Are Schools and Colleges the Next Monkeypox Hotspots?

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Andy looks around the corner to see who may be at risk of Monkeypox next. Should sexually active teenagers and college students get vaccinated? What about toddlers or wrestling teams? Do we need to worry about bedding? Could Monkeypox mutate as it spreads? How close is close contact? Andy gets answers from UCSF Infectious Disease Specialist Dr. Peter Chin-Hong, who has been working directly with Monkeypox patients, and Baylor College Professor of Pediatrics and Molecular Virology Peter Hotez, who has been offering guidance to concerned parents.

Keep up with Andy on Twitter @ASlavitt.

Follow Drs. Peter Hotez and Peter Chin-Hong on Twitter @PeterHotez and @PCH_SF.

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Andy Slavitt, Peter Hotez, Peter Chin-Hong

Andy Slavitt  00:26

Welcome to IN THE BUBBLE. I’m Andy Slavitt. Today’s Friday, August 12th. So monkey pox case numbers have actually doubled since our last monkey pox episode, which was just two weeks ago. Now maybe they’ve doubled or maybe the testing is catching up. But either way, we’ve seen the evidence of a lot more cases. And the US has officially declared monkeypox to be a national emergency. They’ve appointed two people to run the monkeypox effort into the White House. They’re going to be on the show shortly. And with vaccines in short supply, the Biden administration and the FDA is also changing its vaccine strategy to meet demand. Now, monkey pox right now is spreading most rapidly through sexual networks, largely in the MSM or men who have sex with men community. Job one, is to vaccinate, treat and protect that population. One of our guests is a doc on the front line of treating patients in San Francisco at UCSF, Peter Chin-Hong. Peter, welcome to in the bubble.

Peter Chin-Hong  02:46

Thanks so much, Andy. Thanks for having me on.

Andy Slavitt  02:49

Now, as we learn more about monkey pox, and how it spreads, primarily, but not exclusively, through skin to skin contact with an infected person, we are beginning to also get a picture of who else might be at risk. Where contact is close, where surfaces are shared, where same areas breathe. So what about colleges? What about daycare settings, where there are several reports of outbreaks. What about women who have sex with a bisexual man? Are all these folks at risk and what can they do to protect themselves? So, I am also joined today in this Friday conversation by the great pediatrician and the great vaccinology. That’s the same person, by the way, known to many of you, as Dr. Peter Hotez from Baylor. Welcome, also Peter.

Peter Hotez  03:43

Thank you, Andy. It’s wonderful to see you. And also see you, Peter, an honor to be here.

Andy Slavitt  03:48

So we’re going to explore what we know about the exposure and treatment of the risk groups today. And what it means for everyone else who might be at risk. And vaccines are now authorized for kids. Should parents get them? How about college kids? And then we’re going to end the show today by talking about prevention. Now we need to first get out of the way a strategy for talking to Peter and Peter. Probably the most important part of the show where we will confuse everybody particularly me. I haven’t had good authority, Dr. Peter Chin-Hong that you are often referred to by colleagues as PCH. May we call you, PCH for this show so that we can refer to Peter Hotez as Peter and you as PCH.

Peter Chin-Hong  04:33

That sounds great. Andy, I always like to hear PCH because it’s my initials, and also my favorite highway, Pacific Coast Highway.

Andy Slavitt  04:41

If you live on the West Coast, you know that you can’t really go anywhere fun without getting on PCH. So, after the show, I may be convinced that they named the highway after you not after the Pacific Coast Highway. All right. Let’s start with you, PCH. Tell us more about what you’re observing with patients at the medical center. Are you seeing a rise of cases? What are symptoms looking like?

Peter Chin-Hong  05:04

Yes. So Well, Andy, and at the medical center, we’re seeing the sickest of the sick in the general population. So it is an indication of how it’s rising as well, because we are seeing more and more people seeking more advanced care over the last few weeks that I’ve been following this and taking care of patients. So in the beginning, I would say probably our first patient that I saw consulted on the emergency room was on July 4th, actually, I was eating Indian food on July 3, and I got the call at night, there was this patient who we think has monkey pox. What are we doing with treatment, and, you know, we have to galvanize this infrastructure that we had already prepared for COVID to activate again, for treatment. So it was really the beginning. And now we’ve treated 10s of patients. And we’ve also had people come in the inpatient setting, usually they have monkey pox, that’s really, really painful. They have monkey pox plus something else, like syphilis or bacterial infection with it. So, you know, just from this measure alone of the sickest of the sick, I would say that it is really more than doubling, you know, from week to week.

Andy Slavitt  06:17

And what are you hearing about how people are getting infected? Do you ask the question and then attempt to do some epidemiological work or to protect others?

Peter Chin-Hong  06:28

Yeah. So as an infectious disease doctor, we are trained to ask these questions. So we get very, very detailed information from these individuals as to how they think they’ve gotten it. In the beginning, a lot of them actually were through private events, and not through travel, as some of the evidence suggests. So they didn’t know anyone who was coming from Europe, for example, who had then they got it from them. Many of them acquired it in New York, prior to coming to SF, and now the predominant numbers of people are acquiring it locally. So again, probably speaking to the spread, that it may have come. We know, we think it came simultaneously. But I think New York was really a big Epicenter first coming from Europe, Belgium and Spain. And then there’s a lot of interaction between New York and San Francisco. So some of the early cases example, were in the setting of going to pride events in New York Fire Island, staying with a bunch of friends and having a lot of intimate contacts. And some of the cases they actually knew because they kept in touch with their contacts that people were getting monkeypox before and then they were able to, you know, put the two and two together. I think diagnosis was really tough, particularly in the beginning. Because again, the rash look really, really different from the textbook. So I had some patients who are going from er to ER to urgent care to urgent care to doc to doc and they’re saying, hey, this doesn’t look like the pictures. We expected monkeypox, so a lot of delayed care, a lot of suffering a lot of feeling stigmatized as well.

Peter Hotez  08:05

And, by the way, along those lines, you know, I know we’re talking mostly about the United States right now. But you know, if you look in Europe, the some of the largest numbers of cases are in Portugal and Spain. And the reason that’s relevant is, of course, there’s a lot of commerce and, and traffic in between Portugal and Spain and Latin American countries, particularly Brazil. And so one of the things that I’m really concerned about is, you know, historically, when something catches fire in Brazil, it really catches fire. We saw this with HIV AIDS, we thought was Zika, we saw it with dengue, we saw it with a lot of other viral infections. So I think that’s another hidden aspect of the pandemic, which I think could become, that we’re not really talking about is what’s happening in Brazil and Latin America. So I think I really worry about this speak, really gaining a foothold in the new world in the Western Hemisphere.

Peter Chin-Hong  08:57

And Peter, we did hear about the first death in South America, which was in Brazil. So when you said Brazil, I was already thinking of about that community as well.

Andy Slavitt  09:08

And PCH, is it entirely sexual contact or skin and skin contact? Are you seeing any cases at this point, that have spread either through aerosol or through bedding or through other means?

Peter Chin-Hong  09:22

Right now, in the cases I’ve seen, they’re pretty much 100%, than through sexual contact, you know, and whether or not that’s primarily skin on skin versus a combination of skin and skin, and bodily fluids. You know, we can debate that. But, of course, we know that there have been about five kids in the US who have gotten infected as well. Scores around the world and they have likely obtained this through household contact. But if you think about the vast number of kids in households and also other individuals, and a small proportion of Those who have had confirmed cases, it really speaks to the power of skin on skin, you know, and that’s how I expect monkey pox to infect each other. Anyway, this is not really a new trick of monkey pox. This is kind of how it’s traditionally infects one to the other.

Peter Hotez  10:16

And the fact that we’ve had, you know, I mean, how many cases in the US so far getting up towards 10,000 cases and 98-99% are in that high risk demographic group suggest to me that more casual contact is probably not going to be a big mode of transmission, at least yet.

Andy Slavitt  10:35

Let’s get into that in a bit. I also want to ask you, do we know whether or not someone needs to be symptomatic, to spread? And I know that it’s a maybe a difficult question to ask, because, as you said, some of the ways that these lesions showed up look different than people thought. And so it may be easy to confuse someone who may say they’re not symptomatic, or someone who has a different symptom. But what I think is important to try to understand is if people will be able to tell when they’re infectious or whether or not it can spread, you know, skin and skin with people who are have yet to get to show signs.

Peter Chin-Hong  11:12

I mean, I think that’s an interesting question, Andy. And there was this interesting study that’s in preprint, from Belgium, where they went back to about 200 male patients who visited an STI clinic during May, and they found that there was monkey pox, and some individuals, three men before they had symptoms, but then they did a contact investigation and none of the contacts while they were asymptomatic, actually, in this particular study, got monkey pox. I think that, you know, the teaching from infectious disease perspective is that unlike COVID, where there’s this pre symptomatic transmission, in monkey pox, you kind of are most transmissible and primarily transmissible, when you have symptoms that is from I’m feeling that flu like to all the way to the end of the rash. And of course, one big question is, how long does it last and semen because even though you’ve rushed might have gotten better? What do you tell patients about when they should resume sexual activity in an unprotected fashion with their partners?

Peter Hotez  12:19

And I think the reason one of the reasons for that is, and again, we were extrapolating a lot from smallpox is in those pustules, there’s a lot of virus, I mean, the virus titer in those pustules is really high. So if one of those ruptures or is when that happens, probably a lot of virus particles are being released, and some of it through skin abrasions, maybe some of it a little bit aerosolized, or through droplet contact, but I think it’s the presence of those pustules. That is, is a big one.

Peter Chin-Hong  12:48

And that’s a great point, Peter, because I think we should step back 50,000 foot and look at this, at the end of the day, this is an animal virus, like, you need a ton of virus to really cause disease in a human, it’s trying to find a rat, or a squirrel or prairie dog, and not really feeling happy when it’s in a human. So you need a ton of virus to really shake up that human body. And that’s why that HI virus inoculum is best transmitted in that intimate contact, where you’re rubbing this lesion with tons of virus. I’m making these small abrasions on the uninfected skin and then the virus gets across that way.

Andy Slavitt  13:29

So it sounds like we’re not talking about a handshake. Like people who are like, hey, I don’t want to have a handshake with someone. Because I’m worried. It doesn’t sound like that’s the kind of skin contact you’re talking about.

Peter Hotez  13:39

Yeah, in fact, you know, we I got asked a few days ago, there was an individual with monkey one of the teachers and with monkey pox was in a classroom, a preschool classroom and everybody was worried that teacher was going to spread monkey pox throughout this preschool classroom. And I said unlikely, right? And can’t tell you zero. And we’re still learning about the transmission of monkey box in this form. But it’s not that easy. It’s very intimate, very prolonged, intimate contact, I think.

Andy Slavitt  14:09

I think. Okay, we’re going to come back after the break, and we’re going to talk about risks to the rest of the population and prevention strategies. PCH, one more question that I want to just hit on before we turn to you Peter Hotez, and talk a little bit about some of the other people that may be getting close to type of skin to skin contact, and how to think about that. So what are the main differences between COVID-19 when it first hit the US. And monkey pox, in addition to some of the other differences you talked about, is that we already have vaccines and treatments for monkey pox, that are pretty effective. Now, we have to get those to people, we have to get those into the community, we have to get them working. My understanding is that the therapy to POCs, when it’s available, is quite effective. And the vaccines, if we get them out to people are quite effective. Can you tell us a little bit about what’s going on the ground in San Francisco, which is one of the center points. How are we doing getting vaccines to people? And, you know, we’ve had Jay Varma and Jo husband sitting on the show, talking about the delays and getting people access to the treatments they need and all of the hoops that the CDC has had people to have to jump through. Is that getting better as well?

Peter Chin-Hong  17:56

Yeah, so let’s address each of those boxes. Andy, first of all, with vaccines, way, way below what we’d like in San Francisco that’s leading to a place of the haves and the have nots, they’re a bunch of people who feel happy, because they were able to either take the whole day off of work line up at times the school general or combination of that going to another place Steamworks has given out on a you know, show up and you will get it until we run out basis. There are people who are not able to do that. We know that we have a higher number of that next patients getting presenting with more advanced disease 30% in SF 40% in Santa Clara. So that’s, you know, really speaking to that that issue. The other part is that, you know, we asked for 35,000. We’re just above 10,000 tons of delivered, and we really should be asking for 70,000. So that’s to give you an idea of what the gap is. So that’s vaccines and of course with the new intradermal administration, hopefully planned, people are feeling a little bit more hopeful. But I’ve had like faculty members who are part of the community trying to get vaccines and no one is evil. It’s a very frustrating perspective.

Andy Slavitt  19:12

Can I ask you  both, before we go to the therapy, it’s gonna ask you both about the intradermal. To refresh. This week, the FDA announced a way that they could get five times the reach and the vaccines by using something that’s not unheard of. It’s done off it in case of emergencies, which is to give a fifth of the dose, but do it between the layers of skin intradermally instead of subcutaneously, which goes into the fat layer below the skin. Peter Hotez What do you think of that?

Peter Hotez  19:44

Well, a couple of things. First of all, before we talk about the intradermal adaptation, I think it’s important to point out that this vaccine was approved before the pandemic I think it was in 2019. And it was approved on the basis of what’s called immuno bridging studies, meaning the true vaccine effectiveness was not measured in people, it was based on the fact that it induced high levels of viral antibodies and induce T-cell responses and the fact that it worked in, again, in laboratory animal experimental models, meaning animals that were vaccinated, then challenged via the respiratory route, which is quite different from the way monkey pox is currently being transmitted among people in San Francisco and elsewhere in the US. So we believe that the vaccine is going to be highly effective. But I think it’s really important that we don’t know that for certain just yet. And those vaccine effectiveness studies have to be done on the fly, meaning that during the and we’ve seen this before the challenge of doing COVID vaccine effectiveness studies, during a pandemic, we’re gonna have the same challenge with the monkey pox vaccine. I think another piece of this is now in addition to the typical route that this was approved in with, there’s one study showing that again, a immuno bridging of an immuno bridging study that may also work via the intradermal route with a far lower dose of vaccine. And the reason you can may get away with that is because in the skin, there’s a unique type of antigen presenting cell, that’s a dendritic cell called the langerhans cell, which is very potent in transmitting antigens on to the rest of your immune system. And that’s how the immune system has evolved. Because we don’t want the pathogens coming into our skin on a routine basis. And so that’s how it’s evolved. So again, it’s likely going to work. But there’s a lot of assumptions here. And I think that’s something that we’re gonna have to be very careful to watch. I think it’s the right decision, I think they made a good decision, because it’s dose sparing. And it’s unfortunate that we got to that situation that there were a lot of lapses that were done over the last decade, you know, with allowing expired doses to expire, and things like that. So I agree with the decision. But it’s not without risk in terms of the assumptions.

Andy Slavitt  22:08

Questions, at least. And I did hear from Peter marks from the FDA, and I’m sure you did as well, but that there’s no safety concerns, no additional safety concerns. It’s the same basic safety profile done intradermally. So you’re not adding that type of risk, at least?

Peter Hotez  22:22

Well, I think the other thing is, it’s not hard to do an intradermal injection. It’s like when you get a TB test that PPD form a little blip up in the skin, but it does take a little bit of training to get good at it.

Andy Slavitt  22:34

So PCH, […] on that. But also, I’d love to hear your thoughts on the therapies and availability of the therapy.

Peter Chin-Hong  22:41

Regarding therapy now, I think, what a journey we’ve had with therapeutics, we have more than 2 million courses in the national stockpile, but a bottleneck at the ways in which we can give it to patients. I think one of the grounding comment is that in every disease and infectious diseases, the earlier you give therapy, the better it is to the patient. We’re kind of in a topsy turvy situation like we did in COVID. And beginning where we’re giving the sickest patients therapy now, because we want to give them something and because there’s no randomized control data at cetera. But again, like with PAC, Sullivan, and COVID, it probably would be best to treat someone early on with monkey pox to help prevent them from getting bad stuff rather than what we’re doing now. But anyway, coming back to the red tape issue. This is an investigational drug for monkey pox, even though it’s FDA approved for smallpox has a good safety profile, but not a lot of clinical data, except some case series. We had to fill out paperwork to the CDC show they had an IRB and it’s expanded access all of that. But every institution has its own little bells and whistles that you have to go through. You make friends with your local IRB, you say, hey, we want to use the CDC-IRB.

Andy Slavitt  24:00

Tell everybody what an IRB is since everybody’s had the pleasure.

Peter Chin-Hong  24:03

Yeah, so IRB is an Institutional Review Board, which is set up for absolutely the right reasons, which is to protect participants who are getting investigational drugs for which we have no data or note great data. We want to give them all the information we know but also the information we don’t know, including some potential downsides, like safety issues, the adverse effects.

Andy Slavitt  24:27

It’s a great practice for disclosure, it’s a tough practice to implement during a public health emergency.

Peter Chin-Hong  24:32

Totally tough, it takes an hour. You know, you have to set up your system. To do that you have to follow up patients at day seven and end of treatment, even if they’re feeling better, which most patients are by that time 100%. In my experience.

Andy Slavitt  24:48

Before we get to the red tape, though your experience with this drug is that it is highly effective?

Peter Chin-Hong  24:54

Yeah, so this is why I have to separate my scientists hat from my clinician hat. So as a clinician, wow, like, I’ve seen these crazy cases come in like disseminated rash all over the body. Day two of therapy, it’s completely, you know, getting better patient feels better, much better self-esteem. As a scientist, I’m not sure what I’m seeing is, you know, because we don’t have a control group. But I would say that, so far, I’ve been really impressed with how patients have tolerated the drug, very, very good safety profile. They’ve tolerated this better than ibuprofen or Tylenol. Like nobody complains. Probably because you’re really starting off with such awful looking disease. When you look at yourself in the mirror, you’re really motivated to take it. The other aspect is the length of time at which they feel better you want. A couple of patients told me they stopped taking pain meds after two days of therapy. So I’m trying to disentangle my scientific side where I don’t have a control group with my clinical experience.

Peter Hotez  26:02

But I think you bring up an important point PCH, which is that if it does turn out to have such a great safety profile, and I’m optimistic that it might, it may suggest some alternative uses until the vaccines are available. So what we call post exposure prophylaxis, if you’re you know, had sex or an encounter with somebody who you know, has had monkey pox, then you could start taking the medicine or even as a form of prep, potentially, to start going on it now if the doses are available in abundance, and it has that level of safety profile. And that may be more impactful than simply just waiting another two years for enough vaccine doses. So I think that’s something we’re really going to have to look at.

Andy Slavitt  26:46

It sounds like we’ve got to get past this red tape issue, we’ve got a high potential, if people are willing to prescribe it off label and to get the CDC to make the process easier and easier. I want to turn now to talk about other populations. But I want to do so a little bit carefully. Because I don’t want us to be in a pattern where the public starts to care about this only because they think, well, now it might affect me, we should have learned enough to know that we need to care about others. And we can be self-interested in caring about others, or we can care about others because we truly care about others. But it’s important to start this conversation where we did because people are suffering now. I know there are a lot of people that are worried that there are other settings or this base spillover. So I want to give that conversation it’s due. But I also want to say that if you come to the conclusion at the end of this, that you’re very, very, very low risk, and that there’s only other people that are in high risk. I really hope that doesn’t mean that we take our eye off the ball in terms of the urgency here. So that’s my disclaimer. And so, let me go back to you, Peter. What other types of populations based on what we know about how this spreads? Should we be thinking about as high risk and I really want to think about colleges, daycare centers, other places where, you know, there’s a lot of skin to skin contact, there’s wrestling, there’s diaper changing. There’s, I mean, I don’t think there’s a thing a three year old wouldn’t touch her lick. Given the opportunity, at least based on my three year olds, when they were three year olds that are now in their 20s they’ve stopped looking quite as much.

Andy Slavitt  27:06

They may not stop the licking and independent.

Andy Slavitt  28:25

But they don’t tell their dad about it. Okay, Peter Hotez, what other populations should we start to be thinking about?

Peter Hotez  28:31

Well, I mean, I think you know, I mean, the worry is, you know, we’re at 10,000 cases, probably, that’s an underestimate, I can’t tell you if it’s a factor of 2 or 10. But clearly, that’s an underestimate what happens now, as the numbers continue to climb, what if we get to 100,000 or 200,000 cases, then that means what we sometimes call the force of infection is really accelerating. And when that occurs, and we start with Covid, bad stuff starts to happen, and we start seeing spillover and other populations. So it is a real possibility. And I would say right now, you know, wherever you see young adults, teenagers in high contact settings, that would be my first concern. So when you talk about boarding schools and you know, or colleges, I think that could be a place that where I’d like to see a start to vaccinate. I don’t know that we have to move to kids just yet. But there are those other settings.

Andy Slavitt  29:38

Let’s speak to parents for a bit. Mike from FDA has said it’s okay for kids under 18 To get this vaccine. Now we have a supply issue. So it’s curious, but it also means that they have enough belief that there’s enough risk with kids, for them to put that statement out, I presume. So how should parents be Think about that.

Peter Hotez  30:01

Again, I would say that the risk of your kids getting infected through casual contact is modest. But, you know, if you have teenagers that are sexually active, you know, 15-16 year olds, then yeah, that that that is potentially a concern. And hence the need to think about vaccinating those boarding school populations and colleges as well.

Andy Slavitt  30:29

What likely happened at this daycare center was that in Illinois, what’s the likely cause?

Peter Hotez  30:35

Well, again, I don’t know that there were actually kids infected in that daycare center, there was a concern. And there was people pressed, I don’t want to say the panic button. But people did sound an alarm, likely the risk to those kids getting infected was quite small. So it was done out of that, you know, that horrible phrase you an abundance of caution. But I think that’s probably it.

Peter Chin-Hong  30:59

I mean, I want to interject here about the infection risk in the general population, that’s setting too, because a lot of times you’re in the public, you’re close, you’re covering most of the legions with clothing. And that already cuts down the risk in general, because like Peter said, early on, the risk of respiratory droplets is really, really low. Again, as an animal virus, you need like hours of contact with saliva for it, as we know it to spread. And then from the lesions on the skin, you know, it’s if you cover it is generally going to cut down at risk.

Andy Slavitt  31:33

So, just a second vaccines then. And I think, given both the supply issues we have as well as you know, risk people might be feeling sort of go through a couple of use cases, because I’ve gotten these pair the each of these questions, I’ve gotten, a parent setting the kid back to college, should they get their kid vaccinated? In your opinion?

Peter Hotez  31:50

It depends how you’re asking that question, assuming if there’s an abundance of vaccine. Sure, I think the vaccine has got a great safety profile. And, you know, college kids have a lot of intimate contacts. And you remember what Clarcor, the Chancellor of UC Berkeley once said about governing a university, its, it was all about sex for the students, football for the alumni and parking for the faculty. And so with that, that was the basis for the university. That’s the basis of a research university. So with that in mind, you know, students are going to have a lot of sexual contacts, sure ideally, but the problem is, we barely have enough vaccine right now to immunize the highest risk group. So I think it’s, it may be move at least for a while.

Peter Chin-Hong  32:39

I like that same theater. I’ll remember that for a future talk or something. But I want to come back to that vaccinating on the penumbra, the fringes part. I mean, one thing that I’ve been concerned about is that, and I totally agree with being laser focus on with men and trans people on sex with men. But you have to declare yourself as being part of that community, even though you may still have the same risk, but not consider yourself part of that community. So that’s what the college students are worried about a little bit where they may be people, you know, in the process of forging that sexual identity, who probably wouldn’t line up in a line that’s very visible, who may then become the night as in a college campus setting.

Andy Slavitt  33:22

So it feels like it’s realistic to expect some spread of monkeypox in colleges, although maybe not a lot at you know, as you said, it’s a it takes a lot and some of the data research that’s been released by CDC does indeed indicate that the disease has largely contracted people that have had several sexual partners. So, there is a really tight network here. But it also feels like for the spillover to occur is Peter, you’re talking about the force of this, you know, for a bisexual man to have sex with a woman at college and for there to be sexual partners there. It doesn’t feel like an outlandish scenario.

Peter Hotez  34:08

Yeah, I think every college and university right now should be making monkey pox preparedness plans. And I think and I think most universities are at this point.

Andy Slavitt  34:18

And so parents, you know, to the extent that there’s sufficient vaccines available for the primary target population, I think that that may be the most important consideration. Beyond that. It sounds like there is a no harm and maybe some modest risk reduction. Once that occurs for college students, and people in other potentially secondary groups to get vaccinated. Is that the right conclusion?

Peter Hotez  34:45

I think yes. And plus, if we can collect some data on the use of tech of aramet for post exposure prophylaxis or for prep that also be helpful.

Andy Slavitt  34:55

What about things like wrestling teams, and you know, daycare kids, etc. Any recommendation on vaccination there? Yeah. And is it the same recommendation once we get the highest risk population vaccinated? We should be focused in some of those spot areas as well?

Peter Hotez  35:16

Certainly if you’re in a wrestling team, you know, education about if you don’t feel well, and certainly if you have lesions, you don’t want to be in that competition that’s going to be paramount. In addition to if we have the vaccine, it would be great to vaccinate.

Andy Slavitt  35:33

Alright, let’s take a quick break. We’re going to come back and talk about how to make sure we prevent ourselves from getting monkey pox in the first place. Alright, I want to close by talking about prevention. And I want to take it into two chunks, if you will. I want to start by talking about prevention among the high risk population. And you know, this is a touchy topic. It’s one that the CDC you know, put out some guidance on. But if you are someone who is in the MSM population, you’re at risk. Talk about maybe PCH, you can begin, the best prevention strategies that you would counsel people?

Peter Chin-Hong  37:37

Well, I think, you know, like with any time I meet somebody, in general, as a patient, I want to find a way they are first because I can say something like don’t have sex or don’t do drugs. But if I don’t really meet them where they are, that’s going to fall on deaf ears. So I think that’s the first thing I do. But in general, I think what we’ve been finding works really in that harm reduction model is you kind of finding where people are, but some techniques. So all recommendations people have had recently were limiting sexual partners period, or like a Covid pod, you think of a sexual and social pod, where you kind of in that pod, have a contract a social contract about not having intimate contact outside of that group of individuals. And then at the basic level, if somebody wants to be continued to be sex positive, and we all want to be sex positive in this world in 2022 have an open conversation, when you meet a new contact, you say, how are you feeling? This is how I’m feeling, you normalize it. I asked this to everybody I meet, when was your last HIV test? This was mine. And you maintain touch with that person, on some level, you know, if anything happens, please feel free to let me know after the fact, I have no judgment, I just want to make sure we’re both healthy. So I think that post contact is really important to perfectly if somebody comes on with symptoms, and we have more vaccines, you can get vaccinated within the first four days, we believe to abort the volume of disease. So it’s not like a totally dismal situation and all accounts. So in general, that’s what we’re thinking.

Andy Slavitt  39:17

it is testing becomes more available. Is that another good assurance to add to the layers?

Peter Chin-Hong  39:23

Yes, definitely. I think we have to move beyond the sort of like less tests on the skin situation because it’s so retro. It’s very prehistoric. There lots of people who have lesions that don’t involve the skin, you can swab the skin until there’s no tomorrow. So I think we have to develop new testing strategies to and think about more beyond the skin.

Andy Slavitt  39:45

And then keep talking about some additional guidance around hygiene and bedding and sexual toys and these are all things that are brought up by the CDC. And I think to everyone’s care at it, you’re having a real conversation about these things, rather than wrapping them in stigma probably makes sense.

Peter Chin-Hong  40:07

Yeah. So I think first of all, one thing that was controversial in San Francisco a few months ago, because it was a recommendation from one of the nonprofit organizations was the issue of around condom use. And because you can mainly get it skin to skin, but sure, you can also get it through bodily fluids. But by weighing the condom, you don’t obviate risk of disease. So I think that’s important to disclose to patients as well. So that’s one thing. And then within the household, you know, cleaning bedding, linens, towels, sex toys, fetish care, is really important. Between intimate encounters. I was very surprised and pleasantly surprised to see very explicit recommendations on the CDC website this year.

Andy Slavitt  40:55

Now, Peter Hotez, let’s talk about prevention strategy for other folks that might feel like they’re at some risk. And I think we should acknowledge what you said earlier, which is, the risk is greatly reduced if you’re not part of these networks. And in fact, it requires a lot of skin contact. And so the message to parents isn’t your kids are in very high risk. Nevertheless, people want to take common sense approaches here. And so can you talk about some of the things for people who might be concerned that you would recommend people think about from a prevention standpoint, whether they’re at college, or whether they’re in contact with someone that they may think may be infected or other sorts of things?

Peter Hotez  41:38

Well, I think, first of all, it’s really important to have situational awareness because the situation right now, I mean, we’ve gone from a handful of cases to 10,000 reported cases pretty quickly. And if that trajectory continues, we maybe could have been, might be having a very different discussion two months from now. So I think it’s really important that this is not static, that we could start seeing much more spillover. I’m also concerned with the fact that now that we’re detecting monkey pox in the wastewater, this means that it could eventually get into some animal populations, whether urban rodents or squirrels. And if that happens, then it could become a more permanent fixture in the United States. So it’s not well known not only be endemic on the African continent, and Central Africa and West Africa, but in North America or the Western Hemisphere, as well. So this is still a fluid situation, and we’re gonna have to think about that accordingly.

Andy Slavitt  42:39

So given that is, get out of the sexual context, into people who are either young internet, sexually active or just aren’t sexually active, but are in other situations, I want to just either dispel myths or verified some precautions, you know, should people be going to hotels and changing the sheets? Should they be worried about the bedspreads? Should schools put in place cleaning protocols in areas where there’s a lot of contact, you know, recess, and so forth? These are all questions that are naturally occurring to people on their mind. And they may sound like they’re not highly educated questions, but they’re, I can tell you, they’re very much on people’s mind. Because exactly what you said, Peter, which is, they know what it looks like today, but they fear that it could look different in a couple of months. And so they want to, they want to get a sense for the best strategy is to stay safe.

Peter Hotez  43:36

Well, I mean, right now, I mean, we’re at right now I feel pretty comfortable going to any reasonable hotel fact, I just did it. I was at the International Conference on emerging infectious disease, the CDC meetings in Atlanta, and I didn’t go stripping the bedsheets off the bed, and that kind of stuff. It was business as usual. So I would say no. And same with swabbing things down. I think these are right now that these are relatively minor modes of transmission. If you want to reassure parents or want to reassure the general population, just right now just look at the numbers, again, out of the 10,000, 97-99% of the cases have been among men who have sex with men. And so if we were starting to see greater spill over to the general population, I would have thought we would have started to see it by now. But we really haven’t except for a handful of celebrated cases.

Peter Chin-Hong  44:34

And this airborne thing, I think, it gets really nuanced and confusing to people, but the only credible sort of like, air thing that I’ve seen is really in 2018, in the UK, where there was a healthcare worker who changed the bed sheets of a patient with monkey pox before they knew the patient had monkey pox, and was like flicking the bedsheets all the scarves got in the air and the healthcare worker breathe it in and got monkeypox in the face without using protection. So I think in that setting that’s the linen connection. I’m sure it can survive on stuff. But you’d have to like scrub it into your hand like a scrubbing brush with a high inoculum for that to really infect an average person. So, a thrift store completely, very, very low risk at this point. You know, changing the bedsheet of somebody with scabs in your bed with monkeypox. Much higher risk.

Peter Hotez  45:27

Yeah, I mean, this is how Lord Jeffery Amherst Wade’s biological warfare during the French and Indian Wars, he loaded up blankets smeared with smallpox, pustules and enlarge use it against Native American populations. But that was smallpox, not monkey pox number one, which is much more highly transmissible, and it was fresh material. And in a very different situation for what we’re talking about.

Andy Slavitt  45:52

Well, we will stay close to this as things evolve, and as things change, but YouTube, YouTube has given us I think, our marching orders for how to stay safe, and some really good sound advice and perspective on how to treat and vaccinate. And when you do it all as quickly as possible. I’m very grateful to both of you, not just for being in the bubble. But the work that you both have done. The book you’re just out with Peter Hotez, the vaccine, you created a gateway to the world, the underground work, you do PCH, everyday taking care of people in such a compassionate way. I’m sure you both have inspired our audience with your work.

Peter Hotez  46:28

That’s very kind and you’re also an inspiration, Andy, thank you so much for everything you’re doing.

Peter Chin-Hong  46:33

Thanks, Andy, for communicating to the world. And to Peter, thanks, all those sayings and history lessons. I’m going to take it away with me.

Andy Slavitt  46:40

Thank you. Okay, let me tell you what’s coming up next week. What really happened in the family separation process? We have a really explosive interview and conversation about that. I think we finally have the real answers to what went on. We’re also have an episode with Tony Fauci coming up one with Christian Anderson, who’s been studying the origins of COVID-19 and why that’s important. And so lots of good stuff coming up. Maybe a couple more things before the month of August gets out. And we’ll end August on a great episode about learning loss and heading back to school. Everybody have a great weekend. I really appreciate you listening.

Andy Slavitt  47:40

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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