Avoiding ‘monkeypox’ and stigma that comes with it, a conversation with Oregon doctor

On August 4, the White House declared monkeypox, also known as hMPXV, a national emergency.

The virus, which causes a painful, blistering skin rash, continues to spread in Oregon. As of August 2, there were 72 known cases in the state. In Multnomah County, more than 1500 people are on a waitlist for a vaccine.

Dr. Tim Menza, a senior adviser with the Oregon Health Authority, joined Host Jenn Chávez to talk through what we know about hMPXV so far.

This conversation has been edited for length and clarity.

Jenn Chávez: So the current outbreak that we’re seeing is fueled by hMPXV-2, the virus’s second variant. What do we know so far about how this version of the virus is being transmitted?

Dr. Tim Menza: This version of the virus is being transmitted largely through direct skin-to-skin contact with the sores, the scabs and the fluid of the rash of someone with hMPXV. There are other ways in which hMPXV can be transmitted that include touching, sharing clothing, linens, towels or other objects used by a person with hMPXV. The least likely [way to get the virus] is contact with respiratory droplets or secretions of a person with hMPXV.

Chávez: How severe is the outbreak in Oregon?

Menza: The way I conceptualize a public health emergency is that something unusual is happening. I would say that the spread of hMPXV is not something that’s typically seen in the United States or in Oregon. And it requires a coordinated, judicious response. Calling it an emergency is not to provoke panic but to marshal resources to respond to the outbreak.

Chávez: And this variant so far is less contagious and less severe than the previous version but it can still be incredibly painful. What symptoms should people be on the lookout for?

Menza: That’s right. So the symptoms range from what we might call mild to pretty severe. At this point in time, we’ve had one person in Oregon who has been hospitalized for hMPXV, largely related to a secondary bacterial infection. But there are a few things that folks can watch out for.

The first is the rash itself, which can be itchy and or painful. Things that people can use for the itch can be sort of like topical calamine lotion. Petroleum jelly can also be helpful — Vaseline or Aquaphor.

There can also be pain related to rash or sores on particular body sites, like inside the mouth, inside the urethra or inside the rectum and the anus. And what we’ve been hearing most is that the majority of folks who do have rectal sores do have pain with bowel movements. It can be quite excruciating and there are some methods to help alleviate that. An at-home method might be something called a sitz bath. It’s just sort of soaking the perineum in warm water. Lidocaine jelly, Tylenol and [Aspirin and Advil] can be used if necessary. Narcotic pain medications [could be prescribed by a provider].

For folks who do have really severe pain, treatment with an antiviral can also be helpful and that also goes for lesions or rash that can be found in the mouth, which can also cause pain. Home remedies could be a baking soda rinse to something called a magic mouthwash that can be prescribed by a provider in addition to the oral pain medications and potentially the antivirals.

Chávez: So we’re talking about how people can address symptoms that they’re experiencing. What are the best ways for people to reduce their risk of contracting the virus in the first place?

Menza: We can kind of try to put activities to specific risk levels. Things that I would say are unlikely to transmit hMPXV are things like taking public transportation, going out to eat, going to the grocery store, going to have coffee with friends, being in an office with your coworkers and learning in a classroom. Those things are all low risk activities. Hanging out outside at a bar or a club or a cafe, totally low risk activities.

Being in more crowded spaces where there’s less clothing and more skin-to-skin contact, like a bar or club perhaps, that’s where that skin-to-skin contact comes into play. We’ve been trying to message to folks to just consider the amount of skin-to-skin contact you might expect in a situation or a place that you might be or an event that you might be attending.

And then the things that then move up in scale are things that include more prolonged skin-to-skin contact. Like perhaps massaging an area with skin that is affected by hMPXV, or hugging in contact with skin that is affected by hMPXV. Or perhaps cuddling. The other thing is we know that when we talk about respiratory secretions we think about saliva too. So things like kissing or sharing a toothbrush might be a little bit higher risk.

And then the things that have the most risk is when there’s that really direct prolonged skin-to-skin contact with the sores, the scabs or the fluids of the rash.

Chávez: Thank you for breaking that down for us. So this virus has been around for decades. A vaccine already exists, but it is in short supply. How available is this vaccine right now to Oregonians?

Menza: Since July 7, Oregon has received two phases of vaccine allocation. Totaling almost 3,500 doses of vaccine. All but 36 doses of that vaccine are now in the hands of local public health partners, clinical partners, health systems and community-based organizations that are now deploying that vaccine and getting folks who are at greatest risk of being exposed to hMPXV be vaccinated.

What we’re doing is we’re prioritizing three things while vaccine supply is limited. We’re prioritizing folks who have had close contact with someone with hMPXV. We’re prioritizing folks from the most affected communities that may have a greater likelihood of exposure to hMPXV.

[And] we’re taking a pragmatic approach to vaccine delivery. We’re prioritizing first doses of vaccine. If we think about the way that the vaccine has been approved to be administered — it’s a two-dose series, a dose at day zero and then a dose at day 28. Scientific data does show that the immune response to the vaccine is quite robust and quite fast. The goal is to increase community immunity as rapidly as possible and provide as much vaccine to as many people who can benefit as quickly as possible. And what we plan to do is deliver that booster dose that’s typically given four weeks later, perhaps two to three months later to provide that longevity of protection.

Chávez: Right now my understanding is that many of the cases in Oregon have been found in cisgender men who have sex with men. And I’m wondering how you are approaching public health messaging around this — resisting stigmatization and shame and blame while also still targeting those most at risk right now with resources.

Menza: It’s quite the challenge. What we’ve been trying to do as best as we can is stick with what we know.

In the United States, we know that people assigned male at birth who have sex with men and people assigned female at birth, including at least one pregnant person, have been affected by hMPXV in Oregon. We know that cisgender, men and nonbinary people are affected by hMPXV. While most identify as gay or queer and report close contact with people assigned male at birth, we have cases that also identify as straight and bisexual and report close contact with people assigned female at birth.

That being said, it is a challenge because just like you pointed out, we want to use our data to prioritize and drive our outbreak response. So from our perspective, Oregon Health Authority really needs to provide the people most affected including cisgender men who have sex with men, nonbinary folks and folks who identify as gay and bisexual with support care, vaccines and other prevention tools, especially when resources require thoughtful prioritization.

At the same time, we know that anyone can be affected by hMPXV. And so we want to provide a level of awareness to those who may not be affected to quite the degree that gay and queer men who have sex with men are affected. And so at times we do feel caught between how we communicate to the general public and then how we have another channel of communication to folks most affected by hMPXV. And our strategy has been this is to really use our community partners to do a lot of the community engagement and communication to folks who are most affected by hMPXV. Partly because … the messaging is best delivered by folks and organizations who know the communities best. And so our task has been trying to partner as much as possible to listen to those communities and to hear how best we can support [them].

Chávez: I understand there’s a push to change the naming convention for the virus itself and move away from calling it monkeypox. During this conversation, we’ve been referring to it as hMPXV. Why is that push happening?

Menza: The term monkeypox is problematic in a couple of ways. It places blame on other locations for the origin of the illness when right now it’s not affecting the [places] in which it typically circulates. Monkeypox is [also] kind of a misnomer in that the virus itself — we think that the natural hosts are actually rodents and not non-human primates. It just so happened that this virus was discovered in a primate lab and therefore was named for the first animal that humans saw it affect. So scientifically it may not be the most accurate term.

There is a great article by a number of African scientists really trying to promote a naming system and naming convention. And that’s what we’ve adopted at OHA — hMPXV. I know it doesn’t roll off the tongue. But we’re trying to be true to the statements of these African scientists, and their message to the world and to us, about how to message about an outbreak that is really not affecting the countries in which this is typically endemic.

Chávez: If a state of emergency were to be declared in Oregon, what would that mean for state and local response?

Menza: It would potentially free up some funding that we would be able to use to further resource the OHA response to hMPXV. One of the things that we’ve been wrestling with is isolation support. So, folks who have hMPXV may need to isolate for up to four weeks. The isolation period sort of ends when the new healthy skin covers over all of the rash. Wanting to provide financial support during that time, potentially housing support, food support. [A declaration] may free up money to do that.

It may free up money also to do more community engagement, to create a wider bench for folks to bring their expertise to the response. It also might also put pressure on the federal government around vaccine supply and potentially releasing or making more vaccine available more quickly.

Chávez: Do you think we are going to be able to stop this outbreak in Oregon?

Menza: I think it’s too early to tell. We’re working pretty fast here and I think there’s a couple aspects to this that we’re paying attention to. You know we talked about public health communication, but the other part of the community is health care providers and making sure that they are aware that hMPXV is circulating. That, yes, they should be watching out for hMPXV among cisgender and queer men who have sex with men but also among other folks. So not just casting a narrow net, but thinking more broadly because we do know that hMPXV is affecting people outside of those who are most affected.

And then making sure that testing [is available] and reducing barriers to testing. We have both the state public health laboratory online for testing as well as nationally seven commercial laboratories are now offering testing.

On the flip side, we talked about ways that people can protect themselves and think about their activities and potential risk of hMPXV.

But we need all of those things to kind of be working in synergy because probably no one aspect is gonna contain this.

Chávez: Is there anything else important that you want to communicate about hMPXV that I’ve missed?

Menza: Knowledge is power. And we really need to be talking about this. We need to talk to people in our lives, our friends, people we have close contact with including our sex partners. And the other piece is the stigma piece, and there’s no shame in finding out that we have or someone has hMPXV. Many of us are learning we have it because we’re taking proactive steps to look after our health and keep our communities safe.

We know that stigma stops us from accessing healthcare and contacting our sexual partners and it hurts our mental health. The community has really been taking care of themselves and each other and I think that’s an important piece of the community response to hMPXV that OHA is really trying to support.

Chávez: Dr. Menza, thank you so much for being here and talking us through this.

Menza: Thanks so much.