The nation’s monkeypox response is shifting from crisis mode to a more long-term approach as the Biden administration acknowledges that it will be impossible to eradicate the virus from the country anytime soon.
Long before the 2022 outbreak, monkeypox was a regular occurrence in a few Central and West African countries. With the U.S. now joining the ranks of countries where the virus is common, it is shifting its virus treatment and vaccination strategies.
“Domestic transmission in the United States is unlikely to be eliminated in the near future,” the Centers for Disease Control and Prevention acknowledged last month.
The agency expects cases will likely decline and plateau over the coming weeks and months, but cautions that because cases are not declining all over the country right now, predicting long-term trends is difficult.
Demetre Daskalakis, the White House’s national monkeypox response deputy coordinator, told reporters late last month that the United States is in this epidemic for “the long game,” but it’s still possible to prevent the virus from becoming endemic year after year.
“This isn’t something that we’re going to see go away in a matter of weeks or months, but it’s something that if we keep the pedal to the metal, as it were, we should be able to get to a point where we have really potentially good outbreak control and the ultimate goal being that we do not have endemicity in the U.S. But that means investing,” Daskalakis said.
But even if the U.S. lowers its monkeypox levels down to nearly zero, it’s likely to soon be reintroduced into the population because of overseas travel and infected visitors. Monkeypox is currently circulating in 107 countries, 100 of which had not historically reported it. But the U.S. has a higher case count than anywhere else — more than 26,500 cases as of Oct. 7, with Brazil next at 8,207 cases.
“The most likely scenario is that we will continue to see kind of a low level of monkeypox cases kind of continuously, as we do with other sexually transmitted infections and that unfortunately, it will concentrate predominantly in urban areas among young Black and brown men, and probably in various parts of the Midwest and South, similar to what we see for syphilis and HIV,” said Jay Varma, director of the Cornell Center for Pandemic Prevention and Response.
Future of treatments
The U.S. outbreak is currently concentrated in communities of color, even though it originally circulated predominantly among white men who have sex with men. As of Sept. 30, among the cases for which the CDC has data, non-Hispanic Black men represent 51 percent of cases, and Latino or Hispanic men represent 70 percent of cases, according to Daskalakis.
Black and Hispanic men who have sex with men are getting vaccinated against monkeypox at a much lower rate than at-risk white men as well.
The federal government is trying to prevent the inequities from skewing ongoing clinical trials as the government works to get more information on the orthopoxvirus drug Tpoxx. There is no proven treatment for monkeypox, but the CDC expanded access to the smallpox drug Tpoxx on an investigational basis.
Now that the drug’s safety has been proven against monkeypox, researchers are gathering more data about how well it combats the virus. These results could not only help fight monkeypox but also future orthopoxvirus outbreaks.
“We have a great opportunity to learn quickly about the efficacy of this drug. And there are parts of the world where this condition is endemic, and we really have the opportunity to know how to treat this infection so a similar pandemic doesn’t arise again,” Daskalakis said.
Scientists are still studying how the virus spreads. For example, people who have HIV have a higher risk of contracting monkeypox, said Carl Dieffenbach, director of the Division of AIDS at the National Institutes of Health, and it’s unclear if this is because of sexual behavior or because of HIV-related increased susceptibility.
Timothy Wilkins, an infectious disease specialist at Weill Cornell Medicine, said that the NIH asked its AIDS clinical trial group, which he leads, to provide a controlled trial of Tpoxx necessary for Food and Drug Administration approval to treat monkeypox.
About 500 participants will be enrolled in the randomized portion of the trial, where most receive Tpoxx and some receive a placebo. Those with more severe disease will have the option of moving from the randomized trial, where they could be receiving a placebo, to an unblinded study, where they definitely receive the drug. The NIH is including immunocompromised people, pregnant people and children to try and get a fuller picture.
Case counts have been falling, though, and this could make clinical trial enrollment difficult, according to CDC officials. Confirmed cases peaked at more than 600 per day in August and are now down to fewer than 100 per day.
Future of vaccines
Right now, cases are largely confined to men who have sex with men, and the U.S. public health apparatus has centered its monkeypox response around vaccinating the most vulnerable. Several months into the vaccination effort, many of the most-eager early adopters have been vaccinated and the CDC is turning its attention toward those more hesitant but still at high risk.
Roughly 873,550 Jynneos vaccine doses had been administered across the U.S. as of Oct. 4, according to the CDC, with the overwhelming majority going to men and people identifying as white.
Now that many early adopters have received the vaccine, the public health apparatus is trying to reach high-risk individuals in more rural areas or those who are hesitant to get the shot. One way is by making the two-dose vaccine available in more sites across the country.
Earlier this month, the Department of Health and Human Services signed a declaration expanding who can administer the vaccinations, including pharmacists and veterinarians.
“By expanding the pool of providers who can administer monkeypox vaccines, we can increase equitable access for people at high risk for monkeypox infections who have not yet had an opportunity to get vaccinated,” HHS Secretary Xavier Becerra said.
Because scientists do not have complete real-world data on how long Jynneos vaccines provide immunity against monkeypox, there’s uncertainty about where the virus will go from here, Varma said.
He said it’s hard to also predict how long high-risk people will continue behavioral changes such as abstaining from new sexual partners. CDC officials have repeatedly emphasized that Jynneos is a two-dose vaccine, and people should remain vigilant about being at risk until they receive both doses.
But, Varma emphasized, behavioral change should not be limited to those at high risk.
Instead, he said, health care clinicians need to change their behaviors. Because monkeypox often presents similarly to other sexually transmitted infections, clinicians need to continue to check for monkeypox to slow its progress.
“We know that that’s one of the reasons a lot of diseases, especially sexually transmitted infections, get missed and propagate, is because health care providers are kind of reluctant to ask about sexual practices,” he said.