In This Episode
A global monkeypox outbreak has infected over a thousand people worldwide. Monkeypox is nowhere as transmissible as COVID, but the choices our public health system makes now could shape how many people could be infected in the long term. Abdul interviews Prof. Anne Rimoin, an infectious disease expert, about monkeypox, what it is, why it’s spreading, and how we should be thinking about in the wake of COVID-19.
Dr. Abdul El-Sayed: The FDA appears on the verge of authorizing Novavax’s COVID vaccine, opening an alternative booster for most Americans. Also on vaccines, the White House has outlined a plan to vaccinate the youngest children, pending FDA approval for their vaccines. Is there a cure for rectal cancer? A new study showed 100% cancer removal for a new immune drug. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. It’s been more than two years since this happened:
[news clip] Stay at home. That is the order tonight from four state governors as the coronavirus pandemic spreads. New York, California, Illinois, and Connecticut all ordering non-essential employees to stay home.
Dr. Abdul El-Sayed: Since, we’ve been living through a global pandemic that’s claimed upwards of 15 million lives, a million of them right here in the U.S.. But the experience, the day-to-day of the pandemic was so much more than that. From wiping down individual boxes of cereal in those first few weeks, to getting really, really comfortable in sweatpants, living day-to-day through a pandemic has indelibly changed how we think about our world. For the millions of us who’ve lost loved ones, there’s no back to normal. At best, there’s an after the pandemic, and we’re not even quite there yet. That’s why this news is so frightening”
[news clip] Concerns are growing now over the potential spread of monkeypox here in the US. One case already confirmed in Massachusetts and now–
Dr. Abdul El-Sayed: And now another outbreak of a scary-sounding disease, even before we’ve gotten done with this one?! No. Please no. Monkeypox is a zoonotic viral illness that spreads most easily through direct contact, but also through aerosols from infected people. It spreads commonly in a number of animal host species, jumping into humans when there’s contact. First described in wild monkeys from Central Africa, it was given the name monkeypox, but it has a lot of similarities to a disease that has a long history in humans: variola, better known as smallpox. But before you flip out, monkeypox is both less severe and less transmissible than its cousin we eradicated decades ago. We’ll talk quite a bit about the virus that causes monkeypox with our guest today, but I want to take a second to talk about smallpox, because it’s one of the most important public health stories in history. So for centuries, smallpox wreaked havoc on people. There’s evidence that it infected Egyptian mummies, and it was written about by Chinese scribes as early as the fourth century. It decimated Native peoples of the Americas when it was brought over, deliberately used as a weapon of war by Europeans. But as early as the 16th century in China, the Ottoman Empire, and Sudan, people began to recognize that being exposed to harmless amounts of smallpox from other infected people who were recovering could protect people from the disease, should an outbreak occur. It was called variolation. There were various means, including snorting ground smallpox scabs–I know that sounds disgusting–from another person, or stabbing yourself with a knife that had been used to stab someone who was infected and recovered. Over time, that evolved into light scratching. Every scratch left a small, short-lived rash, which afterwards left the veriolized subject at lower risk for smallpox should an outbreak occur. This was the earliest precursor to vaccinations. People had observed for some time that milkmaids were generally immune to smallpox. Physician Edward Jenner postulated that exposure to pus from the udders of cowpox-infected cows, was the reason why. In the first known vaccination, he inoculated a nine-year old boy with pus from the blisters of a cowpox-infected milkmaid named Sarah Nelmes. He then tried to variolize the boy, which, if you remember, should leave a rash, but no rash developed. The boy was immunized. It was the first vaccination. Smallpox vaccines have changed a lot since then, but the smallpox vaccine has been probably the most effective vaccine in human history. And that’s because smallpox no longer exists outside a few highly-secure research labs. It was eradicated in 1980, just 21 years after the W.H.O. undertook a campaign to eradicate it. It was painstaking public health work, identifying every known contact of someone infected with smallpox, and then quickly forming a vaccination circle around them in a technique known as ring vaccination, encircling and ultimately eliminating smallpox transmission opportunities. This works because smallpox, like monkeypox, has a long incubation period–the time it takes for someone to develop symptoms and transmit the virus after they’re infected. That means that even after they’re exposed, you still have time to vaccinate them and prevent the infection from taking root. There’s no telling how many lives public health saved through smallpox eradication, but all of that requires a competent public health system, one that lets nobody slip through. It also requires public trust, that people are open, honest, and committed to protecting one another. Smallpox represents the power of a competent, capable, committed public health system, but in some respect, the eradication of smallpox may have set us up for a monkeypox outbreak. See, smallpox vaccines protect against monkeypox, too, just like cowpox. But since it was eradicated, we no longer vaccinate most people against smallpox. So population immunity against monkeypox has waned. The current outbreak has a long history. As far back as 2017 cases emerged in Nigeria, a place where monkeypox was rare before then. It’s been spreading in Nigeria ever since, and efforts by Nigerian public health officials to sound the alarm have largely gone unheeded. Monkeypox requires close contact to spread and this outbreak appears to have spread from two raves in Belgium and Spain, and has largely infected gay and bisexual men who had attended. But I want to be clear about something here: there’s a long and dangerous history of blaming communities for diseases that first emerge among them. Monkeypox can infect anyone, and so it’s critical not to stigmatize certain communities, as we stupidly did during the HIV-AIDS pandemic. It doesn’t help, and it contributes to the kind of stigma that we talked about last week with Heather Zayde. We’re now at a critical point in the outbreak. There have been more than 1,200 cases across 30 countries worldwide, including dozens of cases here in the US. But if you remember, viruses go, well, viral. And stopping this outbreak early is absolutely critical. Our guest today, Professor Anne Rimoin, is a professor of epidemiology at UCLA’s Fielding School of Public Health. She’s been studying monkeypox for two decades. I wanted to really understand what’s at stake with this outbreak, so I reached out to her for a conversation. Here’s Professor Anne Rimoin.
Dr. Abdul El-Sayed: Okay. Ready to go?
Prof. Anne Rimoin: You bet.
Dr. Abdul El-Sayed: Okay. Can you introduce yourself for the tape?
Prof. Anne Rimoin: Sure. My name is Anne Rimoin. I’m an infectious disease epidemiologist, professor of epidemiology at the UCLA Fielding School of Public Health.
Dr. Abdul El-Sayed: Professor Rimoin, really appreciate you taking the time to join us today. You are much sought after right now, considering the news, and you’ve been studying this virus for about two decades. And so before anybody knew there was a monkeypox, you’d been studying it. And just really grateful for you to take the time to chat with us and educate us about it. So let’s just jump right in. What is monkeypox?
Prof. Anne Rimoin: First of all, thank you for having me. I’m really happy to be here and to actually meet you in person as opposed to being on a split screen somewhere on some CNN late-night discussion about COVID. So now we get to talk about my favorite topic, monkeypox. Something I’ve been working on for–I’ve been working on this virus for two decades! So now people are finally interested in discussing it. I’m like, Oh, yeah, sure. I’m happy to talk about monkeypox. Finally, somebody is listening.
Dr. Abdul El-Sayed: Been there, done that. Just not, just not physically.
Prof. Anne Rimoin: So, right. Exactly. So, monkeypox is a zoonotic orthopox virus. It’s a cousin of smallpox. It was first discovered in 1958 in a colony of monkeys. And this happened at a point when they were testing polio vaccines, so they had, you know, had a lot of monkey colonies. And so it was the first time that they’d ever seen a pox-like illness in in monkeys. So that’s why I was named monkeypox. It was then first discovered in humans in 1970, in a boy in the Democratic Republic of Congo at the very end of the smallpox eradication campaign, because they were doing viral culture on any case of rash illness just to be able to determine exactly what it was, and as a result, they discovered that monkeypox actually infected humans.
Dr. Abdul El-Sayed: Hmm. And when you talk about zoonotic, you know, it’s one of those big words, and most folks recognize the zoo part, right, which has something to do with animals. Can you talk to us about what the characteristics of zoonotic diseases are, and maybe what makes them so hard to to get rid of?
Prof. Anne Rimoin: So a virus that’s zoonotic is a virus that actually resides in animals naturally. And it can spill over into humans when humans are in contact with these animals, but the natural reservoir isn’t necessarily humans.
Dr. Abdul El-Sayed: That’s really helpful. And the reason I ask right, is because oftentimes we sort of assume that the kinds of viruses or bacteria or parasites or even fungi that can infect us, only infect us. And oftentimes when you’re talking about this virus–obviously monkey is in the name–but even something like COVID, you have to appreciate that we are constantly sharing space and air and contact with a whole set of animals that are really quite similar to us, particularly when you talk about monkeys. And the implications of virus control can be really informed by that. So I want to ask, you know, what are the signs and symptoms of monkeypox, and how is it spread?
Prof. Anne Rimoin: Well, so the signs and symptoms of monkeypox depends upon if you’re talking about the West African clade, which is what people are really interested right now, because that’s what we’re seeing spreading globally. Or the Central African or Congo Basin clade, which is what I have traditionally worked on in Democratic Republic of Congo. Both diseases start with fever, malaise, fatigue. You can have headaches and flu-like symptoms, but then you end up with a very characteristic lymphadenopathy–so swollen lymph nodes–then a characteristic rash appears. Now this rash is often focused on the extremities, the hands, the feet, face, the genitals, but the West African clade, which appears to be milder than the Central African clade, has really recently been associated with a very limited clinical presentation, which really can sometimes only include a few pox marks. And so you can see why it would be very easy for somebody to just, to misdiagnosis this, or to ignore it, and that it could just potentially go unnoticed, which is probably what’s been happening. The Congo Basin clave tends to be, as we understand it, tends to be more severe, is associated with higher mortality, and generally speaking, a wider, or a much more extensive rash.
Dr. Abdul El-Sayed: That’s helpful to understand, right? Because all of the symptoms that you described associated with this Western African clade are pretty nonspecific, right? I mean, you can get that sort of traditional viral syndrome with the lymphadenopathy–I know that can be a big word for folks, so for listeners, it’s that feeling that when you have a cold or some sort of infection or if you have a really bad cold sore, when you turn your face and your face hits your shoulder, you feel like a pressure and a pain in your jawline, that’s lymphadenopathy. What that is, is a chain of lymph nodes that are filling up with blood cells that are going out to fight whatever infection that is, and because most infections start with your face, because your nose, your eyes and your mouth are there, you tend to feel it most in your face. But that’s pretty nonspecific, right? You can go with a cold sore. You can get with monkeypox.
Prof. Anne Rimoin: Absolutely.
Dr. Abdul El-Sayed: And then if you have a couple of pox, you could imagine, Well, I’ve got a couple of pimples, weird outbreak, I might just change my facial routine. I’ll be good. And so you can imagine how people are missing it.
Prof. Anne Rimoin: Well, exactly. And so a couple of just interesting points here. You know, the main difference between smallpox and monkeypox is that monkeypox really caused the swelling of the lymph nodes, whereas smallpox did not. So it’s this lymphadenopathy that we’re talking about is pretty interesting in that sense. So you end up with this rash, often in the way that we usually understand it is it usually starts on the face and then spreads to other parts of the body. But like I said, you know, we really understood now as we’re starting to really look for this virus that there is, you know, a real range in this clinical presentation, and only having a few pox could make it very difficult.
Dr. Abdul El-Sayed: How does monkeypox spread?
Prof. Anne Rimoin: So monkeypox, this is an important question, and, you know, it’s one of the million-dollar questions right now, but what we know about monkeypox in the context in which we know it, in rural sub-Saharan Africa and in peri-urban sub-Saharan Africa, is that it generally spreads, well, first, when a person comes in contact with, you know, either an infected animal, an infected person, or materials that are contaminated with the virus. It could be from an animal. It could be a bite or scratch or saliva or, you know, from hunting or butchering animals, or by use of products that have been made from infected animals. But when we’re talking about person-to-person contact, it’s generally really close, direct contact with body fluids or sores on the infected person, this rash, or with materials that have touched those fluids or sores, you know, clothing or linens or any, you know, towels, those kinds of things. And, of course, it certainly could be with respiratory droplets, face-to-face contact certainly, you know, it could certainly result in infection. Anything that really constitutes close contact. And that’s what we’re really seeing right now is the you know, it’s managed to make its way into populations outside of Africa, and is spreading very likely due to close contact.
Dr. Abdul El-Sayed: Is there a difference in the transmissibility depending upon what phase you’re in? So I know that it starts with that viral syndrome that we talked about with the nonspecific viral symptoms, and then it, you start to get the characteristic rash. Do you see more spread via aerosols early on with a movement to spread via bodily fluid, or is it pretty persistently spread via aerosols the entire time?
Prof. Anne Rimoin: Well, that’s a good question, and I actually don’t know the answer to that, and I’m not sure that that’s been well characterized. We do know that people are infectious, at least until the rash has scabbed over, the scabs fall off. Though it’s possible it could be for longer. I mean, I think that this goes along with one of the questions that we really need to get to, which is having a much better understanding of the, you know, the transmission dynamics of this virus, and understanding clinical presentation and how all of this, you know, works together. We don’t really know, could people be infectious in a pre-symptomatic phase or could they be asymptomatic and infectious? We we just we just don’t have enough data, because all of the studies that were done were done, you know, under very rural, remote conditions until the studies that were done in Nigeria. And those studies in Nigeria, you know, the Nigerian scientists have stated very clearly that they just have not had the funds to be able to truly do the kind of investigations that would shed light on this.
Dr. Abdul El-Sayed: Mm hmm. You know, it’s an important reminder. One of the topics that we talk a lot about in the show is the notion of the deep inequity in research funding for diseases that disproportionately affect low-income people and the global south. And, you know, this is an example of exactly why you should definitely care about the diseases that affect people who may not look like you or live in a place that you’re from, because at some point the world is extremely globalized, and at some point they could become the diseases that you suffer with. And the fact that we just don’t know enough is not a function of the fact that monkeypox hadn’t been around. It’s a function of the fact that, you know, folks in countries like ours haven’t been paying as much attention. I want to ask about treatments and preventives. Do we know how to treat monkeypox? Do we know how to treat it well? And then do we have a safe and effective vaccine?
Prof. Anne Rimoin: So, you know, there are no, so in terms of treatment, there are no treatments that have been approved specifically for monkeypox, but there are antivirals that have been developed for smallpox specifically. And those have been, I think that there’s a lot of evidence that suggests that they are beneficial to individuals who have monkeypox. I know, you know, there are some studies that were en route before this had started but have not yet been done. So the first one is tecovirimat, also known as TPOXX. And that’s an antiviral medication that actually has been approved by the FDA for treatment of small pox. You know, there’s also a compassionate use authorization for this for monkey pox during and outbreak. There’s also a Cidofovir, which is another antiviral medication that is actually for cytomegalovirus retinitis in patients who have AIDS. So that’s also something that’s that has been used. And then there’s also Vaccinia immune globulin, which has been used for complications due to Vaccinia vaccination. And that’s also something that could potentially be used. There’s also Brincidofovir, which is another antiviral med that was just recently licensed for use for smallpox. So, you know, so there are a number of things that are kind of, that are available and are certainly being used in the treatment of monkeypox now that we actually have cases that are, you know, in places where these things are available. So we’ll certainly learn about a lot more about how useful they are. You know, there are several vaccines that are specifically against, you know, created for smallpox, but the JYNNEOS vaccine, which is a two-dose vaccine, also has an indication for monkeypox. And then there’s the ACAM 2000, which is specifically for use for smallpox, but can be used for monkeypox as well.
Dr. Abdul El-Sayed: So it seems like there’s a lot of sort of general use antivirals that have some reactivity against monkeypox, most of them coming out of smallpox considering the clear similarities in the viruses. And then similarly with vaccines. Have these vaccines been used in communities where there have been persistent outbreaks, whether you’re talking about the Central African clade or the Western African clade?
Prof. Anne Rimoin: Well, there was a study in health workers in DRC for what’s the JYNNEOS vaccine now, which was, appeared to be pretty effective. And certainly right now, I think that there are many places that are employing ring vaccination and vaccination of contacts, which is really terrific. I mean, it’s exactly what you want to see happening, is that they’re actually employing the tools that exist. And, you know, these vaccines are good not only for preventing disease as pre-exposure prophylaxis, but also as post-exposure prophylaxis– we think that they will very, you know, potentially avert infection or at least be able to reduce the severity of infection.
Dr. Abdul El-Sayed: Yeah. And that’s important to understand. There’s a long window within which the virus has to take hold to make home in your body before it actually causes disease, and so that does offer an opportunity for us to get in there with a vaccine that can be effective even after someone’s exposed. And we talked a little bit about ring vaccination in the way that it was leveraged to eradicate smallpox earlier in the episode, but the idea that it’s being used against monkeypox now makes a lot of sense. Interestingly, right, listeners will have obviously the contra positive of COVID in their minds–this is what we’ve just come through–and there are some important differences between COVID and monkeypox, right? One of them is that you do have this much longer incubation period that gives you opportunities to target vaccines in ways that you can’t really with COVID. And then the second is that monkeypox is not nearly as transmissible as COVID. And I want to ask you, now–we talked about the million-dollar question, this is the $10 million question–is there going to be a monkeypox pandemic?
Prof. Anne Rimoin: Well, I mean, you know, we have some choices here, as you know, are we going to get in front of this or are we not? And, you know, because we have the tools to be able to do that, but it’s really going to take a serious, concerted effort. You really can’t compare COVID-19 and monkeypox. You know, SARS-CoV-2 is one of the most infectious viruses known to man, and monkeypox is just doesn’t have that same capacity to infect as well. It really does require, as we understand it, very close contact as the most standard way that it’s going to transmit. You know, the stakes are high with monkeypox for a variety of reasons, but they’re different than they are for SARS-CoV-2. So, you know, the things that worry me about monkeypox is that if we don’t get in front of this now, we’re going to end up, you know, potentially with a with a pox virus that will be circulating in humans. And we know when we give these viruses opportunity to to spread, you know, eventually even a virus that’s stable is something like monkeypox, you know, we could see adaptation and improved fitness, and so we really do want to avoid that. And particularly if we start seeing it spread in populations that are immuno-compromised. You know, we’ve talked about this with SARS-CoV-2 on numerous occasions, that you give this virus an opportunity to spread to another person, and the more people it spreads to, the more opportunity it has to replicate. And if it can replicate, that eventually, you could end up with a constellation of mutations that are advantageous to the virus, but not to humans. And so I think it’s, you know, I think that that’s a real concern that we could see that happen. And even if we just see the virus established in human populations and circulating at a low level, you know, sooner or later you’re going to end up, you’re edging closer and closer to seeing some sort of zoonotic spill back effect. And, you know, I’ve said this before and I’ll, you know, I think that that outbreak in 2003 was really an important warning sign, because what happened was, it was Gambian pouched rats that were put next to prairie dogs. The prairie dogs, the Gambian rats were infected with monkeypox. They infected the prairie dogs. And then the prairie dogs ultimately went on to infect humans. And, you know, that just demonstrates how, you know, this is a virus that has a wide host range. You know, monkeypox is a rodent virus, it’s not a–primates are incidental hosts, humans, you know, non-human primates and human primates are incidental hosts, really, as we understand monkeypox–and so I think that the problem of a reverse zoonotic spillover is real. And we’ve seen this with SARS-CoV-2. I mean, we’ve seen it with the white tailed deer. We’ve seen it with mink farms, you know? And that’s where you get into this–you know, you talked about this at the beginning where you were just trying to, you know, you were talking about zoonosis and the fact that this, you know, kind of a concept of one health, which is that everything is interrelated–and that’s just really true, and something that we have to consider that the, you know, that we are all part of this ecologic landscape. And if this virus is able to become endemic in a wildlife species outside of Africa, you know, that really is problematic, and we’ll have to really reconsider how important it is for us to keep a pox virus at bay. And if we decide we are determined to do so, we may have to reconsider vaccination strategies to keep this virus under control. But once it’s in animal reservoirs, it’s very, very difficult to control.
Dr. Abdul El-Sayed: Yeah. And just for folks who may not have followed the logic, right, we know that this is a virus that lives in rodents in sub-Saharan Africa. It incidentally, falls into humans. Humans infect other humans. They travel around the globe, they infect other rodents in places where there wasn’t previously the virus, and now all of a sudden, it’s infecting all of those rodents. So, you know, the prairie dog example is a good one. Or you could imagine a situation where someone lives in a small, cramped New York City apartment that’s infected with rats. The rats pick up monkeypox, and soon enough, it’s endemic in rats in New York. And every time someone comes in contact with a rat, there’s a risk of reinfection of a human, and now, all of a sudden, you’re going from a outbreak to new endemnicity, which means that it’s just normal. It’s part of baseline. It’s one of those diseases that just infects this population simply because. And that brings us to the question of this particular outbreak and the public health response. And I’d love if you could give us a sense of what is causing, or what has caused this particular outbreak, what is driving it? Why are we just hearing about monkeypox now? And then, your sense of the public health response and what we need to overcome the, you know, never scenario that you just laid out?
Prof. Anne Rimoin: Well, so here what’s happened is, is that we’ve been seeing rising cases of monkeypox for, you know, for decades. We documented that in 2010. My research team and my colleagues in DRC together, we really documented a 20-fold rise in the incidence monkeypox since the cessation of smallpox vaccine, which at that point had been 30 years. We were very concerned about this, this increase, because we we saw that it was much more than had been anticipated, and based on the early models of of monkeypox. Important to remember that those early models were based on the studies done in the early ’80s, from ’81 to ’86. There were studies done in the DRC really after the eradication of smallpox truly to understand, you know, whether or not this virus was something we needed to worry about. After the disease surveillance that they did there, there were like really 338 cases, and, you know, but the thing is, this virus really didn’t have anywhere to go. Right? It was, most households if they stopped vaccinating in DRC in 1982 when they were studying it from 1981 to 1986, you know, most households were almost all vaccinated except for very small children. So our understanding of this virus is really predicated at that time period, the R-0, you know, all of the issues related to transmissibility, clinical presentation–you know, all of those things were based on those really seminal, important studies, but, you know, it was a long time ago and a very different epidemiologic and ecologic landscape, and do–
Dr. Abdul El-Sayed: And just to interrupt there for a second, and that’s because that was a time when smallpox vaccines were common. And we talked earlier about what the preventive was: these are all vaccines against smallpox. And so if we’re vaccinating people against smallpox, we were also vaccinating them inadvertently against monkeypox, which was reducing the spread of monkeypox at the time. So all of our baseline models are almost tainted by the fact that that was a time and a place where everybody was assumed to have some immune response to monkeypox. And now we live in a time where that’s not the case. I wasn’t vaccinated for smallpox. I don’t know if you are, but very few people are vaccinated for smallpox unless you work in very particular settings. And that means that we’re all pretty immuno-naive.
Prof. Anne Rimoin: Right. Well, I was vaccinated when I started working on monkeypox because I was born–
Dr. Abdul El-Sayed: That’s make sense.
Prof. Anne Rimoin: Yeah, I was born right at the time when they stopped vaccinating. So I was like right on that cusp. And so I missed it only by a few months here in the United States. So I, got vaccinated when I started working on monkeypox. But, yeah, no, I mean, the issue is, is that we just, you know, we have waning population immunity, and probably some level of individual immunity as well. But really, this waning population immunity is what’s really tipped the scales here. I think we’ve just kind of reached a threshold at which we now have you know, the vast majority of people are naive to this virus, or other pox viruses. And that’s why over the last several years, we’ve seen other pox viruses spread as well. We’ve seen camel pox. We’ve seen a rodent pox in Alaska. We’ve seen ecrtomelia virus, which is mouse pox in Europe. Vaccinia in Brazil. You know, so we’ve seen, more and more we’ve seen these spillover events that have occurred just because, you know, we don’t have that baseline herd immunity from smallpox vaccine when that was part of routine immunization. So, yes. So those models are definitely, you know, they are certainly not reflective of the kind of immunity that’s in the community today. And, you know, if you think about household studies and how important those kind of household studies are now, now most of the people in a household will have no immunity to a pox virus, whereas back then, you know, only the very small children had any kind of, you know, real significant susceptibility to it. And I think that that’s what’s really changed. And that’s why I always say, you know, we have to be careful. You know, we know something about this virus, it’s not that w don’t know anything about it. It’s just we don’t know, we don’t really understand the virus in its new modern context, and that’s what we, you know, we really need to spend time understanding. You know, this this pandemic has certainly taught us to be humble about what we know, what we don’t know, and modest in our claims of certainty about how a virus is going to act. And I think that this is a perfect example of that. That, you know, we certainly know–it’s not that we’re starting out with zero knowledge, it’s just now we have to move quickly to understand this in a new context.
Dr. Abdul El-Sayed: And I want to ask you, how do you feel about the state of the response, especially considering the fact that we’re on the heels of the worst pandemic in any of our lifetimes?
Prof. Anne Rimoin: Well, you know, I think it’s, we have a very fragile and exhausted health system in place, but at the same time, I think we’ve learned a lot about surveillance, contact, you know, case investigations, contact tracing–the public is much more familiar with these terms. So, you know, on the flip side, I think that people have a much greater understanding of what this is. So there has to be some benefit to that as well. I think that having gone through what we went through with diagnostics and, you know, having adequate case, you know, case definitions, and having the right information out there, you know, being worried about not having the right information out there–I think we’ve learned from that. So but, you know, monkeypox is complicated. I mean, this is a virus that we don’t have, we don’t have great diagnostics for, you know? But there are orthopox assays that can be used–so kind of looking at the bigger family–and then doing a more, sending it off to have a more specific test to determine, Okay, we see that there’s orthopox here, it’s likely going to be monkeypox, now, we need to look a little further to see if this is actually monkeypox to confirm that. But, you know, we need to be able to plus up our diagnostic capacity. We need to look at rapid diagnostics because now we’re thinking about this as like a sexually-transmitted infection as well. And being able to get those diagnostics to providers is going to be really important. Also for providers really being able to recognize what the signs and symptoms are, and to be able to recognize this kind of characteristic rash, and have the general public be able to understand it. You know, I mean, these are all key points in a response to an outbreak of a, you know, reasonably novel pathogen–novel, at least in in a new setting. So what I would say is that we are better placed today than we were back at the beginning of 2020, but, you know, of course, we can always do better. And, of course, you know, there are always things that we need to improve upon. So I think the sooner we can really get, you know, we can plus-up diagnostics, get really good clinical materials out there so the clinicians can diagnosis quickly and to raise awareness in communities, the more situational awareness we’ll have. And once we have some of the situational awareness, I think it’s going to be a lot easier. Just right now, don’t we don’t really understand where we are in all of this. I, you know–I’ve said this before, I’ll say it again here–this is very similar to, you know, we’re tuning into a new TV series, you know, we kind of know what it’s about, but we don’t know what episode we landed on. It is Episode 2, is it Episode 5, Episode 10? Is t Season 2 or 3? You know, what did we miss? Where’s the origin story? You know, we really, I think we need to do some really good, solid epidemiologic investigations, you know, paired with the molecular epidemiology and the sequencing to really get a sense of how many introductions have there been, you know, is this something that has been spreading for a while, are we seeing changes and what kind of changes are we seeing, as we see these kinds of serial chains of transmission–which, you know, we’ve only seen in limited, limited terms in sub-Saharan Africa, but here, you know, we just may see much longer chains of transmission. So things that we just have to keep an eye out for. So, you know, I think it’s a lot to do in a short period of time. On the one hand, everybody’s tired, but on the other hand, everybody knows what to do a lot better than they did before.
Dr. Abdul El-Sayed: I appreciate that. As folks listening out there are thinking about this, how should they be processing the news, and, you know, what level of concern should they be holding?
Prof. Anne Rimoin: That’s a lot of questions, how to process the news!
Dr. Abdul El-Sayed: Yeah, there are a lot of other things in America that will kill you before monkeypox, unfortunately.
Prof. Anne Rimoin: But news about monkeypox is a different story here. I know we’ve all been really inundated with really some bad and sad news over the last couple of years here. And, so how do they need to process monkeypox? Well, you know, I think that this is a situation where this is, you know, we’ve been hitting a snooze button on this alarm for many years. I mean, we’ve known that this is a virus that is, you know, potentially a problem, not just from a practical perspective, but kind of an existential perspective of what’s going to happen with vaccination, and are we going to have to really think about it completely, you know–start starting to think about bringing back smallpox or, you know, pox virus vaccinations. You know, this is an important warning moment that an infection anywhere is potentially an infection everywhere, and that we have to care about–even for people who don’t want to care about it. I mean, you and I care a lot about what’s happening globally, but some people say, Well, but, you know, we have to worry about what’s going on here, we don’t have time to worry about what’s going on in other places. But we have to. And, you know, they’re really wonderful, talented, extremely skilled researchers in places like DRC and Nigeria, that if they had the resources to be able to study these viruses, you know, we’d be so much further along–and frankly, we would have been able to to stop this more likely at the source, instead of worrying about this kind of international spread. So I think that overall, you know, how should somebody process this? Well, you know, you should, if you’re in a high-risk group, if you’re somebody that is potentially going to be in contact with or has been in contact with somebody who may have been exposed to monkeypox or has monkeypox, you know that’s certainly something to worry about. Of course, infections never stay in one population. They’re all, you know, we all live together. We don’t live in vacuums. So, you know, eventually we’ll have to worry about this in one way or another. The extent of that, you know, we just don’t know at this point. It’s not something that is, you know, we’ve never seen a death in, you know, associated with monkeypox outside of Africa. So I think, you know, there’s, you know, there’s no, this isn’t a panic situation in terms of what we’re seeing on that level. But, you know, we should all be concerned because this, you know, has big implications for what happens in the long term. So that’s really how I would process it, is it’s important. It’s something we need to get under control. It’s, you know, potentially has larger implications than just whether or not somebody gets infected. And that if we don’t finally get in front of these viruses, and do the kind of surveillance and have that kind of situational awareness, we’re constantly going to be paying that price. I mean, it’s a, you know, it’s a “pay now or pay later” scenario, and we keep wanting to pay later, but, you know, it’s much more expensive on that on that later and then on the early end.
Dr. Abdul El-Sayed: That’s really helpful. So what I’m hearing is if you’re a public health professional or a physician or nurse out there, pay attention. For everyone else, this is one of those things that’s not imminently of worry to you now, but, you know, we all got to do what we can to advocate for a more robust investment in public health, both at home and abroad. Professor Rimoin, really appreciate you taking the time to educate us today, and to join us. Thank you.
Prof. Anne Rimoin: Oh, it’s my pleasure.
Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. A team of advisers to the FDA have recommended that the agency authorize a new vaccine for COVID. You might be wondering, it’s been two years since the pandemic even started! More than a year since we’ve had a safe and effective vaccine. The FDA has recommended three or four doses for everyone but the youngest kids. Why do we need another vaccine again? Well, there are three reasons. First, this vaccine is a more traditional vaccine. It uses COVID proteins to cue an immune response, rather than mRNA that encodes those proteins in the first place. While I doubt that there are many people who are still resisting vaccination for whom this particular molecular biology might change their minds, having more approaches and more vaccines just might. But maybe more importantly, the vaccine supply has been limited to mainly two companies in the US, and I think more entrance to the vaccine market will be helpful, both for the supply, should we need more, and to quell fears that there’s some sort of collusion between the manufacturers. Finally, there’s a good immunological argument for diversifying your vaccines. And should we need more boosters, having more ways in will be helpful. In good news for the parents under five, the White House has outlined a plan to rush vaccines out to our kids once the FDA approves them. Look, I’m the father of a four-year old who had COVID, but given the pace of change of this virus, I know that my kid could still get sick again. And that’s why I’m going to make sure she gets vaccinated as soon as we can. Finally, you may have heard these headlines this week:
[news clip] The tumors are gone–with no chemo, radiation, no surgery. 14 patients with advanced rectal cancer are in remission after taking the same drug. It’s a small trial, but so far it had a 100% success rate.
Dr. Abdul El-Sayed: All 14 patients enrolled in a study of this new drug, dostarlimab, had a complete response, with no residual evidence of cancer on MRI, and no serious side effects. To be sure, this kind of perfect response is unheard of. It almost never happens. Importantly, the drug, dostarlimab, inhibits a receptor on immune cells that stops them from attacking cancer cells. So by turning off the off-switch, they turn on the body’s own cancer fighting abilities. So is this the cure for cancer? Well, cancer is complex, and there are many different kinds of cancers, and many different pathways to cancer–but it may be a cure for a particular kind of rectal cancer, and it will certainly improve our understanding of cancer biology in an important way, opening the way for yet more breakthroughs.
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