We’re Anu Hazra, a doctor treating monkeypox patients, and Fenit Nirappil, a Washington Post reporter covering the monkeypox outbreak. Ask us anything.

Why is monkeypox no longer in the news?

What percentage of monkeypox patients are gay (ie "men who have sex with men")?

Great questions. Like we have seen with COVID, news coverage can be closely tied rising rates/surges of infections. Rates of new monkeypox (MPX) has been declining in Europe and Canada as well as most large US cities. However several parts of the US still need to ramp up testing and vaccination efforts to continue addressing this outbreak.

The most recent CDC technical report (https://www.cdc.gov/poxvirus/monkeypox/cases-data/technical-report/report-2.html [cdc.gov]) is able to breakdown cases by reported gender and sexual history. Among the nearly 8,000 cases with sexual history data available, 78.9% were men with recent male-to-male sexual contact. Among the nearly 5,000 cases with sexual orientation data available, 93.3% were gay or bisexual men.

- Anu

Hi! I’m Fenit, and I’m a reporter on the Health & Science team. I can tell you my teammates and I are still very much reporting on monkeypox, and personally it’s been my top priority all summer. But I think your point is about the intensity of coverage. Usually we see the highest level of news coverage and interest tied to specific points in an outbreak: When it starts, when it’s declared an emergency and when cases surge. When we write about monkeypox deep in the outbreak, we are trying to offer something new or illuminating to readers rather than repeating what we’ve already reported or providing incremental updates.

My teammates did that recently with a story on how monkeypox and other virus surges this summer reflect the consequences of climate change and news stories about signs of the outbreak slowing nationally and in the D.C. area. I have more in-depth stories in the pipeline I’ve been working on for several weeks, including one about racial equity in vaccination and another about the experiences of monkeypox patients.

- Fenit

Any idea why /r/monkeypox moderators remove news content that dont break subreddit rules in favor of Washington Post articles?

Is a moderator of /r/monkeypox on staff at Washington Post, does Washington Post pay /r/monkeypox moderators to remove normal redditor content in favor of their own, a conflict of interest, some other reason?

This Washington Post AMA was also promoted by /r/monkeypox moderators, the repeated bias is getting hard to ignore

1.) Mods explained their reasoning for the removal

2.) No

3.) No

4.) We reached out to mods about crossposting this AMA about monkeypox because their subreddit is focused on monkeypox

• Angel

Do you anticipate outbreaks on college campuses or other places where many people live in close contact, share laundry facilities, etc?

While Monkeypox can be spread among close household contacts through shared bedding and close contact (such as in a college hostel/dormitory), we have not seen this a primary means of transmission during this current outbreak. When looking at case curves in Europe and Canada, there is no secondary outbreaks noted in these populations. At this time, while most experts remain vigilant, they do not strongly anticipate outbreaks on college campuses.

- Anu

The college question came up at a White House briefing yesterday. Federal officials have been in contact with university administrators and health officials to talk about safer sex messaging and vaccine outreach, but they aren’t bracing for significant campus outbreaks. “Realistically, given the way that this virus is spreading through the population, the risk in those settings is low,” Demetre Daskalakis, the deputy monkeypox response coordinator said. “Awareness is more important than anxiety.”

Still, monkeypox is something colleges are taking seriously, as my colleague Nick Anderson reported last month.

- Fenit

I got the standard dose four weeks ago and the fractional dose today. Is there any real world info on the efficacy of the fractional dose itself? If not, what was the process and basis for giving it the go-ahead?

We have a lack of real world experience with the Jynneos vaccine because we (thankfully) have not needed to use a smallpox/monkeypox vaccine on a wide scale before. However several studies have looked at specifically immune response and safety data related to this vaccine. This published study (https://pubmed.ncbi.nlm.nih.gov/26143613/ [pubmed.ncbi.nlm.nih.gov]) was the first to show that intradermal (ID) administration of the Jynneos vaccine (also known as modified vaccinia Ankara (MVA) vaccine) developed an equal, if not better, immune response than the standard subcutaneous administration. I explained biologically why this is a case under my response to u/noop279 ‘s question.

The New England Journal of Medicine published an excellent perspective last week getting at exactly what’s at the heart of your question (https://www.nejm.org/doi/full/10.1056/NEJMp2211311 [nejm.org]). By using intradermal (ID) administration, we can expand out vaccine stockpile by over five-fold – this is transformative in addressing the ongoing challenges we face in meeting the demand/need for this vaccine in our communities at risk. The decision to move toward ID vaccination was not one made lightly, the CDC weighed the evidence supporting its use as well as population level benefit in maximizing our vaccine supply.

- Anu

To address your question on the process, intradermal shots were made possible by Health and Human Services Secretary Xavier Becerra issuing a declaration allowing emergency use of the existing monkeypox vaccine, a move swiftly followed by the Food and Drug Administration granting emergency authorization for the alternative injection method.

• Fenit

If I were treated with TPOXX, would I be susceptible to catching monkeypox again and if so, when should I get vaccinated? Are there any adverse side effects to being vaccinated soon after infection?

There is no data to suggest that people treated with TPOXX (tecovirimat) would be susceptible to repeat Monkeypox (MPX) infections. From our understanding of other MPX outbreaks around the world, repeat or re-infections was not a phenomenon that was observed. Based on this data, the CDC does not recommended persons who have been diagnosed with MPX after May 2022 to be vaccinated at this time, because recent MPX infection likely confers durable immune protection.

• Anu

Is there anything known currently about the efficacy of the fractional dose vs the standard dose?

I got the standard dose (0.5mL) but didn't get the 'wheal', is that because of the different method used for administration?

Yes, there are two different administration techniques for the Jynneos vaccine which is being used to protect folks from Monkeypox. The standard technique is via subcutaneous (SC) administration where the vaccine goes under your skin into the layer of fat just below it. The dose required for SC vaccination is 0.5mL, you will not experience a “wheal” or “bleb” since it’s a deeper injection. Data shows that another technique via intradermal (ID) administration is able to produce the same immune response as SC administration with a much lower dose of 0.1mL. With ID administration, the vaccine goes just under skin in between its layers. Since this injection is SO close to the surface, you should see a “wheal” or “bleb” if it was administered correctly.

Fun fact: you have TONS of immune cells living in the intradermal area in between your layers of skin, this is what protects us if you get a cut or break in your skin. Because of this high concentration of immune cells, we are able to see such a robust response with a lower vaccine dose with ID vs SC administration. However, because of this, you may experience more of a reaction at the injection site which would include redness, itchiness, and mild swelling. These signs just mean your immune system has recognized the vaccine and is doing its job.

- Anu

Dr. Hazra answered that one so well! I’ll just add a link to this graphic we made explaining the differences between the injection methods: https://www.washingtonpost.com/health/interactive/2022/monkeypox-vaccine-stretch-doses/

-Fenit

Is it really a good thing for people to label it as "the gay virus"?

Absolutely not – the virus, as the White House’s deputy monkeypox response coordinator recently put it, is a piece of DNA wrapped in some fat and doesn’t recognize sexual orientation.

But there is a tension here in balancing the need to warn sexually active gay men that they are at heightened risk for contracting the virus against the potential of stigmatizing a long marginalized group.

This is something I wrestle with as a reporter and as an openly gay man, and I wrote about this early in the outbreak. It’s important to get the word out to my community, and the clear warnings that this is an outbreak that was overwhelmingly affecting men who have sex with men galvanized people to take steps to protect themselves and to watch out for symptoms. It’s also important to not mislead the public into thinking they are at equal risk when the virus is predominantly spreading by intimate close contact during sex and not merely being around a gay person.

The reality is bigots are going to use this outbreak to demonize gay people no matter how we word things in our articles. I fall on the side that it’s better to get accurate information out with the appropriate context, including specifying how the virus transmits and how there’s nothing inherently gay about this virus.

-Fenit

It is wholly inaccurate, stigmatizing, and counterproductive to label monkeypox (MPX) as a “gay virus”. MPX has been documented in humans for nearly half a century and we have seen outbreaks in all types of people and communities. The current 2022 Global MPX Outbreak is disproportionately impacting gay, bisexual, and other men who have sex with men; however nothing about MPX inherently favors any certain sexual orientation or community. It is still important to report and document the communities that are impacted by the virus so we can prioritize resources and biomedical interventions for these communities (much like we did with any outbreak). Balanced but accurate messaging (from medical and journalism folks) is critical in informing the public without perpetuating stigma.

- Anu