‘Testing bottleneck’ for monkeypox puts control at risk, experts warn

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Iinfectious disease experts are increasingly concerned about the US monkeypox testing strategy, warning that it is creating a bottleneck and wasting the limited time the country may have to bring the outbreak under control.

Under the current system, samples must be sent to one of 74 labs nationwide before being sent to the Centers for Disease Control and Prevention. Experts who spoke with STAT argue that the United States should test monkeypox more widely, allowing more labs to be part of the process.

“Every day that we don’t fix the testing bottleneck, every day that we fail to get the information out to the networks that need to be aware of it, that’s time we’re wasting in terms of that window closing. about containment,” said Boghuma Titanji, assistant professor of infectious diseases at Emory University.

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Titanji, who in his native Cameroon was involved in an investigation into an outbreak of monkeypox, said the number of cases in the United States – significantly lower than other similar countries – is almost certainly an underestimate of the scale of transmission that actually occurs here. The United Kingdom announced on Monday that it had now detected 302 cases. Canada reported 77 cases last Friday.

“The US probably has as many cases as Canada or the UK,” she said. “We just aren’t testing enough to be able to reliably say there are only 25 cases. I think we need to test way more than we do,” she said. After STAT spoke with Titanji, the CDC updated the number of monkeypox cases from 25 to 31; 13 states have detected cases.

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Jennifer Nuzzo, director of Brown University’s new Center for Pandemic Preparedness and Response, said the current system makes sense for a smaller outbreak, but doesn’t meet the needs of clinicians who should be actively looking for monkeypox infections.

“This two-step process is not going to scale,” she said in an interview. “It’s a cumbersome process. When you have something spreading in a way that we can’t see – in the sense that we find cases with no known contacts or known transmission links – it really feels like we’re in a response mode different. ”

STAT has contacted the CDC to ask if it is considering changing the testing protocol, but has not received a response at the time of this publication. At the end of May, the agency said he weighed what it would take to expand testing capacity to other labs.

The unprecedented outbreak in several countries caught the world’s attention in mid-May when the UK announced it had discovered four cases of monkeypox among men who had not traveled to the countries of West and Central Africa where the virus is endemic in nature. Since then, around 40 countries have detected more than 1,000 monkeypox infections, the vast majority of cases in men who identify as gay, bisexual or who have sex with men.

Emerging reports from national public health agencies have revealed that some of the cases do not follow disease patterns described in the medical literature. Some develop the monkeypox rash before experiencing systemic symptoms like fever and malaise, for example. Many have localized lesions in their genital and anal areas. Some have only a few lesions.

The discrepancy between what the medical literature describes and what frontline health workers see adds to concerns that some people with monkeypox may not feel sick enough to seek treatment or may not be recognized as having the disease. of monkeypox if they do.

“This level of community spread goes undetected, and we can’t help people make good risk decisions, we can’t help people protect loved ones and sexual partners unless we know what is happening,” said Joseph Osmundson, a molecular microbiologist in New York. University.

Osmundson prepared an online primer for men who have sex with men about the virus, with pictures of anal and genital lesions caused by monkeypox, and with information people can provide to clinicians to help them get tested. Community health groups report that some people seeking tests have found that their clinicians are unwilling to provide one, Osmundson said.

“You may need to advocate for a monkeypox test as some providers are unaware of the situation,” the intro warns.

Currently, if a medical worker suspects a patient has monkeypox, someone must contact the state health department and send a swab from the patient to a facility in what’s called the Laboratory Response Network, which has been set up to test for biological or chemical threats. These labs can determine if the sample is positive for an orthopoxvirus – the family to which monkeypox and smallpox belong. Orthopox’s combined testing capacity for this network is nearly 7,000 tests per week at 74 labs in 46 states, the CDC said.

If the sample is positive, the CDC performs confirmatory testing. The CDC said its two-step method has been sufficient so far and emphasized that a positive orthopox test was treated as a suspected monkeypox infection, activating all the clinical and containment measures required for a final diagnosis. This includes contact tracing, vaccination of high-risk contacts, and access to antiviral medications for the patient, if warranted.

Ranu Dhillon, a global health instructor at Harvard Medical School, said the testing system should be designed to standardize testing for monkeypox, so the net can be cast wider to find more cases. Dhillon, who works part of his time at a community hospital in Vallejo, Calif., said as it stands, he would have to authorize the ordering of a test with his hospital’s lab chief.

“It would be a process, it would be a discussion,” he said. “I think the sooner we move to standardization the better it will be to reduce that work stress or that embarrassment of asking for a test for something you’ve never seen. [before]…. You need to be able to screen widely as we learn of Covid and many tests come back negative. That’s how you’re going to find the ones that are positive.

Casting a wide net is essential because, although currently most cases are detected in men who have sex with men, this is unlikely to remain the case if monkeypox continues to spread.

“Given that the disease is unknown to many and its presentation is quite variable, it is undoubtedly true that there is undercount, particularly among the milder or atypical cases,” Paul Sax said. , an infectious disease physician at Brigham and Women’s Hospital in Boston. STAT in an email. “I would also worry about a case being missed if it doesn’t fall into this currently high-risk group.”

Luciana Borio, former director of medical preparedness and biodefense at the National Security Council, said the country should remember a lesson from the testing fiasco at the start of the Covid-19 pandemic and get commercial testing companies involved. diagnosis to response.

“We need to open up testing and bring testing to where it is normally done. We learned that from Covid, didn’t we? said Borio, senior global health researcher at the Council on Foreign Relations. “It’s much more efficient.”

It will undoubtedly take time for companies to carry out and validate tests. But that work should be ongoing, she said.

“He has to start now – if he hasn’t already,” Borio said. “And it will take as long as it takes. But we shouldn’t wonder if it’s necessary.

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