Infectious disease physician Dr. Laura Bamford has become an expert on a disease that barely existed outside Africa until earlier this summer. Over the past two months, she’s treated or helped colleagues to treat dozens of men who have sought care at UCSD’s Owen Clinic, which specializes in HIV/AIDS. “They tend to be pretty freaked out,” she said in an interview.

And with good reason: Monkeypox lesions can be exquisitely painful. The most effective monkeypox treatment is reserved for severe cases and has been hard to get. And patients, who often must isolate themselves for weeks while they’re contagious, fear they’ll be permanently scarred.

Meanwhile, the county is running low on vaccine.

Now, there may be some positive news. Dr. Bamford said she’s hearing about fewer cases, and countywide numbers have declined slightly since hitting their height – 56 reported new cases in a week – in early August. The number of new cases are declining worldwide and nationally, suggesting that the entire outbreak may be on the wane. Officials think monkeypox vaccinations and less risky gay sex could explain the dip.

Here are frequently asked questions – and answers – about monkeypox in San Diego.

How big is the outbreak here?

As of Aug. 29, 279 people have been confirmed or suspected of being infected with monkeypox in San Diego County, up from just a handful in mid-July. The national total is more than 18,100.

An analysis of 270 local patients found that 266 were male, 4 were female or transgender female, and 92 percent of those who provided information about their sexual orientation were gay or bisexual. Six percent said they were straight.

According to the county, 46 percent of patients are White, 44 percent are Latino/Hispanic (even though they make up a third of the population), and 9 percent are Black. Most cases have been in central San Diego.

How does our outbreak compare to elsewhere?

San Diego hasn’t been walloped by monkeypox like several other big cities such as Los Angeles, Washington D.C. and New York City. San Francisco, which has about a quarter the population of San Diego County, has reported more than 2.5 times as many cases. However, San Diego County is outpacing Orange County, which has a similar population but only about half as many cases.

Is the outbreak declining?

The number of reported cases dipped from a height of 56 in the first week of August, not long after San Diego Gay Pride celebrations, to 49 in the second week and 44 in the third. The county has reported just 13 cases from Aug. 21-27, but that number is probably incomplete.

Click here to view the number of reported Monkeypox cases in San Diego in a new tab.

Who’s getting sick?

So far, the worldwide, national, and local outbreaks have almost entirely infected gay men. Others – straight and bisexual men, women, and children – have rarely been infected. Statistics suggest that gay men with high numbers of recent sex partners face by far the largest risk of infection, possibly because the disease is most easily spread through sex between men. A study of 528 cases worldwide (98 percent in gay men) found that infected people who answered questions about recent sex reported a median – not an average – of 5 sex partners over the past 3 months. The highest number was 15.

How are local patients doing?

Eight local patients have been hospitalized since the first case appeared in early June. While monkeypox can be fatal, only one person with monkeypox has died in the U.S. so far, and this person is reported to have had a severely weakened immune system. It’s not clear if monkeypox was responsible.

According to Bamford, the cases she’s seen have generally been mild, with no more than three lesions. “Most people are doing very well,” she said, and they recover within weeks. But the lesions can be itchy and extremely painful. In some cases, patients may have as many as 30-40, Bamford said, and they often appear on the penis and in the rectum.

Many patients have rectal pain even if they don’t have lesions in that part of the body, she said. Patients can also have no symptoms at all.

In severe cases, physicians can prescribe a smallpox drug called tecovirimat (Tpoxx). It’s been hard to get, and it’s not clear how well it works against monkeypox. A recent tiny study from Sacramento found that lesions vanished within a week in 40 percent of infected men who took the drug, and 92 percent were free of pain and lesions within 21 days.

It’s not clear if monkeypox lesions will cause scars.

Why is monkeypox so painful?

“The virus seems to be irritating the nerve endings in the skin,” Bamford said. “We don’t know what the virus is doing to cause rectal pain [when there aren’t lesions there].”

Why are gay men at such high risk?

Nobody knows. Previous monkeypox outbreaks in Africa spread among both males and females in households. It’s not clear how the virus has found a new way to infect people.

Some health officials are urging at-risk people to cut down on having sex with multiple partners and with strangers, but this is controversial. Activists fear a focus on risky sexual behavior will boost shame and stigma, and they say men may ignore suggestions that they abstain. Still, a new survey suggests that many American gay men are having less sex in response to the outbreak. 

There’s a related debate about how to describe the people most at risk: Are they “gay and bisexual men”? “Men who have sex with men”? Or, as CNN put it recently, “gay, bisexual, transgender, nonbinary, and men who have sex with men”?

To be clear, the risk of monkeypox is heightened among gay men who have sex with lots of other men – not gay men as a whole.

What about condoms?

Condom use may lower risk, but no one knows for sure. The worldwide study found that a third of 528 men infected in the early wave of the outbreak took medication to prevent infection with HIV. These men often don’t use condoms because they’re at very low risk of getting HIV. Another 41 percent were HIV-positive, but many men in that category don’t use condoms either, often because they’ve controlled HIV through medication and are extremely unlikely to infect anyone else.

When should I get worried that I may be infected?

You should be especially concerned if you’ve been exposed to someone who potentially had monkeypox or if they’ve had multiple sex partners over the past couple of weeks, Bamford said. According to physicians, the lesions can look like pimples, blisters or the lesions caused by chicken pox, herpes, syphilis and even insect bites. Often, the lesions don’t produce pus, have a dimple in the center, and look like a bowl.

Bamford said the lesions go through stages before scabbing over. “Some people have symptoms before the lesions – one, two, three or four days of fevers, chills, sweats, swollen lymph nodes, a kind of malaise and feeling unwell, even mild respiratory symptoms like sore throat, congestion, and cough. Anyone who experiences that and then goes on to get lesions should certainly reach out to their medical provider.”

What’s the deal with the monkeypox vaccine?

A smallpox vaccine by the Jynneos company is approved for use as a monkeypox vaccine, and it’s being distributed around the country to people at risk.

But as I reported in an article for MedPage Today, a medical news site, no one knows how effective it is against monkeypox. Some news outlets have declared it to be 85 percent effective, but that number is based on a small and limited study from the 1980s in Africa, where outbreaks are quite different than the current one.

There’s also controversy over the limited supply of the vaccine and the Biden Administration’s untested new strategy to split single doses into 5 doses to they can be given to more people. The Biden plan doesn’t seem to be going well.

Locally, at least one health provider – UCSD – is giving the split doses via intradermal injection – into the forearm instead of subcutaneously in the upper arm. The Washington Post explains the difference in how the vaccines are administered here.

No one knows whether the routine smallpox vaccine shots that Americans got until the 1970s provide protection against monkeypox.

Can I get vaccinated?

Maybe. People at high-risk have priority, and the local vaccine supply – like the national one – is running out.

The county has distributed almost its entire supply of nearly 6,000 vaccine vials, which can be used to vaccinate one or more people, depending on how the doses are administered. The vials have been sent to clinics, healthcare systems, and hospitals, and the county says “most vaccine has been exhausted.” For more information, click here.

It’s not clear how many people have actually been vaccinated or whether there will be enough vaccine for people to get the recommended two doses. The county asked for more than 31,000 vaccine vials.

The vaccine can also be given to people who’ve been exposed to monkeypox to help their bodies fight it off.

What now?

Some health experts fear the Biden Administration bungled its monkeypox response, and it’s now too late to stop the virus from being with us forever. The White House is trying to be optimistic, sort of. “I’m pretty confident,” an official told Politico, “that we’re on the right track.”

For now, we can track local monkeypox numbers – they’re posted every weekday — and watch for signs in the sewage. Yes, researchers have added monkeypox to the list of germs they’re monitoring in San Diego’s wastewater. So we’re flush with data, if not fixes.

Randy Dotinga

Randy Dotinga is a freelance contributor to Voice of San Diego. Please contact him directly at randydotinga@gmail.com...

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