Spread of mpox virus a cause for concern, not panic

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The mpox virus has emerged as a global emergency, and here to tell us what Central New Yorkers need to know about this virus is Dr. Elizabeth Asiago Reddy. She's an associate professor of medicine and Upstate's chief of infectious disease. Welcome to "The Informed Patient," Dr. Asiago Reddy.

[00:00:32] Elizabeth Asiago Reddy, MD: Hello, Amber. Good to talk with you.

[00:00:35] Host Amber Smith: Now I understand the first case of mpox outside of Africa this year was reported in Sweden. Are there cases in the United States?

[00:00:43] Elizabeth Asiago Reddy, MD: So an important thing to understand about mpox is that there are two different variants of the virus. We call them clades. There is clade 1 and clade 2. So there was a big outbreak of clade 2 virus, which I know we'll talk about later in this interview. But the case that was reported in Sweden was of concern because of it being the clade 1 type of the virus. And that one historically has been more severe, with a higher risk of death from infection.

[00:01:17] Host Amber Smith: So clade 1 is the more severe, but is clade 2 still a concern?

[00:01:23] Elizabeth Asiago Reddy, MD: It is a concern. Ever since the outbreak calmed down considerably after 2022 -- it actually has continued to percolate so that we've seen anywhere between one to 10 new infections in the U.S. on a daily basis. So it is still occurring.

[00:01:45] Host Amber Smith: Is this mpox virus the same virus as monkeypox that infected, I think, about 100,000 people worldwide in 2022?

[00:01:54] Elizabeth Asiago Reddy, MD: It is. Yeah. So the mpox virus was renamed because of a goal of trying to de-stigmatize the concept of it being associated with monkeys. So the reason why monkey pox virus was originally named monkey pox virus is that the first cases were identified in lab animals that were primates. It was identified in lab monkeys, essentially. But otherwise it is not specifically associated with monkeys in any particular way, aside from the fact that they can carry it. And so the thought was that people would have a concern about this ongoing feeling or sense that somehow this was associated with humans having contact with monkeys, which in most cases it's not.

[00:02:43] Host Amber Smith: Is it related to smallpox?

[00:02:46] Elizabeth Asiago Reddy, MD: It is. It's in the same family of viruses as smallpox, and it has some similar features in terms of how the rash appears.

[00:02:55] Host Amber Smith: Now has it evolved, the virus, since 2022? Is this the same virus, or has it changed in a meaningful way?

[00:03:04] Elizabeth Asiago Reddy, MD: This is actually a question that scientists are still looking at it. It hasn't, when you look at the structure of the virus, it does not appear to have drastically changed. So it seems more likely that what has changed is human behavior and the level of contact that people have with each other. So we're an increasingly global world with increasingly complex interconnections between us. And it seems likely that that is more the reason why the virus started to spread more than it had in the past.

[00:03:39] Host Amber Smith: So the monkeypox in 2022 spread globally, mostly among gay and bisexual men. How was that kind of brought under control, and then it's now again out of control?

[00:03:52] Elizabeth Asiago Reddy, MD: Excellent question. So the clade 2 virus that was circulating throughout the globe in 2022 was, it appears that there were at least a couple of events including an international event in Europe that may have kind of generated a lot of spread, where a lot of people from different countries had convened.

And this was actually a unique feature that had not been previously well described of the virus spreading sexually. There have been cases where it was considered that it might have spread sexually, but nothing on this scale. And some of the features that made it a little bit difficult at first was that it was not clear that sometimes the lesions at the beginning may be very small or people might not even have clear symptoms when they're sick early on that would allow for some asymptomatic or presymptomatic transmission -- so meaning that somebody could spread it onto another person before they were clearly sick with anything.

And that also the rash associated with this clade 2 outbreak in 2022 was oftentimes located only to one region of the body, especially the genital region or other regions that might have come into sexual contact. And that was unique from previous cases or outbreaks of mpox. It was not as easy to identify early on because people were not used to seeing something that was so localized, and so it was being mistaken for other sexually transmitted infections initially.

[00:05:31] Host Amber Smith: So today, in 2024, is mpox a risk to the U.S. in general in Central New York?

[00:05:38] Elizabeth Asiago Reddy, MD: Yes. I'm going to say it is, and yet I'm going to temper that. OK. So I'll mention a little bit about what's going on in the Democratic Republic of Congo right now. So, in the DRC, there has been a huge number of cases compared to the typical number of cases. The typical number of cases in that country would run in the hundreds to thousands per year. And now, since January of 2024, they've documented at least 27,000 cases. And, that's just the ones they've documented. So for sure there are more cases that have not been documented.

And the unique features in this case, we're talking about the clade 1 virus, which, like I said historically has been more severe. The previous case fatality rate that had been described for the clade 1 virus was 10%, meaning that potentially 10% of people who were diagnosed with the illness would actually die of that illness. So it's one in 10. Fortunately during the course of this outbreak, it has been more like 3%. And I say fortunately, obviously with that being better than 10%, but still being a concerning number. The other version, the clade 2 version of mpox end up with a less than 1% case fatality rate. So it still appears to be more severe.

Again, a lot of the people who are unfortunately becoming infected in the Democratic Republic of Conco have a lot of underlying health risks that are putting them at risk for more severe disease. So that 3% number is likely to not be the case.

In somewhere like the U.S. where people have access to better healthcare now, why am I concerned about this and why is my concern tempered? So I'm concerned because clearly the numbers that are occurring in Congo are very high. And a lot of the transmission there appears to be initially heterosexual transmission with, then, subsequent transmission to close household contacts. And so a lot of the impacted in this, epidemic have been children who are living in these households. And children, unfortunately, are a high risk group for more severe disease.

So I think the fact that close contact and children. Obviously that's something that we get very concerned about. Again, we don't really know whether or not there is something different about the virus or the way our immune systems are handling the virus. We suspect again that this is just something that got kicked off because of closer contact, larger populations and therefore larger ability to spread.

But one of my kids came home from school the other day and said, "mom, did you hear that now there's a new Covid in the U.S.?" And so I said, "no?" And she said, "it's called mpox." And so I said, "OK. No."

First of all, the one that we would be most concerned about has not yet arrived in the U.S. And second of all, yes, this is a contagious illness. Yes, we need to take it seriously. It is not like Covid because it really requires very close contact, skin to skin contact with others for spread. in the vast majority of cases. And so this is not like a situation where people are breathing in and breathing out and spreading Covid, as was the case obviously up until today. So, I'll pause there because I know I've said a lot all at once.

[00:09:03] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago Reddy. She's chief of infectious disease at Upstate, and we're talking about the threat of mpox.

So let's go over what this virus does to humans. What are the typical symptoms?

[00:09:21] Elizabeth Asiago Reddy, MD: Initially about three days after an exposure -- could be as short as three days, could be as long as 10 days,could potentially be even more quick, but that three days is about an average -- you could start to get some systemic symptoms, which include things like fever, malaise, sore throat, headache, and swollen lymph nodes all over the body. And then within a few days after that, the rash appears.

As I kind of alluded to, the 2022 outbreak had some unique features, which included that some people were not clearly having prodrome symptoms. They were just going straight to the rash. They didn't remember ever being sick prior to seeing a rash, or the rash was appearing more quickly, in close concert with the other symptoms. So it used to be that we had these very clear progression of symptoms, and now things seem a little bit more blended than what they used to be.

But the typical is still kind of the generalized bad feeling for a couple of days with fever, and then the rash appearing after that. The rash goes through some very classic stages, so it looks like kind of a smooth bump at first, and then it turns into what we call a pustule, which is where you could see some liquid and some pus underneath that bump. And then it gets this appearance that is very classic for the orthopoxvirus family, which we call umbilicated. So that is where you see a very round lesion with an indent in the middle of it. And oftentimes you can see some fluid underneath that. You may not always be able to see fluid underneath it at that stage.

Other features are that different rash lesions can appear at different times, so you may see multiple different types of rash lesions going on all at the same time. And so that kind of helps providers to understand what they might be dealing with when they see something like that. The rash classically will last about a week, but it can take two or even four weeks sometimes to resolve in severe cases.

[00:11:30] Host Amber Smith: Is that how it's diagnosed, just by looking at the rash?

[00:11:34] Elizabeth Asiago Reddy, MD: That's where we start to have an index of suspicion. So, of the cases I've seen, I would say once you're aware of this as a possibility, that's the biggest thing is keeping it on your list. Then, again, the cases I've seen have been classic. It may only be one, but when you see it, it just, the way that it looks is unique to other types of rashes. And so that's where you have the index of suspicion, and then you would go ahead and test. Sothe testing that is done is actually done by swabbing the rash lesions themselves.

[00:12:10] Host Amber Smith: And then what is the course of the disease typically like?

[00:12:14] Elizabeth Asiago Reddy, MD: A mild illness could be something that would maybe resolve over the course of seven to 10 days.But a more severe version could last as long as four weeks. And I have seen, both of those happen.

[00:12:31] Host Amber Smith: And are the people typically isolated to stay away from others?

[00:12:35] Elizabeth Asiago Reddy, MD: Yeah, so the biggest issue is contact with the rash lesions. During those first few days that I mentioned where people are having fever, maybe a sore throat, there is a small possibility of close droplet transmission. So if somebody were to have a cough or kiss somebody else in that stage, they could potentially transmit it that way. That appears to be more limited, with the vast majority of transmission occurring by actually skin to skin contact with the rash lesions.

So the most important thing once that initial phase of the illness, as we call the prodrome phrase, when people are just feeling generally ill, once that has passed and the rash has started, the most important way to protect others is to keep that rash covered and not come in contact with others.

[00:13:23] Host Amber Smith: Now what about vaccines?

[00:13:26] Elizabeth Asiago Reddy, MD: There is, fortunately, a vaccine available, and there was a vaccine available, which is how the clade 2 pandemic was brought under control to a great extent. Both through vaccination and behavior change. But the vaccine was created to help protect lab workers and potentially others who might be at an elevated threat, say from even weaponization of the virus or something similar. So that vaccine was already available, and it protected against multiple members of the orthopox family to include smallpox and mpox.

And so it is a two vaccine course. The vaccines are given four weeks apart. And it looks like, as it relates to the clade 2 virus, it was most certainly highly effective because once the vaccine started being available, we saw a very rapid drop in cases and entered into a situation where we're seeing, like I said, a handful of cases a day versus hundreds and hundreds of cases a day. From retrospectively, try to look at the data -- although it dropped off so quickly, it's a little hard to get all the information -- it looks like your first shot will maybe give you about a 50% protection, and then the second shot goes up to 70 to 85% protection against a another episode of illness.

[00:14:53] Host Amber Smith: How much potential do you think this mpox outbreak has to become a global pandemic?

[00:15:00] Elizabeth Asiago Reddy, MD: I admit, I'm concerned. I'm also happy that the WHO (World Health Organization) has identified this as an epidemic of global concern because that offers the ability of more resources to the Congo, where the cases are rapidly spreading.

And certainly, unfortunately, Congo has traditionally been a location that has suffered from a lot of health inequities and lack of access to healthcare. And so those are locations where something like this can really thrive and proliferate, and people can face more severe courses, et cetera. So, vaccines have been deployed. There is still going to be a challenge in getting those really moving on the ground. But things are definitely moving in the right direction with awareness.

And the U.S. Has actually, since December of 2023, been providing surveillance to multiple areas. So for example, here in New York State, we have the New York State Wadsworth Laboratory where specimens can be sent and are being evaluated regularly to see if these specimens belong to the Clade 1 group. So there are a lot of opportunities for us to test virus and try to see if something like this is starting to show up in the United States.

So I think, again, the level of awareness is where the key really is to keeping this under control. SoI think we are seeing an appropriate level of concern at the international level to avoid this becoming a very significant, severe pandemic.

[00:16:40] Host Amber Smith: I want to thank you for making time to tell us about mpox.

[00:16:43] Elizabeth Asiago Reddy, MD: Absolutely. Thank you for having me.

[00:16:45] Host Amber Smith: My guest has been Dr. Elizabeth Asiago Reddy, chief of infectious disease, and an associate professor of medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.