Q: Good afternoon, Dr. Chan. Thank you so much for taking the time to meet with the Pandemic Center team to talk about this important topic. As an infectious disease clinician, what has your involvement been with the mpox response?

A: I've been actively involved in all levels of the mpox response from policy development at the Rhode Island Department of Health down to individual clinical patient care. At Open Door Health where I see patients, we had a vaccination day very early on for mpox providing the JYNNEOS vaccine. I was here for a full day administering vaccines myself, some of the first doses here in Rhode Island.

Q: What were some of the challenges at the beginning of the mpox pandemic from a public health official and physician perspective? Did you see any similarities to COVID-19?

A: For all of us involved in the mpox response, and for those of us that were involved in the COVID-19 response, there were certainly, and unfortunately, a number of similarities. There were lessons learned from the COVID-19 pandemic including some things that we did better for sure.

When I think about how the mpox pandemic evolved, the first challenge very early on, similar to COVID-19, was just getting a handle on what was happening because so much of what was unfolding was overseas, where we didn't have great visibility on it.

The data, initially, was all over the place and it was concerning. We were following it on an hourly, if not a minute-by-minute basis. At least for mpox, one of the challenges was figuring out who was being affected or infected. In retrospect, mpox has primarily affected cisgender gay and bisexual men, as well as some gender-diverse and non-binary folks. That's what the data shows. Early on we were getting reports of that, but we didn't want to stigmatize this population. We in public health are being very careful not to stigmatize the LGBTQ+ community. What I've always believed is that you have to rely on the data, the science, and the evidence. The danger here was that we would ignore what was happening to gay and bisexual men. In fact, that’s what happened during the early days of the HIV epidemic. We couldn’t ignore this, and I don’t think we did. There’s this conversation happening in public health about how to walk that balance. Eventually, I feel like we did okay. In hindsight, we could have probably done a little bit more, sooner, but it wasn't clear and we didn't want to overly stigmatize.

We had a taskforce for mpox [in Rhode Island]. We solicited input from different LGBTQ+ groups and stakeholders, which is what should be done, whether it be related to LGBTQ+ folks or other groups. You really need community input from the groups impacted the most about how to address the public health issue at hand to make sure that you are messaging things correctly and that you are doing whatever you're doing in a way that is culturally competent and appropriate for that community.

We then moved into the testing realm. One thing that was a disaster, in my opinion, early on in the COVID-19 pandemic was that we didn't have enough testing and that there were some delays, among other things. For mpox, however, testing was largely successful. If you look at what the CDC did, they actually rolled out testing to the commercial labs very early on. The logistics of testing are always challenging. You're trying to develop these systems of transporting and storage with hospitals and clinics. Generally, access was good, and the logistics went smoothly, certainly compared to COVID-19.

For many of us who have worked through both the COVID-19 pandemic and mpox, the vaccine roll-out of mpox was pretty stressful because, similar to COVID-19, we were faced with really high demand and a low supply. It was that same feeling of helplessness, of wanting to do more and not being able to for both pandemics.

The game changer was that the CDC released an updated recommendation that the vaccine could be given intradermally [between layers of skin]. It allowed us to exponentially increase the amount of supply doses, which essentially fixed the problem overnight. We lucked out by having tools available to address mpox, such a JYNNEOS vaccine and Tecovirimat supply. We didn't need to develop a new vaccine. The barrier with Tecovirimat was the couple hundred page application needed to apply for an investigational new drug, because it was not authorized or approved yet by the FDA. The CDC reasonably took correct steps to shorten that process. Moving forward, there needs to be consideration about the barriers that paperwork creates in a time sensitive situation.

Q: You’ve also been involved on the policy side. What is happening in that space and what do you hope to see moving forward?

A: The [Rhode Island] Department of Health did have a taskforce on how to address the mpox pandemic with different structures available depending on the response. For COVID-19, they had an all-government response with an Incident Command Center, which was much more encompassing.

For mpox, it did not quite reach that level, because it wasn't as widespread as COVID-19, but there was a taskforce that really guided different parts of the response. That was where the decisions were made, for example, about who was eligible for a vaccine, about how testing was done, about who should be tested, and what the recommendations were for testing. The taskforce really oversaw all parts of the pandemic and was made up of many policy-level decision makers.

Q: Given the few reports that have come out of other countries recently (e.g. the cohort in France that was fully vaccinated and ended up getting mpox, the report of the first recorded case in Pakistan), are you concerned at all about a resurgence among people after being fully vaccinated, or about other countries that haven't seen it yet having an outbreak, and not being quite prepared?

A: It's always on our radar, and it's always a concern that things can again surge, or there could be a new strain of mpox. There were a couple of strains of mpox, one of which was much more deadly than the strain that we saw [here]. We've all realized that the mpox vaccine, the JYNNEOS vaccine, was not 100% [effective]. There is good data showing that very rarely does a vaccine ever provide full protection to everyone who is vaccinated. None of us are surprised that there are some breakthrough cases. One thing for people to consider is that, similar to COVID-19, the vaccine may not protect you from being infected but we do expect that the vaccine should mitigate some of the more severe symptoms. It is definitely worth being vaccinated.

We always worry about new strains, new variations. What I want to remind people about mpox is that it's an orthopoxvirus, which is a DNA virus. The reason we had the JYNNEOS vaccine is if someone has immunity to one virus in the orthopoxvirus family, for example smallpox, which is totally different, you get immunity against all the viruses in that family. It’s different from SARS- CoV-2 which is an RNA virus. It does not mutate anywhere near as fast. It's more stable. We would anticipate that the JYNNEOS vaccine should also protect against other emerging strains of mpox.

Q: Do you see any areas for improvement in our response for another outbreak, whether it's mpox or something else?

A: There's always room for improvement. In general, we did relatively well for mpox, and we did learn a lot of lessons. There are just some situations that are difficult to address, and the one that comes to mind during mpox is the vaccine issue, the overwhelming demand for vaccines and low supply. We saw that in COVID-19, we saw that here, we'll probably see it next time.

I've learned the best we can do is communicate with people. Communication is key. One thing that has worked well in general, both in my clinical role as well as my public health role, and also during the COVID-19 pandemic, is the implementation of a waiting list and a way to message people about vaccine availability.

If you don't manage expectations with clear communication, people will feel like something else is happening behind the scenes. People will believe either you're doing nothing, or other people are getting the vaccine and there’s questions of “why am I not getting the vaccine?” and “who are you giving it to?” It's impossible to make everyone happy all the time, but the best we can do is communicate in some of those difficult situations. It is important to set up mechanisms early to communicate when the time comes, and not just react when people get upset. It is also important to anticipate some of these behaviors from the public, all of which are reasonable and understandable.

Q: Is there one thing that you would want the public to know to prepare for next time, or if they're worried about contracting mpox?

A: The biggest thing I'd like folks to know is that there are often a lot of people working behind the scenes to do the best they can, and I would encourage people to communicate with us, whether it be us at the Rhode Island Department of Health, or others elsewhere. Try to understand that these are difficult and challenging situations for many reasons. We're always looking for feedback and want to do better. My one comment would be: some of these situations are just really difficult and really challenging. It does take an army to address some of these huge public health challenges.

The biggest threat to public health is the rise of misinformation. I would encourage everyone to consider your sources and to think critically about the information that you are receiving. Not to rely on your Twitter news feed, or Facebook, but to really consider medically accurate sources of information. The spread of misinformation has a detrimental impact on how we address public health, and it's been one of the biggest challenges in general in public health related to vaccines, related to treatments, treatments for Covid, etc.

On behalf of the Pandemic Center: thank you, Dr. Chan, for your time and your commitment to combating mpox and making us less vulnerable to further outbreaks.

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