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Responding to Health Disparities and Clinical Challenges of Monkeypox (Mpox)

Learning Objectives
1. Describe the challenges that Howard Brown Health encountered in their response to the monkeypox (mpox) outbreak
2. Explain how the clinical staff at Howard Brown Health responded to these challenges and lessons learned
3. Describe the health disparities that emerged at the onset of the monkeypox (mpox) outbreak
0.5 Credit CME

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0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and

0.5 CME points in the American Board of Surgery’s (ABS) Continuing Certification program.

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Audio Transcript

Welcome to Stories of Care, a podcast from the American Medical Association and the CDC's Project Firstline. This is the second part of our episode covering the outbreak of monkeypox, or mpox. This part focuses on the impact of the outbreak on local health clinics and how these health care professionals have responded.

Our guest today is Dr Magda Houlberg, the Chief Clinical Officer at Howard Brown Health in Chicago, IL. Howard Brown Health was founded in 1974 and is now one of the nation's largest lesbian, gay, bisexual, transgender, and queer (LGBTQ+) organizations.

Please note that this episode was recorded before the WHO and CDC changed monkeypox terminology to mpox, so you will hear it referred to as both monkeypox and MPV.

[00:00:00] Megan Srinivas, MD, MPH: Hi, Dr Houlberg. Thank you so much for joining us today.

[00:00:04] Magda Houlberg, MD: Hi, great to be here.

[00:00:06] Srinivas: I'm excited to have this conversation with you about something that a lot of my patients, a lot of people in the community have so many questions around: monkeypox. We just are overcoming spikes of one pandemic and then a new infectious disease emerges that everybody's scared is going to mimic what we've just been through.

[00:00:27] So what do we know about monkeypox? With your staff, you have a large clinic that is dealing with one of the susceptible populations to MPV. What did you feel like your staff was most worried about when this first emerged, and how did you handle those concerns and make sure they were prepared to deal with this new disease?

[00:00:48] Houlberg: Certainly. So it's, it was quite a difficult, I think it was quite difficult for a lot of health centers. We work and focus primarily on the LGBTQ population and have expertise in HIV care as well and serve a lot of populations that were disproportionately impacted by MPV or monkeypox.

[00:01:10] So we were one of the first places to see cases in Illinois. Howard Brown Health is a federally qualified community health center and a lot of the work we do is in sexual health and in infectious disease. So it was something that we began to recognize fairly quickly in our sexual health walk-in clinics, in our general medical visit clinics. As you can imagine, rashes are very common, rashes of all kinds are common. Rashes may or may not be anything to worry about. But really understanding that this clinical phenomenon was happening required us to mobilize very quickly, so something that we also had to do with COVID. But I think also a lot of the things that I think we had hoped to learn from COVID on the national level in terms of the infrastructure that supports our national health response.

[00:02:07] A lot of us were thinking, yes, now we've learned all these lessons from COVID and those will be available to us and our mobilization will happen very differently. And vaccination and testing distribution will happen very differently now that we've learned from this incredible experience. And that wasn't always really the experience we were having. So a lot of the same things did occur, meaning that having difficulty accessing testing or elaborate requirements for testing that made it difficult for us to easily identify patients. But additionally, you know, access to treatment, which was also very challenging and then access to vaccine supply. A lot of this was all organized through the health department, so the Illinois Department of Public Health and Chicago Department of Public Health, both who did really an amazing job in responding to this with very little notice. Even in those settings, really because it's distributed at a national level, it was very difficult for that trickle down to happen. So that was a very similar situation that we saw with COVID. So staff really had to learn about something very quickly that we didn't understand very much of. So doing a lot of research, working with our infectious disease specialists to also inform us about this and understanding how it might be transmitted, understanding how the community might be impacted and really what the incubation period might be. So at that time we were really looking at summer festivals and times where actually a lot of LGBTQ people, particularly post COVID, will have the ability to socialize and get together and do all those things that people have not been able to do historically.

[00:04:03] And in that process, that probably created some vulnerability to MPV or monkeypox transmission. Because even if you wear masks all day, it's something that is really a physical or it's touch, it's transmitted from surfaces and touch, so it behaves a lot more like MRSA transmission. So wherever we see people congregating in very close quarters is where we're going to see that type of transmission if it enters that environment.

[00:04:35] So those were some things that we were struggling with, and so having to respond to a very large number of patients who in fact did have monkeypox. So a lot of people coming in with classic symptoms that needed to be assessed and tested and treated.

[00:04:51] And then a lot of individuals who were concerned or worried about it but who probably did not have monkeypox, for example. And responding to kind of that public health urgency. And an urgency around vaccine access, some of which we didn't have access to. So initially we were able to vaccinate when we were able to get access to vaccine, but outside of that, we could not.

[00:05:19] Even though there was a huge demand for vaccination, that wasn't going to be something we could do without receiving that vaccine from the health department systems and being able to mobilize that. Something, which a lot of places, a lot of health centers, did during COVID, in terms of vaccine distribution.

[00:05:37] So I think what was challenging for the staff was it was probably pretty traumatic because their thought process, much like mine was like, we've been through this experience, we've learned a lot from it, and it probably nothing like this will happen again in our lifetime, or at least that was the hope.

[00:05:52] And granted this is quite different than than COVID. It is an outbreak type situation. It does adversely impact specific populations and travels in specific populations. Those were some things that coping with probably preexisting burnout and stress and worry. Including worrying about one's own personal safety, and putting in long hours, which all of our staff did. So all of our staff were dedicated to serving the community and understood that we were in a unique position to do that. But that does require longer hours, different access points for care, different systems. So that does take its toll on staff, I think, in terms of burnout.

[00:06:34] Srinivas: I would love to put this in the context of time for everyone to realize where we were. So this is all emerging. We've been through what, two years of fighting COVID at this point, and it's May, 2022. So almost two years and two months to the date after really COVID emerged to a certain extent in this area. In the setting of feeling like, Hey, we're coming down from our most recent spikes, most people that we can are getting vaccinated. Having a little bit of feeling that maybe people can be a little bit more relieved from a staffing standpoint as far as the rush coming in. And that's when we suddenly start to see this happening. without really having any time for the staff to, to rest or to recuperate after this. So you're touching on burnout and I would love to know how you helped to support your staff in this setting where it felt like it was just one thing that came right after another.

[00:07:31] Houlberg: Yeah, I think I think it was challenging. There's probably things I would go back and do differently during COVID to support people than what I ended up doing. I think in this case we tried to enlist more support from larger academic centers. So being that we can't do everything by ourselves, so this idea that we should work as part of a larger team if there are places that have better capacity or more staff, for example, to respond. So however we want to get this done, you know, get it done with the most help that we can. So that was one piece was so to accept the fact that there were a lot of things that we just did not have capacity to do at that time.

[00:08:12] And to make sure, you know, in some ways that staff understood that that was inevitable, that there are limits. So I think we went past our limits in COVID, like many places where it felt like there's this moral imperative to go. There isn't, you can't do too much. You know, there's so much that needs to be done that no one else is there to do. You know, and that's, that's also, you know, can make people feel... I guess I'd say guilty for, for taking rest when they probably need to, to even function. So I think trying to be understanding about the stress and the burnout from it. But yeah, definitely some of it couldn't be ameliorated, I'm pretty sure. Meaning that I knew people were experiencing that. I mean, I was probably experiencing it myself.

[00:09:03] Certainly a lot of our health care professional team was in that mindset, and we could try to rely on, I think each other or human relationships to try to sustain us through this, but also understanding it's kind of an impossible situation, you know? So you do have to kind of forgive yourself for what you can and can't do because it's just not, a lot of these things, I guess let's say, I hope these are lessons that we'll learn for any future outbreaks of this or anything else. But we just didn't have time to build up that type of infrastructure nationally, and I think you see it in hospitals as well, and most health systems, you're, what you're seeing is it, it's sort of looks like everyone's okay on the surface. It sort of looks like everything's functioning in the hospital, for example. But the reality of it is, is deeper than that. Meaning I think there's, there's capacities and reserve, human reserve that will take years and years to kind of replenish after this experience. So I think it was a little bit of a one two punch for us.

[00:10:13] I think a lot of it was challenging with MPV because there's a lot of, I guess let's say it's, it's the testing was not commercially available, so that means we really had to utilize our state lab and they have a limited capacity, so they have to meet certain criteria that would make it fairly likely that the person had monkeypox before we even tested them.

[00:10:39] And, and that was probably a limit or a, it was, it would limit the amount of people that we could actually assess or test. We struggled a lot with also people being assessed in, in an urgent care setting and then having it be misinterpreted as something other than MPV. But because we had seen a lot of MPV, when we saw it, it was very clear what it was.

[00:11:04] I think getting medication, getting patients in and out of the center, for example, you know, we have other patients that are immunocompromised as well, so bringing people through the health center for assessment in a way that keeps everybody safe. Even though contact precautions is certainly, you know, plenty for this, it still created some complexities around that for other patients.

[00:11:29] So it, it kind of impacts patient care in general in primary care access. We still have patients still trying to catch up with, for preventative care of all kinds, you know, which we've not caught up with and and really would like to. And then this definitely requires resources, a lot of resources in a very short period of time in order to like stem, the tide.

[00:11:52] And so that's the tricky part of things like outbreaks, which is that every action you take early on magnifies. So if you take an action early, that magnifies through that, throughout the whole process. So it does, a couple of days does make a difference, you know, in terms of how it plays out in trying to protect our community.

[00:12:13] So in order to get medications to patients as well as many of, you know, to treat MPV the medications that we utilize are, they're not fully FDA approved for this indication. And so we did it under a particular protocol that is almost like a research protocol, which required a lot more paperwork for the patient and for the provider, which probably slowed up treatment, but also it meant that I, you know, we would have to go to someone's house in order to get them to sign the consent form because it can't be signed remotely. It has to be signed in person. You can either bring that patient back into the space when you know that they have active monkeypox or MPV or you can go to their house, which is a health care provider entering their home, you know, when they have that. So it's like there's kind of like a very, very similar to a COVID treatment in the sense that there's no, like, how do you get the medication to the person?

[00:13:08] Srinivas: With having to go to, to the homes and risks affiliated with potentially having your health care staff exposed. How were you able to, to make sure people felt protected and safe entering spaces where they could potentially come across it?

[00:13:22] Houlberg: Sure. I think it was a, probably a few patients where we did that because of severity, I think. Meaning I, you know, I was one of the folks that would go to people's houses and that was actually based mostly on, on severity of that patient. Meaning that they had so many lesions that I was actually concerned, you know, about physically bringing them back into the space. I tried to keep the visits very brief, you know, using personal protective equipment.

[00:13:49] Srinivas: What, what type of PPE were you able to get and were you able to get it right away? Did your staff feel protected in it?

[00:13:55] Houlberg: Oh, sure. Absolutely. Yes. We have quite a lot of PPE. So luckily we have pretty much everything we need. And it's I would say eye protection and contact precautions, so gloves and gowns. And then a regular mask is really, is sufficient. So I can't say that we sent a lot of people to the, to treat in the homes, but you can see the challenge because otherwise we're bringing in patients that need to be treated and we need to have some sort of interaction in the health center. So that will require getting gowned up and that. So, but yeah, we were very fortunate in the sense that we had and still do have a really good supply of, of personal protective equipment and a really good understanding of how to use it.

[00:14:34] Srinivas: So that's a, that's at least a step up from where we were when COVID first started. Well, one thing to assuage the worries, and honestly, as we've seen studies show when health care workers feel safe, it helps to reduce the feelings of burnout. So at least that was one big thing that helped. But one thing you really touched on too, that really intrigued me was the fact that you were talking about how all the distribution happened at the county health department, which is how typically, you know, the spoke and wheel model of our public health system in this country works and how the Chicago department of health was great and being able to communicate with you and trying to get you the testing, vaccines. And even then you had some, some issues with shortages, especially in the beginning. But then it does raise the question of what about the people who don't fall under the Chicago department of health? Is that where we're seeing inequities arise in that certain health departments are more well staffed or well resourced or just have people who are able to answer those questions because of their experience a little bit more than perhaps a rural health department.

[00:15:33] And how did that impact your ability to give care to these different situations?

[00:15:37] Houlberg: Yeah, absolutely. We did see that, and I think that's something that played out in a similar disproportionate way, with COVID response as in MPV, which is, health departments has various levels of funding, you know, depending on how much resource they have. And so for patients that would come in and they're not actually, they don't actually live in Chicago city limits, they may live in a suburb many of which are under-resourced, meaning in Chicago, like a lot of the big cities, is that suburbs are not necessarily affluent places. Sometimes they can be really challenging resource wise.

[00:16:14] And people move to the suburbs because the city cost is so high. But in some of those health departments, they don't have the number of staff. They may not have staff that, they haven't seen a case yet. So they've referred to us for expertise to some degree. So being like, What should we do? That was kind of often a question. We were happy to collaborate, but we had to go through each network in a specific way, depending on what health department was involved, you know. And so the Chicago Department of Public Health has I think a very sophisticated level of, of support, you know, and knowledge in these areas.

[00:16:52] When I think about the state of Illinois as a whole, it's, you know, I don't know what, I can only imagine that there are, that things do not play out that way throughout the whole state. So if you're going to utilize, if your main piece of infrastructure that you're utilizing to distribute testing or vaccines or resources or treatment are local health departments, then you're going to perpetuate the inequities that you see in local health departments because they're not all created the same. They're not all resourced the same. Some of them have staff, some of them have very part-time staff. And so you feel for people because you're on the phone with them and you've got somebody that's from their district and they're wanting to help this person. But they've also never navigated any of it. So you kind of are navigating it with them, you know. And sometimes that would take hours to be honest. And so I do think that that's one piece just for for our national health infrastructure to reflect upon. If this is if this is kind of the way you want to distribute. We saw something similar, I think with COVID in terms of distribution, which is that there was a widely varying distribution of vaccine access based on a lot of different factors. That probably is not the most efficient way to distribute. Now, looking at large pharmacy chains as partners, even when that was looked at for COVID, it didn't, from my perspective, did not realize the potential that quick enough. So it could have, in some ways, that partnership model could have gotten vaccines to every corner that the pharmacy's at in theory, but it, but it didn't, you know. It's, so, there are obviously logistic, you know, there's logistical issues there and capacity issues there, meaning pharmacies as well are also experiencing, so you notice like a lot of pharmacies, their hours are less, their staffing's less. And it, it is, I, I believe, it's really cuz of a lot of what, what our health care system's gone through and it impacts kind of all aspects of it.

[00:19:07] So I think that's something to think about, which is not every health department has resources. You're depending on that, and, you know, so our, our, our state department of public health is very very well organized and, and I think does their best. But if you're going to have to filter things through state to city to small city to village. You know, it's kind of like each of those steps requires, you know, each of those steps, things can go wrong, you know? So I don't know that I have the answer to it. I just would want to observe that this was what, I guess I believe to be kind of a repeat of what we saw with COVID, which is that resources went, didn't necessarily go where they were most needed first.

[00:19:55] Srinivas: And I, I think you're highlighting a very important point. I mean, with the geographic and equity, just thinking rural versus urban, even. We really need to make our guidelines take that into account. And after what we saw with Covid, you would hope that following guidelines would take that into account.

[00:20:12] But just looking even at the pregnancy guidelines and thinking about health care staff who might be pregnant, who are wondering if they need to take care of MPV. The guidelines there, say for each pregnant person, because we're not sure what exactly happens in pregnancy and what the risks are, that each pregnant person should consult their local infectious disease physician. And that's, once again, assuming that every rural area has an infectious disease physician. And I can tell you that most rural counties in Iowa where I'm based do not. And that creates that inequity that you're discussing right there that we need to learn from. And, while we learned a lot of things during COVID, there's still a lot of things that we're still amplifying in the way that we're repeating those practices.

[00:20:57] So I think that's such a, such a great point that you're bringing up.

[00:21:01] Houlberg: Yeah, that makes a lot of sense because also really our infectious disease specialists you know, talk about, you know, soldiering on through this. It's in, like in, in more and more demand for their expertise. You know, I think it was probably particularly challenging just having some, you know, some of my colleagues being in that category. Just the need at the hospital level, the need at our center level is you know, I, I think it was extremely stressful, particularly for infectious disease doctors because it's, you're, you're under demand, you know. But it's also like middle of the night, like lots of things. I mean, it's, it's all of those things.

[00:21:48] Yeah, I would say you're on call 24-7 in some ways. And I'm an internist by training. I, I do a lot of infectious disease like things, but, but yeah, definitely our infectious disease specialists that we work with have been real heroes with this, but, you know, it's like another, you know, another thing where you know, everyone is asking you the same questions, you know, so everyone's calling you and being like, I don't know what to do. And, what do I do with this? And is this right? Is this wrong?

[00:22:20] Srinivas: We always said before this, so I'm infectious disease. So we always said before this that there was already a scarcity, and then after COVID said it, yeah, it just widened that scarcity. So, no, it's been, it's been an interesting time. But it's, you know, it's one of those things where there's so much for us to learn and it's how do we fight the inequities within the system to make sure other health care workers feel safe and empowered to approach the unknown. And that's I think, the most important thing when we're thinking about how to repeat this in the future. So where are we now? Where are we with MPV locally where you are? Nationally? What do you see the trend being?

[00:22:58] Houlberg: Our local rates appear to be going down. So we've been able to do quite a lot of complete vaccination. So kind of over time and with a lot of the work in terms of distributing that information in the community, being able to offer the vaccines at various spaces and really having fairly good access. Eventually, when the flow started, when the vaccine started to flow, we had good, good supply. So that's, that's definitely been helpful in terms of we're not seeing the same number of cases. It looks like right now we see probably one or two a day, which I know sounds strange, but we have a little list. We have a little pop-up list where we keep a running list of everybody being assessed for or treated for MPV.

[00:23:47] And at one point it was six or seven or 10 a day, you know, and it's, it's a few. You know, so those numbers are going down in terms of people impacted, which is great news. You know, the thing that I also, you know, I had been on some calls with I would s, well, I would say the, the White House did a nice job of reaching out to community-based LGBTQ organizations to talk about this early on, to talk about what was needed, what some of the concerns were, what the White House response would be.

[00:24:19] And I think that was particularly helpful. You know, some of what we also identified there is that it's, it gets pigeonholed as a men who have sex with men situation or a sexually transmitted situation. So once you label it that way, everybody else feels like they're not at risk for anything. But I, I think that was, I felt like they had a good appreciation of the fact that what happens if this goes into the nursing homes, for example. Of course, in a nursing home environment, it meets all the criteria for something that would travel through all the people who live in a nursing home, frankly. So you could, you could do I mean you could use personal protective equipment, but the amount of care that people need in some of these settings is, is something where, if it enters that setting, you could see that that would be very dangerous. And then certainly conjugate living sites of any kind. I think in terms of correctional institutions, these are places where once it's there it's very difficult to I guess I'd say it's very difficult to protect it from moving forward.

[00:25:35] Srinivas: But there's one other thing that you were, you were talking about with the vaccines and it, it brings to mind as you're discussing the distribution and everything that's happening in your conversation, even with the White House meeting that you were discussing. At what point do we stick to the current algorithm? Because I know there was a shortage at first, and so they had to be very strict about who was going to be given these vaccines. And unfortunately, as you know, that can result in a lot of stigma and discrimination just by the labeling. But at what point do they broaden the algorithm?

[00:26:05] Houlberg: The mortality from it is quite low. The morbidity from it is, you know, it is extremely, depending on how, some people had very little, they had very few lesions and they were not completely recognizable. So they were. But yes, the time for isolation that you need to have is a significant amount of time compared to COVID. So you're really out for about a month. The other piece is that when people had a significant amount of lesions or pox, it's very obvious, you know, to other people who might be familiar with it, but that's what they're, they're experiencing.

[00:26:44] So if you are walking around, people can visually see that and that that's very stressful and stigmatizing. And, and people often could get quite, quite ill from it. I mean, we're very lucky that it's not the MPV vaccine that is I guess it says a 10% fatality rate. You know, there's some that are really, will kill. But this is far from being a little deal, you know, in the sense of what can happen, which is that people can have scarring, they can have facial scarring, they can have a lot of, the whole process is extremely and the whole process is extremely stigmatizing if you think about it, you know, for several reasons from the patient perspective. So we're having to document a lot of their lesions with photography, for example, which certainly they can refuse, but. If you think about coming into a clinic visit, you're not expecting to have, as, let's say, you're not expecting for people to take pictures of all your lesions, you know, and then they're gowned up and you know, they're kind of holding you at arm's length and other people can sort of see that that's what's going on with you based on the skin findings. And you have to arrange for how to care for yourself for like a month and you can't go to work. You know, it's like, the whole thing is, is really stigmatizing.

[00:27:58] Srinivas: Well, you have definitely opened up a world of conversations and are asking such good questions and have dropped so much knowledge while probing people to think more about these issues. So thank you so much for all of your thoughts today. Is there any last parting sentence you'd want to leave our audience with?

[00:28:18] Houlberg: I hope that nationally or locally we have the time to step back and really actually look at kind of what we've gone through and learn from it. Cuz I remember in the middle of these crisises, we often think like we're going to have this wealth of knowledge after. But then you go on and people do want to pretend like it never happened, you know, subconsciously or consciously. And it's still here. I mean, a lot of these things are still here. We haven't conquered them actually. But. But yeah, it's a, it's an amazing process and an amazing time to be a part of medicine. I say that it's really an amazing time to be a part of medicine and I feel, like, very fortunate to be able to work with the people I work with, who I respect so much, and who have put so much of their time and energy and life into it. And so I think that's, that's a great feeling to be a part of something like that. So.

[00:29:17] Srinivas: Wow. On, on that wonderful note of appreciation, I want to thank you for being a part of this conversation and, hopefully helping to create others, both locally and nationally, as you encourage people to learn and reflect and move forward to fight inequities together.

Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings and other infection control resources, visit CDC.gov/projectfirstline and AMAfirstline.org.

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Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

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