Doctors call for testing monkeypox outside the LGBTQ community

(CNN) — A man came to an emergency clinic in New York with red bumps on his skin in an area where he had a lot of hair.

The doctor at the clinic diagnosed the lumps as folliculitis, an infection of the hair follicles. The doctor prescribed antibiotics and sent the man, in his 30s, to his house. At home, he continued to help his wife with his five children, one of whom is a newborn.

Despite antibiotics, the bumps spread beyond the first pustules in his groin to his palms, arms, legs, and face.

About four days after her first doctor’s visit, she developed a fever and returned to the ER for a second exam. The clinic physician consulted with Dr. Daniel Griffin, an infectious disease specialist at Columbia University Medical Center, who advised testing for monkeypox.

A few days later, the test came back positive.

“It didn’t look like it was going to raise any alarm bells, and I think part of it was that he was a happily married man, working in an office. He didn’t have any risk factors that anyone would be worried about, which is unfortunate.” said Griffin, who is now treating the man and has been given permission to share his story. The man declined to be interviewed.

The US Centers for Disease Control and Prevention (CDC) state that 99% of monkeypox transmission occurs between men who have sex with men, and there is no doubt that this continues to be a very affected community. However, some infectious disease experts believe that focusing on this population may lead doctors to rule out signs of monkeypox in other people.

Monkeypox is not a sexually transmitted disease, but it can be spread through the type of close contact that occurs in sexual intercourse and other intimate situations. In the United States and other countries, it has skyrocketed among sexually active gay and bisexual men.

At a briefing Friday, public health officials stressed that few cases have been diagnosed in people outside the men who have sex with men community, and even outside cases have been related or contiguous. For example, the first two children recently diagnosed with monkeypox in the US are believed to have contracted the infection from household sources.

Separately, in an appeal Saturday to educate doctors about monkeypox, Dr. John Brooks, chief medical officer for the CDC’s monkeypox response, said that one case of monkeypox had occurred. mono in a pregnant woman in the United States. Monkeypox can cross the placenta during pregnancy and infect babies in the womb. Brooks said the woman had given birth to her baby and the child does not appear to have been infected. The baby received protective antibodies, called immunoglobulin, as a precaution, and both mother and baby are doing well, he said.

But this does not represent the majority of cases.

“Actually, 99% of our cases report male-to-male sexual contact,” said Dr. Jennifer McQuiston, deputy director of the CDC’s Division of High Consequence Pathogens and Pathology.

More than 3,500 cases of monkeypox have been diagnosed in the United States. CDC officials have said they do not have detailed demographic information on all of those cases.

“There is no evidence to date that we see this virus spreading outside of those populations to any degree,” he added.

Our network is not wide enough

But Griffin says it feels like the early days of Covid-19, when it was hard to get a test unless you could prove you had recently traveled to Wuhan, China.

Monkeypox tests are available, and gay and bisexual men are being adequately considered for testing, but many doctors are still unaware of the risk to people outside of this population, Griffin said. And that’s despite outreach, webinars, and health alerts to doctors from the CDC.

“I think we’re making a big mistake,” Griffin said. “Monkeypox is probably out of this population already, and we’re letting it spread because we’re not willing to acknowledge it, because we’re not testing, because our net isn’t wide enough.”

Other experts agree.

“I am concerned that it has spread beyond this community,” said Dr. David Hamer, an infectious disease specialist at Boston University who has been monitoring the monkeypox outbreak in international travelers through his GeoSentinel network of 71 sites worldwide.

Hamer said the outbreak appears to have been fueled by three mass gatherings in Europe; at least one was a rave, where people caught the virus and brought it home. Most of those people were gay and bisexual men.

“But there are others who have clearly been infected, including some young children, and it’s not very clear how they were exposed,” Hamer said.

One such case in the UK was a young child, “and they didn’t understand where and how that child got the infection,” he said.

“We have to think more broadly. We have to educate primary care providers” to think about monkeypox if they see someone with a rash, Hamer said.

Little demand for monkeypox tests

At the beginning of the outbreak, clinicians were allowed to test for monkeypox only in very limited circumstances, as testing capacity was limited to about 6,000 tests per week. However, the CDC recently partnered with five commercial labs to expand testing. When all programs are up and running, they will be able to process more than 10,000 tests per day and 80,000 per week.

Expanding testing to commercial labs makes it easier to request these diagnoses from doctors, but there is little evidence that much testing is done outside of sexual health clinics that serve primarily the LGBTQ community.

“Once it gets to the commercial labs, we have a much more liberal ability to order them. No one asks us to document any criteria or anything to order the test,” said Dr. Stacy Lane, medical director of the Central Outreach Wellness Center, which runs eight LGBTQ wellness-focused health clinics in Pennsylvania and Ohio.

Although many of the commercial laboratories do not disclose the number of monkeypox tests they are doing, there are indications that testing capacity is being underutilized.

A spokesperson for Quest Diagnostics, for example, said in an email that “we have experienced modest demand, which continues to grow.”

Dr. Carlos del Rio, an infectious disease specialist at Emory University School of Medicine, said he didn’t think primary care providers were up to speed.

“We need a lot more information and education for providers on how to use a test and what to do with it,” del Rio said. He added that his own friends and family were sending him photos of his rashes, asking if it could be monkeypox.

In most cases, he says, it offers reassurance that what they have is probably not monkeypox.

“I think it’s still pretty contained in the community of men who have sex with men,” says del Río. “That doesn’t mean it’s going to stay there.”

The cost of a misdiagnosis

Griffin said his patient has no idea how he was exposed and is now isolated in the basement of his home. People with monkeypox are thought to be contagious for at least four weeks.

He is taking an antiviral drug called TPOXX, which is being made available to monkeypox patients.

Doctors were able to vaccinate the patient’s wife, and are carefully monitoring her children, including the baby, whom she held before she knew he was contagious.

Public health authorities have recently expanded access to the Jynneos monkeypox vaccine to children under certain circumstances.

Griffin says that while the vaccine should be safe, there is no data on its use in children. The drug TPOXX is also recommended for children younger than 8 years old, a group that the CDC says is at higher risk for serious outcomes from the virus.

For now, the man is stuck in his basement and unable to help out at home, which Griffin says has been hard on him and his family.

“The father, who is really important in the first few weeks of the baby’s life, is now locked in the basement, which is tragic,” Griffin said. “Those weeks are not recovered.”