’ve done and the work that we’ve done on social networks and understanding sexual networks. And the networks overlap, right? So, you have men who have sex with men who also have sex with women, and then those women have sex with other men. And, you know, these networks overlap, and this is our reality. And we need to just be, you know, really, I think, open and understanding about this as we think about the spread of the virus and how we want to, you know, deploy resources to improve communication and public health response.

[0:56:36]

RICK WEISS: Great. Appreciate those emphases. I know Dr. Damon has a hard stop at 3:00, so we need to wrap up in a moment. I have one quick question for you, Dr. Damon, and then we’ll just go around with last take-home messages from each of you. But we do have a question from Ben Ryan—freelance in New York—about how long it will take the manufacturer of the JYNNEOS vaccine to deliver that U.S. order of a half a million doses?

[0:56:59]

INGER DAMON: Yeah. So, I don’t have a specific date, but I’m told that it will be this year. So…

[0:57:03]

RICK WEISS: This year.

[0:57:03]

INGER DAMON: And, actually, ASPR has actually blogged about this. And so, a lot of the numbers that I provided to you are part of an ASPR blog. So, if you just google it, you can find it.

[0:57:13]

RICK WEISS: It’s ASPR meaning the Assistant…

[0:57:16]

INGER DAMON: Secretary for Preparedness & Response. A-S-P-R.

[0:57:19]

RICK WEISS: Great. Great. I appreciate how many questions we’ve gone through. There’s going to be a few that I’m afraid we’re not going to get to, but we do need to wrap on time today. So, I want to just go around to each of you now, very briefly in a half-minute or less, one take-home message that you want to leave people with as we wrap up today. And I’ll start with you, Dr. Rimoin.

[0:57:40]

ANNE RIMOIN: Well, I would say that, you know, the key points here are that monkeypox is something we do know something about. It’s something that we will learn a lot more about. But if we’ve learned anything from Zika, from H1N1, from COVID-19, an infection anywhere is potentially an infection anywhere. We have to be careful about, as Dr. Roess was saying—you know, saying, well, it’s only in this network. It’ll never end up in another network. We’re all interconnected. So, we all need to—you know, we need to be cognizant of what we know, be humble about what we don’t know and remember that we’re going to learn a lot. And we do have tools that are very important, that Dr. Damon has described very clearly, that can be used to be able to control this virus and to get in front of it instead of chasing behind it.

[0:58:43]

RICK WEISS: Great. Dr. Damon, I’ll jump to you second in case you need to drop off to your next thing.

[0:58:48]

INGER DAMON: Right. Not a whole lot more to add but just the sort of the general underlying principle here, that it’s important that we all continue to work hard to identify infections quickly in order to prevent further spread, provide guidance to potential others who are at risk, whether at the home or direct intimate contacts of those individuals. So, one of our big take-home messages is we’re really urging health care providers to keep an eye out for possible monkeypox virus infections. We’ve tried to publish representative photos from what we’ve seen here in the U.S., what the U.K. has seen and for individuals to seek care if they have any signs, such as a new unexplained rash that’s typical or may have come into contact with somebody who has such a rash. So, we’ll continue to update our website with additional information.

[0:59:37]

RICK WEISS: Great. Thank you. And Dr. Roess.

[0:59:40]

AMIRA ROESS: Yeah. The only thing that I have to add is just really to emphasize what Dr. Rimoin and Dr. Damon had just said, right? We do need to make sure that the public is educated about this and that they know what the signs and symptoms look like and that they have the numbers, you know, for who to call at the first sign of a symptom or if they’re concerned about that. So, we do need to see more communication about that and to make sure that health care providers and other individuals who are interfacing with patients, that they know what to say and what to do.

[1:00:15]

RICK WEISS: Great point there. I think that reporters can help by including phone numbers for local public health agencies that should be the place to get in touch with if you see something. Great.

I want to thank the three of you—the two of you who are left now. CDC is off to their next briefing. But thank you so much for all the information you’ve shared today. And thanks to reporters for joining us today. For reporters, as you log off today, you’ll see a short three-question survey as you leave. It would be very helpful if you would take the half a minute it takes to answer those three questions so we can keep improving these briefings for you. Check out our services at sciline.org. Follow us @RealSciLine and thank you all again. We’ll see you at the next SciLine media briefing. So long.