Providence Reporter

Brown scholars from a variety of departments and perspectives offered key facts and insights on the persisting public health emergency.

PROVIDENCE, R.I. [Brown University] — Even before the U.S. had emerged from the COVID-19 pandemic, the country’s first case of the monkeypox virus was reported in May 2022. In late July, the World Health Organization declared the ongoing monkeypox outbreak a public health emergency, and in early August, the U.S. government followed suit.

Over the past few months, the monkeypox outbreak has both offered opportunities to apply lessons learned from COVID and presented its own unique challenges. Although the U.S. is currently seeing a decline in cases, the outbreak continues to affect patients both domestically and abroad.

Scholars from Brown’s School of Public Health and Warren Alpert Medical School offered some key facts and insights on this complicated public health issue.

Philip A. Chan

Associate professor of medicine, associate professor of behavioral and social sciences; consultant medical director of the Rhode Island Department of Health

Gay, bisexual and other men who have sex with men are primarily being affected by monkeypox —although anyone can get it.

The virus can spread via direct contact with a person with monkeypox or by touching objects, fabrics and surfaces that have been used by someone with monkeypox. We don't know yet whether monkeypox is sexually transmitted, but it is associated with sex. It was initially believed that monkeypox was spreading by droplets (similar to SARS-CoV-2), but that type of transmission appears to be much less common than expected. Monkeypox is much less infectious than COVID-19.

Gay, bisexual and other men who have sex with men are primarily being affected by monkeypox — although anyone can get it. It is important for public health to continue to actively communicate risk to affected populations so they can make informed decisions about behavioral changes and prevention options, which include vaccination.

Despite the death of a person in the U.S. from monkeypox (and a second possible death in Texas under investigation), it is not believed that the virus is becoming more lethal. We do know that people who are immunocompromised (e.g., who are HIV-positive with a low CD4 cell count), who are receiving chemotherapy, or who have been diagnosed with certain other medical conditions) are at higher risk of complications from monkeypox. People who are immunocompromised and diagnosed with monkeypox should seek treatment immediately.

There is a need for more federal public health resources to address monkeypox, as well as COVID-19, avian flu and whatever else happens in the future. Our country is in urgent need of a framework and a national plan with resources on how to address these emerging threats to public health.

Joseph Metmowlee Garland

Associate professor of medicine, clinician educator; medical director, Infectious Diseases and Immunology Center, the Miriam Hospital

Unfortunately, you can’t just get a monkeypox vaccine at your local pharmacy like you can the COVID vaccines.

The monkeypox vaccine is issued from the CDC directly to state health departments, who determine how to distribute their limited supply to the highest-risk populations. Unfortunately, you can’t just get a monkeypox vaccine at your local pharmacy like you can the COVID vaccines.

On top of that, there’s a shortage, which is the result of several factors. First, the vaccine is intended for smallpox, so those planning for a stockpile were not necessarily anticipating a widespread outbreak of monkeypox. Further, expiring vaccines had not been not replenished and there were delays in ordering and securing replacement vaccines. The vaccine we are using, Jynneos, involves two doses; it is only manufactured by one company in Denmark, and they have a certain capacity. The global spread of this epidemic has put an acute demand on the vaccine manufacturers from countries around the world, including many in Europe.

In order to get the vaccine to more people, providers are following the CDC’s alternative dosing regimen of administering the vaccine intradermally, or between the skin layers, instead of subcutaneously, or under the skin. An intradermal vaccine can induce a stronger immune response because of how many immune cells we have in our skin. The FDA did a study on the difference between intradermal and subcutaneous administration of the Jynneos vaccine at the currently used doses and found that study participants had similar levels of immune response (measured by antibody levels) with the lower dose intradermal vaccine. That allows us to give a much lower dose to get the same level of effect: one-fifth of the dose induces the same level of immune response in studies — that allows for potentially five times as many people to get the vaccine.

But there’s a trade-off. In general, this is a harder way to administer a vaccine, and more people have skin reactions to this method— we’ve seen mild swelling, redness or discoloration at the injection site. In some people, that can persist for a long time, which is important to be aware of. 

And it must be said that no vaccine is 100% effective. We don’t have much data on any vaccines for monkeypox specifically. Jynneos was tested in an animal model of smallpox (a very similar and related virus), but we still need to see actual results in a real-world setting. Data show that it takes about six weeks from the first dose (and two weeks after the second dose) for people to reach full immunity. Up until that time, people still have a risk of being infected. After that time, most people should have protective immunity — but again, we still will need to back that up with real-world data as we accumulate it. 

Amy S. Nunn

Professor of behavioral and social sciences, professor of medicine; executive director, Open Door Health

We haven’t encountered much vaccine hesitancy with monkeypox at Open Door Health. Our challenge has been unprecedented demand for a new service.

At our Open Door Health clinic, we provide primary care and other preventative and sexual health services for the LGBTQ+ population. We have vaccinated over 700 people to date, and more people are coming in every day.

We always ask the people we serve what they want, and how we can do it in the way that’s best for them — instead of telling them what we think is best for them. One thing that came up in our community listening tour with gay men was that people were worried about scarring on their face, body or genitalia, and they said that concerns about scarring really motivated them to get vaccinated. People were also afraid of getting sick, or experiencing a great deal of pain from monkeypox.. People were also afraid of getting sick or experiencing pain caused by monkeypox.

We haven’t encountered much vaccine hesitancy with monkeypox at Open Door Health. Our challenge has been unprecedented demand for a new service.

We built the infrastructure to do this very fast. When we started, the entire clinical team worked 80-hour weeks so that we could offer the monkeypox vaccine to everyone who walked through the clinic’s doors – men who have sex with men, sex workers and others who might be at risk. Now we’re trying to integrate monkeypox vaccinations into our primary care work flow. The thing is, there’s currently no federal funding for this work that we can access. We do it because it’s important to the people we serve and aligns with the clinic’s mission and values, but this mission has cost the clinic $200,000 so far in terms of staff, time, communications – we’ve even had to bump other priorities. There needs to be a federal financial response to the monkeypox outbreak to help clinics like ours care for our patients. This problem isn’t unique to us; this is a crisis for clinics around the country who want to do the right thing.

William C. Goedel

Assistant professor of epidemiology

To keep on top of the monkeypox outbreak, we need to accelerate access to promising therapeutics.

For most people with monkeypox, treatment generally involves symptom management. But the antiviral drug Tecovirimat (also known as TPOXX) may be able to alleviate severe symptoms. TPOXX is approved by the U.S. Food and Drug Administration for the treatment of smallpox, a virus similar to monkeypox. Health care providers can request TPOXX through their local health department, but they may be unaware of its availability or the process for obtaining it. Because TPOXX was developed to work against smallpox as part of a bioweapons strategy in response to the events of 9/11, TPOXX is only available from the Strategic National Stockpile. In order to prescribe it, providers are required to fill out significant amounts of paperwork. This process creates a barrier to access: The bureaucratic process for obtaining tecovirimat from the CDC is cumbersome and time-consuming for providers.

To keep on top of the monkeypox outbreak, we need to accelerate access to promising therapeutics. The development of an emergency use protocol by the CDC could significantly streamline the process, saving precious time for patients in need of the medication. In the meantime, it’s essential that prescribers are trained and educated about this monkeypox treatment — not just how to use it, but the steps to obtain it from the CDC and the paperwork involve in that process.

Jennifer Nuzzo

Professor of epidemiology; inaugural director of the Pandemic Center at the Brown University School of Public Health

We need to learn from this to move forward with this outbreak and future pandemics… And we need to train future public health leaders to act swiftly in the face of a new infectious disease threat.

Jennifer Nuzzo Professor of epidemiology; inaugural director of the Pandemic Center at the Brown University School of Public Health

The outbreak of monkeypox in the U.S. was yet another test of our country's capacity to act swiftly and effectively to stop the spread of an emerging pathogen. We were well-positioned to succeed. Public health labs in states throughout the country and at the CDC had the capacity to run tests for the virus when it was first detected. The U.S. had a stockpile of vaccines to stop transmission and experimental treatments to heal patients. However, we were slow to expand use of these tools and to make sure that patients and health care providers could access them easily enough to rapidly stop the virus from becoming entrenched. We also lacked the ability to rapidly assemble and analyze data on who was getting monkeypox and to ensure that our efforts to expand testing, vaccinate and offer treatments were sufficient or whether we needed to change course. And we struggled to communicate who was likely most at risk of infection and how they can protect themselves without encouraging stigmatization of these patients. These missteps allowed the virus to spread throughout the U.S. and jeopardize prospects for containment.

We need to learn from this to move forward with this outbreak and future pandemics. Infectious disease threats — like monkeypox, COVID-19 and the recent resurgence of polio — are the hazards of our time, and we need to prepare for them as we would for other recurring hazards, like natural disasters, fires or hurricanes. We need to build better data systems and a well-coordinated, responsive testing system that can identify cases early, accurately and efficiently. And we need to train future public health leaders to act swiftly in the face of a new infectious disease threat, even when there is uncertainty about how it may unfold.

Original source can be found here.