Hundreds waiting hours for a monkeypox vaccine only to be turned away. Residents taking to social media to detail struggles getting diagnosed and treated. State and local leaders demanding federal action. Emergency orders declared.
At face value, these details paint the picture of a country and state in crisis, struggling to apply lessons learned from the past two and a half years of COVID-19 response. However, scientists, public health leaders, and physicians who spoke with CalMatters said infrastructure and resources augmented during the COVID-19 pandemic have, in fact, aided the monkeypox response.
Still, it has its faults.
鈥淲hat we learned from COVID is that speed is everything. When we look at the response of monkeypox later on, we鈥檒l see speed is the main thing we take issue with,鈥� said Dr. Peter Chin-Hong, infectious disease specialist at UC San Francisco and member of the state鈥檚 scientific advisory committee for monkeypox.
California has the second-highest number of monkeypox cases in the country, with more than 1,300 infected residents, . Gay and bisexual men have been disproportionately impacted, making up 96% of cases. Some experts say we鈥檙e already past the point of controlling monkeypox, which was .
The culprit? Too little testing and treatment and too few vaccinations 鈥� all of it layered with too much red tape at both the federal and state level. It鈥檚 a familiar refrain and one that has frustrated state and local leaders.
A asked the U.S. Department of Health and Human Services to allow the state to reallocate some of the $1.5 billion in COVID-19 response funds to monkeypox. Others submitted a for monkeypox resources, and the California Department of Public Health sent a letter to the Centers for Disease Control and Prevention requesting 600,000 to 800,000 vaccines 鈥� that鈥檚 more than half of the total available doses for the entire country.
California is expected to receive 72,000 doses of the used for monkeypox, with an additional 43,000 sent straight to Los Angeles County. Those doses represent 鈥渁 drop in the bucket鈥� of what鈥檚 needed, state epidemiologist Dr. Erica Pan told county health officers in a meeting last week.
"Monkeypox is a serious concern, but public health is far more prepared now than we have ever been."Sarah Bosse, Madera County Public Health Director
During a Senate oversight hearing held Tuesday, Sen. Scott Wiener, a San Francisco Democrat, said 鈥渟evere public health failures鈥� at the federal level led to the current outbreak.
鈥淲e need to turn this around,鈥� Wiener said. 鈥淲e need to continue to push hard to make sure that our state, federal, state and local public health authorities are directing the resources where they鈥檙e needed most and rapidly expanding support for vaccination, testing and treatment to slow and hopefully stop this spread.鈥�
Lessons learned
Despite continued resource challenges, public health systems are better prepared to respond to monkeypox than they were to COVID-19. In the early days of the pandemic, .
鈥�(Monkeypox) is a serious concern, but public health is far more prepared now than we have ever been,鈥� said Sarah Bosse, Madera County public health director.
Madera County has not reported any monkeypox cases, but neighboring Fresno County has seven cases. Bosse said her department is already in talks with the state on how to redirect COVID-19 contact tracers to monkeypox response and how to scale up vaccination clinics.
鈥淭he state has been very proactive in identifying counties that need additional support,鈥� Bosse said.
In comparison, in 2020, for COVID-19 before Gov. Gavin Newsom declared a statewide emergency, freeing up staff and fiscal resources. This time, only San Francisco beat the state to the punch, a signal that state officials are closely in tune with local needs.
鈥淭o someone like me who has been doing this for 30 years, this actually moved very fast,鈥� said Dr. Timothy Brewer, an infectious disease specialist at UC Los Angeles, who recalled it was three years between when the first case of AIDS was described in Los Angeles and identification of the HIV virus. It took an additional three years before the first treatment was developed.
Comparing monkeypox to the HIV/AIDS epidemic and COVID-19 pandemic 鈥� both of which activists and state leaders have done 鈥� isn鈥檛 exactly apples-to-apples. What researchers knew about each disease at the onset of their respective outbreaks and available treatments varied widely.
鈥淲hat鈥檚 frustrating is that unlike COVID, which was a brand new virus that we had never seen before鈥ith monkeypox we do know about it. It鈥檚 been around almost 70 years,鈥� Wiener said. 鈥淲e actually have a vaccine and an effective treatment. You would think that would be a recipe for very quickly controlling an outbreak.鈥�
However, the influx of attention and money on the state鈥檚 chronically underfunded public health resources during the past two years has helped agencies ramp up for monkeypox much more quickly than they did with COVID-19.
For example, six months after the first confirmed COVID-19 case in California, the state was still and struggling to process a backlog of results. In comparison, one month after the first monkeypox case in the U.S., the Centers for Disease Control and Prevention onboarded five commercial laboratories, making monkeypox testing widely available at hospitals and doctors鈥� offices. In the same time period, the California Department of Public Health doubled its weekly testing capacity from 1,000 to 2,000 tests with an average turnaround time of three days, far shorter than the .
The state also had to build data reporting systems for contact tracing, testing and vaccinations from scratch in 2020. County health officials say they鈥檙e now using those same systems for monkeypox. By Aug. 15, the state plans to launch a monkeypox vaccine appointment portal through the .
鈥淲e have weekly calls with (the state health department) and everyone is saying we need funding resources for this,鈥� said Tulare County Public Health Director Karen Elliott. 鈥淚 think that鈥檚 one of the reasons (the state health department) wanted the state of emergency. It cuts a lot of red tape.鈥�
Some of that red tape stems from reallocating money earmarked for COVID-19 to monkeypox, which requires both federal and state approval. Public health funding is notoriously categorical, representing a history of crisis allocation rather than continuous investment in safety-net systems and disease prevention. This severely limits the flexibility needed to respond to an outbreak.
鈥淲e have a specific budget for tobacco prevention, a specific budget for obesity prevention,鈥� Madera鈥檚 public health director Bosse said. 鈥淲e have 78 (funding streams) for one department that all have to be tracked separately.鈥�
The state allocated in the past two years. Some counties have money left over or have staff hired to run COVID-19 clinics and conduct contact tracing, but haven鈥檛 been able to use them for monkeypox, which Elliott says they鈥檒l need as cases increase in Tulare County.
The Legislature also approved $300 million in ongoing public health funding for local health departments in June, . Typically that money would take several months to make its way to county health agencies, but the state of emergency has helped them get the money now, county officials said.
Still, county officials emphasize that spending flexibility is needed in public health. Riverside County Public Health Director Kimberly Saruwatari said the employees responding to monkeypox are working 鈥渙utside of their grant requirements鈥� and local departments won鈥檛 be able to sustain that spending. San Diego County Public Health Director Elizabeth Hernandez testified during Tuesday鈥檚 hearing that her department is spending $90,000 per week on monkeypox response and has incurred more than $400,000 in expenses.
Shortfalls remain
Even with a more coordinated statewide response, bureaucratic delays and shortages at the federal level threaten to upend local efforts to control the spread. The CDC recommends doctors only test a small subset of the population that suspects they are a close contact of someone with monkeypox or are symptomatic. Also, the antiviral treatment for severe cases is considered experimental and requires hours of paperwork for each patient along with an ethics review, rendering most clinics unable to give it to patients. Meanwhile, vaccines remain far too scarce.
UCSF鈥檚 Dr. Chin-Hong said limitations on who can get tested mean cases are diagnosed far too late.
As of Aug. 2, the state health department had received 6,682 monkeypox test results, with the positivity rate around 19%. Generally, a positivity rate higher than 5% means not enough testing is being conducted.
鈥淚n an outbreak setting you want to test as many people as possible. You know you鈥檙e successful if you have a lot of negative tests,鈥� Chin-Hong said.
The earlier a case is diagnosed, the easier it is to conduct contact tracing, which becomes critical in the face of vaccine shortages. That, however, continues to be an obstacle.
"We don't have enough money for robust contact tracing, given the number of cases."Dr. Peter Chin-Hong, infectious disease specialist at UC San Francisco
that San Francisco鈥檚 health department has largely abandoned contact tracing as a primary containment strategy 鈥� citing difficulties in getting patients to divulge sexual partners 鈥� and is instead telling people to 鈥渟elf-refer partners.鈥� Monkeypox is not a sexually transmitted disease but has been spreading through sexual networks due to the close skin-to-skin contact needed for transmission. In comparison, contact tracing for COVID-19 quickly became infeasible in part because the ease of airborne transmission made it impossible for many people to pinpoint where they became infected.
Epidemiologists say monkeypox could feasibly be contained given its long incubation period of two to three weeks, but it requires public health departments to have ample employees to do the work of getting a detailed history from patients and calling every known contact.
鈥淲e don鈥檛 have enough money for robust contact tracing given the number of cases,鈥� Chin-Hong said. 鈥淭hat leaves people to do their own contact tracing. They need to get tested.鈥�
Elliot, Tulare County鈥檚 public health director, said most counties will have trouble scaling up contact tracing without state support. Her staff has three communicable disease investigators who work to find close contacts of each case and two public health nurses that are in daily contact with positive patients to monitor their symptoms.
鈥淲e have two cases but we鈥檇 be ignorant to think we won鈥檛 have more,鈥� she said. 鈥淓ventually, we won鈥檛 have the bandwidth for this anymore.鈥�
Los Angeles County Health Officer Dr. Muntu Davis said his department has 鈥渋nsufficient resources for contact tracing鈥� and has requested help from the state. Confirmed monkeypox cases in Los Angeles County doubled in the past 10 days to 647 infections, Davis told legislators at Tuesday鈥檚 hearing.
With lackluster testing and contact tracing resources, Chin-Hong said the primary strategy for monkeypox containment becomes 鈥渧accinate like crazy鈥� for the most at-risk population: gay, bisexual and transgender men.
Yet again, that strategy comes with severe limitations.
鈥淚 want to be clear, the state of emergency and emergency budget request? Neither will solve our most basic need, which is for more vaccine. We can鈥檛 distribute a vaccine that we don鈥檛 have,鈥� said Kat DeBurgh, executive director of the Health Officers Association of California.
Officials continue to stress that risk remains low for the general public, and some say the political discourse has caused unwarranted panic.
Monkeypox won鈥檛 infect as many people as COVID-19 due to its mode of transmission and has not caused any deaths in the United States, although it can cause painful lesions on the skin. Twenty-seven patients, representing 3% of all cases, are hospitalized in California primarily for pain management, according to State Health Officer Dr. Tom谩s Arag贸n.
In comparison, more than and 93,056 Californians have died since the beginning of the pandemic.
鈥淭his is a self-limiting, non-fatal disease,鈥� Solano County Public Health Director Dr. Bela Matyas said. 鈥淗ere we are redeploying from COVID to monkeypox. COVID kills. Monkeypox doesn鈥檛. And I think it鈥檚 fair to ask where the logic is in that kind of decision-making.鈥�
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