Monkeypox Update from Top White House Coordinator

Demetre Daskalakis

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Marianne O’Hare : Welcome to Conversations on Health Care. This week , we
welcome Dr. Demetre Daskalakis, White House Deputy
Coordinator for Monkeypox , and Director of the CDC ’s HIV
AIDS Prevention D ivision . He talk ed about efforts underway to
contai n t he monkeypox outbreak in the U . S .

Dr . Demetre Daskalakis: Whether it's a sexually transmitted disease, a sexually
transmissible disease , I think at the end of the day the advice
is the same.

Marianne O’Hare : Lori Robertson joins us from FactCheck.org , a nd w e end with a
bright idea , improving health and wellbeing in everyday lives.
Now, here are your hosts, Mark Ma s selli and Margaret Flinter.

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Mark Masselli: The Biden Administration has urged all Americans to take
monkeypox seriously . It’s a rare i nfect ious viral disease. The
U . S . has the highest number of known cases of any country
right now , and the World Health Organization has declared the
recent outbreak a public health emergency.

Margaret Flinter: And joining us today is Dr. D emetre Daskalakis , the White
House National Monkeypox Response Deputy Coordinator . He
also serves as the Director of the Division of HIV Prevention at
t he Centers for Disease Control.

Mark Masselli: Well, thank you D r. Daskalakis for joining us.

Dr. D emetre Daskalakis : Tha nk y ou so much for having me, excited to talk.

Mark Masselli: Let's start by asking you to update us on the l atest situation
with the spread, the vaccination, and treatment for
monkeypox. We understand the U . S . now has one death likely
attributed to monkey pox.

Dr. D emetre Daskalakis : So , our current case count is 18,989 cases. There is one case
that's being investigated , so they're still working to get clarity.
The individual ha d multiple medical problems , and so they're
still looking to evaluate the actual role of monkeypox in that
person's demise. And so of course, we send all of our
condolences to the family , and continue to see what the
outcome of the epidemiologic evaluation is. We continue to
work really tirelessly to increase a couple of swathes of wo rk
that are important to the monkeypox outbreak. So , the first is
vaccine. So we , through FDA emergency use authorization of
th
the vaccine that was published on August 9 , we re able to
extend the number of doses that could be extracted from a

Demetre Daskalakis

single vial of vaccine b y changing the route of administration.
So rather than subcutaneously it is an intradermal vaccine, and
we're really seeing great uptake across the country, which
means that what vaccine we do have , we're able to extend. It's
up to five doses. In real life , it's closer to four for most people.
And , also have worked really hard to increase production. And
that means both offshore at the Bavarian Nordic plant in
Denmark, but also just announced a [inaudible 00:02:4 1 ]
facility in Michigan . It is a fa cility that i n effect bottles the
vaccine so it's actually usable. So that means that we are
increasing production domesticall y, increasing production
abroad, have more vaccine flowing , as well as extending what
we've got.

Testing continues to sort of bec ome more acces sible. We're up
to 80,000 tests that can be conducted i n any week in the
United States. That compares to 6000 at the beginning of the
outbreak, so a lot of progress there. We continue to evaluate
the investigational drug T POXX or Tecovirimat. The exciting
news , that is in a few days the NIH - sponsored studies will
launch Tecovirimat while we continue to work on the
ex pa nded access. One of the sort of big news flashes is it used
to take several hours to complete the IND paperwork for
TPOXX from the perspec tive of access , now it's down to about
15 to 30 minutes per patient , so really exciting . Also , we have
pre - positioned a lot of the drug closer to people so that
everything happens much faster.

W e ’ re lastly, continuing to do the work to provide really cl ear
messaging. And that really means being frank, really focusing
on the exposures and really working very intentionally to not
generate stigma as we increase awareness of monkeypox
across the country.

Margaret Flinter: Well, there's some very goo d news t here around testing and
vaccines and treatment. And we certainly have been very
appreciative of being able to get the vaccine and to administer
it at sites in our community health center sites around
Connecticut. But , I know you've announced some p lans to
s upport large LGBTQ + events and some equity interventions to
reach communities that are at highest risk of contracting the
virus. Can you tell us a little more about these plans ? What are
you trying to accomplish? Are you trying to make up for
some thing per haps that we haven't been doing ? And maybe
share an example of how they're going to work .

Dr. D emetre Daskalakis : Great. So I'll say that we're not really making up for anything .
What we're doing is finally able to do extended work because

Demetre Daskalakis

we're n ot in a sc arcity model for vaccine anymore. And so I
think that the very first step in the equity interventions is not
one that is one of the pilots, but it's actually making sure we
have enough vaccine to be able to really work hard to get it
everywhere , in the arms it needs to get . So , bringing it closer
to people as opposed to having people try to find a vaccin e. So
that's all very exciting.

We have two different equity pilots that are happening at the
same time. The first equity pilot, I like to call t he macro pi lot,
which is large events that come up on jurisdictions that focus
on LGBTQ IA+ individuals. And so there are several examples of
events that we're looking at. So , I'll give you the short list.
We've done Charlotte Pride in North Carolina , a nd t here they
al most did 600 vaccines in folks who ’ re attending various pride
events . They actually not only focused it on pride, but focused
it on venues and events that focused on Black and brown
people , to really try to increase the reach of equity access o f
the vaccin e .

Labor Day weekend, there will be two other events . One is
going to be in New Orleans called Southern Decadence . And
they're doing just an amazing combination of events. They're
actually going to venues and small events , and again, really
fo cused on the communities who are overrepresented in the
outbreak, but underrepresented in the vaccine counts. But
also , they're doing what they're calling a Health Hub, which is
putting in testing as well as vaccination right at the mouth of
the Louis Arms trong Park , so very prominent, very central to
the event. So they actually have CDC folks on the ground as
well who are helping them. So it is a great example of all hands
on deck s trategy for these large events.

The other one is Black Pride in Atlanta , a nd that is very
specifically designed to be an equity intervention with a lot of
focus on events that are really geared to attract LGBTQ AI +
people of color. Oh, and w e also announced Oakland Pride
festival. And so that's also coming to o.

The micro version is what if you don't have an event with
50,000 people ? W hat if you have smaller ideas or big ideas or
smaller groups of people that may benefit equity ? And so the
second equity innovation pilot really focuses on providing a
supply of vaccine to jurisdicti ons to really be a little bit of a lab
to see what works best to get vaccine in people's arms. And
so , we're going to allocate for both of those 10,000 vials . It's a
pilot , and if it goes well, we'll obviously extend it. But that's
really what the strategy is to try to do a real equity

Demetre Daskalakis

intervention, which is what can we do to augment what's
happening in a jurisdiction so that we can reach people in a
way that they're not being reached by the sort of industrial
[inaudible 00:07:41] strategies for vaccine dis tribution .

Ma rk Masselli: You know, I want to pull the thread on that sort of
intervention strategy , b ecause we've seen monkeypox cases
slowing down in the United States . Vaccines and community
outreach efforts are leading to declines in New York City . We
see that wastewater sam ples in San Francisco show that the
concentration of monkeypox virus has stabilized in recent
weeks . Yet , we have students returning to college campuses
a nd that poses a risk . What's happening w ith outreach to
young people?

Dr. D emet re Daskalakis : Yeah . So , where we've had some great experience i s working
with colleges and universities, as well as K - 12 schools. So ,
some examples include special sessions that have happened
with university and college health services, as well as work
th at's happened in sort of K - 12. Included in the K - 12 w ork is a
fact sheet that focuse s on some of the most important
questions , and that's actually gone out to many jurisdictions
and to their school systems. We have created a package of
guidance that is sor t of the suite of guidance that when
brought together , really defines like what strategies ought to
be on campuses and in schools. So , for instance, university
guidance really includes congregate settings guidance but also
our safer sex guidance , lots of o utreach and clear c oncise
guidance that is availa ble to all of the universities.

Also, I think we've been really clear about messaging that
monkeypox is something that can affect anyone , but at the
end of the day, over 90% of the cases are among gay , bise xual ,
other men who ha ve sex with men, often associated with
sexual transmission. So , other ways of getting monkeypox
include other forms of skin to skin contact, touching objects
that someone with monkey pox lesions have touch ed , and also
rarely through cl ose contact of respira tory secretions, though
the skin to skin contact associated with sex is the most
common. And I think that that should give people awareness
of the disease , with also addressing some of the anxiety that
there's ways that are w a y effici ent for transmitting the vir us ,
and ways that really aren't.

Margaret Flinter: Demetre , there was really a very moving story in The New York
Times from a patient of yours , a nd he said that when he was
diagnosed , that you really tried to console him, suppor t him,
assure him that things wou ld work out. Tell us more about

Demetre Daskalakis

your experience , and what you're hearing from your
colleagues about the personal side of treating this virus. What
are patients expressing in terms of a sense of shame or stigma ,
or have we m oved down from that?

Dr. D emetre Da skalakis : Yeah . First I will start by saying that governmental public
health and government needs to be the role model in terms of
com municating in a way that is non - stigmatizing. And I will say
that I think I'm pretty pr oud of the way that we've worked
about giving information about exposures and about this virus ,
without creating documents and guidance that stigmatizes
individuals or groups. With that said, there's definitely the
experience of stigma and the pain of actu ally sort of
experiencing this inf ection. And I've heard from many, you
know, that it's (a) stigmatizing, (b) a lot of people experience
significant pain, whether that's because of the oropharyngeal
lesions , or for the genital lesions. So , it's really abou t not only
sort of treating the virus, i f folks qualify for Tecovirimat and
TPOXX , but also like addressing the sort of psychological and
pain issues that really are things that we can do to improve
how people persevere through this infection. I think we n eed
to be the leaders to make sure that we mitigate stigma and
work in ways to actually reduce stigma by actually not
propagating it through the way that we talk about this
infection.

Mark Masselli: I want to get back to the answer that you gave just a mom ent
ago about whether or not thi s monkeypox meets the
definition of a sexually transmitted disease. Indeed, most
cases, as you noted , ha ve been linked to community of men
having sex with men. Can you just clear that up, is m onkeypox
an STD?

Dr. D emetre Das kalakis : Yeah . So I thi nk that the official jury i s still out in terms of how
to define it. But I think that it's really important to
acknowledge that the most efficient mechanism of
transmission we have in this outbreak is sex , and specifically
occurring in sex between men. Now, that could be because of
the social network . I think we're still learning about this
infection. But ultimately, I think that the guidance for folks and
providers as well as for people who could potentially be
exposed to monkey p ox , remains the same. If you'r e at risk , get
vaccinated. And so I think we have pretty clear guidance on
that. And it's not just about vaccine . Since it is sexually
transmitted , there are ways to change behavior temporarily as
we get the immune wall built arou nd the population to
actu ally reduce the possibility of acquiring monkey pox.

Demetre Daskalakis

We have good data from surveys from the AMIS study , that
gay , bisexual , other men who have sex with men have changed
their behavior because of monkeypox , and they report 50%
fewe r one - time partnerships , 50% have reported not having
multiple partners , and specifically in response to monkey pox.
So I think whether it's a sexually transmitted disease, a
sexually transmissible disease, I think at the end of the day,
the advice is the s ame.

Margaret Flinter: Well Demetre, I know that you obviously are expert in HIV care
and prevention , a nd the numbers do show that a significant
number of patients with monkeypox are also HIV positive. I
wonder if you could share a little bit with us about that
connection , maybe share your thoughts on that .

Dr. D emetre Daskalakis : Thanks, Margaret, really a question near and dear to my heart
here. So I think from the perspective of HIV, we know that
there are some studies that show that individuals living w ith
HIV could have more severe disease . Generally speaking, the
stronger someone's immune system is , and the better their
HIV is managed from the perspective of viral suppression s and
being undetectable , the more they're going to approximate
someone withou t HIV in terms of the way that they manifest
their monkeypox disease . Regardless of T - cell count or viral
suppression, it's really important that people living with HIV ,
who are at risk for monkeypox , get vaccinated. And so now
with increasing vaccine supp lies, I would say that the message
is virally suppressed or not , T - cells of 500 , or T - cells of 50 , get
vaccinated because that's going to be important in protecting
you. So , I think there will be more data coming. So , I would just
watch this space closely around the issue of how people l iving
with HIV may have a different experience with monkeypox.

Mark Masselli: Y ou know, Demet re , I want to talk to you about your work
globally in terms of monkeypox. Are you having conversations
with colleagues around the g lobe ? They're certainly suffering
from the lack of vaccines, certainly in Africa . You know, this is
a disease, one of those rare diseases of public health
significance, right, really sort of missed by CDC , by others here .
We don't seem to be prepared , and I'm wondering what's your
sens e of what's happening globally with monkeypox, how well
it's be ing addressed. And I think one thing we've learned from
COVID is that these are global issues and that we really need
to solve these problems globally , not only lo cally a nd of course
locally it sounds like you are doing a great job in terms of
leadership. But talk us a little bit about your conversations that
are going on with colleagues around the globe and what we're
learning.

Demetre Daskalakis

Dr. D emetre Daskalakis : Yeah. So , the administration is really dedic ated to making sure
that we control this epidemic, this outbreak in the U . S . , and
also make sure that we're addressing issues around the world,
not only for the U . S . , because obviously if we address issues
around the world , i ntroductions become less common h ere,
but also for the sake of the other parts of the world. And so
one of , I think, a clear signal of importance is that part of the
Monkeypox response team includes a global group, so with
leaders from UNAIDS , as well as f rom the CDC . And so I think
we're actively having conversations about what support can
look like. And there's already been, I think, support from the
perspective of vaccine that's been provided . So , this is a space
to watch really carefully as we explore h ow we can best
support monke ypox interventions outside of U . S .

Margaret Flinter: Well , Demetre , I wonder if I can build on that , just ask you a
little bit about who are the people that are doing all of this
work . You talked about the big events that are go ing on in
Atlanta and in other large urban areas . You have talked about
global work . We know that we need to pay attention to all of
the states, right ? It's not just the big states . And workforce
everywhere is such an issue. Maybe just give our listeners
s ome insights into w hat is the new CDC workforce Boots on
the Ground of people who can go out into communities
around the country and educate and reassure and also deliver
vaccines, tests, whatever it is . Maybe talk a little bit about that
with us .

Dr. D eme tre Daskalakis : Sure . I'll start by saying, as someone who was a local health
official, I used to always think of myself as a CDC and HRSA
extender. So , it's like one big team. And so part of the
experience , is that we're really working with our local
juri sdictions to do the work on t he ground . And again, public
health is always a very local experience , and so really making
sure that we provide vaccine and the technical resources that
are needed for jurisdictions to do work. Also, I think I cannot
possibly be on this call without shoutin g out the community
health centers , and say that they're so critical in the work. And
we're really excited that through HRSA there's also an
allocation of vaccine that has gone to community health
centers, and that I think wi ll increase as vaccine availabi lity
increases over tim e. So , that's really great news.

Definitely, from the CDC perspective, like there are responders
on the ground. And so for instance, in New Orleans, there is a
team that's been deployed that is really h elping to sort of
orchestrate with New Orleans . It 's not a CDC takeover of New
Orleans, but it is a hand in glove interaction between state,

Demetre Daskalakis

city , and Federal , and the community health centers and the
community - based organizations that are really, really t he
boots on the ground, that ar e out reaching the communities
that we need to reach the most. So I've got to say, like having ,
coming from an experience with local jurisdiction , and then
also having conducted a lot of outbreak responses , this is
when the m agic happens when you have all of the various
components of government and community coming together.

And I think that these equity interventions are such a great
example of that, because, you know, the community asked for
us to do it , a nd then we figured out a way to do it from the
perspect ive of vaccine allocation. And then the partnership got
deeper and deeper to the point where it really feels like one
team New Orleans , one team Atlanta , one team Oakland , and
one team Charlotte. So , it's really excitin g. And I can't wait to
s ee what happens with the micro ones , the micro events
because with that I think we're going to really see (a) a lot of
effectiveness , but then also we're going to learn some great
id eas that other folks can adopt.

Mark Masselli: You know, I really like the word ‘ partnership ’ here , and in
public health there's always questions and criticisms. And as
you know, some have said CDC has not learned from its COVID
m istakes around testing as it faces monkeypox . But it sounds
like maybe you c an assure Americans th at really the brightest
minds and best strategies are in place , a nd it's really an
opportunity for partners to come together an d work
collaboratively on this.

Dr. D emetre Daskalakis : Sure. I'll start by saying that having worked on a lot of
outbreak respons es, you know, measles in New York City I was
the incident commander for COVID - 19 for about eight months
in New York City. The speed at which this is sort of moving , is
pretty astounding. But I'll also s ay for instance, testing is a
g reat example. So , within a week of the first case,
conversations were already happening with commercial labs
to move into commercialization , and within a month and a half
it started to happen. So that is actually really fast , and really
builds on the lesso ns of COVID , number one.

Th e other example is, I think, you know, the lessons that we've
learned not from COVID, but HIV. And so when you look at the
messaging and the strategies to sort of reach people, those are
hard. The re are hard learned lessons from 41 years of
experience. And w hat I say us ing my HIV hat is, it only takes
one moment to create stigma that can last for decades. And so
I think we were so intentional, and by ‘ we ’ I mean the big ‘ we ’ ,

Demetre Daskalakis

about trying to really be intentional about how not to attach
an infection to an ident ity, but really focus on how exposures
happen. So , I think there are a lot of lessons that we can pull
from everything that we do in outbreak response. But I feel
like when you look at this, it's really moving with a great
a mount of urgency. And I mean, I'm excited to be a part of it
here at the White House. I was excited to be a part of it at the
beginning. And I think that, you know, we're starting to rea p , I
think some guarded optimism , but starting to reap some of
the ben efi ts of the work that's happened .

Margaret Flinter: Well, Dr. Daskalakis Demetre, many thanks for your time in
public service , and for both your passion and compassion in
this work. And thank you to our audience for being here.
Remember, you can learn mor e about Conversations on
Health Ca re, or sign up for our email updates at
www.chcradio.com . Thanks again, Demetre.

Dr. Demetre Daskalakis: Thank you so much for having me. And thank you for being the leading edge of care in the U . S . at the Community Health
Centers. So we really rely on you to just make sure that we're cari ng for our people. So thank you .

Mark Masselli: That’s great .

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Mark Masselli: At Conversations on Health Care, we want our audience to be
tru ly in the know when it comes to th e facts about health care
reform and policy. Lori Robertson is an award - winning
journalist , and Managing Editor of FactCheck.org, a
nonpartisan consumer advocate for voters that aim to reduce
the level of deception in U . S . politics. Lori, what have you got
for us this week?

Lori Robertson: President Joe Biden signed into law the Inflation Reduction Act
on August 16 . Part of the law deals with Medicare and
prescription drugs . The law will lower at least some Medicare
benefic iaries prescription costs on Par t D , that's Medicare's
prescription drug program, and on Part B, which covers drugs
administered in a doctor's office. The law requires the Federal
government to negotiate prices for some Medicare
medications. It caps senior s ’ out - of - pocket drug cost at $2, 000
a year. It requires rebates from drug companies if their prices
increase faster than inflation. It expands eligibility for
prescription drug benefits in the Part D Low Income Subsidy
Program. It caps monthly insulin co - pays at $35. It makes
vaccines f ree with no out - of - pocket cost. Again, that's all for
Medi care, not private health plans.

Demetre Daskalakis

Republicans have focused on the price negotiation aspect , and
the pharmaceutical industry has long fought against attempts
to enact s uch a policy. Their argument is t hat the policy would
reduce the number of new drugs pharmaceutical companies
bring to market. The nonpartisan Congressional Budget Office
estimated there would be just two fewer drugs launched over
the next decade under the legislation. Seniors who spend
m ore than $2,000 a year on prescriptions , would clearly
benefit . That cap on yearly spending would launch in 2025 ,
and it could affect more than 1.4 million beneficiaries.
According to Kaiser Family Foundation e stimates , rig ht now ,
out - of - pocket cost of more than $7,050 for Part D drugs
pushes seniors into what's called the ‘ catastrophic phase ’ .
They pay 5% of their drug costs after that threshold. The
Inflation Reduction Act eliminates the 5% co - pay , benefiting
more than 1.3 million seniors . The cap on insulin co - pays also
could affect millions.

In 202 0, 3.3 million Medicare Part D enrollees used insulin .
About 400,000 Medicare beneficiaries who receive partial
benefits under the Low Income Subsidy Program , could benefit
fro m an expansion in eligibility for fu ll benefits. Experts on
health law and economics told us seniors who now can't afford
to buy needed medicines , also would benefit from the bill. The
benefits of price negotiation to seniors are more difficult to
anticipa te. The law requires the Secretary of Health and
Human Services to negotiate prices for some high cost drugs
that lack competition from generics or similar products and
that have been on the market for 9 to 13 years. 10 Part D
drugs could be negotiated in 2026 .

That's my fact check for this week. I'm Lori Robertson,
Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players , and is a project of the
Annenberg Public Policy Ce nter at the University of
Pennsylvania . If you have a fact that you’d like check ed , email
us at www.chcradio.com . We’ll have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on Health Care.

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Mark Masselli: Each week , Conver sations highlights a bright idea about how
to make wellness a part of our communities and everyday
lives. Anxiety disorders are on the rise among the nation's
youth , and experts in the field of child psychology feel t he
condition starts much earlier in chil dhood, and it's far more

Demetre Daskalakis

common than previously thought , with an estimated one in
five children being affected . But too often these so called
internalizing disorders go undiagnosed. Unlike children with
more expressi ve conditions, such as ADHD or Autism Sp ectrum
Disorder, young kids struggling with anxiety or depression just
seem like an introvert to the casual observer. University of
Vermont Child Psychologist Ellen McGinnis says the process of
diagnosis for younger children is often painstaking and can
ta ke months to confirm.

Dr. Ellen McGinnis: The whole point of it was to find an objective assessment
battery for children with Internalizing Disorders , because they
have similar things for children with Externalizing Disorders
and for autism, but not anxiety , depression, which I think are
the most overlooke d disorders in that age group.

Mark Masselli: Dr. McGinnis says the traditional method of diagnosis involves
creating scenarios that induce anxiety, and the results can be
inexact. So she teamed up with her husband and fellow
researcher, biomedical engineer Ryan McGinnis , to create a
wearable sensor that can pick up on physical cues that suggest
the presence of anxiety, using accelerometers and simple
algorithms to c o mpare normal stress responses.

Dr. Ellen M cGinnis: So , the device is called an Inertial Measurement Unit , and it's
about the size of a business card . And so we strap that to belts
on each child when they d o the mood induction task . And it
has an accelerome ter in it , and so we're able to pick up
angular velocity speed, how much the child is bending forward
and backward, and it actually picks up 100 samples per
second, so much more than the eye can see. And so we ’ re able
to see if kids with anxiety and depres sion move differently in
response to a potential threatening information , and they do.

Mark Masselli: Dr. McGinnis says that it can pick up anxiety and depression
disorder symptoms in a matter of minutes, instead of months.
Their research paper published i n the publication PLOS One ,
shows the d evice was nearly 85% accurate in making a correct
diagnosis.

Dr. Ellen McGinnis: What's really great about it is that we increase the sensitivity
compared to subjective parent reports and questionnaires that
they fill out, so we're picking up more kids who might have
go n e previously undetected .

Mark Masselli: A simple , wearable tool that can assist parents and clinicians in
determining if a child is suffering from anxiety disorder,
leading to less guesswork and more ra pid diagnosis and
treatment , n ow that 's a bright idea.

Demetre Daskalakis
[Music]
Mark Masselli: I'm Mark Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and H ealth .
[Music]
Marianne O’Hare: Conversations on Health Care is recorded in the Knowledge
and Technology Center Studios in Mid dletown, Connecticut,
and is brought to you by the Community Health Center , now
celebrating 50 years of providing quality care to the
underserved where health care is a right , not a privilege .
www.chc1.com and www.chcradio.com .
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