Where Did All the Monkeypox Go?

Within months of first hearing about monkeypox spreading outside of endemic areas, Demetre Daskalakis, MD, MPH, was appointed deputy coordinator of the White House Monkeypox Response Team.

MedPage Today sat down with Daskalakis to discuss the transformation the epidemic has been through, from a rocky start with fear and few answers to now just a trickle of cases of what was recently renamed “mpox” in order to reduce stigma and racism.

Testing, vaccination (Jynneos), treatment (tecovirimat, Tpoxx), community cooperation, and a mass targeted communications campaign that was particularly aimed towards LGBTQ+ communities slowed the virus such that the mpox epidemiology (epi) curve has returned to where it was in June. The Biden administration announced last week that mpox will no longer have health emergency status after January.

That progress was not without many bumps in the road.

Stigma, conspiracy theories, and politics were great enemies of the virus from day one. Mpox Clade IIb is most transmissible during human skin-to-skin contact and thus highly transmissible during sex. The community of men who have sex with men (MSM) accounted for more than 95% of cases; and particularly severe cases were found in people co-infected with HIV.

Daskalakis had both pandemic experience as former senior lead on equity in COVID-19 data and engagement for the New York City Department of Health and Mental Hygiene and an “in” with the LGBTQ+ community from his work in HIV prevention and his transparency about being a gay man.

Daskalakis is a self-described “queer health warrior.” As the founder of the Men’s Sexual Health Project, he went to sex clubs and bathhouses to test men for HIV and other sexually transmitted diseases (STDs) to help direct them to treatment. For mpox, that meant getting vaccine to gay events, testing and treating in STD clinics, and meeting people “where they were.” He also tackled equity challenges, particularly in reaching Black and Hispanic communities, and challenges educating health professionals about potential stigma.

Not shying away from a fight with stigma, Daskalakis playfully took part in a campaign endorsing NYC’s promotion of open conversation about sex and drugs between patients and their doctors, posing shirtless for the “Bare it all” campaign, baring his muscles, tattoos, and a big smile.

His bold strokes as a doctor and as a communicator have been both applauded and criticized.

“Don’t be jealous because he also looks better than you with his shirt off,” David Holland, MD, an infectious disease specialist at Emory University in Atlanta, tweeted in response to negative comments about images of Daskalakis clad in a leather harness. “He’s a brilliant scientist, tireless public servant, and has always worked right on the front lines, including this amazing ad campaign.”

The conversation with Daskalakis that follows has been lightly edited, mainly for length. It occurred before the virus was renamed mpox.

What did you carry forward from the HIV and COVID-19 outbreaks into the monkeypox outbreak?

Daskalakis: From the monkeypox perspective, I think that the lessons we learned from the COVID-19 pandemic are that complications are expected; they’re not surprising. You learn that in HIV, and you learn that in COVID. So really, it’s critical to take a proactive intentional path when doing public engagement and addressing the issues right from the start.

With that said, it still didn’t work perfectly for monkeypox.

We still have inequities, and we still have challenges. Some of that is just based on logistics. When you don’t have enough vaccine at the beginning of the outbreak, it’s really a challenge. But I feel like the strategy of trying to increase vaccine [supply] is one of those important equity interventions, along with moving to do testing quicker — that’s a lesson from COVID-19.

I definitely think the messaging is less about the details of what you say and more about the fact that you [as the government-appointed person leading this] need to have humility in terms of what you know and what you don’t know. And so, I feel like that is my mantra from COVID-19 actually, and also for monkeypox: Risk messaging is of critical importance; and being able to sort of say “I know this” and “I don’t know this” and “what I know today is going to be different tomorrow,” that changes everything.

The data show that people are still getting infected after they get the vaccine. Does that reflect the vaccine or behavior?

Daskalakis: None of that is surprising. No vaccine is 100%. We are going to learn more about the vaccine efficacy as we go forward, but I think definitely that post-vaccination infections are to be expected.

It’s not good harm-reduction to expect or to tell people to change their behaviors for life for a virus that is like this.

I always go back to thinking about early HIV and having the desire for people to change their behavior for HIV. It worked for a while. But you would have to get people to change their behaviors for a couple of generations to get rid of HIV. This one [monkeypox], you don’t have to change behaviors for generations; it’s for a few months. Once you build your force field of immunity with vaccines, people can make their own informed decisions about their risk. If I’m still willing to accept any risk, I may cool some of the things I would normally do, but if I’m willing to accept more risk I may not. But I will have some confidence that I have some level of protection. That’s harm reduction. That’s the way to do this.

The second dose of vaccine brings you to a higher level of protection based on lab data. I’m not a vaccine efficacy expert, but we tend to see the epi curve going down. It shows you whatever we have done so far with behavior, and people who have had infections are immune, all those things come together to really get us to a place where we’re controlling this outbreak.

Will we see this virus eradicated?

Daskalakis: I think a long tail is what we can expect. This outbreak went straight up, and it’s going down. Do I think we’re going to get to zero next week? No. Will we have weeks when we get to zero? I think yeah. Not quite yet.

This is where we have to ante up and move faster with the vaccine, because it’s working. We’ve seen some softening in vaccine demand, and so we just need to sort of get the word out and keep magnifying it. This is not the time to back off. The more protection we can get during this peaceful lull, the better we are in long-term infections.

What are the long-term effects of monkeypox infection?

Daskalakis: Definitely there is some concern about long-term scarring, like skin scarring. There’s the potential for scarring in places you don’t want to scar, that can cause urethral and rectum stricture.

But we know this virus is not going to recur. Once it’s gone, it’s gone. We have to watch carefully — there are so many post-viral syndromes people have. It’s super important for us to see longitudinally what happens to folks.

What has been your biggest challenge working in the White House?

Daskalakis: When Bob [Robert Fenton, White House national monkeypox response coordinator] and I started the job, President Biden said, “I really want you to make sure we’re improving the health of men that have sex with men, and especially those of color.”

I was like, “Yes, sir!” I can’t believe I signed up for this. It wasn’t in my bingo cards to be in the White House, so if this is what the boss says, well this is great. This is what I want to do. Let’s do it!

So the biggest challenge has been the normal outbreak stuff — trying to be as transparent as I can with what we know and what we don’t know. Sometimes it’s fraught with complications. What do we know enough about to say? And what don’t we know enough about to say?

In terms of signing up to get what the community needs, I can say with confidence that the Biden administration strategy worked, as demonstrated by our epi curve. But I feel like the fact that the foundation of the response was engagement with the community just tells you that that’s where it all starts.

Do you know of any other country that has approached the epidemic the way the U.S. did, by reaching out to vaccinate the MSM community at gay pride events?

Daskalakis: One of the biggest successes is San Francisco, where they made the magic happen [getting the number of cases down to zero quickly]. The bottom line is getting vaccines out. One of the most important events in my opinion was Black Pride in Atlanta, where we gave 5,000 vaccines and 4,200 injections were administered.

We really try to take strategies to improve equity programmatically but also by addressing some of the important barriers that are experienced, like people saying “I don’t want this mark on my forearm” [out of concern for stigma]. So we worked with the FDA and the CDC and we were able to move to other sites that people can receive vaccine, like the upper back.

I feel like we are kind of unicorns in this. It shows that this is the way to do it.

Did it take too long to decide monkeypox was “like” an STD?

Daskalakis: I feel like we can say with great certainty that monkeypox has been transmitted with close physical contact associated with sex.

From the programmatic perspective, we’re treating it with a syndemic strategy, and the way we’re doing it using sexually-transmitted infection and HIV resources signals so much about the right way to control the outbreak.

It’s really more the “how” than the semantics of it. Every state is able to decide if they want to move it into an STD category. So, for example, New York did that; for some 90-day period, they are calling this an STD, so that there is access to resources already there.

Our signal is to use the HIV infrastructure to address this, and people responded really well to that.

Is there ongoing funding for monkeypox?

Daskalakis: There’s no specific funding that’s been allocated for monkeypox. We sent a supplemental request that wasn’t funded. We need a longitudinal plan.

You’ve advocated home testing. How would home testing affect the ongoing surveillance and statistics on monkeypox?

Daskalakis: I come from that HIV space, where sometimes you have to give up something to be able to make movement in other things. People that are going to order home tests are going to be motivated to action in other ways. And so thinking about HIV home testing, which was the grandparent of COVID-19 home testing, this really shows us how you reach people you’re not going to reach when you have lab-based, provider-only testing.

When you look at the HIV home testing data from the CDC, 26% of the people that ordered a home test had never been tested before. That is way higher than what you would expect.

It’s a “power to the person on the street” issue for me. That’s so important, that if you’re not going to build a testing center where people will come, then if you can get the test to them — even if it causes a little bit of a pause in data or difficulty understanding the data — that home-based testing ends up becoming really important. I feel pretty strongly that you can’t hold the operational and programmatic things that you know can improve your outcomes hostage for perfect data.

The reality is that a multiplex test in the lab is really important for monkeypox, like a point-of-care test. As seen with secondary syphilis, for example, people tend to come to point of care because they’ve got something going on.

For people that may be symptomatic but don’t need to go get clinical care for monkeypox, who don’t want to go into an environment where “Oh! I have to disclose my sexuality, or this disease potentially discloses in some people’s minds my gender identity,” I think there’s high utility in that.