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Monkeypox: Updates from Fulton County
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Rosemary Pitrone

Dr. Jodie Guest is joined by Dr. David Holland, associate professor of medicine at Emory University and chief clinical officer for the Fulton County Board of Health, to talk about the monkeypox outbreak in Atlanta — including strategies for preventing infection and the safety, efficacy and availability of vaccines.

Since early May, cases of monkeypox have been detected in countries around the world that have not historically reported the disease. In July, the World Health Organization declared the monkeypox outbreak a global public health emergency.

The outbreak has now spread to 82 countries where the disease is not endemic. Most infections have been reported in the U.S., where more than 9,492 cases have been confirmed. In response, the U.S. declared monkeypox a public health emergency on August 4.

Like smallpox, monkeypox is a type of orthopoxvirus. While it is less deadly and transmissible than smallpox, it can cause a painful rash and other symptoms including fever, body aches and chills. Symptoms can last from two to four weeks. 

As of August 9, Georgia is among six states in the U.S. to have reported more than 700 cases of monkeypox, with 749 cases. Most of the cases in Georgia have been reported in Fulton County among men who have sex with men.

Jodie Guest, PhD, professor and vice chair of the department of epidemiology at Emory’s Rollins School of Public Health, teamed up with David Holland, MD, associate professor in the Department of Medicine at Emory University School of Medicine and chief clinical officer of the Fulton County Board of Health, to discuss the monkeypox outbreak in Atlanta — including strategies for preventing infection and the safety, efficacy and availability of vaccines. 

Their conversation is part of an online video series hosted by Guest, who also leads the Emory COVID-19 Outbreak Response Team, answering questions related to the ongoing COVID-19 pandemic and other public health topics.

Q: How is monkeypox spreading from person to person during the current outbreak?

A: “Based on our epidemiological investigations, it seems to be pretty much exclusively spreading by skin-to-skin contact,” says Holland. “And not just casual contact — not like a handshake or brushing by somebody at the grocery store — but prolonged, very intimate contact that you might see during sexual activity.”

“The length of time that someone is connected to someone with monkeypox seems to be really important in the spread of it,” says Guest.

Because it is spreading primarily through prolonged skin-to-skin contact, monkeypox infections are much rarer than COVID-19 infections, which spread through airborne droplets and particles.

“I think people have maybe been a little bit worried about catching monkeypox at the grocery store or something like that, but that just doesn't seem to be the case,” Holland explains, noting that while transmission through droplets has been observed in previous monkeypox outbreaks, it “does not seem to be spreading that way in this particular outbreak.”

Q: What are the symptoms of monkeypox? When is monkeypox contagious?

A: The most common symptom (and often the first symptom) of monkeypox is a rash. This may be followed by other symptoms including fever, headache, swollen lymph nodes, body aches, chills, respiratory symptoms and exhaustion.

“It's important to note that as far as we can tell, people do not seem to be contagious before the rash or lesions appear,” Holland says. “That said, the early stages of the lesions can be very small and hard to notice, so I think people may actually be infectious before they know anything is wrong.”

Monkeypox lesions may first appear as small bumps that could go unnoticed or be mistaken for a mosquito bite or pimple. They are considered infectious until they scab over and begin to heal.

“People who are engaged in the kind of activities that might lead them to be at increased risk of monkeypox might want to be extra careful and on alert” for any signs of a rash, Holland says.

Q: Who is eligible for a monkeypox vaccine?

A: Most cases of monkeypox in the current outbreak have been reported among men who have sex with men (MSM), suggesting possible spread through sexual networks. For this reason, MSM who have multiple sexual partners are being prioritized for vaccines, which are limited in supply.

The outbreak in Atlanta is also different from many other U.S. cities, where most cases have been reported among white MSM.

“Within Georgia, and in particular within Fulton County, the majority of cases are now among Black men who have sex with men,” Holland says. “So, we are extra-prioritizing that group with some equity efforts to make sure that vaccines get to where they are needed.”

Q: How are monkeypox vaccines being administered in Fulton County?

A: The Fulton County Board of Health is administering monkeypox vaccines as post-exposure prophylaxis and as a form of prevention for individuals who are at high risk of exposure.

“We have two allocations of vaccine from the Strategic National Stockpile,” Holland explains. “The first is what we call the immediate post-exposure prophylaxis. These are for individuals who have been identified through a case investigation and contact tracing as people at very high risk of acquiring monkeypox; these would be intimate partners of someone who was diagnosed. Those are individuals that we’re trying to get vaccinated within four days to actually prevent the infection.”

In Fulton County, only individuals named as close personal contacts by someone who has been diagnosed with monkeypox are eligible for a vaccine as post-exposure prophylaxis.

The other allocation of vaccine is for expanded post-exposure prophylaxis. “It kind of looks a little like pre-exposure prophylaxis, but that’s actually not what it is. It’s for people who have reported multiple sex partners in the prior 14 days,” Holland says.

“At some point, there may be enough vaccine that we can start thinking about pre-exposure prophylaxis, but technically everything we're doing is still post-exposure,” he adds.

Follow the Fulton County Board of Health on Facebook, Twitter and Instagram for information about upcoming vaccination events.

Q: Is the monkeypox vaccine safe and effective?

A: The Fulton County Board of Health is administering the Jynneos vaccine, which was developed for the prevention of smallpox but is also licensed for the prevention of monkeypox by the U.S. Food and Drug Administration. The vaccine contains live poxvirus that does not replicate efficiently in human cells and has been proven to be safe in adults.

“Studies have shown that the Jynneos vaccine is very, very safe,” Holland says.

The Jynneos vaccine regimen consists of two doses administered 28 days apart. The maximum antibody response is reached 14 days after the second dose, but there are no data yet on the effectiveness of the vaccine in humans during the current monkeypox outbreak.

“The proof over efficacy of this vaccine against monkeypox has only been done in animals, not in humans,” Holland says. “There has just been no way — until now — to test how efficacious it is.”

In animal models, the vaccine has been shown to prevent monkeypox illness if administered within four days of exposure. If administered within 14 days, the vaccine offers less protection but can still prevent severe illness.

“So, you do get some protection, we just don’t know yet exactly what the dynamics of that look like,” Holland adds. “We should know pretty soon, though.”

Q: Does someone who recently had monkeypox and recovered need a monkeypox vaccine?

A: “As far as we can tell, no,” Holland says. “Immunity from orthopoxvirus infections appears to be pretty good, so there's no evidence that a vaccine would benefit somebody who's recovered from monkeypox.”

“That is very different than what we see with our COVID-19 vaccines,” Guest notes.

Q: Besides vaccination, how can you lower your risk of getting monkeypox?

A: “There’s some really good information on the CDC website about protecting yourself from monkeypox in sexual situations, developed by a team at the CDC in the Division of HIV Prevention,” Holland says.

“People are going to have sex and people are going to go to parties, and nobody is suggesting that anyone stop doing that,” he continues. “I would say that to protect yourself, just think carefully about the number of partners that you choose to have and how they're selected.”

“I think it is always important — for gay men, in particular — to have conversations about risk and protection with their sexual partners, no matter what the environment is,” he adds. “That said, I'm also very much in favor of making sure that public health interventions are so widely distributed that those conversations no longer become necessary, because everybody has already been able to access the protective modalities that work best for them. Unfortunately, we're just not there yet.”

Q: How do you encourage individuals at high risk to take preventative measures to protect themselves and their communities without creating stigma or unfounded fear?

A: “That’s a really good question, and the tack that we’re taking is we are working very closely with our community-based organization (CBO) partners that serve men who have sex with men — organizations that deal with Black MSM, Latino MSM, trans communities, and so forth — and working through them to get the messaging out,” says Holland.

“It works a lot better that way, because they are trusted messengers, and then it kind of tees us up to be able to launch things like vaccines when they become ready.” 

Q: Can monkeypox be transmitted through swimming pools?

A: No cases have been traced to swimming pools. “As far as we can tell, there's no risk [in pools],” Holland says. “There’s pretty good evidence that the chlorine or the saltwater — whatever is killing everything else in the pool — would kill the orthopoxviruses, as well.”

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