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September 8, 2022

Monkeypox roundup: Experts see coinfections of monkeypox and HIV

Daily Briefing

    The Biden administration awards a $19.8 million contract to increase the distribution of monkeypox treatments and vaccines, a new study suggests that two doses of the monkeypox vaccine generate low levels of neutralizing antibodies, and more in this week's roundup of monkeypox news.

    • HHS on Tuesday awarded a $19.8 million contract to AmerisourceBergen to increase the distribution of monkeypox treatments and vaccines. Under the contract, AmerisourceBergen will ship up to 2,500 shipments of frozen Jynneos vials and 2,500 "ambient temperature" shipments of the Tpoxx antiviral treatment every week. In addition, the contract will expand the number of locations where the shipments can be sent. Previously, the U.S. Strategic National Stockpile only sent products to around five locations in each jurisdiction. Since the monkeypox outbreak began, state and local governments have struggled to acquire enough doses to vaccinate at-risk populations. "Today's announcement is the result of our real-time and ongoing conversations with states and jurisdictions aimed at improving the national response. This new commercial contract will help deliver vaccines and treatments to communities and at-risk individuals more quickly and bring us a step closer to ending the current outbreak," said HHS Assistant Secretary Dawn O'Connell. (Choi, The Hill, 9/6)
    • According to an overview published in Annals of Neurology by Kenneth Tyler and Daniel Pastula of the University of Colorado School of Medicine, animal models, case series from previous monkeypox outbreaks, and preliminary reports suggest that the monkeypox virus has the potential to be neuroinvasive. Experts recently warned that neurologists should be able to detect, diagnose, and treat neurologic symptoms and neuroinvasive disease amid the ongoing monkeypox outbreak. "Although neurological manifestations are exceedingly rare, they can occur," Tyler said. "It's a numbers game, and prior studies of outbreaks with hundreds of cases did include rare neurological events like seizures and encephalitis." According to Tyler, "[t]he current case numbers are orders of magnitude greater than the case series reported before, increasing the likelihood that rare events will emerge." Recent reports have suggested that encephalitis may have occurred in some cases. "There are also unpublished discussions of possible transverse myelitis-like disease in patients with monkeypox virus," Tyler said. In addition, "evidence from related orthopox viruses including smallpox, vaccinia, and vaccinia vaccination suggest the possibility of things like encephalitis, myelitis, or acute disseminated encephalomyelitis-like events," Tyler noted. According to Tyler, most reports of related viruses indicate that a majority of neurologic complications could be post-infectious or para-infectious immune-mediated processes. "However, animal studies with monkeypox suggest it can be directly neuroinvasive as well," he added. (George, MedPage Today, 8/19)
    • Amid the ongoing monkeypox outbreak, many experts have seen patients with coinfections of monkeypox and HIV. For instance, Monica Gandhi of University of California, San Francisco (UCSF), said she has seen cases of coinfections among patients in San Francisco, a city with some of the highest monkeypox case counts in the country. While Gandhi noted that she sees a skewed population in her role as medical director of a large HIV clinic at San Francisco General Hospital, she said there is a lack research on monkeypox in people living with HIV. "Definitely this has to be tracked," said Gandhi, who also directs the UCSF-Bay Area Center for AIDS Research. "Is there a proclivity in people living with HIV?" she added. According to Gandhi, because smallpox was eradicated in 1980—before the HIV/AIDS epidemic began—there is very little research on the relationship between orthopoxviruses and HIV. Notably, Gandhi questioned whether people with HIV may be more vulnerable to orthopoxviruses like monkeypox. However, she noted that she has not seen any studies that suggest that people with HIV are more likely to suffer from severe illness from monkeypox, with the exception of one case researchers said suggested monkeypox could be more severe with immunosuppression and untreated HIV. Still, with the focus on vaccines and treatment amid the ongoing monkeypox outbreak, "we may be modifying the natural history by early intervention, as we should be," Gandhi noted. (Henderson, MedPage Today, 8/19)
    • A case report published on Friday found that a Portuguese patient with a monkeypox infection developed myocarditis one week after symptoms appeared. According to the report published in JACC: Case Reports, roughly one week after the 31-year-old male's onset of symptoms, he went to the ED with complaints of chest tightness radiating through his left arm. The patient was admitted to the ICU where cardiac magnetic resonance mapping was confirmed the inflammation in his heart muscle. After one week, he was fully recovered and discharged. "This case highlights cardiac involvement as a potential complication associated with monkeypox infection," said Ana Isabel Pinho, lead study author and physician in the department of cardiology at São João University Hospital Center. Notably, myocarditis is usually triggered by a viral infection. It was previously associated with the smallpox virus, which comes from the same family as the monkeypox virus. (Carbajal, Becker's Hospital Review, 9/2)
    • Findings from a preprint study published last month in medRxiv suggest that two doses of Jynneos generate low levels of neutralizing antibodies. While the study has not yet been peer-reviewed, the researchers said the early findings raise concerns about how much protection the vaccine provides. According to the researchers, the findings also suggest the United States' dose-sparing strategy may also reduce virus immunity. "At this moment it is unclear what the relatively low [monkeypox virus] neutralizing titers mean for protection against disease and transmissibility," wrote the researchers from Erasmus Medical Center in the Netherlands. "Studies following vaccinated individuals are necessary to further assess vaccine efficacy in risk populations and determine correlates of protection for this emerging pathogen," they added. (Branswell, STAT, 9/2; Carbajal, Becker's Hospital Review, 9/6)

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