From: Don Weiss
Sent: Monday, July 18, 2022 12:03 PM
To: Commissioner Vasan 
Cc: redacted
Subject: Monkeypox is a sexually transmitted infection, messages suggesting otherwise are misinforming and prolonging the outbreak

Dear Commissioner,

Monkeypox in NYC is a sexually transmitted infection. Not communicating this clearly and often is a public health failure. The evidence is overwhelming:

• The vast majority of NYC cases have occurred in men who have sex with men and a few in the transgender community
• No children, heterosexual men, persons born as women, or household contacts have contracted MPX.
• Lesions have predominately been on the genitalia, oral, perianal, and rectum. Often with no skin findings elsewhere.
• Mounting research is documenting the presence of the virus in saliva and semen, but we suspected this weeks ago based on the epidemiology and our experience with other viruses, such as Zika and Ebola.
• It is also very likely that transmission can occur prior to symptoms and in asymptomatic persons.
• The current outbreak in NYC has been explosive. Cases tripled in one week. Previous MPX outbreaks in Africa have been self-limited and stopped without vaccine.
• The virus is not well adapted to humans and has not been readily transmissible, until now. This is different.

CDC has over stated the risk from skin-to-skin transmission. In the 2003 US outbreak none of the 47 cases were determined to have been from person-to-person transmission. None occurred by droplet and none by skin-to-skin transmission. All the cases handled infected animals and had breaks in their skin before becoming infected.

In Friday's DOHMH Press release is the following paragraph:

In addition to vaccine, prevention measures offer protection. These include avoiding close physical contact if sick, especially if there is a new or unexpected rash or sore. For those who choose to have sex while sick, it is best to avoid kissing and other face-to-face contact. Also, sores should be covered with clothing or sealed bandages.

DOHMH continues to emphasize skin-to-skin contact as the major risk and have now dangerously suggested that sex is not a risk, as long as you don't kiss and cover your sores. This is completely contrary to the evidence. The only way to stop MPX transmission is for MSM to abstain from sex for a period of time, perhaps 3-4 incubation periods. The possibility exists that cases will spread beyond the MSM community, and like herpes and syphilis, eventually cause catastrophic neonatal disease. The window to gain control is closing. Vaccine alone is not the correct strategy.

I, and several of my DOHMH colleagues, have repeatedly communicated this message through conversations, emails, and during ICS meetings, but to no avail. It appears leadership is more concerned with stigma avoidance than giving people the risk information they need to protect themselves and others. People are suffering.

I cannot in good conscience permit improper messaging to continue. I have shared the above information with The New York Times with the goal of fulfilling the health department's mission of informing the public about communicable disease risk.

References

Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcelona, Spain, May to June 2022.

https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.28.2200503

Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022, https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.22.2200421

Asymptomatic monkeypox virus infections among male sexual health clinic attendees in Belgium

https://www.medrxiv.org/content/10.1101/2022.07.04.22277226v1

The Detection of Monkeypox in Humans in the Western Hemisphere, NEJM, January 22, 2004

https://www.nejm.org/doi/pdf/10.1056/NEJMoa032299

Don Weiss, MD, MPH

Director of Surveillance

Bureau of Communicable Disease

New York City Department of Health and Mental Hygiene

Gotham Center, CN# 22a

42-09 28th Street, 6th Floor

Queens, New York 11101-4132