PROVINCETOWN — New data emerged last week on the global outbreak of the monkeypox virus. A report from the World Health Organization (WHO) shows that cases are falling off in several hard-hit countries, including Portugal, Spain, and France, but cases in the U.S. are spiking.
When the Centers for Disease Control (CDC) completed another study on July 22, there were 2,767 cases total in America. Since then, 6,167 new cases were reported in less than three weeks. The country’s official case count tripled in only 18 days.
Nationwide, the availability of vaccines is limited. There are not nearly enough doses to vaccinate the at-risk population of major cities like New York and San Francisco. Provincetown, however, has had a relatively large and steady supply of the Jynneos vaccine since early July.
Outer Cape Health Services has given first doses of Jynneos to 2,100 people, according to Communications Director Gerry Desautels, who reported another 550 doses were on the way as of Aug. 9. There is a waiting list of several hundred people, Desautels said, but the organization is getting continuing shipments of the vaccine, and state Dept. of Public Health (DPH) staff were deployed to Provincetown to help deliver second doses in early August.
“I think Provincetown has been really fortunate,” said state Sen. Julian Cyr. “Five or six weeks ago, I was expecting a much tougher summer. Monkeypox is affecting people, and we have to be vigilant, but I think our ability to vaccinate people has reduced the cases we’re seeing.”
Cyr said there were several factors that led to Provincetown’s large allocation of doses, but last year’s Covid outbreak was one of the big ones.
“The Delta outbreak established very strong relationships between the DPH, our health care providers, and our local and county health agents,” said Cyr. “I think the state was confident we could get shots in arms quickly.”
Transmission in Networks
While the WHO and CDC studies indicate there are reasons to worry about the course of the disease in America, the good news, if there is any, is that the outbreak is still almost entirely confined to the gay and bisexual male community and is not readily spreading outside it — not even to roommates or “household contacts.” The WHO’s report shows that 99 percent of cases globally are male, and 97 percent are gay or bisexual.
Prior outbreaks in Central and West Africa have seen a high degree of spread within households and families, with nearly equal numbers of male and female patients and many children. But a report from the health ministry in Madrid said that, after tracking hundreds of household contacts there, the only cases of transmission were to sexual partners. There are two women among 500 cases studied in Madrid. The CDC report shows only five cases in women out of 1,195 cases studied.
The WHO report says that “at present there is no signal suggesting sustained transmission beyond these networks” of gay and bisexual men. Occupational infection of health-care workers, for example, has been virtually nonexistent.
With Covid, the ability to spread the disease without having symptoms, or before symptoms developed, was a huge driver of the pandemic. Monkeypox is still thought to spread only after symptoms have emerged.
A troubling finding of the CDC study, however, is that only about half of the cases in this outbreak have begun with what are called “prodromal” or flu-like symptoms: fever, malaise, chills, headaches, or swelling of lymph nodes. When these symptoms appear first, people know they are sick — many have reported thinking they have Covid — and they are more likely to avoid intimate contact.
Many patients have only small skin lesions as their first symptoms, often in the anogenital region where they aren’t immediately noticed. The Madrid report notes that this has contributed to a lack of awareness of the disease among those infected.
A Mild Case
Joe Fischel is a professor in Yale University’s Department of Women’s, Gender, and Sexuality Studies and a summer resident of Truro. He got a Jynneos shot on July 8 but developed a relatively mild case of monkeypox on the night of July 12 from an exposure that he thinks came over the July 4 weekend.
He went to Outer Cape Health Services with a fever and swollen lymph nodes on July 13 and was instructed to pay careful attention to his skin and return if any lesions developed. The next morning, he found one, returned to OCHS, and was given both the antiviral medicine tecovirimat (TPoxx) and strong medicine for pain.
Fischel was sharing his family’s home with his mother and his partner — although all three were sleeping in separate bedrooms.
“I asked if my mother should get the shot,” Fischel said. “I described that we’re in separate bedrooms, separate bathrooms, separate linens. We’re not going to eat on top of each other.” Fischel and his family continued to take meals at the same table, although with more distance between them than usual.
“They said she probably didn’t need one — she’s probably fine,” said Fischel. “That kind of captures everything that’s scary about this: what does ‘probably’ mean?”
Fischel’s case resolved fairly quickly, he said. He had one night of significant pain, and his lesions lasted only two days, although he continued in quarantine until his skin was fully normal. He thinks the TPoxx may have shortened his illness.
That drug comes from a federal stockpile meant to protect the nation from smallpox, and the process of getting it has been onerous for many providers nationwide. OCHS apparently had doses on hand.
“Part of what quelled the fear around HIV was queer activists who promoted the science of how HIV was transmitted,” Fischel said. “From everything we know, monkeypox is more transmissible than HIV, and not only through sexual fluids, and that can generate anxiety.
“The chances of my giving HIV to my mother by having dinner every night is zero,” Fischel added. He knows the chance of his transmitting monkeypox is extremely low — but the public needs data to know that.
Fortunately, there is at least one other enormous difference between monkeypox and HIV. Fischel had symptoms for about a week, and he continued to quarantine for about 10 days after that. He was back to normal by August.
