Monkeypox Is Here

Monkeypox is here. There were 866 reported cases in the US on July 11 and the number has increased to 1814 by July 16.

The bad news is that, unlike Ebola, the previous African microbe to hit our shore, this one is unlikely to be passing a fad. The good news is that we already have a vaccine, the same one that prevents smallpox.

Monkeypox is a virus similar to smallpox, which has been eradicated in nature. The first case in humans was recorded in Central Africa in 1970. In Africa it has an animal reservoir and causes a disease similar to smallpox, but milder. It traditionally starts with a fever and viral syndrome followed by a characteristic rash, involving the face and extremities. But in the current outbreak, the virus has been behaving in new ways. The disease is currently spreading in the US and Europe, primarily among gay, bisexual and other men who have sex with men. It consists primarily of a rash in the oral and/or anogenital region, with or without a viral syndrome which can include fever, headaches, muscle aches, and swollen lymph nodes,. It Is spread via close physical contact with an infected individual.

It is diagnosed by lab PCR testing of a skin lesion which is currently available. An infected individual is contagious for 2-4 weeks until the skin lesions are completely healed. It is recommended that infected individuals use condoms for 12 weeks as the virus may remain in the semen for a prolonged time.

Due to their location, the skin lesions can be painful.

The current approach to the outbreak is to vaccinate at-risk people. However, the supply of vaccines is presently limited and is being prioritized for individuals with known recent exposure to the virus. As supplies increase, they will probably be offered to all individuals at risk. While mortality in previous outbreaks of Monkeypox in Central Africa has reached 10%, the current outbreak in the US has not been associated with mortality.

Important unknowns include: whether the disease will cross into the general population and what form it will take in the future.

The presentation can be confused with herpes, other sexually transmitted illnesses, and other causes of rashes. An experimental antiviral drug is available for severe cases.

Gun Violence and Mental Health

Every time there is a mass shooting event in the US, in addition to the debate about gun control, there is always a cry for more investment in mental health resources.

I don’t believe this would work.

Gun violence in the US consists of two categories of events.

The first category consists of isolated events where a disturbed individual, with a severe sociopathic personality disorder, sometimes psychotic at the time of the event,  commits mass murder. Sometimes the victims are a specific group of people that are the focus of the shooter’s hatred. Other times the victims are totally random.

The second larger category consists of the daily gun events, largely in big inner cities with long-standing crime problems, often gang-related.

Spending money on mental health resources will do nothing to help prevent either of these categories of events.

People with personality disorders are notoriously resistant to any type of mental health intervention. They don’t want to talk to mental health providers and if they do are very resistant to treatment. Similarly, investing in more mental health facilities will do little to prevent gun violence that is deep-rooted in complex socio-economic and cultural issues and issues related to crime prevention.

There is little doubt that life today is associated with more mental health problems for more people, and that more and better mental health care is needed. However, we are fooling ourselves if we think spending more money on mental health will have any effect whatsoever on the gun violence plaguing our country.

Should I Take Paxlovid?

Like almost every question about Covid, the answer is that we don’t completely know the answer. This is what we do know.

  • Paxlovid received emergency authorization from the FDA to use as an UNAPPROVED PRODUCT for the treatment of Covid in
  • mild to moderate cases of confirmed Covid in adults and children over 12
  • who are at “high risk” for progression to severe Covid disease

It should be started as soon as possible after diagnosis, within 5 days of onset of symptoms. It consists of two medications that are taken as 3 pills twice daily for 5 days. The most common side effect is a bad taste in the mouth.

The emergency authorization was based on a study that showed it decreased hospitalization by 89% in unvaccinated, high-risk individuals when started within 3 days from onset of symptoms.

While that seems very impressive, most of the people taking Paxlovid now are fully vaccinated and many have relatively minor risk factors compared to those in the clinical trial. Being vaccinated already largely protects us from severe illness. We don’t really know to what extent Paxlovid benefits fully vaccinated, healthy, younger individuals,l with less significant risk factors, such as being overweight or suffering from anxiety/depression, or former smokers, all of which have been associated with a higher risk of severe Covid. Many people with Covid do report feeling better 1-2 days after starting Paxlovid.

There is also the unanswered question of Rebound. There are reports of people taking Paxlovid, feeling better, and then having a recurrence of symptoms 3-5 days after completing Paxlovid. Some of these patients had negative Covid tests after completing the Paxlovid and then reverted to positive tests when their symptoms returned. Is it possible that Paxlovid may increase the period needed for isolation for active cases? We also don’t yet know what effect Paxlovid has on developing immunity. Is it possible that with the help of our vaccine-induced immunity we might be better off letting our immune system fight the disease? Perhaps that will provide us with better protection against future infection? These studies have not yet been done.

Finally, there is the question of Paxlovid having interactions with many prescription medications that must be considered individually. Certain anticoagulants, antiarrhythmics, anticonvulsants, psychiatric, immunosuppressive, lipid-lowering and other medications cannot be taken with Paxlovid. For those at high risk for severe disease who cannot take Paxlovid, monoclonal antibodies should be considered.

In summary, it is best practice to make the decision to take Paxlovid, when diagnosed with Covid, in consultation with your doctors, after considering your individual risks, circumstances, and the medications you are taking.

You might even want to discuss this with your doctor prior to being infected.

I took Paxlovid when I tested positive.

Telemedicine is here to stay

Like in other areas of our life, where the pandemic accelerated pre existing trends of technology changing the way we live, telemedicine came into its own with the start of the pandemic.

This was fueled not only by need, but by the implementation of several changes in regulatory, licensing and reimbursement policy by government and healthcare providers. Licensing restrictions were loosened such that doctors licensed in one state could now provide telemedicine care to patients in other states. Insurers, including the government started reimbursing telemedicine consults whereas previously they did not.

The concept of substituting, a trip to and from the doctor’s office, and waiting in waiting and exam room, with a simple telephone call or video consult is very appealing. It is also very cost-effective medical care.

The current challenge in telemedicine is to define the scope of practice that can be safely and effectively provided by telemedicine, and integrate this area of practice into the overall healthcare system.