Mpox (And Meningitis) – Risk, Treatments, Vaccines and HIV Overlap

Announcer

Welcome to the Academy Exchange HIV today and tomorrow in this podcast host we discuss the latest advances in HIV prevention, care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Hello and welcome back to our listeners. This is episode four of the Academy Exchange: HIV Today and Tomorrow. And again, my name is Bruce Packett, your host, and I'm the Executive Director of the American Academy of HIV Medicine. And on this podcast, we typically look at clinical advances in HIV care, treatment and prevention. But also importantly, in the case of today's episode, the attendant social and clinical conditions around HIV, some of the common co-infections, parallel epidemics or what we call syndemics, which is really just a fancy way of saying there's more than one epidemiologically similar epidemic at a time that an at risk population might be facing.

So we're taking a slight pause on strictly HIV centric topics today, I think for very timely reasons, and we're going to be talking about monkeypox and meningococcal meningitis to some extent, which I can only assume most of our listeners have been reading and hearing a lot about in the popular press over the last several weeks and months, and really right on the heels of another viral, viral pandemic, which of course, was COVID 19.

Just a couple of weeks ago, back in September, Dr. Richard Silvera gave a talk for the Academy on the latest in the monkeypox and meningitis outbreaks in the U.S. and sort of what doctors and providers need to know and to look for in their patient cohorts. And there's a really good reason why we're using an HIV podcast to talk about monkeypox and meningitis, because there are some common risk factors which we'll get into over the course of today's episode.

Dr. Silvera is Associate Program Director of the Infectious Diseases fellowship and Assistant Professor of Infectious Diseases at the Icahn School of Medicine at Mount Sinai. He completed a master's in public health at NYU Medical School at the Icahn School of Medicine at Mount Sinai, residency in Primary Care and Social Internal Medicine at Montefiore Medical Center, a fellowship in Infectious Diseases at the Icahn School of Medicine, as well as a certificate in health informatics at the Oregon Health Sciences University.

Dr. Silvera, thank you for joining us today to talk about well, I guess firstly, the monkeypox virus and then also to some extent, the recent outbreaks of meningococcal meningitis.

Dr. Silvera

Thank you so much for having me. I'm happy to talk about these issues.

Bruce

Absolutely. And I want to start our conversation a little bit backwards, because usually I like to zoom out and start with the basics and sort of define our terms, especially for listeners without a clinical background. But I want to ask just to help us frame the conversation and sort of, beyond my initial comments in the introduction because, I should certainly know why I want to include a podcast episode on something seemingly outside of the HIV disease state.

But maybe you can help us understand from a clinical perspective, why is monkeypox related to HIV? And why do providers of health care who work in HIV as a disease state need to know about monkeypox and its clinical presentation?

Dr. Silvera

So I think monkeypox is going to be really important for the care of people with HIV. It's because monkeypox is a virus that the population who has HIV is very much being affected by. About 40% of monkeypox cases have been among people with HIV. So this is very much an illness that is affecting people with HIV. Is it is involved in the communities that these people are a member of and therefore this is a medical concern of people with HIV and therefore providers for those people have to be well versed in this will take good care of those patients. And so I think this is very much a thing that is affecting people's HIV as well as people without HIV.

But this is this is something that certainly we have concern for people with HIV. And therefore, I think we all have to be ready to answer questions and to do the best we can for those patients.

Bruce

Yeah, absolutely. That's great. And I hope we'll be able to pass out a little further what is similar and what is different as we continue on. But now I'm going to go ahead and pull back, right, and ask about the history and maybe sort of the etiology and biologic behavior of monkeypox before we get into what's happening here in 2022.

So just basically, what is monkeypox and what is its general history in the world as an infectious agent to humans?

Dr. Silvera

Sure. So monkeypox is a viral infection. It's part of a family of viruses called the orthopox viruses. And orthopox viruses have many members in that family. Some of the members of that family are very scary and dangerous. Other members of that family or less so. So kind of the scariest, most well known orthopox virus is smallpox. That is an extremely deadly respiratory infection that cause numerous deaths over the last several hundred years for humankind.

The W.H.O., actually announced the eradication of smallpox in 1980. So that was a great public health success. So that's kind of the most notorious member of the orthopox family of viruses. Monkeypox is not smallpox. They're cousins, but they are not the same. Monkeypox is nowhere near as severe an infection. But they do share some traits that let treatments and vaccines that work against smallpox work gets monkeypox as well. 

But to talk more about monkeypox specifically, it is not a new virus. We've actually known about monkeypox since the 1950s. It was first identified by Danish scientists in the 1950s in a laboratory. And then it's caused several human outbreaks since then, mostly in Africa, but also in Europe as well. So monkeypox is not a new infection.

It is an endemic infection in Africa, so there have been ongoing outbreaks of monkeypox and infections since the 1960s. But other than that, there have been outbreaks of infection in other parts of the world as well. Several cases of monkeypox have been identified in America and in Europe as well. So this is not a new virus. This is not a new not a new occurrence. This may just be the biggest outbreak we've seen, but we have seen outbreaks before. Just want to reassure listeners of that.

Bruce

Yeah, absolutely. That's all great information. I think the history is important to understand as we try to figure out how monkeypox came here in force in 2022 and how to combat it as an epidemic here in the U.S. and really across the world, as you pointed out, we've all been confronting the outbreak of monkeypox this summer and 2022.

Can you sort of bring us up to date on where we are today epidemiologically? So, for example, are we seeing increases in cases right now or are we seeing decreases right now? And I'm hoping maybe you can talk about what are the trends we're seeing at the population level. So I guess if we can just paint a picture for connecting the history you just described to where we are right now in the U.S. with monkeypox.

 Dr. Silvera

Sure. Absolutely. So let me take a slight step back and talk about where monkeypox, how the outbreak in 2022 started and then where we are now. So this all kind of began in the late April of this year where a returning traveler from Africa returned to the UK was found to have monkeypox infection and then cases kind of spread from there.

So we kind of had an increasing number of cases through the early summer up until about August of this year, and that's kind of when cases have peaked, both locally here in New York City, where I am, was kind of the epicenter of monkeypox in America currently, but as well as in the U.S. and the world, it all kind of peaked around August of this year.

And since then, we've actually been seeing a decline in the number of new cases of monkeypox identified. So both here locally in New York City as well as here in the U.S. there have been declining cases of monkeypox identified. So, it looks like things are heading in the right direction. But I don't want to say that too early because, of course, you know, things may change.

But the most recent numbers I have is of early October. This is October 3rd of this year, where currently has about 70,000 of cases of monkeypox has been identified worldwide in seven different countries. But the trend has been down trending since mid-August, both in the U.S. and New York City and worldwide. So things appear to be heading in the right direction.

Bruce

Yeah great. Absolutely. And, you know, as with COVID 19, when we talk about cases, we sort of talk about them uniformly. And I sort of want to follow up by digging a little more into who specifically is at risk for severe disease and even death. So let's start with the idea that someone has contracted monkeypox and is diagnosed by the HCP.

What is their actual prognosis at that point and what factors might make them a candidate for severe disease or, heaven forbid, even death?

Dr. Silvera

So so let's just take the most severe manifestation upfront deaths. There have been no deaths associated with the monkeypox outbreak in America. There's been one death reported worldwide, so far, out of 70,000 cases. So that's a very good mortality rate. So death is not really on the table for it for monkeypox in this current outbreak so far. Luckily.

But I'm going to take a step back from that. So most people who catch monkeypox will have mild disease that does not require any intervention or medication and will self resolve. So most people how catch monkeypox will be ill for a couple of weeks. They'll stay home. They'll have some skin lesions that will then resolve and then they'll get better. That's the majority of people. 

Now, some people will be at higher risk of having more severe disease. I think that's where people with HIV kind of come in. So someone with well-controlled HIV has the same chances of having regular kind of having non severe disease. Take a step back and repeat that. People with well-controlled HIV will likely have the same outcomes as people without HIV. When having monkeypox, people with well-controlled HIV will likely have mild disease that will self resolve without intervention. 

But people either with uncontrolled HIV, so people who have a detectable viral load, or people who have severe or untreated HIV, so people with AIDS or people with untreated HIV, they are at higher risk of having a more severe disease.

So what does severe disease mean? Severe disease could mean having extremely painful lesions. Painful lesions in parts of the body can be very inconvenient. So in the mouth, in the rectum or in the genitals to prevent urination or defecation could also cause in rare cases can cause more severe infections of other parts of the body, though that's very unlikely here in the US. But we do worry about things like meningitis. So that has not been reported as of yet.

Bruce

All right. So I'm hoping you can also touch on some of the symptoms, the symptomatology, the clinical presentation of monkeypox, what that looks like, what patients and clients should be aware of when they're at home observing their bodies and potential symptoms therein. What can you say about the clinical presentation of monkeypox and what people should be looking for?

Dr. Silvera

Sure. So just kind of ,when starting think about the clinical manifestation of monkeypox, there is a lot of variation for monkeypox. That's part of what's made diagnosis so challenging. So while we have some general ideas of what people might experience, everyone might be a little bit different. So it may not follow exactly the same pattern for everybody.

But generally the time period that we've seen is after an exposure to monkeypox, and that can be any form of intimate contact. It could be a sexual encounter, it could be just close contact physically. It could be skin to skin touching, could be handling soiled linens, whatever the exposure is. About seven days later is when people start experiencing systemic symptoms.

And usually with the current outbreak, it's a little bit different than prior outbreaks. People usually start experiencing skin lesions first, followed by systemic symptoms second. So people might get a skin outbreak first and then start feeling unwell after that. But most people in our current outbreak experience some sort of skin manifestation. Then also associated with that is fevers, lymphadenopathy, so swollen glands, either on the neck, in the armpits or in the groin, generalized feelings of lethargy or fatigue, headaches, people can experience body aches or muscle pain and also may experience anorectal pains, so pain with bowl moving pain on or near their butt. Lesions can appear anywhere on the body. They can be disseminated to all over the body, or they can just be concentrated anogenital region, so just on someone's genitals or on their back or on their trunk, limbs or face, any of those are possible.

Most people don't have fully disseminated lesions. They may have them just in one part of their body. And those lesions can sometimes be painful and makes, depending where they are, people may experience difficulties doing their normal day to day things. So if people have lesions in their mouth, they may have difficulty eating or drinking. They will have people have lesions on their genitals they will have difficulty passing urine. If you have lesions on or near their butt, may have difficulty with bowel movements. 

And any sort of severe pain or difficulty doing normal activities would be a reason to consider treatment and seek out a health care provider to talk about your treatment options.

Bruce

Absolutely. And you know, there is hope with this with this virus. And I'm hoping you can tell our listeners a little bit about the vaccine for monkeypox. Everyone knows exactly how much, kind of, irrational push back there was, the COVID 19 vaccine implementation in this country. So I'm hoping you can talk about the differences here and who should absolutely get the monkeypox vaccine, you know, from a clinical perspective and how they should go about doing that if they want to get vaccinated.

And who is the vaccine maybe less important for? Should we strive to have everyone vaccinated? So when we consider who is eligible for the monkeypox vaccine, guidance suggests that it's linked to people's sexual behavior, so men who have sex with men, people with a certain number of sexual partners within a certain period of time, those kinds of things.

What kind of challenges come with, you know, this kind of guidance? So for a provider, you have to be able to ascertain this kind of information from patients or clients and for patients maybe being resistant to sharing this type of information. So I'm hoping just generally you can speak to the vaccine and the challenges that exist when vaccination guidance is tied to an understanding of a patient or client sexual behavior.

Dr. Silvera

So I think if you bring up a lot of thorny issues, Bruce, so let me kind of unpack them one at a time. So first let me talk about monkeypox as a sexually transmitted infection because monkeypox is not a sexual transmitted infection. And that I think is a really important point to make. And so while monkeypox can be threads spread through sex, it is not an STD.

Monkeypox is spread through intimate contact. So sex is one form of intimate contact, but so is hugging, so is playing tackle football, so is dancing really close in a packed nightclub. All of those are forms intimate contact. So just to think that monkeypox is not sexual, it's intimate. Any skin to skin contact can lead to monkeypox. But that can be really tough to parse out because, you know, it's such a vague form of transmission. It's hard to really figure out who might be engaging in risk behaviors. 

And that's really been a challenge for public health officials and clinics and clinicians as well, Because, you know, it's hard to really delve into every skin to skin contact a patient might have. So this has proven a challenge. But we do have some things that we can use to really identify people at highest risk of catching monkeypox in the immediate future. And that's what we really kind of focusing our vaccination efforts right now. 

So the current recommendations from the CDC and of course, this may all change because, you know, this is a currently evolving situation, but our current recommendation right now are for men who have sex with men and trans women who have sex with men who have multiple sexual partners, anonymous sexual partners, or someone in their sexual network who has had monkeypox. Those are the people who should be who should be vaccinated.

If someone's also had a confirmed high risk exposure to monkeypox. So say someone has a sexual encounter and that person later tests positive or has other some of the form of intimate contact with a patient with someone who's confirmed monkeypox positive. They also might be eligible for vaccination.

But so what are the vaccines we have? And kind of to draw contrast between monkeypox and the COVID 19 situation. Because, you know, vaccination efforts have been very challenging with COVID 19.  Monkeypox, we have a slightly different situation and that is because we have FDA approved vaccines. So the vaccines that we have, we have two different vaccines available right now.

One is called the JYNNEOS vaccine and the other one is called the ACAM2000 vaccine. The JYNNEOS vaccine is an FDA approved vaccine for both smallpox and monkeypox. The ACAM vaccine, ACAM2000 is the full name. That one has an emergency access approval for monkeypox. That one has been studied for the use of smallpox. So the one we're using here in the US is the JYNNEOS vaccine.

And the reason why that is, is because that one is safe to be used in people with HIV. And as I mentioned before, people with HIV are a big part of the monkeypox outbreak right now as we really make sure our prevention efforts include those people. So the JYNNEOS vaccine is safe to be used for people with HIV.

The ACAM2000 vaccine is not recommended in use for people who are either immunocompromised, including people with HIV. So we're not really using that one right now in the U.S. What we're really using when we talk about monkeypox vaccine, we're talking about the JYNNEOS vaccine. 

That is an FDA approved vaccine is a two vaccine series. So you get a shot and then you get another shot a month later. And it's been shown that about two weeks after that second shot, we estimate about an 85% protection rate from monkeypox infection. So it's not perfect protection, but it does reduce severity of disease and can prevent infection. But every little bit helps in trying to stop an outbreak.

Bruce

Right? Absolutely. Yeah. Sorry. Go ahead.

Dr. Silvera

And so the question is who should get this vaccine? And so this one, we kind of get to the public health aspect of it because medicine is not just about actually caring for the person in front of you. It's also about managing resources, caring for whole populations, caring for whole countries. And so we have limited supply of the vaccine. We only have so much vaccine. 

So that's why we're really focusing right now on people at highest risk of contracting monkeypox. So those are those folks I mentioned before that are either people who have multiple sexual partners, anonymous sexual partners, or someone in their sexual network has known monkeypox infection. Those are folks who are getting recommended to get vaccinated right now because they're the folks who are most likely to catch monkeypox in the immediate future.

At some point in the future, maybe when we have more supplies or if that or if the outbreak changes, we may recommend other people get vaccinated. But right now, we're really focusing on those folks most likely to get monkeypox in the immediate future. So we are not following a universal vaccination recommendation right now for monkeypox. But of course, I leave the door open that things could change as we learn more about it.

Bruce

Right. Absolutely. Is your hope when you're talking to patients about risk profiles and looking at symptoms and whether or not they might be a candidate for the vaccine or whether or whether or not they might be a candidate for diagnosis of an existing infection. What sort of conversation do you have or would you recommend that providers have with those patients to really get at those risk factors?

Because that's a really difficult stigmatizing, potentially, if not done well, conversation to have with your patients and clients. So I'm just wondering if you have any recommendations for any providers out there who might be listening and potentially seeing cases?

Dr. Silvera

Sure. Absolutely. So this is a challenging conversation to have. This really going to require delving into people's sexual histories and to be able to get someone to be willing to divulge that information to you, it really has to be based on trust. And so trust is really the coin of the realm in trying to get people to discuss sexual history with you.

And trust sometimes takes time to develop. You may be seeing people for the first time, so that can be really challenging. You always have the advantage of having an established relationship and an established trusting relationship. So the things I would recommend would be to really try to have a non-judgmental regard. There is no right or wrong sex.

You're just trying to get someone to tell you what kind of sex they're participating in. And remember, the goal is to try to have people to be to try to and to have them be have safer sex. It may not be a question of getting absolutely zero risk. You have to try to meet people where they are and try to help them reduce the risk where they're able to reduce the risks.

So it's trying to work with someone with where they are and trying to find a way of helping them be as safe as possible and a way that they can actually actually do in their lives. So while we may say ideally, you know, ideally, abstinence is the number one number one way to avoid monkeypox, abstinence and total social isolation, that's not really feasible.

And so we're not trying to work towards that. We're trying to find something that is feasible in someone's life and that may include some level of risk. We're going to find a level of risk that they're comfortable with. You can minimize the risk that they can avoid. And so it's really good to work with patients, try to tailor it to their particular life, their particular exposures, their particular circumstances, and find a way of making the risk as low as possible, but still letting them live their full lives.

And I think the CDC has some great information about this, about safer sex recommendations, and it's a great resource. I would take a look at that if one looks else, inspiration on how to talk to patients about this.

Bruce

Yeah, absolutely. And we can include those in the podcast show notes, so we will do that. Absolutely. Is there any concern in your mind as a clinician, as a provider around asymptomatic transmission? I know we don't have a lot of data on that. It might be anecdotal, but when I talk to people who are not necessarily in health care, working in health care or experts in health care, and we're talking monkeypox, I think that there's the question around, well, is it possible that I could have it not know it and spread it to somebody else? And what should I be aware of in that sense? So I just kind of wanted to ask you about asymptomatic transmission and what your take is on that.

Dr. Silvera

So, I mean, this monkeypox outbreak is a bit different than prior outbreaks that we've seen. So the symptoms are a little bit different. We're seeing a lot more genital lesions in this outbreak. We're seeing symptoms appear a little bit later than before and in a little bit slightly different order. So there are some unknowns with the outbreak compared to prior outbreaks. And there have been suggestions that that might support the idea that here are some asypmtomatic transmissions going on. 

There was a case report of a few cases of likely asymmetric transmission that happened in Europe. And I can say from my own clinical practice that I've met patients who have had monkeypox and, you know, going through their history with them. And I'm very confident they're being very frank with me that they didn't have a known positive person who could have given it to them.

So I think that there is a lot of anecdotal support to suggest that might be asymptomatic transmission going on, but anecdotal is not the same as evidence. So we've got to be really careful before we say something is definitely happening. But the good thing is that kind of the universal precautions that we're recommending for kind of protecting people from protecting yourself from monkeypox.

Let me repeat that. So we don't want to say that something anecdotal is necessarily actually happening because that's not evidence. So the good thing is, even if there was asymptomatic transmission, the precautions that the CDC is recommending would work against asymptomatic or symptomatic transmission. So those preventive practices and ways of reducing risk would work whether your partner is symptomatic or somatic asymptomatic. So those protections work either way. And that could give your patient some reassurance.

Bruce

It's really important information. Thank you. And I just want to switch gears a little bit, but it's still related. So this outbreak of monkeypox may have understandably received, you know, a good deal more attention than another outbreak were we're experiencing in the U.S. and that's meningococcus. Yes. So for our listeners who are maybe unaware, can you tell us a little bit about what meningococcus and meningococcal diease are and how they also are related to HIV?

And they have, again, similar risk profiles to HIV and to monkeypox. So again, who's at risk for meningitis or meningococcal disease? And what can be done with that specifically in terms of prevention and then treatment if they are contracting meningitis?

Dr. Silvera

Sure. Absolutely. So meningitis is taking a little bit of a switching of gears here because monkeypox we were talking about and even COVID 19 those are viruses. Meningococcal is a bacterial infection. So slightly different and meningitis is kind of an inflammation of the lining of the brain, many different things and cause meningitis. But meningococcus  is referring to a specific type of infection that can affect that part of the body.

So it's a type of bacteria that lives in our noses that can be transmitted through exchange of saliva. So exchange through coughing, kissing, intimate contact, things like that. So similar to monkeypox in that it's not easily spread through sex but can be spread through things that sex is included in. So, you know, intimate contact can include a lot of things which and sex is one of those things.

So why is this of concern for people with HIV? So there've been several outbreaks of meningococcal among men who have sex with men. And kind of the biggest one that happened here in New York City, where I am, occurred in 2010. And it's kind of been ongoing since then. And that has been an outbreak, particularly among men who have sex with men who have HIV, and particularly with higher rates among men with sex with men with HIV who also use recreational drugs and also use the Internet to meet sexual partners.

So there've been much higher numbers of cases in that group. And because of that, we have the recommendation of trying to make sure that people who fit into those criteria get vaccinations against meningococcus. We do have vaccines that prevent meningococcus specifically, we have meningitis A and B vaccines. And the recommendation now is that someone who may be at risk for contracting meningitis and that would be people with HIV who meet sexual partners online, would be part of that group to receive those vaccines. And if they haven't had a booster in five years, to consider giving them a booster as well.

Bruce

Right. Absolutely. And what about, I guess, both with monkeypox and with meningitis, what are we talking about? We talk about. Okay, so we have a positive case. You have you have a client in your office who has been diagnosed with both/either meningitis or monkeypox. What are the respective treatment options? And then I guess we sort of talk about prognosis to some extent, but what does that look like once we have a diagnosis and we begin treatment?

Dr. Silvera

So this is where monkeypox and meningococcus are very different. So most people who have meningoccus, I’m sorry, let me repeat that.  Most people who have monkeypox will have mild self-limited disease and likely be treated as an outpatient, may not even require anything intervention mostly supportive care things like that. Meningococcus is a medical emergency. If you have a patient with meningococcus, they need to go to an emergency room and they have to be isolated cause they are highly infectious.[DE1] 

So someone with meningococcus needs to go to emergency room immediately. The time to antibiotics is will make a major impact on their ability to survive the infection. Meningococcus is a deadly infection. So you have to if you have any suspicion of it, you have to send them to emergency room for a higher level of care immediately. Not a time to sit on your hands and wait and see what happens.

Meningococcus is a severe infection that involves the central nervous system and can lead to death. So meningococcus is a much more deadly infection than monkeypox. Monkeypox, you can treat in your clinic.  Meningococcus you should send them to a higher level of care immediately.

Bruce

Yeah, absolutely. Very important information. I just want to end, I guess, with the last question and it's kind of an expansive one so we can spend as much time on it as we need to. It's interesting when you start to look at media headlines around, I guess, you know, the monkeypox situation in general, the epidemic in the U.S. and, you know, the reporting on it, there's quite a number of takes to consume.

You know, I wanted to get your opinion, your professional expert opinion on what the overall prognosis is for the monkey monkeypox outbreak in the U.S. in general. And this sort of also, I guess to some extent, this particularly nasty meningitis outbreak as well, because the CDC says that we can get on top of this, we can eradicate monkeypox.

We always say with HIV, we have the tools, the clinical tools to eradicate new transmissions. But can we truly say the same for monkeypox? You know, we have some media outlets and public health experts who are a little more dire on the prospects and think that it could continue to spread somewhat interminably. So what is your take on sort of the big picture with both diseases, with both monkeypox and meningitis in terms of, you know, you mentioned that meningitis been around in New York since 2010 and that's kind of ongoing. What is the prognosis for both diseases? Big picture.

Dr. Silvera

So I think that this is where public health and prevention really are going to be the mainstay of how we manage these illnesses. So I think that there is a bit of a distinction between monkeypox and meningococcus in that we actually know a lot more about meningococcus than we know about monkeypox. So one still unanswered question of monkeypox is what the natural reservoir of monkeypox is.

So what that means is, we know that humans can catch monkeypox, but not all monkeypox virus lives in humans all the time. There is some source out there among animals where the virus is living and reproducing and then eventually jumps from animals back to humans to cause infections. So we don't know what the reservoir, we call that the reservoir, we don't know what the reservoir of monkeypox is.

We still haven't discovered that it's not monkeys. Monkeypox is a bit of a misnomer. We don't know what the natural reservoir of monkeypox is. And so therefore we don't yet know if the US has an animal that can support monkeypox. We don't know if their reservoir will actually persist in America or not. We don't know yet. So it's really hard to know if it even can be sustained in our ecosystem because this isn't just a virus that affects people. It's a virus interaction between humans, animals and the environment. 

And so we don't yet know if the environment here in the US can sustain monkeypox or not.  It might be able to. We just don't know. We don't know what the natural reservoir is. 

So I think it's really hard to know if this will be an ongoing infection or not.

But that aside, we do have, even with our declining rates of infection, we have shown that both public health response vaccination and engaging with communities, because a lot of this is also the community working to protect itself. All these things working together can reduce infection rates dramatically. So I think just like HIV, I think monkey pox and HIV have that in common, that we have the tools to control and eradicate these infections and it's just using those tools appropriately.

I think we've seen some great success in the control of monkeypox very quickly after it happened. So I think a lot of this I think a lot of similarities between monkey pox and HIV and that a lot of the lessons we learned from HIV were applied to the monkeypox outbreak much sooner, much sooner on. And we've seen successes of that early application, of those lessons learned from HIV.

And so I think much like HIV, we have the potential of controlling monkeypox as well. And I think the successes we've seen have been a reflection of that. The public health officials, clinicians and community members for the community is really protecting itself as well in this. Community has responded to the monkeypox outbreak and I think it really helped protect help protect each other.

So I think these are both these are these are two viruses that we have the tools to control and eradicate. The question, will this be how long that will take? But there's still a lot more questions about monkeypox than there are about HIV.

Bruce

Yeah, understandable, given it's sort of novel status in this country. And I really like the sort of optimistic ending, right, about the lessons learned from the HIV epidemic. It's something that we really applied to COVID 19 as well. What can we take from previous viral outbreaks and what lessons can we learn and apply? And since there are so similar, so many similarities, that gives us a lot of resource and opportunity for tackling the existing epidemic.

So I really thank you for sharing your expertize today with our listeners. There's a lot of information to unpack there and listen to and think about and absorb, and I really encourage all of our listeners, whether you're providers or on the other side of the of the patient table, just to think about this and think about your risk profile related to monkeypox and meningitis and certainly have those very important conversations with your providers and vice versa for providers who were listening.

So thanks again, Dr. Silvera, and I hope you have a nice day.

Dr. Silvera

Always a pleasure. Thank you for having me.

Bruce

Bye bye.

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