Testing and treatment still limited as monkeypox spreads in Virginia
Cases have nearly doubled in the past week, but vaccines are largely restricted to close contacts of confirmed cases
Department of Health offices in Richmond, Va. Virginia. The agency’s response to an outbreak of monkeypox has been limited by a shortage of vaccines and other treatments. (Parker Michels-Boyce for The Virginia Mercury)
As cases of monkeypox continue to rise in Virginia, the state’s response has been limited by a short supply of vaccines, testing and other forms of treatment, raising concerns among some advocates who worry the outbreak will only become more difficult for health officials to contain.
With 47 cases as of Tuesday, Virginia is still far less impacted than epicenters including New York and Washington, D.C., which — with more than 122 infections in the city and surrounding suburbs on Friday — currently has the highest number of cases per capita in the country, according to reporting by the Washington Post.
But the state’s numbers have been rising quickly since the first reported case in late May, and it’s likely many infections are going undiagnosed given the current limitations in testing and general awareness of the virus. In Virginia, as in other states, cases are also disproportionately occurring among people who identify as gay or bisexual and other men who have sex with men, leading some to question why health officials aren’t communicating more aggressively about the risk factors.
“We need to be in front of this, not behind this,” said James Millner, director of the nonprofit organization Virginia Pride. “What’s the threshold for when we start to worry about this? This notion that we have to wait to start communicating about something until the genie is already out of the bottle — well, once you wait, you can’t put it back in.”
Dr. Laurie Forlano, deputy director of the Virginia Department of Health’s Office of Epidemiology, said the agency has been sharing information on the virus with community partners that serve high-risk groups, particularly in Northern Virginia, which accounts for the vast majority of the state’s current infections. The agency listed the AIDS Healthcare Foundation, which operates a clinic in Falls Church that provides primary care services for people living with HIV, as an important contact, as well as Inova’s Juniper Program and other health centers in Fredericksburg and Richmond.
But the shortage of testing and treatment resources appears to be limiting the scope of that collaboration. In a phone call last week, Danbi Martinez, the medical director of AHF’s office in Falls Church, said she wasn’t aware that vaccines were available in Virginia and wasn’t currently offering doses through the clinic. So far, she said she hadn’t encountered any cases of monkeypox, and only a couple of her patients have asked about the virus.
“Since I haven’t seen any infections so far, I haven’t really dipped into the information,” Martinez said.
While Virginia has received a limited supply of vaccines, doses are currently being allocated through the federal government, which is dealing with its own shortages. There are two existing immunizations, originally formulated against smallpox, approved to protect against monkeypox. One of them — ACAM2000 — is in ample supply, but involves a painful inoculation, has potentially serious side effects, and shouldn’t be used during pregnancy or on patients with conditions that cause weakened immune systems, including HIV, Forlano said.
As a result, the state hasn’t requested any doses of that particular vaccine. Instead, it’s relying on JYNNEOS, a safer version developed by a Denmark-based manufacturer. The federal government has already ordered millions of additional doses, but it could take weeks or months for the company to scale up availability, especially given competing demand from other European countries.
Virginia’s relatively small case numbers also mean the state hasn’t received as many doses as harder-hit areas. According to VDH, the federal government shipped 460 JYNNEOS vaccines to Virginia through July 8 and just recently allocated another roughly 3,500 doses to the state. Forlano said the agency requested 1,000 of those doses, which are in the process of being shipped to local health departments.
Like the federal government’s strategy, state distribution decisions are based on a combination of factors, including the overall number of cases in an area and the population of high-risk individuals living there — specifically men who have sex with men and people with living with HIV, who may be more vulnerable to severe symptoms.
Up until this week, doses have only been available through local health departments, which offered them as a post-exposure prophylaxis, or preventative measure, to close contacts of laboratory-confirmed cases (the vaccines can prevent the onset of disease or reduce symptoms if given between four and 14 days after exposure). But that could change — at least in some parts of the state— as supply gradually increases.
Several Northern Virginia health departments, including Fairfax and Alexandria, are currently developing plans to offer what’s known as “expanded PEP” to individuals who aren’t confirmed contacts but are at higher risk of exposure to the monkeypox virus. The Richmond-Henrico Health District is also developing an expanded PEP policy for the roughly 160 additional vaccines it expects to receive later this week, according to spokesperson Cat Long.
Forlano said that groups prioritized for expanded access include members of the LGBTQ community who have sex with men and have also had multiple sexual partners. Sex workers are also included, as well as other individuals who work at or attend venues like bathhouses where sexual activity occurs on the premises.
“It’s about reaching groups who, based on certain behaviors or actions, are at higher risk of being exposed within the last 14 days,” she said. “And we are really focused on that 14-day period right now, because vaccine supply is a factor.”
Limited availability also means that access will vary widely across the state. The Richmond-Henrico district is developing a system for eligible residents to express interest in the vaccines, but none of the aforementioned health departments are planning methods similar to those used in New York and D.C., where officials initially announced immunization appointments online, prompting a mad scramble for doses.
Dr. David Rose, director of the Alexandria Health Department, said randomly releasing appointment slots mostly benefited residents with the ability to monitor social media and quickly sign up online. Like the Richmond-Henrico district, the city department will likely partner with community organizations that already serve vulnerable groups, but that also means that vaccines will remain unavailable to the broader LGBTQ community for the time being.
Forlano said that’s appropriate, given that immunization against monkeypox isn’t routinely recommended and that transmission of the virus appears to be limited to select populations in Virginia. But some advocates are concerned that the state’s limited resources could be masking the extent of the outbreak.
Currently, local health districts aren’t offering public testing events for the virus, which can present with symptoms similar to those of other sexually transmitted infections, including a rash or lesions near the genitals. Testing requires collecting samples from affected areas, and some departments will coordinate with Virginia’s public health laboratory to test specimens if patients happen to visit their STI clinics and monkeypox is suspected based on their symptoms and clinical history.
But some districts, including Richmond-Henrico, are referring residents who specifically request monkeypox testing to private providers or federally qualified health centers. Long said the health department confirms its referred providers actually offer those services, but it’s not clear how many doctors in Virginia are currently comfortable evaluating or treating for monkeypox.
Like the rest of the country, other resources are also limited in Virginia, including the availability of TPOXX, an antiviral approved to treat smallpox that’s now being used with monkeypox as well. VDH has ordered 21 courses of the treatment, but prescribing it requires doctors to fill out what Rose described as an “onerous” series of paperwork for every patient.
“It makes it difficult for providers to be able to offer it,” he said. “And so we haven’t been providing treatment specifically, but we are looking at the process and haven’t taken anything off the table.”
While some patients across the country have experienced severe monkeypox symptoms, including painful genital lesions, there haven’t been any fatalities associated with the virus since the start of the U.S. outbreak. And while the virus can technically be spread through bedding or other items that have touched an infectious rash or bodily fluids, transmission has mostly been linked to prolonged physical contact, making monkeypox much different than COVID-19.
The last thing we want is for public officials to think, ‘This is isolated to certain members of our community and we’re not going to go there.’
– James Millner, director of Virginia Pride
Still, Millner said the state’s limited messaging and resources reminded him of the early days of the pandemic. And he also worried the shortage of treatment options, combined with fears of perpetuating stigma against the LGBTQ community, was leading health officials to downplay the risk of the virus.
“I don’t know that our community is being properly educated about what monkeypox is, and I don’t know folks are being educated as much as they could be that cases in the U.S. are predominantly among men who have sex with men,” he said.
“That’s not to say that monkeypox is a disease only of men who have sex with men — it just so happens that’s the population who appears at this moment to be most impacted,” Millner added. “But every state agency ought to be very clear about how it’s spread and what the risk factors are. The last thing we want is for public officials to think, ‘This is isolated to certain members of our community and we’re not going to go there.’”
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