�ǿմ�ý

Interviewer: Ever since the first case of monkeypox was first identified in the U.S. in May of 2022, there's been concern about the virus and its potential to spread. With newsfeeds featuring images of patients with rashes and lesions, as well as the news that by August, monkeypox has been seen in nearly every U.S. state, it leaves some to wonder if this could be another pandemic.

We spoke with two virologists from University of Utah �ǿմ�ý to get their professional opinion to better understand the virus, how it spreads, and perhaps most importantly, how to protect yourself.

Dr. Sankar Swaminathan is a professor and the chief of the Division of Infectious Diseases at University of Utah �ǿմ�ý. Dr. Adam Spivak is a researcher and physician with the Infectious Disease Clinic.

Dr. Swaminathan, let's start with the basics. What is monkeypox, and how does it impact the body?

Dr. Swaminathan: It's a viral infection caused by a virus that is related to smallpox and causes lesions or sores on the body, and really can be any part of the skin or mucus membranes. That's the inside of the mouth and the genitals. So that's the primary symptom that people have. It can also cause fever and swollen lymph nodes.

The type of lesion can be quite variable, but generally speaking, they start out as bumps, papules, and they can have a little indentation or dimple in the center of that papule. They can become pus-filled, and eventually, they scab over and they fall off, and they can leave a scar. They're fairly deep-seated, so they can be quite painful. And especially if they're in the mouth or genitals or the rectum, these places obviously can cause a lot of pain.

Interviewer: Now, where exactly did the disease come from? I've never heard of monkeypox before until just a month or two ago.

Dr. Swaminathan: It's been recognized in Africa, in various parts of Africa for quite a while, for decades in fact, and there's been very little spread outside of local populations.

Interviewer: And why are we seeing it now?

Dr. Swaminathan: That's a very good question, and I think a lot of people are trying to answer that. Like I said, we haven't seen this sort of person-to-person transmission, particularly in Western Europe, and in the U.S., and other parts of the world, and now it's become essentially a worldwide problem. The WHO has declared it to be such.

And I primarily think it's just found a niche in people who have close contact, particularly sexual contact, and it's spreading in a way that it might not have been spreading before. It doesn't necessarily mean that the virus has changed, although I think that remains to be determined, whether there've been any changes in the virus that's making it behave in a new way.

Interviewer: And speaking of that, when the World �ǿմ�ý Organization declared it an emergency, what are these different groups so concerned about with this particular disease, with its spread, etc.?

Dr. Swaminathan: We realized that there's potential for widespread transmission. And how widespread it's going to be or can be, I think, still remains to be determined, but there's enough of a risk that the WHO has alerted everybody to this.

I think it's compounded by several factors. One is I think our capabilities in terms of testing, vaccination, and treatment have all been somewhat limited, which has allowed the disease to spread pretty rapidly in some areas like New York, and I think the concern is that this could happen elsewhere.

Interviewer: So why don't we move on a little bit to talking about how to identify this disease? So we've talked a little bit about that it looks like a lesion, but some of the things I've been seeing online is it looks like an ingrown hair, or it can be really hard to spot. For someone who is concerned or wants to know whether or not they might have monkeypox, what exactly are they going to be looking for before they go and get help?

Dr. Swaminathan: First I think is how likely it is that they've been exposed. It's people who have been in situations, parties, or group encounters, or raves, or whatever, where they are in contact with a lot of different people, so that's the risk factor.

And if you have had recent intimate contact with somebody, and you don't know exactly what their recent contacts have been as well, it's possible that they may have transmitted it to you without your realizing it.

And like you said, some of the especially initial manifestations may not be particularly alarming or severe, so that transmission could occur even though people aren't aware that they are infected.

Interviewer: Do the lesions change over time, how it expresses itself on the skin?

Dr. Swaminathan: Yeah, they usually progress or evolve. Like I said, they'll start out as a bump and then can become more liquid-filled, pus-filled, can become more painful, and they can break down so that they form an open sore. But eventually, they will scab and fall over. And this can take a couple of weeks or more for it to be fully cleared, and for the person then to not be infectious.

Interviewer: So these particular lesions are . . . like you were saying, they're full of the virus. That's a major infection vector, is the lesions themselves?

Dr. Swaminathan: Correct.

Interviewer: Okay. Are there any other vectors for this particular disease?

Dr. Swaminathan: Certainly other intimate contact like kissing and so on could spread it, but mostly it's skin-to-skin close contact. It can be spread by infected or contaminated clothing, bed sheets, towels, things like that. So any time people are living together in the same household, there's a possibility for transmission even if they're not having intimate contact with each other.

And also, we think that droplets . . . This doesn't seem to be a primary means of spread, but droplets from person-to-person who are sitting in close enough proximity that coughing, sneezing, even a lot of talking could potentially have airborne spread in that manner through respiratory droplets.

Interviewer: Now, does the disease impact anything other than the skin, or is it just a lesion-based kind of virus?

Dr. Swaminathan: Like I said, the other systemic manifestations as we call them are that you can have fever, and swollen lymph nodes, and fatigue. There haven't been any deaths in the U.S. that we know of from this, but it can be quite a severe illness in terms of . . . Usually, there's actually spontaneous recovery, but can lead to fairly severe symptoms that would make somebody not want to get up and leave their bedroom.

Interviewer: Would it require people to get hospitalized for any reason?

Dr. Swaminathan: It could, but generally speaking, we haven't seen that. Hospitalization might be required for severe intractable pain, or inability to swallow, eat, getting dehydrated, or secondary infection, an infection on top of the lesions with a regular bacterial infection, for example. Those would be unusual, but possible reasons why people would have complications and require hospitalization.

Interviewer: So how does someone keep themselves safe from monkeypox?

Dr. Swaminathan: So I think avoiding those types of encounters as much as possible is really almost the only way to protect oneself. Having multiple sexual partners and not knowing very much about what their risk has been, what are their habits, and so on.

Interviewer: In my research, I have been finding some really strange ways to protect oneself. We've had people being like, "I know it's hot in the summer, but just wear a long sleeve t-shirt, and you'll be just fine." I've seen, "Put Carmex on your lesions, and you'll be able to prevent the virus from passing to another person." Are there any known ways to prevent the spread of this disease? And is there any merit to any of these?

Dr. Swaminathan: So I think that you can take precautions if somebody in the household is known to be infected. And I think it would be straightforward, even if it wasn't easy, to make sure that there are no shared utensils, and no shared bedclothes, towels, and all that kind of thing, and that those were properly sterilized in the wash and dryer.

However, as we said, because it's not just from the act of having sex, that intimate contact would be hard to prevent with barrier methods. You'd essentially have to encase yourself from head to foot to prevent skin-to-skin transmission. And once you have lesions, there's no question that you should seek medical attention, and you should isolate. Because until those scabs are all gone, you're going to be potentially infectious, and you should really not have any type of skin-to-skin contact with other people.

Interviewer: So if someone does contract monkeypox, if they see those lesions, what is the first thing that they should do?

Dr. Swaminathan: I think if there's a concern that there's monkeypox, they can get tested. And we have started testing here at ARUP. We can generally get tests back in two to three days, and maybe sooner. And hopefully, we can keep up with the demand because I have a feeling that demand is going to continue to increase. But it's very good that ARUP . . . There are many labs that have now been approved to do this kind of testing, and we're not just depending on one or two centralized state or CDC labs.

Interviewer: So Step 1, if you think you've got something, go get tested. If that test comes back positive, what's the next step?

Dr. Swaminathan: Like we said, prevent yourself from giving it to other people. So you would need to isolate and take the precautions, which you can get detailed instructions from a healthcare provider.

And there is an oral treatment, which is approved for smallpox but is not officially approved for monkeypox because it really hasn't been tested in clinical trials against monkeypox, but we think it would work. It works in animals against monkeypox, and it certainly works in the laboratory, and it's a similar virus. So this drug called Tecovirimat, or TPOXX, should work, but it's only approved and can only be given under strict regulations.

So we're restricted in who we can give it to, and it's basically for people who have severe disease. There are various definitions for that, but it has to be severe disease, not just mild, a few skin lesions. And also for people who are at high risk, so people who are immunocompromised, whose immune system is weak, whether it's from cancer, or an organ transplant, or advanced HIV infection, or other immune deficiencies. So those people would be eligible for being treated, and we can treat them if we think that they have monkeypox, or we know that they have monkeypox.

Interviewer: But for most people, the treatment is not necessarily approved for everybody that gets monkeypox?

Dr. Swaminathan: Correct.

Interviewer: So quarantine, what does that look like in a household? Are you closing yourself off in a single bedroom?

Dr. Swaminathan: That would be the easiest way to do it, but that doesn't mean you can't come out of your bedroom. You should probably not share the same furniture as other people until you are over your period of isolation.

Interviewer: And how long is that period?

Dr. Swaminathan: Three weeks or so. All the lesions have to have been essentially healed over.

Interviewer: And how long after they've all been healed over are you good to go?

Dr. Swaminathan: Once all the lesions are healed, you shouldn't be infectious any further.

Interviewer: Is there any potential long-term consequences for a monkeypox infection?

Dr. Swaminathan: Not that I know of, but again, we're somewhat in uncharted territory. But generally speaking, recovery is thought to be complete.

Interviewer: So not super life-threatening, but you might be left with some scars?

Dr. Swaminathan: Yes.

Interviewer: Severe scars? Mild scars?

Dr. Swaminathan: Again, it depends on the number and location of the lesions.

Interviewer: So let's talk a little bit about vaccination. Is there a vaccine available for monkeypox?

Dr. Swaminathan: Yes. So the one that's currently being given is a vaccine that is based on the same virus that's used to vaccinate against smallpox. We don't routinely use that live form of vaccinia of smallpox vaccine because we've stopped vaccinating people against smallpox since the '70s. That vaccine is available and is thought to protect against monkeypox as well, but the incidence of complications with that vaccine is high enough that that older smallpox vaccine is not being used for monkeypox.

What we have is a newer vaccine that's made with a weakened or attenuated form of vaccinia that can't replicate, but it can stimulate the body to make an immune response against smallpox, and monkeypox, and so on. And that is effective both in animals that are challenged with monkeypox as well as in the laboratory. So that's the vaccine that we can give, but it is in somewhat limited supply currently. And like I said, we prioritize people who are at highest risk for it.

Interviewer: Now, speaking to you, Dr. Spivak, one of the first questions I'd like to ask you just to get it out of the way, with your experience researching viruses and treating HIV, is monkeypox a gay disease?

Dr. Spivak: Nope. It's a human disease. I don't know that there is such a thing, certainly not in virology, not in medicine, and not in existence in the world that I'm aware of such a thing as a gay disease.

And by way of background, I'm a physician caring for people living with HIV, very interested in preventing HIV, and I study HIV in the laboratory. Certainly, there's some background to my answer there, as, of course, HIV as a predecessor to this one, this latest outbreak of monkeypox, was often labeled a gay disease.

And just to elaborate a little bit because that, of course, sounds purely like opinion, the number one risk factor for acquisition of human immunodeficiency virus worldwide is heterosexual sex.

Interviewer: Heterosexual sex, really?

Dr. Spivak: Yep. So there are about 75 million people worldwide that have ever acquired HIV infection. Approximately half of them have died of the disease in the last 40 years since we first discovered it. So there's somewhere around 35 million people living today on Earth with HIV. And again, the majority of those folks acquired this disease sexually through heterosexual sex between men and women.

There's a fairly complex and really fascinating story about why HIV is prevalent among gay men, among men who have sex with men, and transgender women in Europe and in the United States. And that has to do with the transmission of the virus as it evolved, as the epidemic spread, where it first originated in West Africa, out to Haiti, and out to the Western world through sex, but also through blood products.

It's a complex story, but in any case, there are some pretty well delineated and well-understood reasons why HIV is more prevalent among men who have sex with men, again, in the United States and Europe. And that, of course, did give rise to this false notion that this was a gay disease, that heterosexual individuals were not susceptible, that this was somehow something that could be attributed to a man having sex with a man, which is entirely untrue.

And I think that the way I try to summarize that for medical students is to say that the disease actually . . . In the case of HIV, of course, it can also be transmitted through injection drug use, but by and large, we consider it a sexually transmitted disease, and that means humans having sex. The disease does not tend to discriminate, but people do.

Interviewer: And so while we are seeing more cases currently in the U.S. among men who have sex with men, that does not mean that this disease is any . . . there's not anything about the disease that specifically impacts one orientation over the other.

Dr. Spivak: No. There is zero evidence of that being the case. It does appear to be disproportionately affecting gay men at present, but the best we understand . . . And again, I think it's worth pointing out that there are a lot of unknowns here, and I certainly would not ever claim to sit here and have all the answers. In any case, the best science now seems to indicate that this virus spreads through skin-to-skin contact. And that is to say contact with your skin against the lesion on someone else's skin. Sex is a fantastic opportunity for skin to meet skin.

I don't think we really have a good answer as to why it is occurring predominantly among men who have sex with men, but as far as we know right now, there is absolutely no reason to think that this could not be spread from any type of skin contact, again, healthy skin touching against skin where there is a lesion. And we all have skin.

Interviewer: So, with that in mind, is this technically a sexually transmitted disease, or sex just happens to be a place where skin-to-skin happens?

Dr. Spivak: Yeah, I think it's a really terrific question because certainly, the biological mechanisms are exactly as you said, that sex is a great opportunity for skin to be vigorously rubbing against skin, and so a great opportunity for the disease to spread. But that's not the only way that we come into contact skin against skin.

When we call something an STD or sexually transmitted disease, that obviously implies a specific route of transmission. I think this could be categorized as an STD. There are also implications for that, around calling something an STD, because of our morals and our discomfort, I think, in our society about talking frankly about sex. That, I think, has given a lot of people in medicine pause about calling this an STD.

And I think we're trying to be sensitive to the fact that there were lessons to be learned, and there are lessons to be learned about HIV. And as I shared with you, sort of a common misconception 40 years into an epidemic that frankly should be controlled, but isn't . . . and I'm talking about HIV . . . there's still this perception that this is a gay disease. As I shared with you, that's just not born out by facts. There's nothing about this virus that indicates that it has any predilection for gay men at all.

Interviewer: So circling back to the state that we're in right now with monkeypox, we see the news every day, it's on the rise, it's scary, it leaves scars, we've done pieces about how it's transmitted, etc., but are there any steps that someone can take to make sure to protect themselves from potentially getting infected?

Dr. Spivak: Yeah, that's a great question. And the answer in some respects is similar to what we've learned, unfortunately, the hard way with COVID, though you could argue the glass is half full there, and I'm getting at vaccines. We have a vaccine against monkeypox, which is pretty remarkable that we actually had the vaccine present before the outbreak. And again, that's the glass half full.

The glass half empty is there's not a lot, not enough to go around. We don't have it here yet. That's largely because the supply is limited, but the Department of �ǿմ�ý to their credit acquired vaccine from the federal government and tried to disperse it quickly. The Utah AIDS Foundation led by Ahmer Afroz has done a phenomenal job at getting information out and actually getting vaccine and distributing it.

I think we have a long way to go there, meaning that a lot more folks probably should be vaccinated. And frankly, anyone who wants to be, thinks they may be at risk, should be vaccinated. I don't think at this point, and we're in mid-August of 2022, that we have enough vaccine to go around. And so there have been decisions made about who gets priority, which is unfortunate from a public health standpoint because this is going to allow the disease to spread.

It is a disease that's spread skin-to-skin and spread by touching or coming in contact with these lesions, and so what that means is beyond vaccines, which are preventive, if you think you may have this, you should come and get checked out. We have a great diagnostic test.

And ARUP has been at the forefront. They're a phenomenal lab. They're an international leader, and they came out in end of July with their own monkeypox PCR test. Our clinic managers, and the urgent care staff, and people in the ERs, and people in our primary care clinics have rapidly become aware that this is out there. We're seeing more cases because people are coming in, and then physicians, and physician associates, and APCs are recognizing it. And clinic managers, and nurses, and clinic staff are taking the right maneuvers to sample the virus, meaning there are collection procedures that have to be put in place.

All this happened very quickly, and I think COVID did teach our health system how to be a little more quick to respond. And so that's been really encouraging. Working together, we can recognize this. Led by Jeannie Mayer, a hospital epidemiologist here, we can really as a system start to adapt to a new disease. So that's all encouraging.

I would say that people need to be aware that it's out there. They need to come in and get checked. We have a great test, and we actually have a great treatment. I could keep going on and on, but I'll stop there.

Interviewer: There seems to be a lot of fear out there right now, especially with limited supplies of vaccines, etc. Do you think that fear is founded?

Dr. Spivak: I do. Yeah, I do. It's scary. I've cared for a few individuals with monkeypox, and I'd say one thing. Again, I tend to be a glass-half-full, optimist-type person. It's not COVID. And what I mean by that is people are recovering. We have, to my knowledge, yet to have a monkeypox fatality, and yet it is symptomatic. People experience a lot of pain with it.

I think, obviously, it's to be avoided, but it's not quite in the same ballpark, I think, when we talk about in the intensive care units across the country where there was no vaccine, no treatment, and it was spreading like wildfire. We're really not in that situation.

But on the other hand, as I shared earlier, there are a lot of unknowns here. Maybe this is a mild strain, and we're going to see it get worse, or who knows what. But I don't think so. I think this is going to be a little bit milder.

I think the fear is justified because our public health measures aren't enough. We don't have enough vaccine, and we should be vaccinating everybody that wants a vaccine. We don't have quite enough of this therapeutic medicine to go around. It's a bit of a headache bureaucratically to get it, though I'll say that is part of my job, and we'll do it, jump through the paperwork hoops. That's fine.

The first patient I've treated with this drug called Tecovirimat, which is specifically . . . It's not FDA approved, but they have what's called an investigational new drug application, and that allows us to give it for this indication. The very first patient I've used the drug for had a really exciting turnaround in his symptoms, severe pain, and rash, and within about 48 hours, he got better. Now, that is what we call in science an N-of-1, but no side effects and a great recovery. Obviously, we have a lot more to learn, but that's encouraging.