A Palm Springs doctor at a local clinic for testing and treating sexually transmitted infections says the county may not be ready for monkeypox.
Monkeypox is a virus related to smallpox but much less infectious and with milder symptoms. The World Health Organization (WHO) says about 30% of smallpox patients die, and the rate is around 3% to 6% for monkeypox patients.
Symptoms like fever and flu-like symptoms usually begin within one or two weeks of exposure. After that, a rash and lesions can develop on the face, genitalia, or other parts of the body.
Dr. Phyllis Ritchie, a board-certified infectious disease physician, said she saw a patient last week at her Palm Springs-based clinic, PS…Test, who reported a sore throat and other flu-like symptoms after attending LA Pride. The patient had gotten a letter from Los Angeles County saying they may have been exposed to monkeypox.
That’s when the confusion started, she said, both for the patient and the medical professionals trying to help.
“I don’t know exactly how to test,” Dr. Ritchie explained Monday. “We haven’t been given exact guidelines on that. I know they did need to get a vaccine post-exposure, but when I reached Riverside County, they’re just not set up yet to administer the vaccine, which was disappointing.”
When the patient reached out to Riverside County for assistance, Dr. Ritchie said they were told to get the vaccine in Los Angeles County.
“That’s a three-hour drive with traffic both ways,” she said. “And the patient will have to go back again 28 days later for a second dose of the vaccine.”
Lack of vaccines
Barbara Cole, a registered nurse and branch chief of the Riverside County Disease Control Branch, said she instructed those who received the letter to go to Los Angeles not only because that’s what the instructions indicated, but because that’s their best chance of finding a vaccine.
“I told them to follow the specific instructions on the letter that told them how to quickly get the vaccine,” she said, adding, “You have to have the vaccine in order to offer it.”
For people who cannot take a whole day off work to get the vaccine in LA or can’t drive or find a ride, there are no local options available for a pre-exposure or post-exposure vaccine.
The lack of both pre- and post-exposure vaccines not only frustrates Dr. Ritchie, but worries her as well, given the demographic makeup of Palm Springs.
“Right now, monkeypox is mostly hitting gay or bisexual men, men who have sex with men,” she said. “We have a huge population of gay and bisexual men here. We’re a hub. We should be at the forefront of this.”
She emphasizes that just because it’s affecting men who have sex with men doesn’t mean the rest of the world isn’t at risk. The WHO says the virus enters the body through broken skin, bodily fluids, respiratory droplets, and contaminated materials like bedding.
“So what does that mean for our Pride festival coming up in November?” Dr. Ritchie asked. “Should we be masked up because of the droplets? The county has to let us know.”
Jumping through hoops
We’re familiar with how PCR testing works for Covid-19. You drive up or walk up to a mass testing site or a clinic; they ask you about your symptoms, swab your nose or mouth, and you’ll have a test in a few days. But if you believe you’ve been exposed to monkeypox, there are more hoops to jump through.
“First providers report to us and send us information on a patient, and it’s all reviewed by different epidemiological criteria,” Cole explained. “There has to be consistent clinical information, and we have to review what the rash looks like.”
Only then are patients allowed to be swabbed by their provider. Those swabs are picked up by a courier, tested locally, and if the sample is positive it goes up the chain to the Centers for Disease Control, which performs a test to confirm the result.
At the very beginning of the pandemic, when there were fears of a shortage of tests, officials asked that only symptomatic people get tested to preserve the supply. Eventually, it was opened up to everyone. There is no word yet from the county if testing for monkeypox will ultimately be opened up to anyone who may have been exposed, regardless of symptoms.
Dr. Ritchie says she knows better than most physicians what signs to look out for because of the clear guidelines she’s read from the Infectious Diseases Society of America. She fears other medical professionals haven’t gotten adequate guidance from the county.
“When that patient came into my office, I didn’t even know what number to call to let the county know we had a patient who was possibly exposed,” she said.
Cole says Riverside County sent out a public health advisory to all health care providers in the county. But Dr. Ritchie said she never received any advisory. If physicians are confused about what to do and how to protect themselves, she said, then patients are too.
“They should really be having public health education to the general public and to the providers,” Dr. Ritchie said, especially since there are likely more cases of monkeypox than we know.
“The county has only reported one case of monkeypox,” she said. “I think there are way more out there. I hate to say it, but I really believe we may have had a patient with monkeypox in our clinic in April.”
That would line up with some early timelines emerging from the WHO, which reported the virus was circulating in Europe sometime in April and had spread far beyond those borders to about 4,300 people by late June.
With this timeline in mind, Dr. Ritchie thinks the county could have done more to prepare. She mentions that large cities such as New York City and Los Angeles have already set up vaccination programs for people who believe they have been exposed.
“It’s alarming,” she said. “We already have Covid. We should have been ahead of this instead of behind.”
Dr. Monica Ghandi, who spoke earlier this year in Palm Springs during a community forum on Covid, agreed. In a recent article in The Atlantic, she wrote that the U.S. is underreacting to monkeypox.
Cole could not confirm a timeline for when vaccines will become available in Riverside County.
“We had an initial meeting with the California Department of Public Health to talk about our community needs,” Cole said. “They are working on getting additional vaccines for all the jurisdictions in the state.”