First monkeypox case reported in Sonoma Valley

A monkeypox case has been identified at Sonoma Valley Community Health Center, one of a handful of cases reported in Sonoma County. Meanwhile, the illness is moving rapidly across the state, nation and world, prompting conflicting opinions among medical experts as many call for a more proactive approach to curbing the spread.

Monkeypox was first detected in humans in 1970 and there have been occasional outbreaks, but the current outbreak is by far the largest, with 16,358 cases in more than 60 countries, including 2,891 in the United States and 434 in California as of July 23, according to the Centers of Disease Control and Prevention (CDC). There have been few hospitalizations and deaths associated with the disease.

Privacy laws restrict health-care providers from releasing an individual’s personal medical information, but some details about three confirmed or probable cases in Sonoma County have come to light. They are all men who displayed flu-like symptoms, including muscle aches, a headache, a rash and a subjective fever, which is a fever that someone feels, as opposed to something objectively measured by a thermometer. The people are in different stages of the illness and none have required hospitalization.

One man contracted monkeypox after traveling internationally and another did so after traveling to another state. One of the people contracted it after being exposed to another local cases. Public health officials are investigating eight close contacts to these men, but there is no evidence that others have contracted the virus.

Sebastopol resident Mitcho Thompson told NBC Bay Area that after testing positive for COVID at the end of June, he started seeing red lesions on his back, legs, arms and neck, a telltale symptom of monkeypox. He said that his doctor told him that he also contracted monkeypox, noting that it’s rare but possible to have both viruses simultaneously.

Dr. John Swartzberg, clinical professor emeritus of infectious diseases and immunology at the University of California, Berkeley, emphasized that monkeypox has no relationship to the coronavirus and it’s far less transmissible. Dr. Monica Gandhi, professor of clinical medicine at University of California, San Francisco (UCSF), said she doesn’t believe monkeypox is related to COVID in any way, except for one possibility.

“We may be more vulnerable to other infections after staying away from infections for the past two years of COVID restrictions due to an ‘immune deficit’ from not being exposed to other pathogens [viruses],” she said.

Sonoma Valley Community Health Center (SVCHC) received monkeypox vaccines from the state and administered doses to two people who have been in contact with the infected Sonoma Valley resident. The health center is collaborating with Sonoma County’s Public Health Division to learn how to address additional cases if they turn up.

“The county has taken a proactive stance in ensuring that we have a small number of vaccine doses to be administered when public health so directs,” said Cheryl Johnson, CEO of the health center.

No monkeypox cases have been diagnosed at Sonoma Valley Hospital (SVH), which is working closely with the infectious disease team at UCSF and the California Department of Public Health to make sure that it follows the best practices and protocols.

Vaccine distribution issues

“Allocations of the monkeypox vaccines are determined by the California Department of Public Health, from whom we will receive guidance for staff and patient safety and care,” said Kylie Cooper, director of quality and risk for the hospital.

The Jynneous vaccine, which is also used to prevent smallpox, has been licensed by the U.S. Food and Drug Administration to prevent monkeypox infection, but it has never been widely used in response to an outbreak. A very limited supply of it was available in the US at the beginning of the outbreak, but since late May, more than 300,000 doses have been made available nationally.

Following recent complaints about the federal government's slow response to the outbreak, the U.S. Department of Health and Human Services (HHS) announced on July 15 that it ordered another 2.5 million doses of the vaccine from Bavarian Nordic in Copenhagen. Deliveries are expected to arrive at the Strategic National Stockpile later this year and continue through early 2023.

“There is no need for alarm, but there is need for a robust public health and medical response to stop the spread,” Swartzberg said. “We have the tools to do this, with the vaccine.”

Yet on Saturday, Tedros Adhanom Ghebreyesus, director general of the World Health Organization, declared that monkeypox is an “extraordinary” situation that qualifies as a global emergency. The United Nations’ emergency committee was divided on whether to declare it as an emergency, with Ghebreyesus acting as a tiebreaker.

HHS stated in a June 28 news release that “given the large number of contacts and difficulty in identifying all contacts during the current outbreak, the vaccine will now be provided to individuals with confirmed and presumed monkeypox exposures.”

The news release went on to explain that this includes people who had close physical contact with someone diagnosed with monkeypox; those who know their sexual partner was diagnosed with monkeypox; and men who have sex with men (MSM) who have recently had multiple intimate partners in a venue where there was known to be monkeypox or in a geographical area where monkeypox is spreading.

Gandhi recommends that for now, vaccines should be offered to all MSM who have multiple partners and have not had the smallpox vaccine.

“Later, we are likely to extend this to all MSM with more limited sex partners and those who have had the smallpox vaccine,” she said. “And if the virus enters the heterosexual population in higher amounts, the vaccine will eventually be offered to all sexually active adults or at the same time when the HPV [human papillomavirus infection] vaccine is offered to adolescents as a preventive vaccine for an STD [sexually transmitted disease].”

Gandhi says that men who have sex with multiple male partners should not have sex if they have active lesions and should ask their partners if they have monkeypox.

“At this point, I don’t think the general population needs to take extra precautions as the outbreak is quite confined to a specific community,” she said.

Diagnoses and testing

Both the Food and Drug Administration and CDC have stated that a skin lesion should be required for testing, although the CDC is exploring the potential of saliva, throat and blood tests.

Dr. Benjamin Maser, a specialist in laboratory medicine, wrote a story for The Atlantic, “We’re Testing for Monkeypox the Wrong Way,” in which he called for earlier testing.

“This alarming messaging, delivered at a crucial moment in the virus’s spread, will have a profound effect on how quickly new monkeypox infections can be identified, isolated and treated,” he wrote. “With this disease, like many others, early detection is invaluable as a means of promoting early treatment.”

The CDC said that early data from the current US outbreak suggests that gay, bisexual and other men who have sex with men comprise the vast majority of monkeypox cases. These groups aren’t predisposed to the disease, though, Swartzberg said.

“There is no evidence that certain individuals are more susceptible to contracting monkeypox,” he said. “You are more likely to get infected if you have intimate contact with multiple sexual partners.”

The CDC’s website says monkeypox can be contracted in the following ways:

• Direct contact with the infectious rash, scabs or body fluids

• Respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling or sex

• Touching items (such as clothing or linens) that previously touched the infectious rash or body fluids

• Pregnant women, who can spread the virus to their fetus through the placenta

The site adds that it’s also possible for people to get monkeypox by being scratched or bitten by infected animals, or by preparing or eating meat or using products from an infected animal.

The general consensus in the medical community is that monkeypox requires personal or intimate contact, but Dr. N. Adam Brown, a practicing emergency medicine physician and a professor at the University of North Carolina’s Kenan-Flagler Business School, notes in a post on the website Washington Blade: America’s LGBTQ News Source, that scientists have not ruled out airborne transmission.

“As the New York City Department of Health admitted, ‘a lot of cases … are not being diagnosed,’” he wrote. “These unknowns are halting signs. If airborne spread is confirmed, or if it’s found asymptomatic carriers can spread monkeypox, monkeypox spread will be much worse than we currently anticipate. We are still learning about this new viral strain. We must remember that.”

Possible early signs of monkeypox are symptoms such as the flu, with a fever, low energy swollen lymph nodes and general body aches, said Dr. Kismet Baldwin, deputy health officer for Sonoma County Department of Health Services.

“Within one to three days — sometimes longer — after the appearance of fever, the person can develop a rash or sores,” she said. “The sores will go through several stages, including scabs, before healing. They can look like pimples or blisters and may be painful and itchy.”

The rash or sores can be located on or the genitals or anus, but can also be in other areas, such as the hands, feet, chest and face. They can be limited to one part of the body.

“People with monkeypox may experience all or a few of these symptoms,” Baldwin said. “Most with monkeypox will develop the rash or sores.”

Some people have reported developing a rash or sores before or without flu-like symptoms. Monkeypox can spread from the time symptoms start until all sores have healed and a fresh layer has formed, which can take several weeks, she added.

Most people with monkeypox don’t require treatment unless the lesions are very painful or disseminated in multiple places.

Origins and outbreaks

Monkeypox was discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of monkeys kept for research. The first documented cases of humans contracting monkeypox were in the Democratic Republic of the Congo (DRC, formerly Zaire), Liberia and Sierra Leone in 1970. DRC recorded 338 cases and 33 deaths from monkeypox from 1981 to 1986, and 511 cases from 1991 to 1999.

In most countries, cases have rarely turned up among people who have not traveled to Central or West Africa. In 2003 there was a US outbreak in which 47 cases were reported, the first outside of Africa, which was caused by pet prairie dogs becoming infected by rodents that had been shipped from Ghana. In May 2022, an uptick of cases began among people — including Europeans and North Americans — who have not visited Africa, including in Europe and North America.

Dr. Gary Green, an infectious disease expert at Sutter Santa Rosa Regional Hospital, told the Press Democrat that the current monkeypox outbreak is “very likely going to be an endemic process,” which refers to a disease that is ever-present or has unusual prevalence in a population within a geographic area, according to the CDC.

But Dr. Syra Madad, an infectious disease epidemiologist faculty member at Boston’s University’s Center for Emerging Infectious Diseases Policy and Research, wrote in a CNN opinion piece, “This Monkeypox Outbreak Didn’t Have to Happen,“ that it has reached the pandemic stage.

“Regardless of the messaging coming from health officials, monkeypox is a pandemic according to the CDC’s definition, which defines a pandemic as ‘an epidemic that has spread over several countries or continents, usually affecting a large number of people,’” she said.

Brown issues a warning in his Washington Blade article.

“It’s been two months since the first U.S. patient with monkeypox was identified,” he wrote. “There are now 1,900 cases [2,891 as of July 23] that we know of. The nation’s capital, Washington, D.C., leads the country in cases per capita. The opportunity to contain the virus is slipping away.

“The country needs a swift, but comprehensive response. We need more vaccines. We need uniform standards and clearer rules about testing and treatment. Trusted officials need to combat myths. And people must get vaccinated, particularly those at the greatest risk.”

Reach the reporter, Dan Johnson, at daniel.johnson@sonomanews.com.