California Monkeypox Cases Plunge 95%, Outbreak Isn’t Over Yet

The number of people testing positive for monkeypox has plunged in California, with the seven-day average of new cases down about 95% since the peak of the outbreak in early August. Though health experts caution that the virus threat hasn’t disappeared, progress in fending it off so far constitutes a major public health success.

The state has made great strides in reducing the spread of infections after about three months of rapid growth, thanks to improved access to vaccines — which were initially in critically short supply — and effective communication to the populations at greatest risk of catching the virus.

“San Francisco is a shining star in all of this response,” said Dr. Peter Chin-Hong, an infectious disease specialist at UCSF. “The messaging here was very specific with interventions people can make.”

But while San Francisco benefited from a strong public health system and community awareness developed during the HIV/AIDS crisis, some areas lack a similar infrastructure for outreach, prevention and treatment.

Monkeypox “is definitely slowing but it’s still out there,” Chin-Hong warned. The decline in new cases has been noteworthy in big cities, where the virus first struck, he said. “But that doesn’t necessarily reflect what’s happening in rural areas.”

Indeed, even as the United States has ramped up vaccinations and public health messaging, the country crossed the threshold of 25,000 monkeypox — also known as MPX — cases this week, according to data from the Centers for Disease Control and Prevention.

The vast majority of U.S. cases have occurred among men who have sex with men, especially those with multiple sexual partners. A recent CDC study showed that monkeypox disproportionately affects individuals with HIV and other sexually transmitted infections. The disease is rarely fatal but can cause painful lesions.

The national seven-day average of cases is down about 50%, from 415 a month ago to 197 last week, but about two-thirds of the cases are now in Black and Latinx men, compared with one-third reported in minority populations earlier in the pandemic. Those communities can be harder for officials to reach.

“A lot of what we are seeing now in the minority population is mirroring what we saw with HIV because of a mixture of stigma and people not coming forward,” Chin-Hong said. “The divide is getting bigger and bigger.”

Nearly 685,000 doses of the monkeypox vaccine had been administered in the U.S. as of last week. On Wednesday, the CDC posted preliminary data from 32 states showing that people who were eligible but did not receive the monkeypox vaccines were about 14 times more likely to become infected than those who completed the two-dose Jynneos vaccine series.

“We have to remind people it’s still here and it’s not over yet,” said Frank Strona, the San Francisco health department’s MPX response lead team. “Only a portion of people have completed their first dose.”

In August, Gov. Gavin Newsom declared a statewide public health emergency in response to the rapid spread of monkeypox. He followed the lead of San Francisco health officials, who drew national attention by declaring a local state of emergency as the city’s LGBTQ residents were forced to wait in hours-long lines to get a vaccination, sometimes to be told there wasn’t any left.

“We took initiative to protect our people,” Strona said. “It was a big visual and audible and social media approach. We also have a long history of HIV work and STD work.”

The city relied on the best practices and community partnerships it developed during the HIV crisis and reinforced with the COVID-19 pandemic, Strona said. San Francisco has been able to set up sites offering vaccine and Tpoxx, the lone drug available to treat monkeypox, at multiple community clinics and public events.

Last weekend, 1,400 vaccinations were administered at the Folsom Street Fair, and the city plans to offer more doses at the Castro Street Fair on Sunday. The CDC’s updated system of fractional dosing has increased availability and liberalized who can get shots, Chin-Hong said.

Ironically, the initial rapid spread among high-risk individuals may also be contributing to the current slowdown. People who got infected over the summer have probably gained lifelong immunity, Chin-Hong said, giving lower-risk individuals who engage in intermittent high-risk behavior now better odds of dodging the virus.

Chin-Hong applauded the public education campaign that has encouraged behavior modification, with 50% of men in the gay/bisexual population reporting fewer sexual partners and one-time sexual contacts. But as evidenced by the COVID pandemic, he said, that’s not a sustainable response.

California has recorded the most cases nationally, with at least 4,886 as of Friday, including 1,936 in Los Angeles County and 788 in San Francisco, according to state data.

During the current outbreak, there have been nine confirmed monkeypox deaths worldwide in countries that have not historically reported monkeypox, including one California resident.

Longer term, it’s too early to predict what will happen in California and the U.S. as new MPX cases continue to decline. The concentration of monkeypox DNA detected at sewer sheds in and around San Francisco has held steady for the past few weeks, suggesting that the virus may have become endemic in the community.

“The fact that we detected it in wastewater is concerning to scientists,” Chin-Hong said. The reality of 200 new cases a day in the U.S. means that “although it’s at half of the peak it’s still there.”

There’s also a risk that the virus could mutate, though not at the rapid pace of COVID. “The more it stays, the more it evolves,” Chin-Hong said. “It could be harder to eradicate.”

For that reason, it is still too soon to declare victory.

San Francisco’s Strona said monkeypox remains a priority for his office and other Bay Area health departments.

“People who aren’t in the at-risk population may not see it as a concern,” he said. “For those who are at risk, it has not gone under the radar. The community who is concerned is well aware of it.”


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