Q&A: Stony Brook Medical Director Offers Basics On Monkeypox And Who Should Get The Vaccine - 27 East

Q&A: Stony Brook Medical Director Offers Basics On Monkeypox And Who Should Get The Vaccine

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Dr. Susan Donelan, Medical Director of Healthcare Epidemiology at Stony Brook University Hospital.      Jeanne Neville/Stony Brook Medicine

Dr. Susan Donelan, Medical Director of Healthcare Epidemiology at Stony Brook University Hospital. Jeanne Neville/Stony Brook Medicine

Dr. Susan Donelan, Medical Director of Healthcare Epidemiology at Stony Brook University Hospital.   COURTESY STONY BROOK MEDICINE

Dr. Susan Donelan, Medical Director of Healthcare Epidemiology at Stony Brook University Hospital. COURTESY STONY BROOK MEDICINE

Joseph P. Shaw on Aug 16, 2022

On the heels of the COVID-19 pandemic, monkeypox is the new virus of concern.

As of August 15, there have been 2,548 confirmed orthopoxvirus/monkeypox cases in New York State, including 35 in Suffolk County. That puts the county third behind New York City, which has the overwhelming number of cases in the state, and Westchester County.

Locally, Stony Brook Southampton Hospital is offering the monkeypox vaccine through the Edie Windsor Healthcare Center in Hampton Bays. Barbara-Jo Howard, the hospital’s executive director of communications and marketing, said the allotment of monkeypox doses was spread over several days of appointments beginning July 18. As new doses arrive, appointments are offered through the center’s website.

Howard said the center has so far provided 936 first doses, and 14 second doses, which are administered 28 days after the first.

Unlike COVID-19, this new virus is less easily spread and far less deadly. For now, the focus has been on at-risk communities, where a vaccine is being deployed to try to stop the spread.

Dr. Susan V. Donelan, who is the medical director of the Healthcare Epidemiology Department at Stony Brook University Hospital, on Monday offered an overview of the virus, and advice on how people should protect themselves. The interview has been edited for length and clarity.

Can we just start with a primer on what monkeypox is?

Monkeypox is in the family of orthopox. There’s cowpox, there’s smallpox, there’s other animal poxes. And, as you know, smallpox has been essentially eradicated as an occurring infection. If any single case occurred anywhere in the world, one would think it would be an act of bioterrorism, because it exists in, we think, only a couple of places.

So these are zoonoses — infectious diseases that originate in animals. And sometimes we don’t always know the definitive host animal. We have guesses. And it was found some decades ago in some monkeys in the research lab — hence the name — but, probably, rodents are the larger vector.

There are two areas people think about, or two clades. The first clade is in Central Africa, and the [World Health Organization] is actually literally in the process of recreating the names to make them less geographically focused and more scientifically based. But the second clade is primarily associated with the west coast of Africa.

And people in those areas, when they interact with animals that are infected, or infectious, you will see transmission from the animal to the person, and then from person to person within a household, or something like that. Because it does involve skin-to-skin type of things. But there’s never been a global outbreak that is being fueled by person-to-person transmission.

There was an outbreak some years ago that was associated with prairie dogs that were infected. And Chicago was one area where the prairie dogs were in contact with other animals that had monkeypox. They got infected. These prairie dogs went out to pet stores. I won’t comment why anybody would want one of those things for a pet, because they have pretty awesome claws — but no judgment. And there was animal-to-person transition.

But this is really a very different scenario. This is something that is now fueled as a person-to-person transmission.

And I think it’s important to understand that this is not a disease of sex. This is a disease of intimacy — and there are lots of ways to be intimate.

Can you explain that?

Sure. So I think there were some events, at least I think at least two events that occurred in Europe, where the participants were part of a social gathering, what we see all over the world, where there are certain social demographics and certain social dynamics, using apps, or meeting up at parties or meeting up at gatherings, where sexual contact is part of that event. Not a judgment, just fact.

And so I think that at some point there was someone who, unbeknownst to them, was infected, and then that became amplified. And so we’ve gone from some hundreds of cases, about two or three months ago, to now, at least as of Friday, about 35,000 global cases, with more than 10,000 in the United States.

That incident involved sexual contact, but what you’re saying is that it doesn’t have to necessarily be sexual contact.

So when someone has active lesions on their skin and their mouth and their genitalia, intercourse is not the only way that it gets transmitted. If you are cuddling or kissing or being close to someone, without intercourse, you can, if the other person is infected, transmit the infection.

So it’s one of intimacy rather than sex. And I would not want people to identify it as a sexually transmitted disease, because it involves close and intimate contact.

You think about who lives in your household and the kind of touching and sharing that goes on over days in someone’s household. A pregnant woman can transmit it to her fetus, if she’s infected. If a mom is breastfeeding and there are lesions, that can be transmitted.

So the current demographic is heavily impacting gay [and] bisexual men who have sex with men, and people who use social apps to meet partners with whom they may have a fair amount of knowledge about them or not so much knowledge about them. As more of that intimacy occurs, that transmits the virus from one person to the other.

It’s also important: Unlike chickenpox, where someone is no longer infectious once their pox lesions dry and crust, monkeypox is more like smallpox, where the lesions themselves, the crusts, or the scabs, are infectious. And so if someone shares a bed, and some of the scabs are shared in the bed clothing, that’s one way to get it as well.

Some of the lesions itch like chickenpox, for example, and if you scratch them and you unroof them with your nails, that raw area underneath is also infectious until that has a new layer of skin that is healed.

So while the lesions may start to scab, and the evolution is roughly two to four weeks from beginning to end, it’s very important that the person who is infected really have the ability to isolate from others. They shouldn’t use each other’s towels. They shouldn’t use each other’s toothbrushes or shavers.

Monkeypox can persist on inanimate surfaces. So bathroom fixtures, counters or whatever, depending upon what the person touches and then contaminates.

So, ideally, that person is able to move through their illness in a way that they have their own bathroom, they have their own bedroom, they don’t go shaking out their laundry or their stuff, because those scabs can then — particulate matter can get into the air, that type of thing.

So it is a burden on the person that’s ill. And it’s hard … it’s very hard to isolate even for those five or 10 days that we were asking people to isolate [for COVID cases]. Now we’re asking people to isolate for two to four weeks.

I think it’s very important that the people who are being asked to isolate, either because their tests are pending and they’re waiting for the result or because it’s been confirmed, that they are supported in that isolation so that they can be successful in breaking the chain of transmission. I worry about, for example, people who, if they don’t go to work, they don’t get paid. And then saying, “For the good of other people, you have to stay home and isolate until all your scabs are gone and all your lesions are healed.” And that’s a long two to four weeks if someone doesn’t have health benefits, if they don’t have alternative means of supporting themselves — this is not what you want.

And be careful and be smart about it. Vaccination. Yes, there’s pre-exposure vaccination. Yes, there’s post-exposure vaccination. That’s one way. But it’s also the ability to isolate successfully, so that you break the train of transmission even within a household.

You were talking earlier about this being perceived as sort of sexually transmitted disease. And I think part of the reason for that is, unfortunately, the demographics that are involved — people have drawn parallels to the HIV outbreak. Can you explain why the outreach has been specifically to that community?

So here’s the thing. There are two vaccines that are likely to be available within the United States. One of them is not capable of replication. It’s inactivated — it’s live, but it’s inactivated. It cannot replicate. So it can’t make you diffusely sick from the vaccine. There’s no virus that’s going throughout your body. That’s the one that’s in the most limited supply.

The alternative one, it’s called ACAM2000. That one is much more similar to the old smallpox vaccines. … That has live virus. That is capable in certain individuals — they’re very young, they’re very old, immune compromised, those who have eczema, psoriasis, those have autoimmune diseases — it can disseminate in a person who is immune compromised. Think about all of the people who are walking around with somebody else’s liver or kidney or heart transplant, or are on medications that are needed for them, but make them compromised or have compromising conditions. Those are not the people that you want to give that particular vaccine to.

And so what they’ve done is to protect the people who are most at risk right now. And so with not having millions of doses to give out to everyone, they’ve tried to focus on the people who are at the highest risk of having the potential for exposure.

That, unfortunately right now, is people to whom we’ve said, “Please identify yourself as being in one of these categories: someone who is MSM [men having sex with men], identifies as a gay or bisexual, or have used these apps, or attended social events in which there’s at least a reasonable expectation that there will be some kind of intimate contact, regardless of whether it’s sexual intercourse or other intimate contact.”

Because that is a group that is most likely to benefit from the utilization of the relatively limited number of vaccines we have in the United States.

In the [Centers for Disease Control and Prevention’s] estimation, 1.6 million to 1.7 million people are currently in that at-risk demographic that should be eligible for the vaccination. The vaccine is given as a first vaccine and then, four weeks later, a second dose, so that you’re protected two weeks after the second dose — very similar to the Moderna COVID vaccine; you had one and then, four weeks later, you had the second.

They would need 3.2 million to 3.4 million doses to cover that entire at-risk population with those two doses. But they’re only going to have between 1.6 million and 1.8 million doses available by December 2022.

Each dose is 5.5 mLs in the subcutaneous route, the standard dose now. And [the CDC has] some information that suggests that getting five doses of 0.1 mL, but giving it to patients with a small needle in the arm, they would give it similar to people who get a PPD test for tuberculosis. So they slide it under the skin, and it makes it a little bump under the skin.

And that way they could expand the number of potential vaccines being given to that population at risk, because clearly they don’t anticipate having sufficient doses for all the people who identify as at risk, where they could all get two doses.

So it is a very complicated type of thing. It is just one company in Europe that makes it, and even if they ramp up as much as they can, it would be difficult for them to be able to do it globally, satisfying everyone who may be at risk. So it is complicated.

So, for the layman in the larger community, outside the communities at risk that you’re describing, since we have COVID as a comparison, I mean, can we make some comparisons here? It seems like a disease that’s not going to spread quite as virulently as a disease like COVID. Is that fair?

So with COVID, you don’t actually have to work very hard to get it, because the variants have become so changed and so efficient in the ability to infect the upper respiratory tract and than transmit. So it’s much easier to get COVID than it is to get monkeypox.

So it’s important that, I think, for most people who don’t believe that their partner or partners are part of the demographic, they would be usually considered at low risk. If they have no family members who are in that demographic that they’re aware of.

But one of the things we, as clinicians — because this current monkeypox outbreak does not necessarily present in the classic way that the ones did some decades ago. I said that the people in Central and Western Africa, they had interactions with the animals — they would get a very classic rash.

Why this is happening is still being figured out, but the lesions don’t necessarily resemble the classic monkeypox lesions until perhaps some time has passed.

I think anyone who is interested or curious as to what it might look like can simply go on to the CDC website, which has very frank-appearing pictures, because … it’s not to shock us, it’s to educate and inform. But the other thing is that, because of the way that it is currently being amplified by intimate contacts, people may develop lesions in their mouths or on their genitals or in their rectal vault, in their rectum. And just because they can’t be seen does not mean that they’re not there. They tend to be painful out of proportion to what can be seen. And I think that’s important for clinicians to know.

One of the reasons why I’m willing to do this kind of interview is because I want people to understand that there should be no stigma. You can look at pictures, but they may not look classic. There are some reliable and useful resources on the web, such as cdc.gov/monkeypox, that will give very frank advice in plain language with straightforward pictures, so that people can educate themselves on what to look for, perhaps in a new partner, or to have a better understanding of partners before they are intimate with them.

It’s a difficult line to walk, isn’t it? Because you worry about stigmatizing, but you have a community that’s at higher risk. And speaking frankly about those risks is part of how you combat it.

Yeah. The one thing that is important to understand is that we’re all intimate creatures. We all create intimacy, however that intimacy looks. And so that’s why it is important for people who may have bisexual partners, and that they know that and they may need to have a conversation with that bisexual partner, to say, “Listen, this is a time when perhaps we need to rethink our parameters so that we keep each other safe.”

Clinicians are encouraged to test widely rather than just test people who fit into a narrow demographic, because we want to make sure, at some point, it may spread into the non-gay, non-MSM, non-bisexual community. And we want to make sure that people understand that we want to test because we want to treat, we want to take care. We want to limit the spread. If you’re sitting there in judgment as a clinician, you might need to get a different line of work.

So, locally, have we seen many cases?

Well, the numbers, you have to get from the Suffolk County Department of Health, but I can tell you that we certainly have had cases in Suffolk County. Put it this way: New York State has the highest number of cases in the entire U.S. and its territories. New York City is the epicenter of those numbers. And we are an hour or two, depending upon traffic, at the edges of the greatest city on earth, which happens to be an area that also has cases. So I think we would be naive to think that is not something that we were going to see and we have seen.

How dangerous is monkeypox, as far as fatalities? And, again, maybe it’s easiest just to use COVID as a comparison, since everybody’s so hyper aware.

Up to the last time I was able to look, I don’t think we have had any deaths related to monkeypox in the United States.

No deaths at all in the United States? I didn’t realize that.

Not that I’m aware of at 1:25 p.m. on Monday. If it happened, it would be a one-off. The current circulating strain is not known for its high fatality rate, which is obviously tremendously helpful and important.

It just makes you terribly sick and uncomfortable?

Most people do not need hospitalization, except, if where their lesions are, their sores are, makes it difficult to eat or drink or to urinate or to defecate, which they will have to do over the course of two to four weeks. There is an antiviral called Tecovirimat, or TPOXX, which is in the strategic national stockpile and from the CDC, but which has gone out to certain facilities and hospitals. It’s not something you have to wait for days for. And someone has concerning lesions, the idea is for the clinician to go ahead and start that therapy while we are waiting for the results.

Are you aware of how the vaccination effort has been going locally? I’ve heard anecdotally that the facility here in Hampton Bays, in the Edie Windsor Healthcare Center, started offering the vaccine a week or two ago and has been booked solid. Has the outreach effort been adequate, and do you think it’s been well received?

I think it’s been well received simply because the people who perceive themselves as being at risk are eager to get the vaccine. I think the call for the vaccine, the demand for the vaccine, is going to vary from geographic area in the United States, probably in the larger cities where there be more people who are in the social demographic that’s being impacted at the time. They may have a higher demand for it than, for example, in a rural area.

So I think that it’s tremendous that we’re able to offer it in New York City. And I know that there was a vaccination distribution on Fire Island and the Edie Windsor is having a number of vaccination opportunities as well. And I think as soon as people are getting the vaccine, the health systems, they’re trying to get it out there.

But I think again, it’s that potential mismatch between who might need it and that second dose, and how many doses we have in hand, that’s prompted the CDC to reevaluate a different kind of way of distributing it in terms of how it’s delivered. But the idea clearly is to protect as many people as possible.

It’s very early, but what advice can you give to people in the community with how to process this? We’ve all been through the COVID pandemic. And I think everybody’s sort of on heightened alert and everybody, when they hear about something monkeypox, kind of has a tendency maybe to panic a little bit. What just general advice would you give people about monkeypox?

So we have three kind of potentially emerging infections at one time. We have COVID, we have monkeypox, and we have a concern about polio. And I think that, just as for COVID, maximize your vaccination opportunities. If someone has not been, for example, fully vaccinated against polio, has not vaccinated their children — it’s important to do that.

And for right now, in terms of monkeypox, I think people should feel at least somewhat reassured by the fact, this is not COVID, in terms of its ease of transmission. This is not something that sitting across from somebody in a crowded room is going to be likely to transmit. I don’t think we’re talking about somebody’s indoor wedding being a super-spreader event like we did with COVID.

I think situational awareness, keep yourself informed. There’s no need to panic. There are many, many opportunities for people to get information.

I have to say that the CDC’s website at least has taken a stab at answering questions so that people can feel that they can be reassured. “You need to know your partners. You need to know who you are choosing to be intimate with.” I think that’s so important. I also think it’s important for people to understand that one vaccine does not confer protection and that getting the vaccine before you’re exposed, in a preexposure setting, that it’ll take six weeks from the receipt of the first dose to completion of the second dose and two weeks beyond to get that full protection. And full protection may not be a hundred percent, but it may mitigate the impact of it.

But it’s important for people to still not throw caution to the wind. Say, “I’ve had one vaccine — I’m good to go. I don’t want my summer ruined! I pay a lot of money for this timeshare. I finally got a weekend away.”

I think it’s just important for people to be smart.

More information is available at:

ourworldindata.org/monkeypox

cdc.gov/poxvirus/monkeypox/index.html

suffolkcountyny.gov/monkeypox

stonybrookmedicine.edu/monkeypox/vaccinations (Edie Windsor Center)

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