When a New Health Threat Emerges: The Public Health Response to Mpox

Source: County of Santa Clara Public Health Department (July 2022)

Gabriél sits on the examination table at the clinic, the white tissue paper crinkling underneath him, waiting for the doctor to come into the urgent care clinic he found online. He doesn’t want to be here; doctors make him nervous. But, he’s had a rash on his abdomen and inner thighs for a week, and it’s not going away. He’s heard about a new disease going around among his friends who attended Pride celebrations in San Francisco. Remembering past encounters with providers, he’s worried about how the doctor will react if he mentions this concern. The doctor enters, smiles at Gabriél, and introduces himself as he looks over the chart: 25-year-old male, Latino, law student, no prior health history or medications on record, normal vitals, complaining of one week of evolving rash and headache. Eyeing the umbilicated rash and suspecting monkeypox or mpox, the doctor pauses after the HPI and says, “I always ask patients a bit about their sexual history ... What genders are your sexual partners?” Gabriél sighs and thinks, “I’m so glad he asked…”

Normalizing Conversations About Sexual Health

Even when presenting symptoms don’t necessarily indicate a possible sexually transmitted infection, healthcare providers can normalize conversations about sexual health with their patients. Normalizing sexual health topics has a huge range of benefits beyond mpox risk assessment, prevention, and treatment. By having open conversations and using respectful language, physicians can create an opportunity for trust and open dialogue during that individual patient encounter. The County of Santa Clara Public Health Department (SCCPHD) offers training and resources for healthcare providers to learn how to have these sensitive conversations. For some providers, it's something they became comfortable with a long time ago. For others, it can be worth an update to better understand how people are talking about their behavior and sexuality.

Physicians have a significant role in shaping conversations among providers and other staff in their practices as well as being a trusted voice in their community. Talking respectfully about sexual health in all contexts, even outside of a clinical practice, provides opportunities to help decrease the stigma related to sexual health and disease transmission, which has been shown to enhance overall sexual health and related health and safety concerns.

Tips:

• Ask patients how they identify with respect to their own gender and sexual orientation. • Ask patients about the genders of their sex partners. • Ask what sexual behaviors they participate in. Use terms that are clear and technically accurate regardless of someone’s identity, e.g., “Do you have insertive or receptive anal sex? Insertive or receptive vaginal sex?” • Use clinically accurate and affirming language. Using the terms patients use to describe themselves can indicate that you have heard and respect what they’ve shared with you. • Offer multiple options when discussing reducing risk of STIs or unintended pregnancy, acknowledging that everyone should have access to all options that work for them. • Help patients feel comfortable when their activities, identity or risk factors change. Help them feel comfortable approaching their provider to request information.

SCCPHD’s Role in Mpox

There are 211 probable and confirmed cases of mpox reported in Santa Clara County, as of December 21, 2022. SCCPHD plays four major roles in the County’s mpox response:

1. Create data collection systems to analyze the prevalence of mpox in Santa Clara County. SCCPHD interacts closely with healthcare providers to gather information from patients diagnosed with or who have had possible exposure to mpox for epidemiological studies and to prevent spread. SCCPHD is equipping healthcare providers and the community with information and updated research discoveries – this includes processing information from the state and Centers for Disease

Control and Prevention (CDC) and working with local healthcare providers. 2. Set up testing mechanisms to confirm mpox cases and develop guidelines for isolation, treatment, and vaccination eligibility – Santa Clara County provided a key testing site in the early stages of the mpox response, and later became one of the sites offering access to treatment with the antiviral, Tecovirimat (TPOXX). 3. Activate the emergency infrastructure to vaccinate the most vulnerable immediately and re-distribute vaccine to local healthcare providers. 4. Collaborate with community organization partners who have been instrumental in connecting priority populations to information about prevention, testing, and treatment as well as connecting eligible individuals to appointments.

To request training for your staff or yourself, go to publichealthproviders. sccgov.org/diseases/sexuallytransmitted-infections and fill out the form at the bottom of the page. For a comprehensive STI toolkit, scan the QR code with your mobile device and download the PDF.

How Did COVID Help with Mpox Response?

Much of the infrastructure that was developed within the County during the COVID-19 pandemic is being used for the

“In fact, SCCPHD was an early resource across the Bay Area for mpox testing and resources.”

response to mpox. Close working relationships with large health centers, chief medical officers and pharmacy directors have streamlined mpox response to quickly provide vaccines and treatments to healthcare providers. Early on, SCCPHD, with support from local partner organizations, was able to vaccinate close to 600 patients in two mass vaccination events within a week.

In fact, SCCPHD was an early resource across the Bay Area for mpox testing and resources. Samples across the region were sent to the Public Health Laboratory which had the early ability to test for mpox. SCCPHD was also leveraging current wastewater sampling capabilities first used during the COVID pandemic to track traces of mpox in wastewater. This served as a guide for where the County could be seeing the virus in local communities.

Monkeypox (mpox) is a viral zoonosis (a virus transmitted to humans from animals) with symptoms similar to those seen in the past in smallpox patients, although it is clinically less severe. With the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination, mpox has emerged as the most concerning orthopoxvirus for public health. Prior to 2022, mpox primarily occurred in central and west Africa, often in proximity to tropical rainforests or after exposure to exotic animals, including a range of rodents and non-human primates. However, in late 2021 and through 2022, Mpox was seen to spread person-to-person throughout parts of the world that previously had seen little Mpox, with disproportionate impact to men who have sex with men and novel identification of spread during sexual contact. Mpox often presents as a rash or lesion that may be located on or near the genitals or anus and could be on other areas like the hands, feet, chest, face, or mouth, and can include a fever, swollen lymph nodes, exhaustion, muscle aches, headaches or respiratory symptoms.

In this current outbreak, mpox is primarily spreading through prolonged skin-to-skin contact, especially sexual and other intimate contact. As is the case in other jurisdictions across the state, country, and other affected countries affected by the current outbreak, airborne transmission has not been observed. Anyone can get mpox, although it happens to be primarily impacting sexual and social networks of gay and bisexual men. Activities that may increase a person’s risk for contracting mpox may include having sex or direct physical contact with multiple or new partners, attending crowded parties or clubs where sex is occurring on-premises, or having direct physical contact with someone who is feeling sick or has a rash. Taking steps to avoid prolonged skin-on-skin contact can reduce the risk of getting mpox.

Speaking with patients about mpox (monkeypox)

Saying something like:

"Anyone can get mpox. Mpox is primarily spread by prolonged skinon-skin contact (hugging, kissing, sex) or, more rarely, sharing items (bedding, clothing, towels) with someone who has symptoms. I need to ask some more specific questions, including any recent sexual history, to provide potential recommendations. Feel free to ask for clarification at anytime.

Have you been to a crowded event with non-fully clothed people? How would you describe your recent sexual history? In the last few weeks, do you remember having prolonged skin-on-skin contact (hugging, kissing, sex) with someone who has new or unexplained rash, sores, or flu-like symptoms? Currently, do you have a new or unexplained rash, sores, or flulike symptoms?

Recommended Questions

Cu�tura� Humi�ity Tip Share something about yourself related to mpox misconceptions/bias or a subject you have difficulty talking about.

Source: County of Santa Clara Public Health Department (December 2022)

“From quick inquires and guidance regarding sexually transmitted infections history and treatment to collaboration, guidance, and mobilization of resources regarding a number of emerging infectious diseases and outbreaks such as mpox, our public health colleagues from Santa Clara County have been vital and pivotal in providing resources, time, energy and effort to help clinicians such as myself care for my patients in their time of need. I grateful to work with them,” says Dr. Joe Cooper, Associate Medical Director, AIDS Medicine at PACE Clinic.

As it does for the COVID pandemic, the County Public Health Pharmacy acts as the liaison between the California Department of Public Health (CDPH) and SCCPHD. The mpox Response Team coordinates allocation and re-distribution of mpox vaccine and treatment. They also are a clinical resource for Santa Clara County healthcare providers and support the Public Health Officers with clinical information regarding vaccines, treatments, and eligibility criteria.

Common Questions

The most common questions from providers when it comes to mpox treatment, vaccine and clinical assistance are logistical (e.g., storage and handling) or related to access. SCCPHD also receives clinical questions related to new Emergency Use Authorizations (EUAs), what documentation is required to be a vaccine or Tecovirimat (TPOXX) provider, what recommendations are there to minimize waste, and how to get five doses out of the vaccine vial for intradermal injection. Providers are encouraged to request access to provide treatment and vaccine to eligible patients.

Answers to these questions and others can be found at: https://publichealthproviders.sccgov.org/diseases/monkeypoxresources-providers

Mpox Vaccination

The JYNNEOS vaccine is approved for the prevention of smallpox and mpox. It is the primary vaccine being used at this time during the mpox outbreak in the U.S. When properly administered before an exposure, vaccines are believed to be effective at protecting people against mpox. When administered after an mpox exposure, vaccination within 4 days may help prevent the disease, and vaccination between 4 and 14 days after exposure may decrease the severity of disease. The JYNNEOS vaccine is recommended as a two-dose regimen with the second dose able to be scheduled at least 28 days after the first. There is currently sufficient County supply to provide two doses to all those who self-identify as meeting current criteria.

Providers can request JYNNEOS vaccine and administer it to their patients. Many large healthcare systems have received vaccine doses throughout the response to vaccinate their own eligible patients. With an improved vaccine supply now available, providers and pharmacies are encouraged to request and receive vaccine -- they may contact medicalsupply@phd. sccgov.org to inquire about becoming a vaccine provider.

Many people testing positive for mpox have recently had new or multiple sex partners, so vaccination for eligible individuals with new sex partners is especially encouraged. Individuals meeting eligibility criteria are encouraged to ask their own doctor about vaccination. For anyone who experiences barriers in accessing vaccination, please call (408) 792-3720.

Treatment Options

TPOXX is currently FDA-approved for the treatment of smallpox but may be prescribed for the investigational treatment of mpox following under CDC’s EA-IND Protocol or a provider’s local IRB process. CDC currently encourages enrollment of TPOXX-eligible patients into the National Institute of Allergy and Infectious Diseases (NIAID) funded clinical trial to evaluate the effectiveness and side effects of TPOXX (stomptpoxx.org/ stompsites). However, providers should not delay appropriate prescribing and treatment if patients may have difficulty reaching the nearest study site, which is Zuckerberg San Francisco General Hospital. As of November 18, 2022, in Santa Clara County, TPOXX is available at Kaiser Santa Clara, Kaiser San Jose, the County of Santa Clara Health System and at Stanford. If patients are a part of these health systems, they can access TPOXX treatment. If a patient is uninsured, they can be referred by calling Valley Connections at 1-800-334-1000. If they are insured but not through Kaiser or the County health system, then they can be referred through Stanford’s referral center.

Equitable Vaccine and Treatment Redistribution

A comprehensive logistical effort is underway for mpox vaccine and treatment redistribution, including making sure both are redistributed efficiently and equitably. Vaccines and treatment for mpox are currently stored in the U.S. Strategic National Stockpile. From there, the products are allocated to each state’s Public Health Department, which are then allocated to their respective counties. SCCPHD accepts their allocation from the State and redistributes it amongst local providers, including larger health systems. The redistribution process requires SCCPHD to work closely with providers to ensure they can store and handle the vaccine and treatment appropriately. Providers must also be able to document usage and wastage, which is then shared by SCCPHD with CDPH. Providers sign an agreement to be a mpox Vaccine and TPOXX provider. Public Health supports these providers with onboarding, resources, and information.

SCCPHD also works hard to ensure that the vaccine and treatments in Santa Clara County are being distributed equitably. The SCCPHD team works closely to interview providers to get a better understanding of their utilization and capacity, and for what populations they are providing care. The Public Health Officers, the pharmacy team, the Science Branch, and the community outreach team look at patient data for those being treated and vaccinated and use demographic and geographic information to assess outreach needs.