Great piece. But today I choose trollery. I’ve noticed that this public health emergency is not being described in MSM as “penised people” who have sex with other “penised people.”
Given the preciousness around “pregnant people,” I’m interested as to why biological men are not being reduced to to their body parts.
I suspect the situation is substantially worse than outlined here... test positivity rates hover between 30-40%, which is an order of magnitude higher than the threshold for adequate testing. Oh - and that's almost exclusively amongst gay men who have multiple partners. If you don't fall into this category, good luck getting tested for monkeypox - my understanding is that it's almost impossible in most areas unless you can claim direct contact with someone who has already tested positive (especially if you're a woman). This is already spreading through the general population, we're just not looking for it, and in fact we're often actively denying evidence when people who don't fit a narrow demographic show up seeking medical help.
Test positivity rats for straight men, and for women, seem to be much lower. If we were missing lots of cases among them, we would expect their test positivity rates to be higher.
Ooh, sorry I missed this. Been kind of a crazy week. You are correct that test positivity in the UK is lower (so far) which is a good sign for those populations. Unfortunately, in the US this data isn't even being reported on (!?!?!?). So... yeah.
>>The best time to act on building stockpiles and developing logistical plans is before anyone cares. <<
Sure. That would certainly have helped with our current monkeypox problem. But that's a hindsight issue. How many viruses and other communicable diseases should we launch a "crash program" (Matt's words) for, with the vast majority likely to never become a serious public health threat or at least not in the lifespan of the vaccines?
I wasn't thinking about monkeypox back in 2019. Nor was Matt. The West African virologist Matt linked to certainly did warn us of a looming problem, while noting that there had been just eight deaths in NIgeria in the previous four years. But someone is always going to be warning us about something, and sometimes that person turns out to be right but more often not so. Predictions are hard.
I think this post goes astray in castigating us for not doing more about monkeypox earlier or with greater speed and urgency. It wasn't an urgent matter until recently (and still not clear how urgent it is now). A much more useful post would ask how should we approach, and fund, preventative measures for the much much larger range of *potential* healthcare challenges we may -- but mostly won't -- face in the future.
This is one of the major drawbacks of ACAM 2000 btw.
"Skin-to-skin contact with someone who received the live smallpox vaccine can cause a serious infection known as eczema vaccinatum (EV). This infection develops in people who have (or had) eczema.
While EV is very rare today, it is important for anyone who has (or had) eczema to avoid skin-to-skin contact with anyone who receives the live smallpox vaccine. EV can be very serious."
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess one potential difference is how "open" or "closed" the network is. Do jujitsu students usually stay with the same class of people all week, or is it common for people to go to one venue on Tuesdays and another on Saturdays? If people travel for a work trip, how likely are they to go to a class in the other city? (It might not take that many individuals who do this sort of crossing to effectively make it one big network, the way the sexual network is.)
Fair point. I don't think travelers would typically take classes in other cities. Some people might train at more than one school, but the big cross contamination risk would be people who train more than one art. If you do BJJ on Saturdays and MMA on Thursdays, you could spread between schools.
Also, schools are big enough that you probably don't need many such links, as you say. One class is contact with 6-8 people, the next could be a whole different set. People do have regular training partners, but I think people also have regular sexual partners. Do promiscuous people tend to cluster into "pods" with relatively rare inter-pod encounters? Probably not to the same degree that martial artists do, but I don't really know.
The MPH Twiteratti that, *to this day*, giddily tells us to only eat outdoors and never see grandma inside, couldn't be bothered to warn MSM communities to maybe, y'know, skip the piss parties and piggy parties this summer to mitigate community spread. Thanks!
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
Respectfully, as of right now there is crazy scarcity of vaccines (which there shouldn’t be but that’s a different matter) and right now the disease hasn’t spread beyond the msm communities and has not yet reliably been shown to spread in non sexual ways despite it being theoretically possible. It could change of course but until it does someone in your situation getting the scarce vaccine doesn’t make sense for you and would make things worse for everyone because you’d effectively be preventing someone who needs it and is probably orders of magnitude more likely to get infected from getting protection.
Having said all that, I think this is all a good argument to consider opening up the acam2000 for which there isn’t scarcity for volunteers from the broader public. If you’re healthy but concerned you could opt for that. Your individual danger for side effects would be minuscule, you’d get peace of mind and you won’t be taking anyone else’s dose. It’s a shame they don’t give out that option.
I think I will eventually, but I'm still under the impression that the vaccine is in genuinely short supply. We're in a liberal college town with a ton of gay kids, so I do want them to be first up before I take one of their spots. But that's what's frustrating - is there vaccine sitting on the shelves, where we can move to Risk Group #2? I don't know - the messaging isn't there. I'm seeing some friends in public health this weekend and plan to see what they know.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
I had started noticing her byline a few days before she was a guest on Ezra Klein, and then a few days later I started noticing her byline at the Atlantic.
The reluctance to use the ACAM2000 has been short sighted. A high proportion of the at risk community is young and healthy and are fine candidates for this vaccine.
We could have reserved JYNNEOS vaccine for HIV positive individuals; close contacts like children, the elderly, and pregnant women; and perhaps individuals we thought would have low compliance with the aftercare for the ACAM2000 vaccine (as I understand it, you should bandage your vaccine sore).
We will soon be out of JYNNEOS and yet only partially vaccinated the at risk community.
I would have taken the ACAM2000 vaccine and wore my sore as a badge of honor (plus it’s a reliable signal to partners that you’ve been vaccinated).
Is it less unpleasant to get ACAM2000 than to get a mild case of monkeypox? That really hasn’t been made clear to me from the descriptions, since many of the descriptions of ACAM2000 dwell on the “counter indicated for people with immunodeficiency” and don’t spend enough time describing what it’s like to have that open sore for several weeks that could be contagious.
I believe the military uses it in routine vaccinations, so I would wager it is significantly more pleasant than even a mild case of monkeypox.
With all the hyperbole in these comments around the promiscuity and irresponsibility of gay men, perhaps a hot take is the contagious sore isn’t all bad news: if your irresponsible sex partner can’t be bothered to take care of their sore or abstain from sex while it heals, you’d probably rather be exposed to the smallpox vaccine from them instead of monkeypox.
I got it about 12 years ago with the Army and don't remember anything more than a minor annoyance (although since we were training in the swamps of Mississippi at the time, maybe that made it seem less bad by comparison?).
Hmm, I guess that means I'm still somewhat protected, which is nice, and I wonder how many soldiers have been vaccinated over the years? I think it was routine in connection with GWOT deployments, but no longer is (plus the troop numbers deployed to combat zones is much smaller now).
How about we just give the recipe for the vaccine to a drug cartel? If you can get the street value of a dose to 99 bucks, you’d be able to get a dose whenever you need one from your local drug dealer
Will there be non-profit orgs available at the parties to test my drugs to prove that it’s 100% safe and not cut with fentanyl or COVID vaccine or whatever?
"The characteristic raised scar that BCG immunization leaves is often used as proof of prior immunization. This scar must be distinguished from that of smallpox vaccination, which it may resemble. "
Oddly, the procedure is less horrifying than the needle. You can watch a brief video from the CDC, if you like, showing how it is used. (But, trigger warnings, obviously, if you don't like this sort of thing).
The bifurcated needle is not really injected under the skin, it just pokes the surface of the skin.
And it's bifurcated in order to hold the liquid between the prongs (a bit like ink in an old-fashioned pen nib). Neither prong is hollow (as I at first assumed).
Oh god the video looks way worse than a normal vaccine injection. RAPIDLY MAKE FIFTEEN JABS! I expect my needles to go in once and come out once, like the civilized objects they are. This looks like the doctor is trying to stab the patient to death.
Yeah, but they're so shallow and superficial that they are hardly jabs at all -- mere jablets. Jabules. Jabcitos. If they even had cannulae, they would be a cannellini.
I mean, the doc says that one sign of a successful vaccination is that there *may* be a little blood somewhere on the site. Most of those fifteen don't even draw blood!
But then, the difference in our reactions may just go to different flavors of needle-phobia. Would you rather get jabbed once by a horse-size needle, or jabbed fifteen times by duck-sized needles?
Yeah, definitely going with the one horse-sized needle. I can handle anything if it happens once and then it's over. I in fact found the line about the drop of blood horrifying, because "keep stabbing lightly but relentlessly until you see blood" sounds way worse to me than a single hard jab that's guaranteed to draw blood. Thank you, I have learned something about the subtleties of needle-phobia today!
"...I can handle anything if it happens once and then it's over."
That's exactly my philosophy of life. But I don't apply it to individual episodes in life, just life as a whole. It happens once, then it's over -- how bad can it be? I can totally handle it. Or die trying.
1) "Again, to panic is by definition not the right response."
2) "We actually should be panicking about the poor state of our preparedness and public health defenses."
Nah. You were right the first time.
Panicking is still not the right response, even to the poor state of etc. And you know it.
We actually should be <<intensifying our efforts and prioritizing our expenditures to improve>> the poor state of our preparedness and public health defenses.
The catchy kicker is not worth the affront to logic.
I have a big problem with monkeypox (also HIV), and a first reading of your column tends to confirm my concern: There's a flagrantly obvious public health measure perhaps more consequential than the vaccine: What if men who have sex with men could decide to become less promiscuous and try using condoms on a more regular basis? Maybe the gay community could echo this message, instead of focusing exclusively on the vaccine? And focus on self-empowered agency, instead of failures of government?
We focus on government failures because (among other reasons) the government bars us, absent its special dispensation, from purchasing and using the Monkeypox tests, vaccines and antiviral pills. Matt makes this point in the post when he discusses the CDC/FDA's hostility to voluntarism. In other words, even if someone wants to buy tests, the vaccine or pills, with his own money, and someone wanted to sell, the government steps in. You literally cannot take the ACAM2000 vaccine, despite its abundance somewhere in a warehouse. You also cannot order the antiviral pills, unless you have a doctor willing to complete hours of paperwork. The government might have good reasons for obstructing these voluntary transactions. I don't know. But once it obstructs our best ways to address Monkeypox (and testing vaccines drugs are the best ways, in terms of costs and likelihood to work, by a long shot), we rightly hold it responsible for responding to the epidemic.
Also, behavioral messaging is not "more consequential the vaccine." We know this from Covid. Pharmaceutical interventions like vaccines blow non-pharmaceutical interventions like masking out of the water. It's not close!
In terms of "infuriatingness" (if that's a word) you're right. The government has been screwing things up in a manner characteristic of government (a ubiquitous phenomenon that explains Reagan's appeal to much of the electorate). In terms of behavior vs vaccine/therapy, not-so-much. Indeed it's hard to change behavior, and extremely hard for one person to change another's behavior, but at the base of the current epidemic is intimate behavior among men who have sex with men. It's possible (for example) that the disease could be spread by kissing, but other speculated routes of transmission are either rare (e.g. infected needles) or silly.
Americans are entitled to be angry at the government for its poor handling of the looming pandemic. But the infection overwhelmingly has been spread by voluntary behavior among adults. If the virus mutates enough in the context of typical governmental dysfunction and continued disregard for basic sexual hygiene, it may indeed develop new modes of transmission.
You can’t just wish people to have a reaction. You have to figure out what sort of messaging best promotes that reaction, rather than a backlash. How effective would it be for public health officials in early COVID to say, “what if Christians could just decide to stop going to church, and use Zoom on a more regular basis?” If you think of sex as a fun social activity and community building activity that your community does, then cutting down on sex sounds very different than if you think of sex as something that is by default only done with a long term romantic partner.
Your point that messaging style is a crucial part of changing behavior in others is certainly correct. I am neither a public health official, nor a member of the gay community, but I am dismayed that virtually all the monkeypox messaging I have encountered so far focuses on vaccination, not on behavior.
Thanks for the comment; what I said was a bit short on info. Certainly condoms do not guarantee freedom from contagion. There is monkeypox DNA in semen of infected men
https://www.cidrap.umn.edu/news-perspective/2022/07/monkeypox-viral-dna-detected-saliva-semen but unlike HIV, it probably doesn't concentrate there. However, if one ponders the notion of "skin-to-skin contact," it seems likely that prolonged rubbing contact with the skin of the penis is a major mode of transmission, especially considering that the disease has spread overwhelmingly among gay men.
no doubt it depends on multiple physical and biological details. Suggesting that condoms will provide absolute protection is wrong, but it seems likely that condoms will provide some protection.
Mr. Weinberg, I think if you reflect on the likely message people will receive from a "use condoms" campaign, you'll agree it would more likely be A) than B):
A) If you use condoms, you'll be fine.
B) If you use condoms, you're less likely, but still quite likely to contract the disease.
If so, the message would be more likely to increase spread than decrease it.
Of course, you're correct that "less promiscuity" is a justified message to send. However, we know that's a message with limited effectiveness for large segments of *all* kinds of people. I doubt there is anyone hearing of the evidence about monkeypox as an STD does not grasp the corollary instantly. The problem with promoting self-empowered agency is that most of us have difficulty sustaining behavior that prioritizes long-term rewards over short-term ones--we can't handle it when it comes to obesity, and sex drives are often more powerful than the urge for marzipan.
I generally agree. I'm not sure whether this discussion is how most effectively to craft a public service message, or how most effectively to conceptualize the disease. As a biologist, I'm pretty clueless about messaging, not-so-much about diseases and how they spread.
You would think, based on this characterization, that the people who complained about the Covid response in 2020 being too heavy-handed would be super-excited about how the public health establishment has responded to their concerns and corrected course in 2022.
And, of course, you would be totally wrong, because that's not really what it was about.
I'm pretty unconvinced that the debate then or now being had in the public at-large is, fundamentally, a "public health" debate. Like, I think that is a category error. What we mostly have is a front in the larger culture / politics war with vague public health features. Weirdly, that is happening alongside and interwoven with a bunch of actual policy and technical debates, and those are also interwoven with political questions about funding, agency structure, etc., which is why I think the whole thing is totally f*cked.
But I am unpersuaded that a slightly different set of statements made by...who? precisely? is always a really interesting question...but I am unpersuaded that a different set of public statements made at the beginning of Pride would have appreciably altered this outbreak event. A big part of the whole problem with Covid is that everyone has way, way, way overestimated the power and significance of messaging to change outcomes in the real world. You have to do concrete stuff in the world, which we were pretty unprepared to do two months ago (and that is a real indictment of our society / politics / agencies / voters / all of us who can get sick, which is, you know, all of us).
I do think that if local STD testing sites that have strong relationships with the gay community had sent someone to each of the bars and bathhouses, with some sort of relatively neutral informational flyer to put up, that could have helped a bit. And it would also be helpful if Grindr sent out popup messages about it a bit more often (I've received two in the past few months - I forget if it's when I was traveling to bigger cities, which would be a nice sign of them targeting it to locations).
Totally agree. I would classify those kinds of interventions--targeted outreach--more in the way of "doing concrete stuff on the ground" than in the way of "messaging." I think of "messaging" as what you see on official social media feeds and in mass media outlets. But that's probably being hair-splitty, on my part.
I think of messaging as activities that are extremely low-cost, in the way that calling a reporter or holding a press conference is low cost. Good targeted outreach is often actually a lot of work, much of it done prior to the emergency (i.e. developing relationships with the relevant local communities--the gay community in this case, but I'm sure you can imagine ten others of interest for different situations).
Satire always introduces illegitimate elements to get the laugh, but I also think there's not much to the underlying complaint. 2020 involved a highly lethal, extremely contagious disease, and highly generalized behaviors that applied to a universal population. 2022 involves a very low lethality, low-contagion disease, and specific behaviors that at this point are largely relevant to a restricted, generally stigmatized population.
Comments along these lines (there was another one here I can't locate anymore which reference shutting down churches) seem to me to take the focus away from substantive failures, such as the ones Matt emphasizes, in order to trot out caricatures useful in dead-end culture-war battles.
I don't think that statement is likely correct, James, but if you have some basis for it I'm willing to change my mind.
The fatality rate for Covid cases in the US has been a little over 1%. Worldwide it has varied, by country, from below 0.5% up to over 5%. I presume the variance has to do with availability of treatment and comprehensiveness of case reporting, though since the two factors would tend to vary in parallel I'm not sure how the impact would manifest.
Today's (8/3 data) CDC count of US monkeypox cases stands at 6,600+ (https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html), but so far we have seen no fatalities, according to latest reports. Less certainly reliable online figures, a few days old, are for just over 16,000 cases worldwide, with nine fatalities.
Secondary question -- of those infected in the US, how many were already vaccinated for smallpox, or were able to get vaccinated in the 4 day post-exposure window where getting vaccinated is expected to offer a substantial protective effect?
"CDC recommends that the vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease."
US excess mortality over the period in question was about 114,000 higher than 1.06 million, so the # of reported COVID deaths can be taken as a reasonable estimate of the number of COVID deaths*, whereas it is known that the # of confirmed COVID cases is an underestimate of the # of COVID cases by some unknown but larger factor (2-4, probably, once re-infections are taken into account).
It's still too early in the monkeypox pandemic to get a good sense of the fatality of this particular strain because it emerged so recently. The best estimate we have for it is that the case fatality rate is 3.5% in Nigeria, based on the past 5 years of data:
"In May 2022, the Nigerian government released a report stating that between 2017 and 2022, 558 cases were confirmed across 32 states and the Federal Capital Territory. The Rivers State was the most affected by monkeypox followed by Bayelsa and Lagos. There were 8 deaths reported, making for a 3.5% Case Fatality Ratio."
Now, it's certainly possible that this particular virus will exhibit a large discrepancy in lethality where it's less lethal in first world hospitals settings and more lethal in poor countries, since that was the case for many other diseases. However, it's also possible that it will instead exhibit the same pattern as COVID and have a death rate that is overwhelmingly concentrated among the old and infirm, and its CFR is artificially low right now because the population of young gay men who go to a lot of parties are unusually young, thin, and fit compared to the general population.
*Note that excess mortality has been zero for the past month or two despite there still being ~400 covid deaths per day, indicating that people are dying *with* COVID rather than *of* COVID at this point
Thanks for replying with data, James. As James C. points out, the rate from Nigerian data is actually 1.4%. It seems to me that the best comparator to select in order to assess this data in comparison to Covid would be the Nigerian Covid case fatality rate, which was 1.2% (Johns Hopkins data). We do not know the likely undercount for either disease, but the variables are, at least, steady in terms the social, medical, and governmental contexts.
Some Covid deaths have always been "with" rather than "of," as is true, I suppose, of any infectious disease and its fatality rate. I'll second what James C. wrote about lags in complete death record tabulations.
Your question about the impact of a preexisting vaccine lowering fatality rates is valid. However, if the result would be an unknown number of cases where a fatality that would have occurred did not, because of weakened symptoms (artificially lowering the "natural" fatality rate), it could also include an unknown number of cases where symptoms never manifested because of vaccine effectiveness (artificially raising the natural worldwide fatality rate, and, potentially the US rate, if US fatalities occur).
See my note to John about complete death record tabulation.
If we use Nigerian numbers only for both monkeypox and COVID, then we'd both need to amend our initial statements. 1.4% is not 2x 1.2%, so my original claim would need to be changed, but 1.4% is greater than 1.2%, which means that rather than covid being "highly lethal" and monkeypox being "low lethality", monkeypox is "slightly more lethal than covid"
Also, at first glance, the 3.5% CFR seems to come out of no where. From the numbers given, 8/558 = 1.4%. When I followed the citation on wikipedia, it appears they got it because only 230 cases were confirmed, which is obviously a large undercount.
You're no doubt correct that differences in the populations infected are going to confound the CFR anyway, but I'm not sure that will change dramatically over time given their relative transmissibility.
If 1.4% was the true rate, it would still be a >2x higher CFR than COVID (~0.5%).
However, there's also no guarantee that 558 is the correct number of cases, so it's possible that monkeypox's CFR is lower, possibly quite a bit lower.
IIRC, excess mortality stats have a noticeable lag, so I don't think you can't trust them for the last month (it's been at least a year since I looked into this, so I can't remember where I came across that info). I wouldn't be surprised if some COVID deaths are *with* rather than *of* though.
Their last reported number is for June 7th, 2022, and excess mortality has been ~negligible for the period from March 8th to June 7th 2022 by their data.
Two months to collect the data for June sounds reasonable, and March is 5 months ago.
I don't really understand what the "that" and "it" are in your second sentence, Emily, but I certainly get the point of your first sentence. Sure: all the things Matt writes about concerning our missed opportunity are true. But those don't include failing to issue mandates that would have prevented, for example, risky behavior during Pride--the legal hurdles for local government to target conduct involving gay men are insurmountable (justifiably). I certainly saw messaging that warned about transmission through sexual contact early on, and on the messaging front I don't know what more we should have asked for.
The big thing I think we could have asked for is local STD testing clinics to reach out to local gay bars and bathhouses where they have established relationships, and gotten them to put up informational flyers. I don't recall seeing any in early June, and I may not have been to any relevant venues recently, so it's possible they have.
Agreed.
"The CDC did a great job during COVID" would be the greatest #slatepitch of all time.
Try this one crazy trick.
Don’t have sex with anyone who you haven’t been exclusive with for a month or more.
Or just don’t have sex with strangers until the vaccine rollout gets going. COVID restrictions were way more onerous, and we all put up with them.
Great piece. But today I choose trollery. I’ve noticed that this public health emergency is not being described in MSM as “penised people” who have sex with other “penised people.”
Given the preciousness around “pregnant people,” I’m interested as to why biological men are not being reduced to to their body parts.
I suspect the situation is substantially worse than outlined here... test positivity rates hover between 30-40%, which is an order of magnitude higher than the threshold for adequate testing. Oh - and that's almost exclusively amongst gay men who have multiple partners. If you don't fall into this category, good luck getting tested for monkeypox - my understanding is that it's almost impossible in most areas unless you can claim direct contact with someone who has already tested positive (especially if you're a woman). This is already spreading through the general population, we're just not looking for it, and in fact we're often actively denying evidence when people who don't fit a narrow demographic show up seeking medical help.
Test positivity rats for straight men, and for women, seem to be much lower. If we were missing lots of cases among them, we would expect their test positivity rates to be higher.
Ooh, sorry I missed this. Been kind of a crazy week. You are correct that test positivity in the UK is lower (so far) which is a good sign for those populations. Unfortunately, in the US this data isn't even being reported on (!?!?!?). So... yeah.
>>The best time to act on building stockpiles and developing logistical plans is before anyone cares. <<
Sure. That would certainly have helped with our current monkeypox problem. But that's a hindsight issue. How many viruses and other communicable diseases should we launch a "crash program" (Matt's words) for, with the vast majority likely to never become a serious public health threat or at least not in the lifespan of the vaccines?
I wasn't thinking about monkeypox back in 2019. Nor was Matt. The West African virologist Matt linked to certainly did warn us of a looming problem, while noting that there had been just eight deaths in NIgeria in the previous four years. But someone is always going to be warning us about something, and sometimes that person turns out to be right but more often not so. Predictions are hard.
I think this post goes astray in castigating us for not doing more about monkeypox earlier or with greater speed and urgency. It wasn't an urgent matter until recently (and still not clear how urgent it is now). A much more useful post would ask how should we approach, and fund, preventative measures for the much much larger range of *potential* healthcare challenges we may -- but mostly won't -- face in the future.
This is one of the major drawbacks of ACAM 2000 btw.
"Skin-to-skin contact with someone who received the live smallpox vaccine can cause a serious infection known as eczema vaccinatum (EV). This infection develops in people who have (or had) eczema.
While EV is very rare today, it is important for anyone who has (or had) eczema to avoid skin-to-skin contact with anyone who receives the live smallpox vaccine. EV can be very serious."
Niche complaint but the focus on male/male sexual encounters may also cause people to overlook other activities as risky. Martial arts are what I'm thinking of here - a jujitsu student can be in close contact with maybe 6 or 8 people a class, 2 or 3 classes a week... I don't know exactly how promiscuous promiscuous people are, but that has to be in the same ballpark, right?
Niche conspiracy theory: both recent pandemics were engineered by The Illuminati specifically to prevent me from getting back on the mats.
I guess one potential difference is how "open" or "closed" the network is. Do jujitsu students usually stay with the same class of people all week, or is it common for people to go to one venue on Tuesdays and another on Saturdays? If people travel for a work trip, how likely are they to go to a class in the other city? (It might not take that many individuals who do this sort of crossing to effectively make it one big network, the way the sexual network is.)
Fair point. I don't think travelers would typically take classes in other cities. Some people might train at more than one school, but the big cross contamination risk would be people who train more than one art. If you do BJJ on Saturdays and MMA on Thursdays, you could spread between schools.
Also, schools are big enough that you probably don't need many such links, as you say. One class is contact with 6-8 people, the next could be a whole different set. People do have regular training partners, but I think people also have regular sexual partners. Do promiscuous people tend to cluster into "pods" with relatively rare inter-pod encounters? Probably not to the same degree that martial artists do, but I don't really know.
The MPH Twiteratti that, *to this day*, giddily tells us to only eat outdoors and never see grandma inside, couldn't be bothered to warn MSM communities to maybe, y'know, skip the piss parties and piggy parties this summer to mitigate community spread. Thanks!
I found myself smugly brushing off the monkeypox threat, since I don't cheat on my wife, until I realized that my bi-weekly jiu jitsu class is essentially a worst case scenario if any of my dozens of training partners get it. I'd imagine similar risks exist in tons of martial arts and contact sports (as ringworm, staph, etc. always have). I'm frustrated that I am not vaccine eligible according to my county health dept. because I don't bang random dudes, when I do spend a few hours a week rolling around with them, sweatily trying to murder each other. Seems like another failure of imagination / blind spot from health authorities.
Respectfully, as of right now there is crazy scarcity of vaccines (which there shouldn’t be but that’s a different matter) and right now the disease hasn’t spread beyond the msm communities and has not yet reliably been shown to spread in non sexual ways despite it being theoretically possible. It could change of course but until it does someone in your situation getting the scarce vaccine doesn’t make sense for you and would make things worse for everyone because you’d effectively be preventing someone who needs it and is probably orders of magnitude more likely to get infected from getting protection.
Having said all that, I think this is all a good argument to consider opening up the acam2000 for which there isn’t scarcity for volunteers from the broader public. If you’re healthy but concerned you could opt for that. Your individual danger for side effects would be minuscule, you’d get peace of mind and you won’t be taking anyone else’s dose. It’s a shame they don’t give out that option.
I think I will eventually, but I'm still under the impression that the vaccine is in genuinely short supply. We're in a liberal college town with a ton of gay kids, so I do want them to be first up before I take one of their spots. But that's what's frustrating - is there vaccine sitting on the shelves, where we can move to Risk Group #2? I don't know - the messaging isn't there. I'm seeing some friends in public health this weekend and plan to see what they know.
Jerusalem Demsas keeps hitting it out of the park. You should have her as a guest blogger.
Also, in many of the discussions of ACAM2000, it’s been unclear to me just *how* unpleasant it is. Is it as bad as actually getting monkeypox? The descriptions seem compatible with that.
I had just written "If I were Vox I'd really make sure she doesn't leave too" but https://www.theatlantic.com/press-releases/archive/2022/02/jerusalem-demsas-joins-atlantic-staff-writer/622093/
I had started noticing her byline a few days before she was a guest on Ezra Klein, and then a few days later I started noticing her byline at the Atlantic.
The reluctance to use the ACAM2000 has been short sighted. A high proportion of the at risk community is young and healthy and are fine candidates for this vaccine.
We could have reserved JYNNEOS vaccine for HIV positive individuals; close contacts like children, the elderly, and pregnant women; and perhaps individuals we thought would have low compliance with the aftercare for the ACAM2000 vaccine (as I understand it, you should bandage your vaccine sore).
We will soon be out of JYNNEOS and yet only partially vaccinated the at risk community.
I would have taken the ACAM2000 vaccine and wore my sore as a badge of honor (plus it’s a reliable signal to partners that you’ve been vaccinated).
Is it less unpleasant to get ACAM2000 than to get a mild case of monkeypox? That really hasn’t been made clear to me from the descriptions, since many of the descriptions of ACAM2000 dwell on the “counter indicated for people with immunodeficiency” and don’t spend enough time describing what it’s like to have that open sore for several weeks that could be contagious.
I believe the military uses it in routine vaccinations, so I would wager it is significantly more pleasant than even a mild case of monkeypox.
With all the hyperbole in these comments around the promiscuity and irresponsibility of gay men, perhaps a hot take is the contagious sore isn’t all bad news: if your irresponsible sex partner can’t be bothered to take care of their sore or abstain from sex while it heals, you’d probably rather be exposed to the smallpox vaccine from them instead of monkeypox.
Edit: This journal article covers the risks of vaccination and the risks of the contagious vaccine sores pretty well: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069029/
I got it about 12 years ago with the Army and don't remember anything more than a minor annoyance (although since we were training in the swamps of Mississippi at the time, maybe that made it seem less bad by comparison?).
Hmm, I guess that means I'm still somewhat protected, which is nice, and I wonder how many soldiers have been vaccinated over the years? I think it was routine in connection with GWOT deployments, but no longer is (plus the troop numbers deployed to combat zones is much smaller now).
How about we just give the recipe for the vaccine to a drug cartel? If you can get the street value of a dose to 99 bucks, you’d be able to get a dose whenever you need one from your local drug dealer
Lol
Will there be non-profit orgs available at the parties to test my drugs to prove that it’s 100% safe and not cut with fentanyl or COVID vaccine or whatever?
That seems like a solvable problem 😂
I’m here to serve
We're just going to not talk about that two-pronged needle thing?
https://en.wikipedia.org/wiki/ACAM2000#/media/File:Smallpox_vaccination_needle.jpg
Yeah, let's just not talk about it.
If you think that's bad, take a look at how the BCG tuberculosis vaccine is administered:
https://en.wikipedia.org/wiki/BCG_vaccine#/media/File:BCG_apparatus_ja2.jpg
Nine short needles once, or one short needle 15 times? More choices to face!
Sounds like both leave a mark:
"The characteristic raised scar that BCG immunization leaves is often used as proof of prior immunization. This scar must be distinguished from that of smallpox vaccination, which it may resemble. "
You young'uns are getting soft. I had that thing when I was five, and I didn't even cry.
It was the price of being allowed to go to school, and I really wanted to start school.
Yeah, my dad still has the scar on his arm but he says it was not a big deal.
Oddly, the procedure is less horrifying than the needle. You can watch a brief video from the CDC, if you like, showing how it is used. (But, trigger warnings, obviously, if you don't like this sort of thing).
https://www.youtube.com/watch?v=ZAqnsFa3VQ0
The bifurcated needle is not really injected under the skin, it just pokes the surface of the skin.
And it's bifurcated in order to hold the liquid between the prongs (a bit like ink in an old-fashioned pen nib). Neither prong is hollow (as I at first assumed).
Oh god the video looks way worse than a normal vaccine injection. RAPIDLY MAKE FIFTEEN JABS! I expect my needles to go in once and come out once, like the civilized objects they are. This looks like the doctor is trying to stab the patient to death.
"...FIFTEEN JABS!"
Yeah, but they're so shallow and superficial that they are hardly jabs at all -- mere jablets. Jabules. Jabcitos. If they even had cannulae, they would be a cannellini.
I mean, the doc says that one sign of a successful vaccination is that there *may* be a little blood somewhere on the site. Most of those fifteen don't even draw blood!
But then, the difference in our reactions may just go to different flavors of needle-phobia. Would you rather get jabbed once by a horse-size needle, or jabbed fifteen times by duck-sized needles?
Yeah, definitely going with the one horse-sized needle. I can handle anything if it happens once and then it's over. I in fact found the line about the drop of blood horrifying, because "keep stabbing lightly but relentlessly until you see blood" sounds way worse to me than a single hard jab that's guaranteed to draw blood. Thank you, I have learned something about the subtleties of needle-phobia today!
"...I can handle anything if it happens once and then it's over."
That's exactly my philosophy of life. But I don't apply it to individual episodes in life, just life as a whole. It happens once, then it's over -- how bad can it be? I can totally handle it. Or die trying.
1) "Again, to panic is by definition not the right response."
2) "We actually should be panicking about the poor state of our preparedness and public health defenses."
Nah. You were right the first time.
Panicking is still not the right response, even to the poor state of etc. And you know it.
We actually should be <<intensifying our efforts and prioritizing our expenditures to improve>> the poor state of our preparedness and public health defenses.
The catchy kicker is not worth the affront to logic.
I have a big problem with monkeypox (also HIV), and a first reading of your column tends to confirm my concern: There's a flagrantly obvious public health measure perhaps more consequential than the vaccine: What if men who have sex with men could decide to become less promiscuous and try using condoms on a more regular basis? Maybe the gay community could echo this message, instead of focusing exclusively on the vaccine? And focus on self-empowered agency, instead of failures of government?
We focus on government failures because (among other reasons) the government bars us, absent its special dispensation, from purchasing and using the Monkeypox tests, vaccines and antiviral pills. Matt makes this point in the post when he discusses the CDC/FDA's hostility to voluntarism. In other words, even if someone wants to buy tests, the vaccine or pills, with his own money, and someone wanted to sell, the government steps in. You literally cannot take the ACAM2000 vaccine, despite its abundance somewhere in a warehouse. You also cannot order the antiviral pills, unless you have a doctor willing to complete hours of paperwork. The government might have good reasons for obstructing these voluntary transactions. I don't know. But once it obstructs our best ways to address Monkeypox (and testing vaccines drugs are the best ways, in terms of costs and likelihood to work, by a long shot), we rightly hold it responsible for responding to the epidemic.
Also, behavioral messaging is not "more consequential the vaccine." We know this from Covid. Pharmaceutical interventions like vaccines blow non-pharmaceutical interventions like masking out of the water. It's not close!
In terms of "infuriatingness" (if that's a word) you're right. The government has been screwing things up in a manner characteristic of government (a ubiquitous phenomenon that explains Reagan's appeal to much of the electorate). In terms of behavior vs vaccine/therapy, not-so-much. Indeed it's hard to change behavior, and extremely hard for one person to change another's behavior, but at the base of the current epidemic is intimate behavior among men who have sex with men. It's possible (for example) that the disease could be spread by kissing, but other speculated routes of transmission are either rare (e.g. infected needles) or silly.
Americans are entitled to be angry at the government for its poor handling of the looming pandemic. But the infection overwhelmingly has been spread by voluntary behavior among adults. If the virus mutates enough in the context of typical governmental dysfunction and continued disregard for basic sexual hygiene, it may indeed develop new modes of transmission.
https://www.nytimes.com/2022/08/04/opinion/monkeypox-communication.html
You can’t just wish people to have a reaction. You have to figure out what sort of messaging best promotes that reaction, rather than a backlash. How effective would it be for public health officials in early COVID to say, “what if Christians could just decide to stop going to church, and use Zoom on a more regular basis?” If you think of sex as a fun social activity and community building activity that your community does, then cutting down on sex sounds very different than if you think of sex as something that is by default only done with a long term romantic partner.
Your point that messaging style is a crucial part of changing behavior in others is certainly correct. I am neither a public health official, nor a member of the gay community, but I am dismayed that virtually all the monkeypox messaging I have encountered so far focuses on vaccination, not on behavior.
There has been a fair amount of messaging focused on changing behavior as well. Hell, Dan Savage released a special episode of his podcast specifically talking about how the community needs to be careful right now to help prevent Monkeypox from becoming endemic: https://savage.love/lovecast/2022/07/27/how-to-not-get-monkeypox-with-dr-carlton-thomas/
That's reassuring and reflects my ignorance, but I still think the behavioral messaging has been largely submerged by the vaccine issue.
If random sex with strangers is now a “community building activity”, I finally found a situation where I support less building activity.
From what I can tell, condoms are not effective in preventing monkeypox spread.
https://www.towerhamlets.gov.uk/FAQs/Monkeypox/P-Do-condoms-prevent-you-catching-or-passing-on-monkeypox.aspx
Thanks for the comment; what I said was a bit short on info. Certainly condoms do not guarantee freedom from contagion. There is monkeypox DNA in semen of infected men
https://www.cidrap.umn.edu/news-perspective/2022/07/monkeypox-viral-dna-detected-saliva-semen but unlike HIV, it probably doesn't concentrate there. However, if one ponders the notion of "skin-to-skin contact," it seems likely that prolonged rubbing contact with the skin of the penis is a major mode of transmission, especially considering that the disease has spread overwhelmingly among gay men.
The condom only covers a small fraction of the skin that is in contact.
no doubt it depends on multiple physical and biological details. Suggesting that condoms will provide absolute protection is wrong, but it seems likely that condoms will provide some protection.
Mr. Weinberg, I think if you reflect on the likely message people will receive from a "use condoms" campaign, you'll agree it would more likely be A) than B):
A) If you use condoms, you'll be fine.
B) If you use condoms, you're less likely, but still quite likely to contract the disease.
If so, the message would be more likely to increase spread than decrease it.
Of course, you're correct that "less promiscuity" is a justified message to send. However, we know that's a message with limited effectiveness for large segments of *all* kinds of people. I doubt there is anyone hearing of the evidence about monkeypox as an STD does not grasp the corollary instantly. The problem with promoting self-empowered agency is that most of us have difficulty sustaining behavior that prioritizes long-term rewards over short-term ones--we can't handle it when it comes to obesity, and sex drives are often more powerful than the urge for marzipan.
I generally agree. I'm not sure whether this discussion is how most effectively to craft a public service message, or how most effectively to conceptualize the disease. As a biologist, I'm pretty clueless about messaging, not-so-much about diseases and how they spread.
This is from Kat Rosenfield last week:
2020 public health: cover your disgusting face holes and stay the fuck home you bunch of selfish troglodytes
2022 public health: maybe just put a lil gauze on your monkeypox boils before your orgy, y’know, if you feel like it
incredibly selective right wing grievance mongering at work
You would think, based on this characterization, that the people who complained about the Covid response in 2020 being too heavy-handed would be super-excited about how the public health establishment has responded to their concerns and corrected course in 2022.
And, of course, you would be totally wrong, because that's not really what it was about.
I'm pretty unconvinced that the debate then or now being had in the public at-large is, fundamentally, a "public health" debate. Like, I think that is a category error. What we mostly have is a front in the larger culture / politics war with vague public health features. Weirdly, that is happening alongside and interwoven with a bunch of actual policy and technical debates, and those are also interwoven with political questions about funding, agency structure, etc., which is why I think the whole thing is totally f*cked.
But I am unpersuaded that a slightly different set of statements made by...who? precisely? is always a really interesting question...but I am unpersuaded that a different set of public statements made at the beginning of Pride would have appreciably altered this outbreak event. A big part of the whole problem with Covid is that everyone has way, way, way overestimated the power and significance of messaging to change outcomes in the real world. You have to do concrete stuff in the world, which we were pretty unprepared to do two months ago (and that is a real indictment of our society / politics / agencies / voters / all of us who can get sick, which is, you know, all of us).
I do think that if local STD testing sites that have strong relationships with the gay community had sent someone to each of the bars and bathhouses, with some sort of relatively neutral informational flyer to put up, that could have helped a bit. And it would also be helpful if Grindr sent out popup messages about it a bit more often (I've received two in the past few months - I forget if it's when I was traveling to bigger cities, which would be a nice sign of them targeting it to locations).
Totally agree. I would classify those kinds of interventions--targeted outreach--more in the way of "doing concrete stuff on the ground" than in the way of "messaging." I think of "messaging" as what you see on official social media feeds and in mass media outlets. But that's probably being hair-splitty, on my part.
I think of messaging as activities that are extremely low-cost, in the way that calling a reporter or holding a press conference is low cost. Good targeted outreach is often actually a lot of work, much of it done prior to the emergency (i.e. developing relationships with the relevant local communities--the gay community in this case, but I'm sure you can imagine ten others of interest for different situations).
Satire always introduces illegitimate elements to get the laugh, but I also think there's not much to the underlying complaint. 2020 involved a highly lethal, extremely contagious disease, and highly generalized behaviors that applied to a universal population. 2022 involves a very low lethality, low-contagion disease, and specific behaviors that at this point are largely relevant to a restricted, generally stigmatized population.
Comments along these lines (there was another one here I can't locate anymore which reference shutting down churches) seem to me to take the focus away from substantive failures, such as the ones Matt emphasizes, in order to trot out caricatures useful in dead-end culture-war battles.
Monkeypox in its current iteration is probably more lethal than COVID-19 by a factor of 2-4.
I don't think that statement is likely correct, James, but if you have some basis for it I'm willing to change my mind.
The fatality rate for Covid cases in the US has been a little over 1%. Worldwide it has varied, by country, from below 0.5% up to over 5%. I presume the variance has to do with availability of treatment and comprehensiveness of case reporting, though since the two factors would tend to vary in parallel I'm not sure how the impact would manifest.
Today's (8/3 data) CDC count of US monkeypox cases stands at 6,600+ (https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html), but so far we have seen no fatalities, according to latest reports. Less certainly reliable online figures, a few days old, are for just over 16,000 cases worldwide, with nine fatalities.
Secondary question -- of those infected in the US, how many were already vaccinated for smallpox, or were able to get vaccinated in the 4 day post-exposure window where getting vaccinated is expected to offer a substantial protective effect?
"CDC recommends that the vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease."
https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html
According to https://www.worldometers.info/coronavirus/country/us/, the US has experienced 1,057,239 COVID deaths out of 93,593,214 confirmed cases.
US excess mortality over the period in question was about 114,000 higher than 1.06 million, so the # of reported COVID deaths can be taken as a reasonable estimate of the number of COVID deaths*, whereas it is known that the # of confirmed COVID cases is an underestimate of the # of COVID cases by some unknown but larger factor (2-4, probably, once re-infections are taken into account).
https://ourworldindata.org/grapher/excess-mortality-raw-death-count?country=~USA
So that gives a CFR of more like 0.5%
It's still too early in the monkeypox pandemic to get a good sense of the fatality of this particular strain because it emerged so recently. The best estimate we have for it is that the case fatality rate is 3.5% in Nigeria, based on the past 5 years of data:
"In May 2022, the Nigerian government released a report stating that between 2017 and 2022, 558 cases were confirmed across 32 states and the Federal Capital Territory. The Rivers State was the most affected by monkeypox followed by Bayelsa and Lagos. There were 8 deaths reported, making for a 3.5% Case Fatality Ratio."
https://en.wikipedia.org/wiki/Monkeypox#2022_outbreak
Now, it's certainly possible that this particular virus will exhibit a large discrepancy in lethality where it's less lethal in first world hospitals settings and more lethal in poor countries, since that was the case for many other diseases. However, it's also possible that it will instead exhibit the same pattern as COVID and have a death rate that is overwhelmingly concentrated among the old and infirm, and its CFR is artificially low right now because the population of young gay men who go to a lot of parties are unusually young, thin, and fit compared to the general population.
*Note that excess mortality has been zero for the past month or two despite there still being ~400 covid deaths per day, indicating that people are dying *with* COVID rather than *of* COVID at this point
Thanks for replying with data, James. As James C. points out, the rate from Nigerian data is actually 1.4%. It seems to me that the best comparator to select in order to assess this data in comparison to Covid would be the Nigerian Covid case fatality rate, which was 1.2% (Johns Hopkins data). We do not know the likely undercount for either disease, but the variables are, at least, steady in terms the social, medical, and governmental contexts.
Some Covid deaths have always been "with" rather than "of," as is true, I suppose, of any infectious disease and its fatality rate. I'll second what James C. wrote about lags in complete death record tabulations.
Your question about the impact of a preexisting vaccine lowering fatality rates is valid. However, if the result would be an unknown number of cases where a fatality that would have occurred did not, because of weakened symptoms (artificially lowering the "natural" fatality rate), it could also include an unknown number of cases where symptoms never manifested because of vaccine effectiveness (artificially raising the natural worldwide fatality rate, and, potentially the US rate, if US fatalities occur).
See my note to John about complete death record tabulation.
If we use Nigerian numbers only for both monkeypox and COVID, then we'd both need to amend our initial statements. 1.4% is not 2x 1.2%, so my original claim would need to be changed, but 1.4% is greater than 1.2%, which means that rather than covid being "highly lethal" and monkeypox being "low lethality", monkeypox is "slightly more lethal than covid"
Also, at first glance, the 3.5% CFR seems to come out of no where. From the numbers given, 8/558 = 1.4%. When I followed the citation on wikipedia, it appears they got it because only 230 cases were confirmed, which is obviously a large undercount.
https://www.premiumtimesng.com/news/top-news/528825-monkeypox-nigeria-records-558-cases-eight-deaths-in-five-years.html
You're no doubt correct that differences in the populations infected are going to confound the CFR anyway, but I'm not sure that will change dramatically over time given their relative transmissibility.
If 1.4% was the true rate, it would still be a >2x higher CFR than COVID (~0.5%).
However, there's also no guarantee that 558 is the correct number of cases, so it's possible that monkeypox's CFR is lower, possibly quite a bit lower.
IIRC, excess mortality stats have a noticeable lag, so I don't think you can't trust them for the last month (it's been at least a year since I looked into this, so I can't remember where I came across that info). I wouldn't be surprised if some COVID deaths are *with* rather than *of* though.
Their last reported number is for June 7th, 2022, and excess mortality has been ~negligible for the period from March 8th to June 7th 2022 by their data.
Two months to collect the data for June sounds reasonable, and March is 5 months ago.
https://ourworldindata.org/grapher/excess-mortality-raw-death-count?country=~USA
I don't really understand what the "that" and "it" are in your second sentence, Emily, but I certainly get the point of your first sentence. Sure: all the things Matt writes about concerning our missed opportunity are true. But those don't include failing to issue mandates that would have prevented, for example, risky behavior during Pride--the legal hurdles for local government to target conduct involving gay men are insurmountable (justifiably). I certainly saw messaging that warned about transmission through sexual contact early on, and on the messaging front I don't know what more we should have asked for.
The big thing I think we could have asked for is local STD testing clinics to reach out to local gay bars and bathhouses where they have established relationships, and gotten them to put up informational flyers. I don't recall seeing any in early June, and I may not have been to any relevant venues recently, so it's possible they have.
If COVID response wasn’t the nail in the coffin for the whole idea of establishment expertise, this one probably is.