Front Burner - The latest on Canada's monkeypox outbreak

Episode Date: August 10, 2022

Monkeypox cases in North America continue to climb. Last week, the U.S. declared monkeypox a public health emergency. Here in Canada, the number of cases is approaching 1,000. The disease can be painful and the self-isolation period can be lengthy. Right now, men who have sex with men remain the most at risk of infection. Today on Front Burner, Dr. Darrell Tan, a clinician scientist in the division of infectious diseases at Saint Michael's Hospital and associate professor in the Department of Medicine at the University of Toronto, discusses symptoms, transmission, treatment and the vaccine.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Jason D'Souza in for Jamie Poisson. Monkeypox is spreading. Across North America, cases of the disease have been on the rise, surpassing 7,000. Right now, it's circulating in over 80 countries across multiple continents.

Just last week, the United States deemed it a public health emergency. The Biden administration declaring monkeypox a public health emergency. We are going to do everything that we can to end this outbreak. That is our commitment. Cases are climbing here in Canada, too, with the latest numbers just under a thousand right now. You know, the moment we were alerted to monkeypox, Canada's frontline health system immediately started diagnosing the cases. The symptoms of monkeypox can sometimes be painful and the isolation period can be long and agonizing. If you hear of a friend or a loved one

that has this message them, support them, ask them if they need anything, just let them know that they're not some kind of pariah, that they're not dirty. There is hope, however, in stemming the spread of vaccine, but whether there is enough supply to meet demand is unclear. Today we're talking to Dr. Daryl Tan, an infectious diseases physician at St. Michael's Hospital in Toronto, about the risks, the transmission, and what needs to happen now to thwart a crisis. Hi there, Dr. Tan. Hello. So to start, I'm hoping you can clear up any confusion that may exist around this disease.

What exactly is monkeypox? Monkeypox is an infection caused by a virus. It's something called an orthopox virus that has been known to humankind for several decades now. Historically, it's been what we call a zoonotic infection. That's a fancy word that means that it's typically a virus that hangs out in animals and only occasionally infects humans when humans come into contact with those animals. Although human-to-human transmission of monkeypox has also been known for a few decades now. Most of the experience with this virus internationally has come from expertise in Central and West Africa,

a number of countries there that have been what we call endemic for this virus for some time. But it's only recently since May or so that we've started to see a global epidemic spread to other countries that have not traditionally had any cases of this infection in the past, that it's really gotten the attention of many more people. And what factors are behind why it's spread globally as it has? It's a really good question and one that I think we hesitate to be absolutely definitive about. But it is worth noting that even before it spread to other countries such as Canada earlier this year, it had already been kind of starting to accelerate, kind of re-emerge, as we say, in public health for a number of years in

Central and West Africa. That probably has a lot to do with changes like urbanization, with changes in the climate that are, of course, caused by human activity. All these things change the ecosystem that we live in and change the opportunity for interactions between animals and humans, therefore viruses that can come into contact with more and more humans. And then, of course, with globalization, that, of course, allows something that happens in any part of the world to very rapidly spread all over the globe in a very short amount of time. And so what do we know about how monkeypox spreads from human to human? Well, traditionally, the way that this virus transmits from person to person is through direct skin-to-skin contact.

What we've been seeing in the current epidemic is that is very, very often skin to skin contact in the context of sexual activity. But it can also sometimes include things like close contact to respiratory secretions that could happen through, you know, kissing or maybe even through speaking to somebody at a short distance for a long period of time. It can also be transmitted through what we call fomates. Those are objects that have become somehow contaminated with the virus because of contact with someone's skin, for example. So blankets or clothing or linens have famously been an example of fomite transmission that would be possible for this virus as well. As you know, social media can often have a lot of misinformation, disinformation. I know monkeypox is airborne is something that was trending on Twitter last week. How much fact is there behind that? Yeah, it's a complicated

question. And I think the short answer for now is that we really do not think that airborne transmission is playing a major role at all in what we're seeing, certainly right now in Canada and other international settings where the virus has re-emerged recently. I think the reason that there might be a little bit of grumbling about this is that historically, it has been thought that monkeypox could be transmitted in this way. That's for a number of different reasons. First of all, it's very, very closely related to another orthopox virus that absolutely was transmitted through the airborne route, and that's smallpox. Now, smallpox has, of course, been eradicated from the globe as of several decades ago now through a global vaccine effort,

one of the great triumphs of public health in the last century. And by extension, it had initially been thought that this virus could transmit that way as well. And there may be some evidence that it can transmit that way in some of the, again, endemic areas that have much more expertise with this than we have. But what we're clearly seeing now is different. Not only is the epidemic different and the way in which we're seeing it transmit between people different, but there are changes in the virus as well. It does seem to be a different type or what we say clade of the virus. And so there's lots of reasons that what we're seeing now may differ from what had been suspected in the past. When you think about level of contagion,

I think a lot of us think about what we've learned about COVID-19 so far, that level of transmissibility. Is there any comparison at all when it comes to what we've seen in terms of contagion when it comes to COVID versus what we're seeing with monkeypox? I really think it's an issue of apples and oranges. You know, this is a virus that, again, we're really seeing being transmitted virtually exclusively through direct skin-to-skin contact, direct contact with someone in the context of sexual activity, as opposed to through respiratory transmission or airborne transmission, for that matter. If either of those were major modes of transmission, we would be seeing far, far more cases than we are, and it would be much, much more widespread than

it is at this time. What are the symptoms of monkeypox, doctor? Well, this virus can cause a number of things, And this is actually one of the things about what we're seeing right now that's been so devastating and fascinating all at once. The classical experience of someone who contracts this virus is that it can cause a combination of flu-like symptoms. So by that, I mean typical things like a fever, chills, symptoms. So by that I mean typical things like a fever, chills, muscle aches, a headache, just feeling lousy all around for a number of days. It can also cause some pretty characteristic skin lesions. These are the pox part of the name of the virus. And those start on the skin as something simple like a bump that can rapidly change over time to a blister, to an ulcer, to a scab before

healing over. And those skin changes, those skin lesions can appear virtually anywhere on the body. Certainly one of the major places that it can appear would be the part of the body that was first exposed to the virus. And so when we're talking about a lot of what we're seeing being largely transmitted through intimate sexual contact, we're definitely seeing a lot of these lesions around the mouth area, around the genital area, around the anal area. And sometimes we're even seeing it involving the kind of mucosa in that area. By that, I mean the kind of the moist parts of the body, like the throat, the genital tract, the anus or the rectum. And when the virus causes infection there, people have really suffered with really severe symptoms,

really excruciating pain. And then finally, two last notes about the symptoms that it causes are that we're also seeing it cause a whole bunch of much less common, but sometimes much more concerning manifestations if the virus manages to involve other parts of the body. We've seen patients with heart involvement, for example. We've recently heard a couple of really tragic cases of deaths related to brain involvement. We've seen people with eye lesions that can be sight-threatening. So these are all rare, people with eye lesions that can be sight-threatening. So these are all rare, but potentially more severe manifestations that do make us concerned.

And the other note is just to say that, you know, although all of these things are possible, we also see a really, really wide spectrum of disease in terms of severity. So people can have rip-roaring symptoms. I honestly have never experienced something so painful. Anytime it grazes something or touches something it literally feels like someone's taking a potato peeler to your skin. People can have really really mild symptoms to the point that I've had many conversations with patients of my own in which they were pretty convinced that there was nothing wrong at all but I did notice for example maybe minor skin things on their on their skin during a

physical examination go ahead and test it and find evidence of the virus. So it's really quite variable from person to person and a wide spectrum of disease symptoms as well. Given that then, doctor, what do we know about who is being most affected right now? Well, what we're seeing is that 98% or more of cases in Canada, and this mirrors the experience in other industrialized world countries that have been affected by the current epidemic as well, 98% of cases or so are being seen in gay, bisexual, and other men who have sex with men. It's really been concentrating there through existing sexual networks, and that's really held up since our very first cases were seen here in Canada in the month of May. And just to be absolutely clear, this is not a sexually transmitted disease per se. You know, it's a tough thing to be absolutely clear about, actually. Certainly,

when we use the term sexually transmitted infection, we typically think of things that must be or can only be transmitted through contact with sexually transmitted body fluids. So things like cervical secretions or rectal secretions or semen, etc. What we're seeing with monkeypox is interesting. First of all, we do have some hints that it does seem to be present in some of those body fluids, although the data are still being generated on that. And we're also again seeing that the vast, vast majority of cases seem to be acquired through asexual or intimate contact with another person. So for all intents and purposes, most of the time it's kind of behaving as though it is a sexually transmitted infection, even though it doesn't technically meet our typical understanding of what an STI is at this point based on the data that we have.

And it's also clear that it can be transmitted through means other than sex. So unfortunately, it's not a straightforward answer to that question. When you outlined a moment ago, the vast majority of cases of monkeypox that we've seen in North America, men who have sex with men, a large number of members of the LGBTQ plus community, we know that this is a community that has faced stigma over health issues in the past. I'm thinking HIV and AIDS, of course. How do you balance an efficient, targeted health response without unfairly stigmatizing people? I think it's an excellent question. And it's really important that we be constantly asking and readdressing this question all the way through our response. The potential for stigma,

whether we like it or not, is great. And it's really, really important to be attentive to this, given the historical marginalization, discrimination queer people in general faced and continue to face to this day. all, we do use an evidence-based approach that we look at the evidence and the epidemiologic evidence tells us unequivocally that this is concentrating almost, but not exclusively, in queer people, in sexual minority men, 98% of the time. And so we mustn't shy away from that fact, despite the concerns about the potential for stigma, because it's so important to emphasize this fact if we're going to successfully engage queer people, if we're going to encourage clinicians to ask the right questions when taking a clinical or medical history with a patient, if we're going to reach out and educate and raise awareness in affected communities. It's really, really essential that we do that openly

and transparently from the get-go. And yet, because of the risk of stigma being so real, I think that, you know, we mustn't just stop there. We must make sure that the way in which we do this actively engages community voices. And that's fortunately what I think has been largely happening in most parts of the Canadian response from the get-go and allowing and encouraging community representatives to, you know, lead the charge in the awareness raising and coming together in terms of offering supports to each other is, I think, really the way forward. And externally from that community, what does support look like in your view, doctor, from both a healthcare perspective, but a societal one as well? Yeah, maybe we can tackle those two separately. From a healthcare perspective, there's a lot that still needs to be done. And I think a lot of resourcing that I hope will continue to go into the MPOC's response, especially since the WHO recently called this a public health emergency of international concern.

If countries, communities and individuals inform themselves, take the risks seriously and take the steps needed to stop transmission and protect vulnerable groups. I think clearly we need to do more in terms of raising awareness, getting the true facts out there in contrast to some of the misinformation or disinformation that you alluded to just a moment ago. Get the real facts out there and have reliable champions moment ago, get the real facts out there and have reliable champions voicing that to the community. We also need ready access to all the biomedical tools that can help us respond to an epidemic. That starts with testing. I think we've learned that through COVID, you know, you can't deal with something that you haven't diagnosed or tested for. We also need access to treatments and preventative tools. And we're fortunate here that we do have some access to antiviral treatments and vaccines against this

virus in Canada. It's a bit of a complicated picture, but they do exist. But we need to make sure that we deploy those as judiciously as possible, make sure that clinicians are aware that these things exist and can be used in the right circumstances. And toly as possible, make sure that clinicians are aware that these things exist and can be used in the right circumstances and to the extent possible, advocate for the global supply of these to be expanded. In the Dragon's Den, I'm going to go. Canada's entrepreneurs through angel investment and industry connections. their own household income. That's not a typo. 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together.

To listen to this podcast, just search for Money for Couples. How treatable is monkeypox? This also is a great question to which I'm hoping that we'll have more and more insight in the future. You know, at this moment in time, we do have one promising drug in particular. It's got a long name, tecoviramat. It's also known sometimes by the trade name T-pox. This is a leading antiviral contender against M-pox, in addition to a couple others that have been less looked at. And what's fascinating about this drug is that, first of all, it's a drug that does have regulatory approval for use here in Canada. But there are some caveats. That's based on its potential for use against smallpox, which we've already said has been globally eradicated.

The rationale for having this approved for use against smallpox is part of a biosecurity sort of preparedness or a bioterrorism preparedness plan. So it has been approved in Canada for that virus, but not for monkeypox already. Because it has been approved in the context of this biosecurity context, the amount that is stockpiled in this country is actually a federal or kind of state secret. And as such, even the provinces and territories, as they try to secure access to this, don't really know what the total stockpile available is. And that's important to preserve for those biosecurity reasons. So it does exist. The basis on which it's been approved or used, I should say, in people with MPOX is really by extension. There are animal data, for example, showing that it seems to have effect. And there

are human safety data showing that it does seem to be well tolerated and safe for use. But we actually don't have high quality clinical evidence telling us that it works in to be well-tolerated and safe for use, but we actually don't have high-quality clinical evidence telling us that it works in the ways that we want it to work for someone who actually has MPOX infection. And so that's a gap that we really need to fill urgently with research, and that research is being planned right now here in Canada and abroad. On the other side of this, there is a monkeypox vaccine. How widely available is that in Canada? Once again, we're kind of fortunate in a way to have such a product that does have regulatory approval in this country. There's what's called a third generation smallpox vaccine

called Imvamune that does have regulatory approval in Canada, again, as part of this biosecurity or bioterrorism preparedness approach. Once again, the total kind of denominator, the total amount of this product that even exists in this country stockpiled is not known. This is a state secret, as it were. Fortunately, the provinces and territories have been able to access this in a very rapid fashion and rollout of the vaccine began in the first hit provinces, Quebec and Ontario, very soon after cases were first detected here in the month of May. But again, supplies are limited. There's not quite enough to give it to every single person that we would otherwise like to give it to. So we do have to be very, very careful in how this is rolled out. So how then do you roll something like that out? What

would the eligibility, what would the criteria be in a situation like this with this vaccine? It's a really challenging thing to work out, but did need to be worked out in a rapid way. So of course, each province or territory needs to work that out itself. Typically, what has happened is that the P's and T's have decided to restrict eligibility for an immune vaccine to people who self-identify as being sexual minority men. So gay, bisexual, other men who have sex with men can step forward. And in many cases, transgender women as well, or trans men who identify as men who have sex with men as well. Whether or not there are additional criteria beyond that varies between jurisdictions. But ultimately, the whole purpose of putting these sorts of criteria together is to try as best as possible in the face of limited supply. That's a really important premise.

It's not possible to give it to absolutely everyone who wants it, otherwise this wouldn't be necessary. But to put some other criteria that help to identify folks that would epidemiologically be at higher risk of actually acquiring monkeypox than the next person. Something we saw in the earlier days of the COVID-19 pandemic was the supply crunch and some of the ethical questions that brought up when it came to distributing the vaccine across Canada versus in other countries where there was a greater spread or more concerning spread. Are those ethical questions over this vaccine also taking place right now globally? I think they are, yes. Again, when you have a limited supply of something and you know there's got to be some form of triage, that immediately brings up really, really challenging decisions that, of course, those of us in the health field who just want to maximize health for everybody really necessarily have to struggle to contend with.

I think one example of that is the issue of, you know, first doses versus second doses. This is a product where, according to the product monograph, there's a recommendation for a second dose. But again, in the face of extremely limited supply, decisions have largely been made so far to restrict vaccine rollout to first doses only for the time being, with rare exceptions for people who might be very compromised and might not be expected to respond to a first dose alone, in order to maximize the number of people who can derive some benefit from getting that first dose at all. Another really important dimension of the ethical challenge, I think, is when we zoom out to a global scale.

I mean, I think it's really, really, really important for us to notice that, again, this epidemic has been emerging actually in West Africa and Central Africa for years now, that there have been increasing numbers of cases and epidemics locally for some time. And really, those facts have not garnered the attention of the international community almost at all. It really took a spread of the infection to rich countries for a lot of this mobilization to occur. And so as we think rapidly about deploying, you know, sophisticated countermeasures like vaccine and even antivirals here in Canada and other rich countries, we need to remember that, you know, there's great need in West and Central Africa where, you know, the original expertise in this virus started. And I think those discussions have been kind of neglected in our scramble to do the best for our own

population, which of course is important. But I think it's part of what motivates me to ensure that we are always thinking about what capacity we can be encouraging in terms of having more generic manufacturers step up and be licensed to participate in manufacture of vaccines and therapeutics in order to ensure that the supply problems don't end up leading to yet another perpetuation of health inequities on the global scale. Finally, Doctor, over two years now since the COVID-19 pandemic, we've seen this tangible pandemic fatigue settle into different parts of the public and society. Are you worried at all? Are you concerned that that fatigue may bleed into how much attention people are paying right now to monkeypox? I think that's always going to be a possibility. But to that, I would say a few things. First of all, you know, one of the strengths of really having a truly community engaged response is that it does really allow us to draw on the strength and resilience of affected communities, particularly minority communities, in this case, sexual minority communities. And once again, I would really point to the triumphs

and the successes of queer organizations in the response to monkeypox from the get-go, leading the charge in advocacy and education. And that, I think, is really a source of strength, even as many people do run the risk of having a little bit of pandemic fatigue. thing I'll say, unfortunately, whether we like it or not, whether we are fatigued or not, I think we've got to, as a society, come to understand or come to recognize that emerging epidemics, unfortunately, are just a reality of the world that we live in. And there are some really burning social issues that we need to address and that infections like monkeypox draw our attention to. I'll particularly draw attention to the need for social supports and wraparound financial supports for people who need to self isolate when they come down with monkeypox. This is something that people who have the infection,

you know, typically wants to do. They want to follow public health directives and go into self-isolation and not infect people around them. But when they don't even have the social tools, policies in place to allow this, to pay the bills and put groceries on the table, you know, that points to policy failures. And so we mustn't let any sense of fatigue or pandemic exhaustion obviate the need to really step up to have a meaningful and effective epidemic response.

Dr. Tan, thank you for this. Thank you so much for inviting me. That's all for today. Thanks for listening to FrontBurner. I'm Jason D'Souza. Goodbye for now. For more CBC Podcasts, go to cbc.ca slash podcasts.