Experts Review Updates on the Public Health Strategy for Monkeypox

In an interview with Pharmacy Times, experts Alfred L’Altrelli, PharmD, and Rachel Marini, PharmD, or UPMC Presbyterian-Shadyside, discussed the latest updates on the monkeypox outbreak in the United States. Although it has received less attention as flu season begins, public health experts are continuing to urge vaccination against monkeypox. Pharmacists can play an important role in educating the public and providing vaccines.

Q: Monkeypox seems to have gotten a little less attention in recent weeks as attention turned to the flu season. Where does the monkeypox outbreak currently stand in the United States?

Alfred L’Altrelli, PharmD: Yeah, I mean, currently cases are low in the United States. It's something that health experts continue to monitor with a lot of different emerging infectious diseases. It's really what's kind of impacting us at the time so it's natural that we're seeing more about flu, because that's where all of the cases are, really at the moment.

Rachel Marini, PharmD: Yeah, there's a lot of prioritization that happens in the infectious disease world for the pathogens of concern that are monitored. As we know, we are at the mercy of our media colleagues and what is trending and various news stories at the time. That doesn't necessarily mean that our general population and all the trending infectious diseases aren't still being monitored from our public health and health care experts; it just means they might not be at the front of all kinds of the conversations that we currently have at the time. So, we're still seeing new cases of monkeypox and they're not the volume that we saw initially in the summer months, but it is something that is still being actively monitored to make sure that we see any trends in addition to the flu season. As you talked about, we are seeing large rates of flu infection this year, in addition to some of the other respiratory viruses like RSV, so lots of ongoing, emerging infectious diseases that are currently being monitored from a multi-pronged approach.

Q: What does the public health strategy look like? Is it mostly focused on containment or is there potential for elimination of monkeypox?

Rachel Marini, PharmD: So, each emerging infectious disease has a targeted strategy from our public health experts’ perspective that's unique to that infection specifically. There's a lot of different factors that go into influence the strategy. Some of those include the pathogen itself, how it’s transmitted, what the virulence looks like, the various virulence factors, which we have seen that even changed through the COVID-19 pandemic era. Also, the vulnerability of the patient population and how far spread the infectious disease has been transmitting, and then also the disease itself. So, is this a limiting, you feel sick for a couple of days, and then you bounce right back? Or is it causing high rates of morbidity and mortality? And there's a lot of other factors that come into play, whether our public health strategy looks more of a containment, or limiting monkeypox, and this is a fluid plan that continuously is updated and reviewed and monitored as the progression occurs within the various infection in the active situation.

So, take COVID-19, for example. Public health pivoted from their initial potential strategy to containment now, where we initially had an elimination potential for projection for COVID-19. Similar to our influenza season, our public health strategy is about containment [and] management along those routes. So, it's still a little bit early for monkeypox. We did see monkeypox outbreaks before our 2022 outbreak that we're currently experiencing, so it is something that may wax and wane over time. And in this fluid situation, we will see variability from our public health experts on their strategy as the situation evolves.

Q: CDC data suggest that gay, bisexual, and other men who have sex with men are at the highest risk, but monkeypox is not solely affecting the LGBTQ community and it is not a sexually transmitted disease. What is pharmacists’ role in combating misinformation around this?

Alfred L’Altrelli, PharmD: Sure, so that's actually a great question. It's a great opportunity for pharmacists to really discuss transmission. The means of transmission of different infectious diseases are different depending on the pathogen. Early on, you know, there was a lot of information about monkeypox during the outbreak, really, with a lot of unfounded anxiety earlier this summer. So somewhere around, you know, June, July, August. At the time, about 1 out of 5 people in the US were worried they were going to contract monkeypox. There was a survey from the Annenberg Public Policy Center out of the University of Pennsylvania that was really starting to bring light to this. A lot of what was behind that [was] social media information where people are tweeting out things, retweeting things, you know, spreading information about the virus maybe spreading through the air, that cases among women and children were underreported, and you should be more concerned, risk to health care workers, things like that. So, as a medical community, people have been working to address that misinformation.

As pharmacists, we've been really helping clarify those rumors and some of the inaccurate information within the community. Since pharmacists are positioned within the community—retail pharmacies as well as we're out in the community, even from a hospital perspective—making sure that we're connecting with different community members at any opportunity that we have to clarify those things. We've seen a positive influence on the dissemination of this information. The concern isn't nearly what it used to be because of all the efforts that we made to educate and bring some factual data to counteract some of that misinformation.

Rachel Marini, PharmD: Yeah, I think a lot of it also came down to the fear from COVID-19, that it was a little bit too fresh, still in everyone's mind. Is this the next COVID-19 that is going to develop and progress to that extent? And so the fear of the unknown I think was a large part, to that degree also. And then the fear of what's true versus what isn't true and really utilizing the pharmacists that are within the communities and can be that health care expert to get the information out to the public. To know where to find those resources, it can be quite challenging to find those true facts and know when the facts are true versus when the facts may not have all the information together with them, or when you're really getting part of the story, or even some of the health care providers that maybe aren't as specialized in this area or haven't had a chance to stay up to date with the current literature. So, it really speaks to the pharmacists’ capability of helping to support these various pathogens, have ongoing education that's needed, as the situation remains fluid.

Q: There are vaccines available for monkeypox. Have you seen significant vaccination rates?

Rachel Marini, PharmD: Yeah, absolutely. So, there are 2 vaccines that are currently available for utilization. The Jynneos vaccine has been one that our team has heavily utilized, which is a 2-dose series for patients who meet the current eligibility criteria. There are some interesting pieces about this vaccine also that have led to ongoing kind of support within the vaccine community. And also taking that to the next step for opportunities to manage from an emergency health perspective. And so, initially, whenever we had the concern that there was going to be a large need, we didn't necessarily know where the monkeypox outbreak was going to spread or to what degree. Our vaccine supply status wasn't as strong. So, we had those lessons learned from the COVID-19 pandemic, that we might have a higher demand than our supply. And so utilizing the science that was available, is there something that we can do to help from a science perspective to implement operationally? That’s where the information was derived for the transdermal administration of these vaccines, of the Jynneos vaccine, where we would have similar efficacy rates, but also be able to manage that supply a little bit better, to make sure everyone was protected who needed to be protected and help with that containment piece.

Vaccination rates initially were significantly elevated based off the available supply and approved for those at highest risk. And so, I think we do have great data showing that our patients that did meet the highest risk were seeking out vaccinations. This is another great avenue for pharmacists to have education for their patients, make sure that they know that this is available, what it is, what it does, how it works, who could potentially be at risk, and [who could] benefit from these vaccinations. And our team was able to host clinics in collaboration with our infectious diseases team to support the need, and these clinics are still ongoing. So, while we haven't seen the highest vaccination rates that we saw early on, we are still seeing a continued need for patients based off various underlying risk factors.

Q: How are pharmacists involved in these vaccination efforts and how can they be particularly impactful in reaching underserved communities?

Alfred L’Altrelli, PharmD: Yeah, so I think that's a great question. If you think about it, you know, vaccines are estimated to prevent about 2.5 million deaths worldwide every year. So, it's really, you know, among the most effective tool that we have to prevent people from getting infectious diseases and dying from it. Despite the effectiveness, despite the availability of vaccines or the perceived availability, in general of these vaccines, vaccine vaccination rates remained suboptimal, more so in certain areas than others. You know, pharmacists have been really established as advocates for vaccination educators, as well as providing the vaccines, etc.

So, one thing that we did was we implemented different training programs. We have the in-house ability to train people so that they can become certified pharmacist vaccinators, as well as do all of the different patient population education, doing the intradermal training, doing the BCPS training, things like that. So, really, you know, we can facilitate each other through different training mechanisms, so that we have a larger breadth or army of people to go into different areas. That really led us to a position where we've been able to move into communities that typically have been underserved and are able to go there with people from those communities that are part of our own team, which is extremely meaningful. When we go into these underserved communities, a lot of times, you know, people are looking for someone from their community to help them through whatever challenges or questions or misconceptions they might have. So, the ability to connect directly with the community and help them through any of their considerations is huge for us.

Rachel Marini, PharmD: Yeah, absolutely. And in addition to supporting those efforts through vaccination, it also helps us to break some of those barriers to health care for our patients. So, we know vaccinations are one of the most cost-effective preventive strategies against infectious diseases, but there's a lot of other questions that patients have about their health, about their health care, about their medications. And so having that trusting relationship and actually going and taking the show on the road to go into the community means a lot to patients. Maybe some patients don't have the best, easily accessible transportation options available. And so going that extra mile and making sure the patients know that we're there for them does improve health care outcomes and really helps to feel that sense of security for the patients that they haven't felt before.

Alfred L’Altrelli, PharmD: And I think the reach into the underserved community is huge, because you might be going there and offering, you know, vaccines to some degree at this point, you know, as a main driver. But we were recently in an underserved community, and we were able to offer blood pressure screenings, as well as some medication therapy management and counseling. So, kind of like these mini-health fairs for the community give us the opportunity to offer something broader and within the pharmacists’ scope of practice, to connect with communities that don't normally have access to these types of things.

Q: Data do suggest that vaccination rates are slowing. How can pharmacists educate patients about the vaccines when monkeypox is no longer top of mind?

Rachel Marini, PharmD: Absolutely, so this is part of the health care process. We know that preventative strategies are out there. This is just another kind of piece that we should add and do add into our preventative strategy assessment. So, has a patient received their annual flu vaccine? Are they considered up to date on their shingles vaccine or their pneumococcal vaccine? Taking into account risk factors, smoking cessation for patients, and pharmacists can be there to answer questions about the various strategies that that could be in place for patients. And also, for patients that might have questions about what their risk factors are and if they should be considered a candidate or kind of working through some of those side effects questions along those routes, or risk versus benefit for their specific scenario. Allergies is also a great piece. And so, this comes into play also for allergy assessment, and what is a true allergy versus an intolerance versus, “My sister had it so I can't have it”—that mentality and clearing up some of those common misconceptions that can also lead to better outcomes for patients and better patient care.

Q: There are already concerns about the combination of COVID-19 and a stronger flu season. Could monkeypox further strain the health care system this fall and winter?

Alfred L’Altrelli, PharmD: So, you know, that's a low possibility at this point. As we saw the cases drop off, that became much less of a concern. The reality is the health care system is strained today already, so is the health care system going to be strained? Absolutely. But is it going to be, you know, monkeypox that might be what's breaking the system? No, that's pretty unlikely. The main thing that we're looking to do is make sure that we're prepared and we're responding to things that are within our control. So really, like when we were talking about containing this outbreak and containing the number of cases, you know, what we're seeing is we're getting the results from our efforts. So, we’re in a very good position to where we were just 6 months ago,

Rachel Marini, PharmD: Absolutely, and having those plans in place and being able to pivot at a moment's notice is something that COVID-19 has also taught us. So, with continued fluctuations, being ready and being able to make adjustments based off what we're currently seeing on those ongoing continued assessments. So, the strategies for monitoring of the various endemic infectious diseases is also part of kind of the day-to-day. Working collaboratively from a health care provider perspective, and also with our emergency preparedness teams is definitely something that that we have utilized, and I think strengthened within the health care community. So that way, we can respond better and have the tools in place that we need to set up that infrastructure and make slight modifications instead of building from the ground up.

Q: What other aspects of this outbreak are pharmacists involved in?

Alfred L’Altrelli, PharmD: Yeah, I mean, mainly, you know, pharmacists have been serving to educate, providing the vaccines, treatment, prevention, community support, you know, other health care team members support, so on and so forth. So really, all aspects of this outbreak are something that pharmacists can play a role in, even from whenever you're looking at the data you're looking at, spreading transmission from an infectious disease perspective, all of those things, pharmacists really have the opportunity to be contributors to. I think the big thing that sometimes we forget as pharmacists are that we have a very valuable perspective on how a lot of these drugs, vaccines, etc. work. We also have a reputation of being very trusted by the community. We also have access different from a lot of providers. You don't have to make appointments to see us, you know, we're out there doing health care events, drumming up business for independent pharmacies, even chain pharmacies, doing stuff with our schools. The pharmacy is partnering to be out there and have all of these events. So really kind of like we were talking about before, these many health players are these synergies that are able to develop, or something that really helps not just with this outbreak, but all outbreaks. So, I think really the aspect of the outbreak, you know, isn't really limited to what we can be involved in, it's really about what we can put the effort behind and what synergies we can form with each other.

Rachel Marini, PharmD: And there's a lot of different puzzle pieces that we can help to connect. So, you might hear something in a various setting or maybe you want more information after you left your doctor's office because you had a chance to fully digest what you heard. And so, you want to learn a little bit more information, but you don't know where to go. So, talking to your pharmacist, and then if you need to be referred back to your doctor for additional conversations or to get the information that you need. There's a lot of different puzzle pieces for connection that pharmacists can also help to do in the outbreak and other types of health care related settings.

Alfred L’Altrelli, PharmD: I think that's an important point, the follow up and everything. I know I get a lot of questions from people, you know, “Hey, I got the COVID-19 vaccine, or I got my monkey pox vaccine, or whatever. And I'm getting a little bit of a headache, can I take Motrin with that? Or can I take Tylenol? Or, you know, is this concerning?” You know, these are things that are simple answers for us. But you know, whenever you're a community member who just you know, got stabbed, got something injected in your body that's foreign, you know, your mindset’s a little bit different. So even just providing that little bit of support is, follow-up or adjuvant to others, you know, is a great role for us to play.

Q: Is there anything you want to add?

Rachel Marini, PharmD: Yeah, I think just the continued future, and it'll be interesting to see where pharmacists continue to expand scope and support the community and the health care community at large. I think this is not going to be our last, unfortunately, emerging infectious disease that we're going to see in our lifetime. We're going to continue to see these as we did even pre-COVID. It's going to be variable for the degree and also the impact that they'll have, but definitely, I think, something that that we're working to be better prepared for and setting up strategies for multiple, multiple disciplines to help play a role, especially pharmacists.

Alfred L’Altrelli, PharmD: I think it's all about where we go from here. We have the opportunity to rally and show the value that we create in our communities, we add value to the health care system, and we support other health care providers, you know, so where can we take it next? And where can we still show the role of the pharmacist and how critical it is to health care in America. So, really, I think the main thing for us is, you know, how can we continue to do this? How can we continue to support our hospital objectives, our ambulatory objectives, our community objectives, tie it all together, and really, you know, double down on the meaning of our profession.

Rachel Marini, PharmD: And serve the patients.