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Missouri health officials raise threat level of monkeypox, frustrated with limited vaccine supply

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Governor Mike Parson's administration on Wednesday, Aug. 17, 2022, took another step aimed at stopping the spread of monkeypox in Missouri. The Missouri Department of Health and Senior Services issued an emergency order that requires all cases of monkeypox to be reported to state or local health authorities within one day of detection. The order goes into effect on Aug. 29.

JEFFERSON CITY — State and local health officials are taking steps to fend off the spread of monkeypox across Missouri, but the limited supply of vaccine is frustrating those efforts.

Gov. Mike Parson’s administration on Wednesday required that any cases of monkeypox be reported to state or local health departments within one day of detection.

The emergency order issued by the Missouri Department of Health and Senior Services puts the virus on par with other communicable diseases, such as cholera, polio and measles.

“Reporting of the monkeypox virus has not been required in the past, but due to its severity and the rapid increase in the number of cases, it is imperative for the local health authority or DHSS to be notified within one day of detection in order to take appropriate measures,” the rule says.

Monkeypox is part of the same family of viruses as smallpox. It often begins with flu-like symptoms and swollen lymph nodes, then progresses to a rash. Illness typically lasts two to four weeks.

It can spread through intimate physical contact; touching personal items such as clothing or linens; skin-to-skin contact with rash, scabs or bodily fluids; or respiratory droplets spread through kissing or coughing.

There are currently over 12,689 cases linked to monkeypox in the United States. There have been 10 deaths linked to the current outbreak.

As of Tuesday, the U.S. Centers for Disease Control and Prevention had reported 24 cases in Missouri, up from 18 last week.

But Washington University infectious diseases expert Dr. Joseph Cherabie said area health officials have tabulated about 20 cases in the St. Louis region alone, so hopefully the new rule will provide a more accurate account of the outbreak in Missouri.

Cherabie, who sees patients at Barnes-Jewish Hospital, said more people are coming in to area emergency rooms or clinics with the painful lesions associated with monkeypox, or concerns they were exposed.

Vaccine is best given within four days of exposure to a case and can’t be given once symptoms have started.

‘Immediate danger’

The new DHSS rule, which goes into effect Aug. 29, states “there is an immediate danger to the public health, safety or welfare, which requires this emergency action.”

The new rule follows the department’s decision last week to allocate doses of a vaccine used to prevent monkeypox to five regional distribution hubs across the state: Kansas City, Springfield, Columbia, Butler County and St. Louis County, said DHSS spokeswoman Lisa Cox.

With the St. Louis County region experiencing the most cases, it received the most vials to distribute — 1,900.

Also last week, the U.S. Food and Drug Administration approved a new strategy to stretch the doses: injecting the vaccine under the top layer of the skin rather than into the fatty tissues, known as “intradermal injection.”

Intradermal injections allow vaccinators to use just one-fifth of original dose, thereby stretching the current supply by about fivefold.

A 2015 study showed the method is just as effective and safe. Two doses are still required four weeks apart, and those who are immunocompromised will still get the full dose in the fatty tissue, Cherabie said.

The increase in vaccine availability has allowed vaccinators to expand who is eligible to get the shots, but demand still exceeds supply across the country.

Previously, only close contacts (primarily household members and sexual partners) of those diagnosed with monkeypox could get vaccinated. Now others at the highest risk of contracting it can also qualify.

Men who have sex with men have been affected most by the outbreak, and spread has mostly been found to be transmitted during sex. Those who participate in high-risk sexual behaviors such as multiple partners and transactional sex will be prioritized for vaccine, health officials said

To identify those who are at highest risk, DHSS on Friday created an online survey for residents. Results are sent to local health departments, who will then coordinate vaccine appointments with the individuals. More than 1,300 people have already filled out the online survey, Cox said.

Local health officials say they wish they could vaccinate more people, but most doses are going to states with the highest number of cases and at-risk individuals.

For example, federal data shows as of Aug. 12, Florida (with 1,268 cases) had received nearly 66,000 vials, while Missouri received just over 5,200.

“Please know your health department is doing the best we can with the resources that are allocated to us,” said Nebu Kolenchery, director of communicable disease response for the St. Louis County Department of Public Health.

‘Maddening’

Dr. Matifadza Hlatshwayo Davis, health director for the city of St. Louis, told listeners in a virtual town hall discussion Tuesday night that state and local health officials have been advocating for more doses for weeks.

“You cannot even fathom how frustrating this is for us that we are having to make these sort of decisions around a smaller pool of vaccine,” Davis said. The goal is to get ahead of an outbreak, not play catch up.

“It is maddening to us in public health that we have to make plans in this way,” she said, “especially after everything we learned from COVID.”

Davis and Kolenchery say their departments are working to be prepared for increase vaccines supply by planning vaccination sites, training nurses on the new way to do injections, having enough of the proper needles and partnering with community health care providers who tend to care for gay or bisexual patients.

Staff has created webpages dedicated to monkeypox, brochures in different languages, and social media and public service announcements to educate residents about symptoms, testing and prevention.

“We need to make sure that we are not just vaccinating the most privileged in our population who are able to come into a clinic at the drop of a hat,” said Cherabie, who is also the associate medical director for the county’s sexual health clinic.

“We want to make sure that we are vaccinating people equitably … and that means listening to the community and seeing where we can meet them to help get them access to vaccine.”

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