This week on Nevada Week, a rising number of monkeypox cases along with another wave of COVID expected, we explore some of the most pressing public health issues facing Nevada.

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Welcome to Nevada Week.

I'm Amber Renee Dixon.

There's a new threat to public health.

The US declared monkeypox a national emergency, following the World Health Organization classifying the outbreak as a global emergency.

This as COVID-19 continues circulating and reinfecting people who've already had it.

Here to share what we need to know right now about both monkeypox and COVID are Brian Labus, assistant professor at UNLV School of Public Health; Kimberly Franich, communicable disease manager at the Southern Nevada Health District; Christina Madison, a doctor of pharmacy and CEO of The Public Health Pharmacist; and Dr. Shadaba Asad, infectious disease specialist at University Medical Center.

Thank you all for being here today.

First off, to the population as a whole, what is a bigger threat in your opinion, COVID or monkeypox?

Brian, I'll start with you.

(Brian Labus) I would say COVID because it's something that's affecting the population in general.

Monkeypox is not something we're seeing widespread transmission of throughout the community.

So at this point in time, you're much more likely to come in contact with COVID than you are monkeypox.

You're at greater risk if you get COVID of a serious disease and potentially being hospitalized or dying.

So right now, just that huge burden of the disease on our population makes COVID kind of the front runner.

However, monkeypox has a potential to spread in other groups.

So it's not like we can count it out.

But COVID right now will have the probably greater impact on people's day to day lives.

-Does anyone disagree?

-(Christina Madison) Not disagree, necessarily.

But would say that depending on the population that you're part of.

So if we think about our sexual and gender minority populations,our LGBTQ brothers and sisters, it's definitely a higher risk in that population than in the general population.

So would want to say, if you do identify in the queer space, that it is something that you should be looking out for and getting vaccinated if you can.

-And is it important to distinguish that it is being transmitted primarily between men who have sex with men and not the entire LGBTQ community?

Let's go with you, Kimberly.

-(Kimberly Franich) Well, I think it's important to first know that anyone can get monkeypox.

It's a matter of just having that route for transmission or that exposure, which is primarily close physical contact.

However, right now what we are seeing is the majority of men in the LGBTQ community.

But this is spreading rather quickly, more than we expected.

So I think it's important to keep a close eye on it and how this is spreading to other populations outside of this community as well.

-While we're on the subject of close skin-to-skin contact, is it not sexual contact?

It's skin-to-skin?

Dr. Asad?

-(Dr. Shadaba Asad) So, you know, one thing that needs to be clarified is that monkeypox is not necessarily a sexually transmitted disease.

I think the correct terminology should be "sexually transmissible."

So intercourse sex is just one of the modes of transmission of this virus.

The main mode of transmission remains prolonged skin-to-skin contact.

That is the main route of transmission.

It can be transmitted by sex, it is sexually transmissible.

But that's not the only mode of transmission.

It is also transmitted by droplets.

So if somebody with monkeypox coughs, sneezes and your face-to-face contact with that person is over three hours close distance, 6 feet, that can also cause transmission of the disease.

It can be transmitted from a pregnant mother to the fetus as well.

So sexual transmission is one of the modes of transmission of monkeypox, but the main transmission route remains prolonged contact with a lesion of monkeypox.

-Three hours?

I'm thinking is that person sneezing in your face for that amount of time?

-You could just be sharing the same room and sitting on a couch 6 feet apart.

-Wow!

-It doesn't necessarily have to be sneezing, coughing.

Just breathing.

-We're gonna get-- You have something to add Kimberly?

-Just I agree with this, and it is a route for transmission.

But the CDC has put information out about cases who've been on an airline, for example, for long durations of time.

And to date we have not noticed a transmission through that respiratory droplet route.

It is definitely a possibility.

But right now, as you mentioned, the primary risk is physical close contact.

-We're going to talk a little bit more about monkeypox coming up.

But let's talk about COVID.

Right now in Nevada and in Clark County, how are we doing?

Brian?

-Well, for the first time in a long time, we were at that low level of transmission within our community.

So it's nice to see our numbers low.

Now, it doesn't mean there's no transmission; it doesn't mean the disease has gone away.

We just aren't at the high peaks like we've seen in the past.

And the reason we're at a low level and some other places in the country aren't is we started first.

We got to the high level first, and we've been coming down since.

And we've had a lot of people infected in the community.

We've seen different variants since the beginning of this most recent wave, but right now we are in a better place for COVID just because of that community transmission.

But it doesn't mean it's gone away, and it doesn't mean you can completely stop thinking about it.

It's still out there.

-Let me put out a scenario: I've had my original COVID vaccine, I've had a booster.

Now what do I do?

Christina?

-Augh.

Such a fantastic question.

So I think the biggest thing is making sure that you're taking your own risk into account.

So if you're already vacced and boosted, your risk is fairly low.

However, that doesn't mean it's completely gone.

So, if you notice, we just saw Dr. Jill Biden who's been doubled vacced.

She just tested positive for COVID.

So it really is based on, are you around other people who are unvaccinated, under vaccinated, or have you been exposed to somebody who's currently infected?

So I think all of those things combined is really going to determine whether or not you could potentially get infected again.

And so I really want people to understand that the vaccination is not a silver bullet; it is there to protect you.

But really the main reason why we're doing vaccinations is to protect against severe illness, hospitalization and death, not for you to not get infected at all.

-There is distinction with age.

Dr. Asad, do you mind explaining more about that, if you're going to get a second booster.

-So if you're under the age of-- If you're five years of age or older, then you are eligible for one booster.

But if you're 50 years of age and older or you have an underlying condition that weakens your immune system, then you're eligible for two boosters.

-So you can go and get the booster that's out there right now.

There is also the idea out there, well, should I wait, because there may be another booster coming down in the fall that protects more than just what the current booster includes.

Christina, what do you think?

-Don't wait.

-Don't wait?

-Don't wait.

Get boosted now.

-All right.

Dr. Asad?

-Yeah.

Because we don't know.

We don't know how long it's going to be.

-A bird in hand is worth two in the bush.

-Okay.

But if you're someone who, I guess like myself, who has had one booster, original COVID, I don't need to go get another booster, but I could perhaps get the one that's coming down the line?

What is the advantage of the one that is coming in the fall-- we hope is coming in the fall?

-Well, first of all, what the talk is that that particular will take into account the variants that are currently circulating in the community.

So the Omicron.

And the other is that, is there a possibility that that booster is actually going to be combined with an influenza vaccine the way we've seen it in Europe?

So that might be an advantage.

You're going to get an influenza vaccine regardless.

So what if you got a combined vaccine that protected you against influenza as well as the currently circulating variants of COVID-19?

-There may be-- -But there is no point in waiting.

You should be up to date as advised by the CDC as far as all boosters are concerned.

When and if the new vaccine becomes available, we will have guidance as to who should get it and when to get it.

-All right.

Let's get back to monkeypox now.

As we mentioned, monkeypox is primarily spread through sexual contact between men who have sex with other men.

Nevada Week spoke with Silver State Equality.

That's Nevada's statewide LGBTQ+ civil rights organization.

And its state director, Andre Wade, discussed utilizing what Silver State Equality learned through COVID listening sessions to help inform its approach to addressing monkeypox.

So, Andre, you recently held listening sessions within the LGBTQ community about COVID vaccinations.

Why did you choose to do that?

-So we had our initial sessions back in the fall of 2020, when we were in the midst of the pandemic.

And we wanted to work to find out why people were hesitant, or potentially hesitant at that time, to take the vaccination.

And so we worked with UNLV School of Public Health to put on these listening sessions to find out from the LGBTQ community how they felt about COVID, the pandemic, vaccinations, so we can ensure that messaging was on point so people could get the resources that they need.

-And I say "recently," because you held them up until just about a month ago.

-That's right.

So now that things have changed a little bit with COVID, we wanted to have a listening session that was focused specifically on hesitancy, to find out why people were potentially hesitant for getting vaccinated.

And so we learned that people were hesitant, really, because of misconceptions about vaccinations in general, maybe pressure from family members, because we are a group of people, in general, that want to make sure that we are not upsetting our group.

And so if you're one person that wants to get vaccinated but your family and friends don't, then that can have an impact.

And so we just learned things like that.

So we can change our messaging when we are out in the community trying to encourage people to continue to get vaccinated.

-And the misinformation or the misunderstanding about vaccines and maybe family members pressuring you not to, that's an issue that applies to everybody, not just the LGBTQ community.

-Exactly.

Often when we talk about these issues, it's regardless of someone's sexual orientation and gender identity.

However, our sexual orientation and gender identity sometimes compounds things.

And so we want to make sure that people aren't not only getting misinformation in general but then also aren't internalizing these messages as it relates to their identity and how they might navigate accessing health care.

-Compounds it, how so?

-So if you are hesitant in general about, let's say, the vaccine because of what people are telling you, then you might say, well, maybe that's not for me.

But then if you think, well, if I go to a healthcare provider and there is a risk of discrimination and harassment while I'm there and not being treated properly simply because of my sexual orientation or gender identity or the perception of it, then do I want to take that on as well, as I'm already trying to find out is this the path I want to go?

And then do I also want to have the risk of discrimination as a result, and that's especially so for people who are transgender or gender variant.

-And I thought it was interesting that you wanted to pursue finding out why there was hesitancy when you think about, according to U.S. News and World Report , estimates published by the CDC show gay or lesbian adults overall have had higher vaccination rates against COVID-19 compared with straight people.

Why those high vaccination rates?

-So one thing I can speak to is for gay bisexual men.

So even when we did our initial listening sessions back in October or fall of 2020, we found out that people felt comfortable with going through contact tracing.

And because we historically have been going through contact tracing as it relates to sexual transmitted infections and HIV, and so gay and bisexual men are used to going to get tested.

And if there is a possibility of being positive for HIV, going through the process of finding out who your sexual partners have been and giving that information out.

And so it's something that we're used to in our community, unfortunately.

And so when contact tracing was a thing for COVID-19, we're like, okay, let's do it.

-All right.

And then it extended to vaccinations as well.

-Yep, absolutely.

-How do you apply what you took from the listening sessions into messaging about monkeypox?

-So although they are two different things, it's still a public health concern.

We are probably going to do more listening sessions that are monkeypox specific.

And so we know that we need to get information out there.

It has to not have stigmatizing language; that even if we get information out there, is the system, is the public health system even ready for the onslaught of people to try to get vaccinated?

Because if you tried to get vaccinated and you're getting turned away or someone's website doesn't work, you're going to be frustrated.

So then when things are up and running, it's three weeks later and maybe you've come down with monkeypox.

Maybe you are just tired and don't have time anymore.

And so we've tried to make sure that our systems are ready in advance.

And the number of-- The rates of monkeypox are growing here in Southern Nevada, specifically.

And so we-- There's fear that it might be too late for the spread to stop.

So this might become endemic within the gay and bisexual men who have sex with men community, which would be devastating.

-It is interesting what you said about how are you going to go about with messaging for vaccines when the availability of them is semilow at the moment.

-Yep.

There is confusion about who's eligible.

There is misinformation about where to go and how to go about getting a vaccination.

And so these are the things that we have to be mindful of.

And so we recently got our website up and running, and we are going to start doing a social media push.

But we're also talking to the State Department of Public Health to talk about what they're doing and how we can partner with them to get messaging out there and see what funds are available.

So we are not only trying to take an approach in the community, but also advocate within the administration to make sure that things are in place and ready to go.

-It's difficult because anybody can get monkeypox.

But the people that are at highest risk, according to the World Health Organization, are men who have sex with men.

How do you change your messaging so that you're not promoting the stigmatization?

Already there are reports of monkeypox being used as antigay rhetoric, similar to AIDS in the 80s.

-Yeah.

So there's two paths, if you will.

There's the idea that you don't want to talk about monkeypox in the vein that it's solely affecting gay and bisexual men who have sex with men.

But also you can say that it's stigmatizing if you don't talk about it, because it is actually happening.

And it just happens to be this community, this network of community of people, who are transmitting the virus at the moment.

But that doesn't mean that it's going to stay that way.

And the more we learn about monkeypox in its current iteration, the better we'll be.

But physicians, public health authorities did not have a good sense of what monkeypox was in general, and they only knew about monkeypox as it relates to in Africa and Western Central Africa.

And so the virus plays out differently now.

And so when folks are going to their-- Months ago when people were going to their doctor about concerns, they were being turned away because people didn't think it was monkeypox.

And then people also didn't know that it was either sexually transmitted or sexually transmittable or even adjacent to monkeypox.

So when people were showing up to their health care providers, again they were being turned away.

So as this is happening, the virus is spreading.

And as it spreads, it's reaching more people and our systems aren't ready to respond quickly to these sorts of things.

-It sounds like you have quite the challenge ahead of you.

-Unfortunately, we do.

But we are-- We're on it.

We're trying to reach out to our partners and officials with health departments and, again, with the State to make sure that we do play a part, because it's not a time to point fingers and place blame.

We just really want to help things out.

-Andre Wade, Silver State Equality state director, thank you for your time.

-Oh, you're welcome.

Thank you.

-As of August 16th, the Southern Nevada Health District reported 100 confirmed or probable cases of monkeypox.

Kimberly, you are here representing the Health District.

I saw you nodding a few times during that interview.

Is there anything you'd like to address?

-Yeah.

I think I agree with him in that we need to do a better job of providing information that's accurate and answer questions to the community.

Specifically, when vaccine supply is low.

I can imagine how frustrating that can be when you're trying to access that vaccine or get questions.

We're currently working with our partners doing things like town halls and others.

I think, everyone here at the table, to try and correct that misinformation and to also just be available to answer questions.

We know how frustrating it is with a low vaccine supply.

-Who is eligible for a vaccine?

-So it kind of-- It kind of varies from jurisdiction to jurisdiction.

I think where we're trying to focus, as far as the SNHD, is those that are most highly impacted right now.

So we see this within the MSM community, but we also want to make sure that those who had a potential exposure or are within a venue of higher risk that we make that available.

It's truly just a matter of numbers of supply right now.

-Christina, what do you know about methods to try and address the shortage of the monkeypox vaccine?

-Absolutely.

So for me, I'm super excited that the FDA came out with this expanded indication for the monkeypox vaccination.

It's called JYNNEOS.

And so now, instead of only being able to do one dose, we can take that one dose and now split it to five.

And we can administer it through intradermal route.

And that's going to be for anyone 18 years and up.

And then for anyone under the age of 18 who may be at risk, like our adolescents or somebody who's come in close contact or a household contact, we can still administer that under the subcutaneous route.

And so, luckily enough, we've been giving out vaccinations.

I'm currently practicing at Huntridge Family Clinic, and we already started giving out vaccinations as of Thursday when we got our supply and just did a vaccination clinic with the Gay and Lesbian Center yesterday.

And I'm happy to report that they gave almost 300 doses.

So I think we're doing what we can.

We're getting the messaging out there and really making sure that we're meeting patients where they are, especially those who are part of the queer community and are at most risk.

-You said "subcutaneous."

What does that mean?

-I apologize.

So under the skin versus under the fat.

And so the reaction, you can see it.

It's a little well on the skin, and it gets a little bit red.

And, yeah, and then most patients look at it and they go, oh, okay, and then that's it.

-I would think if it's a lesser dose of the vaccine, which is a method of stretching out the supply, that some people would think, is it really going to be as effective if it's less?

Is that a viable concern?

-Of course, it's going to be a concern.

But basically, we look at how much of the vaccine we need to get a response.

And if we're giving you five times as much as needed, we could now cut that down to just the amount needed to get the response and use it for more people.

So that's really what it's about is understanding what's the minimum amount you need to get a response.

Giving more than that really doesn't do anything extra.

So that's why we can stretch the vaccine supply out.

-Something that was said during that interview that I would like to run by you, get your thoughts.

Andre Wade had said there's fear that it might be too late for the spread of monkeypox to stop and that it might become endemic within the community of men who have sex with other men.

How realistic is that fear, Dr. Asad?

-I don't think it can become endemic strictly in terms of what that word means.

"Endemic" means that there is a reservoir of infection in the community that is there forever and continues to spread to other individuals.

We know that humans are what we call end hosts, which means that you acquire monkeypox and then you develop a disease.

After that, the disease goes away from your body and you are immune to monkeypox from that point onwards.

So such an individual is no longer infectious to others.

After the period of infectivity is over, all the rash has scabbed over, clean skin has emerged.

This individual can no longer transmit monkeypox to others and, in fact, is now immune to monkeypox.

The reason why it is endemic in Western and Central Africa is because there are small rodents over there-- squirrels, rats, mice--that are natural reservoirs for this virus.

In other words, they get infected with that virus, and that virus then keeps multiplying in their body without getting that animal sick.

And when humans get in touch-- in contact with those animals, that's when they acquire the disease.

So because we don't have that natural reservoir of the virus locally, I don't think strictly the word "monkeypox" becoming endemic over here in this particular community is correct.

-There are reports of people attacking monkeys as a result of monkeypox.

I know, it's ridiculous.

-Well, monkeys were an accidental host, just like humans.

We identified the virus because there was a colony of research monkeys that were infected from rodents, and they wound up getting the disease.

And so it was first identified in monkeys, and that's how it got its name.

But it has nothing to do with monkeys.

You could just as easily call it humanpox, and it would make the same amount of sense.

This is a rodent disease that's made its way into humans.

And attacking monkeys isn't going to do anything at all to stop this transmission.

It has nothing to do with monkeys other than the name.

-Our viewers have likely seen pictures of monkeypox, the rash with maybe kind of pimple-looking or blister-looking issues on there.

Is there any other way to know you have monkeypox, or is that the only way?

Could you have symptoms that are separate and not have that kind of rash?

-So the way actually-- It actually starts even before the rash becomes obvious.

So typically a patient with monkeypox about seven to fourteen days, so one or two weeks after getting in contact with somebody who had monkeypox, will develop a febrile illness.

And this for all the world looks exactly like COVID.

So they have fever, cough, sore throat.

They feel achy all over.

They're tired.

They may feel swollen glands which, by the way, is the only one thing that is different from how COVID presents initially, right?

So you have this nonspecific syndrome-- fever,chills--and then in about one to three days the rash starts appearing.

Okay?

And it's important to recognize this because these people start being infectious to others from the moment that prodrome starts, or that fever, the cough, and the sore throat starts.

So there is first that prodrome.

Then the rash follows after that.

So from a practical point of view, if there is somebody who is feeling sick, who has a fever, who has a cough, who has a sore throat, is complaining of swollen glands, in addition to thinking about COVID, something else you need to start thinking about is monkeypox.

And what you can do is advocate that that individual go talk to a health care provider, get evaluated, get tested and, if indicated, get treated.

-You made the distinction that it should be called sexually transmissible, not transmitted.

I want to clarify though, can you use a condom to prevent monkeypox?

-No.

Because intercourse involves prolonged skin-to-skin contact.

Even if you can't transmit it sexually, that prolonged skin-to-skin contact with somebody who has lesions will transmit the virus.

-And we are running out of time, but I'm going to end with you, Dr. Asad.

When you were here on February, in February 2020 prior to the pandemic and the shutdown, you talked about some of the most concerning issues for you locally in terms of infectious diseases being influenza, syphilis, and hepatitis A.

Where does Southern Nevada stand with that right now?

-Unfortunately, I think we spent the last two and a half years dealing with the COVID pandemic.

And to some extent, many other problems, infectious as well as noninfectious, were put on the backburner.

Sexually transmitted diseases remain a very high concern in Nevada, particularly in Las Vegas.

And unfortunately, the numbers for all STDs have continued to rise.

I know we were talking earlier about the syphilis.

According to the most recent statistics put out by the CDC, Nevada is number two in the nation for the rates of primary and secondary syphilis and number four for congenital syphilis.

Highly concerning.

-Which is?

-The syphilis that we notice in the newborn, transmitted from the mother and has to do with poor prenatal care of the mother.

-That could be a whole other show that we discuss.

Thank you all so much for being here.

For any of the resources discussed on this show, including more information about monkeypox and a link to the Health District's immunization page, go to our website, vegaspbs.org.

You can also follow us on Facebook and Twitter @VegasPBS.

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