Recognizing and addressing human monkeypox in Canada

A practice article in CMAJ presents 8 images of monkeypox mucocutaneous lesions presenting in Canadian patients from May to July 2022.  The images show a spectrum of common lesions seen in patients with human monkeypox during the 2022 outbreak in non-endemic countries. 

On this episode, Dr. Sharon Sukhdeo and Dr. Darrell Tan, two co-authors of the article discuss their intention that the image atlas be a necessary corrective to the proliferation of images from endemic countries seen early in the outbreak that primarily featured Black patients, often children. 

Host Dr. Mojola Omole speaks with these guests about the current epidemiology of human monkeypox in Canada, lessons learned from the 2022 outbreak, the importance of accurately describing who is at risk, and how generating awareness of monkeypox transmission in communities at risk may have slowed its spread.

Dr. Sukhdeo is an infectious disease fellow at the University of Toronto, and Dr. Darrell Tan is an infectious disease physician at St. Michael's Hospital in Toronto.

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Transcript

Dr. Mojola Omole:

Hi, I'm Mojola Omole, and I am the CMAJ Podcast.

I'm not sure exactly where Dr. Blair Bigham is right now. He's gallivanting across the globe for a well-needed vacation. So you guys are stuck with just me today. Since my plan for world domination involves ousting Blair from the CMAJ Podcast, I might just have a little bit of him at the end, when we talk about our conversation with the two infectious disease doctors about MPOX. So today we're going to be reviewing a paper called Human Monkeypox: Cutaneous Lesions in Eight Patients in Canada.

And the paper by Dr. Sharon Sukhdeo and Dr. Darrell Tan, their goal with it was to create an atlas of what these cutaneous lesions look like in the patient population that we would be seeing in North America. And they describe in the paper the experiences of patients and showing the pictures of what MPOX actually looks like. And then we're going to take a wider lens and look at what the state MPOX is right now in terms of its epidemiology in Canada. So let's jump into this.

Dr. Sharon Sukhdeo is an infectious disease fellow at the University of Toronto, and Dr. Darrell Tan is an infectious disease physician at St. Michael's Hospital in Toronto. We're going to review the paper with them, and then we're going to take advantage of having two infectious disease specialists with us to get a broader update on the status of monkeypox in Canada. Sharon and Darrell, thank you so much for joining me today. How are you both?

Dr. Sharon Sukhdeo:

Thanks-

Dr. Darrell Tan:

Doing well. Thanks so much.

Dr. Sharon Sukhdeo:

Thanks for having us.

Dr. Mojola Omole:

Let's just start off with why did you want to write this article?

Dr. Sharon Sukhdeo:

Yeah, sure.So at the very beginning, let's say this was back to May of this year, we had our first patient in Ontario with a human monkeypox, and we were hearing a lot of things in the news about what this disease was. And it became pretty apparent pretty quickly that there were a lot of misconceptions, and we had an opportunity to set it straight, correct it. And we thought that doing this in the form of an atlas would be a great way to show the types of lesions that are being seen in patients with human monkeypox. That was one of the ideas.

The other was the fact that in, the media, a lot of the pictures that were circulating were of Black skin, these were pictures from prior outbreaks or from Africa. And the difficulty with that, especially early in the outbreak and still pertains now, is the fact that that's a very untrue picture of the demographics of the patients that we were seeing. So we thought it was important to depict the types of patients that we were seeing and the lesions that were being seen.

The other thing was that we saw a big, I would say, knowledge gap and opportunity to educate physicians on the clinical presentation, the systemic symptoms that come with human monkeypox, and then what the lesions look like. Because we were seeing quite a few patients who were being diagnosed or misdiagnosed or bouncing around between one physician or an office to another before receiving their diagnosis, which oftentimes would mean delays in their diagnosis or care.

Dr. Mojola Omole:

So I'm going to get back to that in terms of visually what it looks like. But you had mentioned that there were some misconceptions in the media back in May when they started seeing that this outbreak was going to be spreading. What were some of those misconceptions?

Dr. Darrell Tan:

I think a lot of what was being portrayed relates back to this issue of whether the images that were being shown in the media were representative of what was happening in Canada. And really, kudos, I think, go out to some of our amazing community partners on this work, and a lot of the other work that we do in the field of sexual health and infectious diseases, notably the Black Coalition for AIDS Prevention. Some of our partners there echoed a sentiment that had actually been voiced by the Foreign Press Association of Africa calling out how problematic it was that, as Sharon said, the images that were being portrayed were largely of young, Black African children covered in MPOX lesions.

Because that had been what had been seen in other settings where this virus has been seen in the past, but was very different from what we were seeing in the adult gay, bisexual, other men who have sex with men in the Western world. And especially in a country like Canada where we have people from all parts of the world, all skin tones and a wide diversity of ages. So I think it's largely that that was so problematic, as a manifestation of structural racism and perpetuating false notions that echo problematic ideas about certain parts of the world being hotbeds of infection. Which is really problematic, and not representative of what was happening with the epidemiology.

Dr. Mojola Omole:

And Sharon, you had mentioned previously that patients were going from doctor to doctor with misdiagnosis. So can you just walk us through, either you or Darrell, what are the distinguishing features of monkeypox compared to something like herpes?

Dr. Sharon Sukhdeo:

Yeah, sure. So the patients who present with monkeypox, they've got cutaneous lesions, they've also got systemic lesions. And, at times, the cutaneous lesions can look very similar to those of herpes, for example. Some of the distinguishing features, I would say, is first the location may not be any different. So typically in this outbreak we've seen quite a few of the lesions being located in the genital, in the anal region, in the mouth, that's where they start.

Typically, for monkeypox, they start as either macules or papules pretty quickly. They progress within a day or so into pustules. And, what's pretty unique, I would say, about the lesions of monkeypox is that these pustules, they develop an indentation or an umbilication in the center, so the center becomes depressed, which doesn't typically happen with herpes. And what's distinct about this depression in monkeypox is the fact that the depression can look quite dark or violaceous as well. And that happens right before it starts to ulcerate.

And once it ulcerates, there are a few different ways that it can look. But you typically get these kind-of rolled or pearly edges with a darkened or necrotic-looking center. And then that goes through the stages where, after it ulcerates, it eventually crusts over, forms a scab, and eventually that scab falls off.

Dr. Mojola Omole:

Are there some systemic symptoms that also accompany the cutaneous lesions?

Dr. Sharon Sukhdeo:

So traditionally for MPOX, so before this outbreak, we were seeing systemic symptoms that preceded any of the cutaneous lesions, and typically, that would be in the form of a febrile illness. So you would typically get a fever, perhaps some chills, you would get malaise or fatigue, you may get some muscle aches, some back ache. And what's prominent about some of these symptoms during this time is that you can develop pretty remarkable lymphadenopathy or swollen lymph nodes. That can be quite tender and painful, and that sets it apart from some of the other differentials as well.

Dr. Mojola Omole:

So what do you think is the key takeaway from your article for physicians?

Dr. Sharon Sukhdeo:

What I would say is a few takeaways. One is that monkeypox can present in people of all skin tones, and you should keep a high level of suspicion when considering monkeypox in a differential. But also consider the fact that this is an opportunity to think about other differentials other than monkeypox. And the fact that people who present with MPOX may be coinfected, they may present with other sexually transmitted infections. And we have had the opportunity to make diagnoses of HIV during this time as well.

Dr. Mojola Omole:

And so, on that thread, let's move beyond the paper, so just looking at monkeypox in general. Back in May, it seemed that this was going to be… it could be the next pandemic, but it seems to have really settled down now. Is that what you guys are seeing in your clinics?

Dr. Darrell Tan:

Yeah, I do think that is what we're seeing, fortunately. We definitely have not seen very many true cases for several weeks now, which is really encouraging. And that mirrors what's been reported in the official epi reports for most parts of Canada that are publishing regular reports and also what's been seen in other parts of the Western world.

Notably, there are some exceptions. So there are still kind of raging epidemics going on in some parts of Latin America, certain pockets of the United States, I understand, still have quite active chains of transmission going on. But we are seeing a decline here in our setting, which is probably the combination of a whole host of different factors. It's also important to note though, that I think we have to be very cautious, because at the peak of the epidemic during the summer, it was not often difficult to make a diagnosis of this infection once you kind of knew what you were looking for.

Many people presented with pretty obvious, pretty dramatic symptoms, and people were very eager to seek care, because it was so painful, it was so unusual, et cetera. With the positive changes that we've seen with things like some behaviour change with the rollout of vaccine, it's also possible that the phenotype is going to change a little bit. That people may be presenting or may develop more mild manifestations-

Dr. Mojola Omole:

Oh, really. Okay.

Dr. Darrell Tan:

... if they develop the infection at all. And so I think we really have to keep a very high index of suspicion, and be vigilant about overinterpreting the epidemiology, for that reason.

Dr. Mojola Omole:

So initially it appeared that most of MPOX that we were seeing were affecting gay, bi men and other men who have sex with men. To what extent is this still the case?

Dr. Darrell Tan:

I can try to tackle that. To the extent that we're seeing cases at all these days, I think it's fair to say that that is still the case. That the vast majority of people with MPOX during the whole global epidemic in 2022 have overwhelmingly been sexual minority men, so gay, bi, and other men who have sex with men. The proportion of individuals who self-reported as not being a sexual minority man, certainly did increase over the course of the epidemic through the summer. But we're really talking about an increase from less than one percent to less than 10%. So the overwhelming majority still is people who self-identify as such.

Dr. Mojola Omole:

There was one part, at the beginning, that I found a bit curious was, there was some reluctance to communicate that MPOX was spreading in the community of men who have sex with other men. And part of that was just out of fear of stigmatizing and reducing it to just, "Oh, this is "just a disease of gay men," similar to previous stigmatization of the community. How do you think the thinking around this has evolved over the months from the outbreak back in May?

Dr. Sharon Sukhdeo:

Yes, I think it's important to note that, in the beginning, there was this early recognition that 99%, almost a 100% in certain regions of the people affected with MPOX were gay, bisexual, and other men who had sex with men or identified as such. And, yes, there was the reluctance to say so. I think it was a very good and important move to acknowledge that publicly, because these are the people that were being affected. And I think there's significant value in the public messaging, and getting that knowledge out there, that if you identify as such and you have the right risk factors, you are at risk, and there are steps that you can take to minimize your risk. We have vaccines. If you are presenting with lesions, you can go and get a diagnosis. So I do think that although there may have been a reluctance to admit this in the beginning, this is actually important identification, and getting the right messaging to the right people and the limited resources we have to the right places.

Dr. Darrell Tan:

I'd echo that. Well, I think it's really positive that a lot of mainstream media, a lot of public health officials were hesitant to just go around throwing out there that this was being seen almost exclusively in this population, because of the historical discrimination, of course, that queer people have faced in this country and around the world. And that fear of stigmatization is, I think, something that comes from a really good place. And I think it shows that we've learned a lot of important lessons in public health over the years.

All that being said, the problem is, of course, that as we learned during the HIV epidemic, for example, there's some really nice activist messages out there that have this beautiful pink triangle on a black background that “say silence equals death”. And what the spirit of that activist slogan is all about is that if we don't really explicitly talk about what's going on openly, especially when the data are so overwhelmingly clear that there is an overrepresentation in a key community, then we actually risk a lot of things. We risk not getting the key messages out to the communities that could benefit from those messages most. We risk drumming up excessive anxiety in folks who honestly need not be as worried about it personally. We also risk diverting resources in a sense to the wrong places, in a way. If we perpetuate an idea that everyone is equally at risk, and that every single person needs to have access to certain resources, we actually fail to focus those resources in the equity seeking groups that the folks who really do stand to benefit the most from our energy.

So I think there is a bit of a Goldilocks phenomenon, a bit of a need to find that perfect sweet spot. And I think for me, one of the key ways in which the thinking has rapidly evolved on this is that the way forward involves acknowledging what's happening epidemiologically, but meaningfully engaging the key affected communities. As is always the case in trying to address inequities in society, and bringing those voices to the fore, allowing those communities to lead and own a lot of the response.

Dr. Mojola Omole:

You had mentioned before that the number of cases have been declining, Darrell. Do we know what the reason behind the decline is?

Dr. Darrell Tan:

Let's each take a stab at this. Sharon, what do you think?

Dr. Sharon Sukhdeo:

I think that there are many factors that play into the decline. I think that it should go without saying that it's not entirely clear for sure what is causing this decline. However, there are a lot of good factors at play here. I think that early public health messaging and advocacy and knowledge about MPOX right from the start, played a role. I think that early vaccinations had an effect. If you speak to certain sexual health physicians, they will tell you that within a few weeks of us rolling out vaccines, 90% of their patients-

Dr. Mojola Omole:

Wow.

Dr. Sharon Sukhdeo:

... who would be coming in for their regular checkups, would say, "Yeah, I've already gotten my vaccine. Don't need to worry about me. I've heard it all. I know what to look for, and I've got my vaccine. And I'm doing all that I can." And I think that kind of targeted approach to an outbreak really helped in decreasing the amount of cases.

Dr. Darrell Tan:

I totally agree with that. That all being said, I think some of the really interesting and challenging issues ahead are that, although the vaccine probably did play an important role alongside behavior change and the education efforts that were so pivotal, as Sharon said, I think there's a lot we still don't know about this vaccine. It's worth pointing out that even though this vaccine was approved for use against MPOX by Health Canada, which is this amazing stroke of serendipitous good fortune that it was a licensed just before this epidemic hit, that licensure in Canada is actually based on human safety data, but only animal efficacy data.

Dr. Mojola Omole:

Oh, really?

Dr. Darrell Tan:

Because MPOX hadn't really been around to formally study, of course, in most parts of the world, we don't actually have the key data that would give us the confidence that we really want about the potential impact of vaccines on controlling the epidemic for good. And, specifically, some of the challenges ahead are that when we first started rolling out what's called Imvamune, that's the trade name for this third generation replication deficient smallpox vaccine we've been using in Canada, we didn't know how much supply we had.

So many people were told, most public health authorities were only permitting a single dose of the officially licensed two dose vaccine series. And so many people actually went out there, as Sharon said, and got that vaccine, but they really only got one dose. So we don't quite know what that implies if they didn't get the second dose. Even those who did get the two doses, and maybe it may or may not have been on schedule, we have certainly already seen reports in many jurisdictions of infection post vaccination.

Sometimes people call that breakthrough infection, it might not be the best term, but infection post vaccine. So I think vaccine clearly has played a role alongside the behaviour-change and education. But in terms of what's going to happen a few more months from now, maybe years from now, I think only time will tell.

Dr. Mojola Omole:

Wow. A little grim, but that's okay. It's the reality. I guess part of that is, well, how has the treatment of monkeypox evolved since the outbreak?

Dr. Sharon Sukhdeo:

I would say that for the majority of people who develop MPOX, their treatment is conservative. It's symptomatic based. Most people have, I would say, what I would call a mild disease. And their symptoms, their cutaneous lesions last a few weeks and heal, and they heal without any issues. There are a minority of persons with MPOX who develop severe cutaneous lesions, or they develop lesions in areas that cause them a lot of pain or a lot of morbidity. For example, what I mean by that is, lesions that develop around the anus or perianal lesions, come with a significant amount of pain. And I think this is something that oftentimes we don't fully acknowledge or appreciate. But these people walk around or sometimes cannot walk because of how much pain there is. And, at times, this has necessitated the administration of opiates just to manage the pain. So we're talking about a lot of pain here. 

And some people with MPOX have lesions in their mouth, that prevents them from being able to eat or swallow, and then they end up in the hospital just for hydration or nutrition in other means.

And then some people, a very small minority, less than one percent, have complications of MPOX that may include myocarditis and encephalitis or otherwise. And these are the persons with MPOX that we would consider for an antiviral called tecovirimat or TPOXX for short. And this is, at best, experimental, we don't know if it truly does work for MPOX. There's some animal data, like we mentioned before, similar thread here, there's some animal data that shows that this may be effective, but we don't know for sure in humans whether there's any effect.

There is also the issue of limited supply of tecovirimat. And so we had to be very thoughtful in who we thought would have the most benefit from this medication. And so we reserve tecovirimat for those cases that are most severe, and there are ongoing trials at the moment to discern whether or not tecovirimat plays a role in their outcome. And there's still a lot that we don't know.

And part of the difficulty is that persons with MPOX who recover on their own without any antivirals, their lesions eventually go away. And those who receive tecovirimat the same occurs. And so it can become quite hairy or difficult to really tell if tecovirimat is causing any benefit whatsoever. And so these are some of the challenges, alongside the fact that cases are going down, which is always a good thing, but may limit, at least for the time being, our ability to really perform robust studies with high numbers of patients.

Dr. Mojola Omole:

Great. I guess the lastly is, what are the key takeaways for frontline physicians, family physicians?

Dr. Darrell Tan:

I think it's important for frontline clinicians to feel comfortable referring to this as a sexually transmitted infection. This is another piece that I think was almost controversial for inappropriate reasons, I would say. At the beginning, people were trying to be very agnostic about how this virus could be transmitted and saying, "Oh, maybe it's airborne, maybe it's respiratory droplet, maybe there's fomite transmission." And sure, those are all quite possible, plausible, in some cases, documented based on similarities to smallpox as well as actual reported cases of say, fomite transmission, for example, with MPOX.

But clearly, overwhelmingly, this thing was being transmitted through sexual networks. And the reluctance to acknowledge that it's basically a sexually transmitted infection, which I think we heard an awful lot at the beginning, even through to the end of the summer, was probably, again, based on, honestly, I think folks’ discomfort sometimes with talking about sex openly. We try to advance a very sex positive approach when we talk about sexual health. And I think we've learned, again, the hard way, how important that is and how valuable that can be to developing a robust, community engaged response to epidemics of sexually transmitted infections in historically marginalized communities.

And what that effectively translates into at the bedside, why a clinician needs to care about that categorization, I think, is that it allows for some of the things that Sharon was mentioning. If we think of this as an STI, it reminds us that when we test for it, we should be testing for other STIs, gonorrhea, chlamydia, syphilis, herpes, HIV.

Sharon pointed out that we've had new diagnoses of HIV made in the context of this epidemic. We've used it as a springboard for advancing other HIV prevention options for folks, recommending that people start on HIV pre-exposure prophylaxis, for example. And so framing it as an STI, and not shying away from that, allows us to have the real conversations with patients that are so necessary for them to access high quality care, allows us to think of the full differential diagnosis, and ultimately provide the care that people really deserve.

Dr. Mojola Omole:

Great. Thank you both of you for joining us today for just talking more about monkeypox, and just in general about the epidemiology of it. I've learned quite a lot today, and hopefully our audience feels the same way.

Dr. Sharon Sukhdeo:

Thank you, Jola. Appreciate it.

Dr. Mojola Omole:

Dr. Sharon Sukhdeo is an infectious disease fellow at the University of Toronto, and Dr. Darrell Tan is an infectious disease physician at St. Michael’s Hospital in Toronto.

Dr. Mojola Omole:

Hi, Blair, welcome home.

Dr. Blair Bigham:

Hi, Jola, thanks for letting me back into the studio, and for holding down the fort.

Dr. Mojola Omole:

Blair, you were very interested in this topic. So now that you've had a chance to listen to the interview, what are your initial thoughts?

Dr. Blair Bigham:

I was sad not to be able to join the interview with the two infectious disease experts. They were absolutely stellar, and I learned a ton reviewing the audio on the flight home. But I just have a couple of thoughts that I'll throw out there.

First of all, it's so hard to really get across on a podcast how useful the photo atlas is in that CMAJ article. Seeing all the different lesions, from all over the body, particularly in the mucocutaneous areas, I found really, really helpful. As an emergency doctor, that'll definitely be something that builds my practice. And so I was really, really interested in just the appearance of these. And I hope that our listeners have a chance to escape audio land and head to the CMAJ paper, because the visuals on that are just so incredibly helpful.

And then the other thing that sort of struck me was, they were saying that, for the most part, we seemed to be kind of settling down the monkeypox pandemic. But it was funny, as I was traveling through four or five different countries in Asia for the last two weeks, every time we got off an airplane, there were obviously COVID questions and COVID protocols, but there were also monkeypox posters all over the place.

Dr. Mojola Omole:

Really?

Dr. Blair Bigham:

Yeah. And I realized that, man, this really is sort of like a second, maybe, I don't know if this is accurate to say it was a global pandemic, but definitely that this was an infection of concern in a lot of places. And I was hoping to get a bit of a sense of how the monkeypox outbreak across countries sort of compared to COVID or was influenced by what we learned from COVID. But it certainly sounds like things are improving regardless.

And part of that is because the communities most affected were very engaged with public health teams around vaccination, around transmission reduction, and so it does seem to be a success story. Is that the vibe that you got?

Dr. Mojola Omole:

A hundred per cent. And just to play off what you just said about the community that was most affected, I thought that Dr. Tan made a very definitive point in pointing out that monkeypox, the state that it is now, is a sexual transmitted infection. And that it does affect men who have sex with men at a higher proportion. And I thought that was really important, because if you don't name something, then you're not actually able to engage that community to get things moving, to be able to help to control the spread of it. So I thought that was really an important point that was made. And I do think the reason why it's no longer an issue and it's not a pandemic, is because those communities were engaged, and we were able to stop it.

Dr. Blair Bigham:

In New York City, there were all these articles about gay men lining up for many, many hours really clamoring to get the vaccine. And I think that's sort of-

Dr. Mojola Omole:

Or was it for Taylor Swift tickets? I'm just joking.

Dr. Blair Bigham:

Oh, maybe it was Taylor Swift tickets. That's where you should hold your vaccination clinic. But what a nice, refreshing contrast, hey, to all the anti-vaccine sentiment around COVID. And here we had a group-

Dr. Mojola Omole:

Exactly.

Dr. Blair Bigham:

... of people who were really motivated to get vaccinated.

Dr. Mojola Omole:

A hundred per cent. And, obviously, I don't think we necessarily have pictures of those in Canada, but definitely from speaking to Dr. Tan and Dr. Sukhdeo is that the community here really were instrumental, and a lot of the community organizations were instrumental in rolling out the vaccine and helping to curtail transmission of it.

Dr. Blair Bigham:

Nice to have a good success story on a new outbreak,

Dr. Mojola Omole:

130,000%.

Dr. Blair Bigham:

That's it for this episode of the CMAJ Podcast. Neither Jola nor I have been fired by artificial intelligence yet, and we are very happy to be back together after my little vacation break. Jola, thanks so much for holding down the fort this week.

Dr. Mojola Omole:

It's wonderful to have you back.

Dr. Blair Bigham:

Please, remember to share and like our audio, wherever it is you download your podcasts, it would really go a long way to helping us spread the message. I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. Until next time, be well.