It’s been a month since the last case of monkeypox was diagnosed in Connecticut, and though the vaccination effort continues, the strategy has shifted.
Incidence of monkeypox has decreased nationally, though there are still cases being identified in nearby states. New York, for example, continues to identify new monkeypox patients weekly. In Massachusetts, there were four new cases between Nov. 10 and Nov. 17.
With continued cases right over the border, state Department of Public Health Commissioner Manisha Juthani said it would be “naive” to think “that we couldn’t have spillover. That’s how it always starts.”
The last diagnosed monkeypox case in Connecticut was during the week ending Oct. 29. All told, there have been 143 cases in Connecticut since the first was identified July 4 weekend.
“If you told me in July that we’d have 143 cases and that we’d have three weeks with no new cases by Thanksgiving, I don’t know that I would have believed that,” Juthani said. “I was very nervous of where we were headed with this disease.”
Though she’s not willing to declare an unmitigated victory against monkeypox – “That doesn’t mean that next week we might not have a case,” she said – Juthani believes that a shift in testing strategy and a street-by-street vaccine approach have helped Connecticut stave off the virus.
The availability of monkeypox vaccine doses was a problem initially. There are two vaccines for monkeypox, ACAM 2000 which as a live virus presents administration difficulties, and the preferred vaccine, Jynneos.
Jynneos, however, was in very short supply as monkeypox began to spread over the summer. Vaccine clinics in New York City were overrun with demand, and only states with cases were allocated any vaccine at all.
Connecticut was the last state in the region to identify a case of monkeypox, and so had no vaccine allocation at all and later supplies were limited.
“I had people telling me, ‘I had to drive all the way down to Queens to get a vaccine. I should be able to get that in Connecticut,’” Juthani recalled. “I said, ‘I agree with you. I’m trying to do just that.’ But first, we needed to have vaccine.”
Though not exclusively, this outbreak of monkeypox primarily affected men who have sex with men, in part because the telltale lesions associated with the disease were appearing in and around the anus.
Once vaccine doses became more available, the problem changed. The first wave of patients to be vaccinated were the ones who Juthani said were “banging down the door and want it badly.”
After that, there were the patients who wanted the vaccine but were willing to wait until it became more available. That, Juthani said, involved large, if focused, vaccine clinics: “Initially, we were at pride events and we were doing these mass clinics.”
Eventually, an even more focused strategy had to be adopted.
“The further and further you go down that slope, you now are dealing either with a group that doesn’t know they’re vulnerable and are, or knows they’re vulnerable but their life circumstances are such that they can’t prioritize getting the monkeypox vaccine or they don’t know where to go or what to do,” Juthani said.
Now, even though there have been no monkeypox cases for a month, the Department of Public Health is relying on local public health officials to identify where those smaller at-risk populations are.
That includes sex workers and people without homes, and people with substance abuse problems – groups who are difficult to reach and are perhaps reluctant to make themselves known.
“Now our work is some of the harder work which is going into certain neighborhoods and certain streets in certain areas, working with local health districts in identifying specific communities where there may be a group of eight people who work in a specific park, who they know are at risk, and that local health department with us, we’re going out there to try to get those people vaccinated,” Juthani said.
All told, 5,013 people in Connecticut have so far been vaccinated against monkeypox. More than 700 doses have been administered at 48 mobile clinics in eight Connecticut cities.
In recent weeks, even though monkeypox has not been seen in the state, the state has been administering about 100 doses per week.
Testing for monkeypox, too, presented an initial problem and resulted in a shift in strategy. Mass testing sites were not possible.
“One of the challenges with monkeypox, it’s not like COVID, you just drive up and get a nasal swab or something,” Juthani said. “You need to have a lesion. You need to do a swab of a lesion and sometimes these lesions are in pretty private places.”
Because testing supplies were limited when monkeypox first began to spread, the state initially restricted testing, asking doctors to verify with DPH to determine if, in fact, a prospective case should be tested. If the test was approved, it would then be sent to the state public health lab.
This, Juthani said, was not an efficient system. So the state removed the “middleman.”
“We let the clinical assessment on whether a test needed to be performed stay in the hands of the doctor who was seeing the patient,” she said.
That resulted in more tests performed, and a higher proportion of positive tests.
“We streamlined the process to allow testing to happen seamlessly,” Juthani said. “We were trying to remove barriers to allow for testing.”
Unlike COVID, Juthani is hopeful that monkeypox could be eradicated, as public health officials initially thought when the virus began spreading globally. Previous monkeypox outbreaks had been relatively contained and smallpox, monkeypox’s close cousin, has been seldom seen in the United States.
“The goal was to eradicate monkeypox from the United States, and I still think we have that goal,” she said. “But as it was taking off, I got less and less confident that we’d be able to do that. I thought the chances are much more likely that there will be low levels of monkeypox that continue to rumble around the country, and that we will have outbreaks from time to time.”
She does believe, however, that eradication is possible: “I’d like to be proven wrong. I’d like to see that we actually are able to eradicate it. That’s what these efforts are going towards, is trying to achieve eradication.”
Perhaps that’s not likely, but Juthani believes it’s possible.
“I do anticipate that we may have times when things bubble up. There’s some outbreak in some community somewhere and we all of a sudden have four or five, six cases,” she said. “But then, we’ve got the mechanism in place. We tried to squash it and get it under control quickly. It can be done.”
