While MPX infection rates continue to level off, both in San Francisco and across the United States, health officials from the state level on down are expanding vaccine eligibility in order to continue getting shots into arms. Expanding eligibility, however, doesn't mean officials are making vaccines available to the wider general public, which they believe is not warranted at this time.
The San Francisco Department of Public Health issued an advisory October 12 in conjunction with the California Department of Public Health's recent vaccine eligibility expansion which, if anything, puts a finer point on who is most in need of access to the MPX Jynneos vaccine, which requires two doses, about a month apart.
San Francisco DPH identified three specific groups to be targeted: people living with HIV; people who are taking, or who are eligible to take, PrEP for HIV prevention; and clinicians who are likely to collect laboratory specimens from people with MPX.
This is in addition to groups DPH has been targeting since MPX first appeared in the United States back in May. Recently, however, DPH added non-San Franciscans attending the various fall street festivals, such as the Folsom and Castro street fairs, to the list of those eligible to be vaccinated provided they meet the same criteria required of residents. (That was temporary and expired October 2, according to DPH.)
As with previous vaccine eligibility, people must fall within one of several categories: gay or bisexual men, or any man or trans person who has sex with men or trans people; sex workers of any sexual orientation or gender identity; people of any age or any gender who have had close contact within the past 14 days with someone with suspected or confirmed monkeypox; and people who have had close contact with others at a venue or event or within a social group in the past 14 days where a suspected or confirmed MPX case was identified.
This includes people who received notice from a venue or event of a potential exposure within the past 14 days, as has long been the case; laboratory workers who routinely perform MPX virus testing; and clinicians who have had a high-risk occupational exposure (i.e., examined MPX lesions or collected monkeypox specimens without using recommended personal protective equipment), DPH has stated.
In addition, the city is working to reach out to people of color as Black and Latinx men who have sex with men have been hit particularly hard by the outbreak, as the Bay Area Reporter has reported.
Earlier this month, San Francisco Health Officer Dr. Susan Philip told the B.A.R. that despite more than four months having passed since MPX began to appear in the city, men who have sex with men are still by far the largest group affected by the outbreak. As a result, said Philip, "We're still not at a place where we're saying everyone should get an MPX vaccine."
Types of infections seen in SF
The advisory also further detailed the types of infections being seen by medical professionals in San Francisco. Most cases of MPX in the U.S. are mild to moderate in severity, however severe manifestations and death have occurred, mostly in immunocompromised individuals, the advisory stated. The California Department of Public Health reports one death in the state, which occurred in Los Angeles County in September.
"HIV co-infection with MPX in the U.S. is common," the DPH advisory stated. "San Francisco clinicians treating HIV-positive individuals or those whose HIV status is unknown should be aware of the rare but possible severe manifestations of MPX infection and how to manage MPX in immunocompromised patients."
Immunocompromised people are at higher risk for serious MPX infections. Those folks whose CD4 counts are below 200, in particular, are at greatest risk for significant morbidity or mortality, the advisory stated.
The list of possible symptoms with which members of this population could find themselves struggling makes for very unpleasant reading: rashes with coalescing or necrotic lesions that may require surgical debridement or amputation; rashes associated with secondary infections; bowel lesions leading to tissue swelling and obstruction; and swollen or necrotized lymph nodes that could obstruct airways; lesions that scar or stricture.
Additional symptoms include Involvement of multiple organ systems including lung nodules, encephalitis, spinal inflammation, heart inflammation, pericardial disease or inflammation of the tissue surrounding the heart; pink eye; sight-threatening corneal ulcerations; urethritis and, finally, penile necrosis.
And, while noting its rarity, the advisory noted that there have been "a handful of cases of occupationally acquired MPX infection — primarily related to specimen collection, sharps injury, and poor adherence to use of recommended personal protective equipment."
According to October 8 figures compiled by DPH, of the 824 cumulative cases of MPX in the city, 95% have been men, with less than 1% of cases being trans men. Two percent of cases are trans women and 1% are cisgender women. The largest number of infections — some 88% — has been found in people ages 25-54, with the largest share of those infections — 38% — occurring among people ages 35-44. Thirty-one percent of infections were among 25-35 year olds, and the rest — 19% — occurred among 45-54 year olds. Those over the age of 55 on up accounted for 8% of infections and 3% occurred in people aged 18-24. There were no cases among those 17 and under.
In a statistic DPH has only just begun using, as of October 5, the city has a seven-day rolling average of 1.6 cases per day, which is a more accurate detailing of how quickly the virus may be spreading.
"The seven-day rolling average shows the trend in new cases. We calculate the rolling average by averaging the new cases for a particular day with the new cases for the prior 6 days," DPH explained on its MPX statistics page.
Among the city's various ethnic and racial groups, whites still make up the largest percentage of cases at 46%. Caucasians make up 51% of the city's population, according to U.S. Census estimates for 2021. However, as noted, Latinx and Black individuals are being particularly hard hit with Latinx people accounting for 28% of cases, despite the fact they comprise only 15.7% of the population, while Blacks, at 5.7% of the city's population, comprised 6% of cases. Asians, who account for 37.2% of San Franciscans, made up only 9% of MPX cases.
Gay, lesbian, or same-gender-loving individuals account for the lion's share of cases overall: 68%. People who identify as bisexual comprise 4%, and those who declined to identify their sexual orientation comprise 28% of infections. Heterosexuals accounted for 2%.
While health officials are feeling hopeful, they are still quite worried about those who haven't gotten the second shot, which the CDC says should be given 28 days after the initial vaccination. In the earliest days of the outbreak, places such as Zuckerberg San Francisco General Hospital and Trauma Center were giving out only first doses because of the very small amount of vaccines available. Now, however, they're all about that second jab.
"Numbers could go up," Philip told the B.A.R. earlier this month, referring to MPX cases. There are still plenty of people who are susceptible and have not had even the first shot, she said. "Please come get your second shot."
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