L.A. County reports nation's first confirmed MPX death

Luke Money, Rong-Gong Lin II
Mon, September 12, 2022 

This image shows particles of the MPX virus (orange) found within an infected cell (brown), cultured in the laboratory. (National Institute of Allergy and Infectious Diseases / Associated Press)

A Los Angeles County resident has died from MPX — the nation's first confirmed fatality linked to the disease, public health officials said Monday.

Officials first publicly reported the death Thursday but said the precise cause was still being probed at that point. Further investigation from the county Department of Public Health and U.S. Centers for Disease Control and Prevention determined the death was from MPX, also known as monkeypox, according to a statement.

Another death — of an adult who was severely immunocompromised and had been diagnosed with MPX — was reported in Texas in late August. However, officials there have yet to definitively state whether that fatality was caused by the disease.


The L.A. County Department of Public Health noted that the local resident "was severely immunocompromised and had been hospitalized," but otherwise did not disclose any other details — such as the person's age, gender or city of residence — citing privacy concerns.

"Persons severely immunocompromised who suspect they have monkeypox are encouraged to seek medical care and treatment early and remain under the care of a provider during their illness," the department wrote in a statement.

Health officials in California recently started to use the name MPX — pronounced mpox — instead of monkeypox because of widespread concerns the older name is stigmatizing and racist. The World Health Organization is in the process of formally renaming the disease, which will take several months.

As of Friday, L.A. County health officials had reported 1,836 MPX cases. However, hospitalizations associated with the disease remain rare.

The rate of newly reported MPX cases also continues to slow. For the seven-day period that ended Thursday, L.A. County reported 187 new cases, a 30% decline from the prior week’s tally of 269.

Officials credited the slowdown in part to vaccination efforts and nationwide survey data suggesting gay and bisexual men have decreased their number of sexual partners and one-time sexual encounters in light of the outbreak.

Because MPX is not easily transmitted — it typically requires close skin-to-skin contact for an infection to occur, and is nowhere near as transmissible as the coronavirus — officials say spread of disease is likely to fade relatively quickly compared with more contagious illnesses.

MPX disease is characterized by virus-filled rashes and lesions that can look like pimples, bumps or blisters. It can appear first in the genital area and rectum before spreading to other parts of the body, and because the rashes can be mistaken for other skin issues, the virus can easily spread during intimate encounters. Risk is higher for people with multiple sexual partners.

“We likely will continue to see cases for a long time to come. But at least the current high number that we’re seeing, we are hoping to see that that will go down,” Dr. Rita Singhal, chief medical officer for the L.A. County Department of Public Health, said during a briefing Thursday.

In an advisory issued last week, county health officials noted severe MPX disease has been found in people with inadequately treated HIV, underscoring how essential it is that those at higher risk seek treatment.

"People with advanced or uncontrolled HIV are at risk of life-threatening disease. In previous outbreaks, the majority of monkeypox deaths have been reported in this population," health officials said in an advisory issued Friday.

L.A. County health officials are now specifically exhorting healthcare providers to use a drug called tecovirimat — commonly known as Tpoxx — in patients who have or are at risk of developing severe MPX disease.

A previous county advisory issued a month ago said only that "patients with lesions or pain that interfere with the activities of daily living and patients at high risk for severe disease" should be considered for treatment with Tpoxx.

There is no shortage of Tpoxx, but the drug has been difficult to get to patients, in part because it is not formally approved by the U.S. Food and Drug Administration to treat MPX.

If patients are unable to take the drug orally, Tpoxx should be administered intravenously. Other treatment options include Cidofovir, an antiviral medicine administered intravenously, and Vaccinia Immune Globulin.

U.S. officials also are reportedly considering broadening recommendations on who should get vaccinated against MPX to possibly include men with HIV or those recently diagnosed with other sexually transmitted diseases, the Associated Press reported.

Health officials said clinicians are required to report all MPX cases to the L.A. County Department of Public Health. If patients who are hospitalized have worsening symptoms, such as requiring intensive care, hospitals are asked to contact county health officials for consultation and to get access to more therapeutic options.

This story originally appeared in Los Angeles Times.

Nation's first MPX case in healthcare worker exposed on the job is reported in L.A. County

Grace Toohey
Tue, September 13, 2022 

Licensed vocational nurse Sophia Mineros, left, administers a dose of the Jynneos MPX vaccine to a person at an L.A. County vaccination site in East Los Angeles on Aug. 10. (Mario Tama / Getty Images)

The first U.S. healthcare worker to be infected with MPX while on the job has been reported in Los Angeles County, public health officials said Tuesday, the day after the county confirmed the nation's first MPX death.

"We have identified a healthcare worker with monkeypox who appears to have been exposed to the virus at their worksite," Dr. Rita Singhal, chief medical officer for the L.A. County Department of Public Health, said in a presentation to the Board of Supervisors. "This is the first case of monkeypox in a healthcare worker in the United States that has been linked to a worksite exposure."

Singhal said the county has consulted about the case with Centers for Disease Control and Prevention officials, but the risk of MPX for healthcare workers "remains very low."


Dr. Rochelle Walensky, the CDC director, told the Senate Health Committee on Wednesday that the lone reported case of an infected healthcare worker was the result of a "needle stick injury." Walensky did not specifically say she was referring to the L.A. County case.

Walensky expressed confidence that wearing personal protective equipment keeps healthcare workers protected against exposure.

The L.A. County Department of Public Health declined to answer additional questions Wednesday about whether Walensky was talking about the local case reported this week or elaborate on the healthcare worker's condition.

On Thursday, Singhal said at a news briefing that there have been about eight healthcare workers worldwide who have contracted MPX from workplace exposure, some of whom were infected because of a needle stick injury. "Locally for us here, it was not directly a needle stick injury, but it was an exposure at the work site," she said.

Spread of the MPX virus to healthcare employees from work site exposures is rare.

Before this year's outbreak, there was a single documented case of MPX transmission in Britain, in 2018, in which a healthcare assistant was infected after changing “presumably contaminated bedding” without wearing a mask or respirator. The worker came into contact with the sheets at a time when the patient had skin lesions but had not yet been diagnosed with MPX and placed under isolation, according to medical journals.

Health leaders in California recently started to use the name MPX, pronounced mpox, because of widespread concerns the virus' original name is stigmatizing and racist. The World Health Organization is in the process of formally renaming the disease, which will take several months.

MPX — unlike the coronavirus — is not easily transmitted, typically requiring close skin-to-skin contact with an infectious lesion. Cases in this outbreak have been confirmed primarily among men who have sex with men, as well as transgender people, as the virus can spread easily during sexual encounters — though not exclusively.

In L.A. County, 97% of MPX cases have been confirmed in men, and of cases for which sexual orientation is known, more than 90% have identified as gay or bisexual, according to the Department of Public Health.

While MPX case counts reached a total of 1,914 in L.A. County as of Wednesday, the number of new cases week-to-week has recently started to fall, a sign public health leaders across the nation are hopeful indicates reduced transmission and a sustained decline in cases. There are 4,453 confirmed or suspected cases across California.

But even as the rate of new cases slows, Singhal said disparities are growing among who is catching the virus and receiving the two-dose Jynneos vaccine.

In July — at the beginning of the local outbreak — white Angelenos made up more than 55% of new weekly MPX cases, according to data from the Public Health Department shared Tuesday. But by early September, Latino residents made up the largest proportion of MPX cases in the county, with about 55% of all new weekly cases. White residents' share had shrunk to about 20% of new weekly cases in early September, while Black residents’ share had almost doubled in two months, to about 10%.

Accounting for population, county officials found that Black Angelenos had the highest rate of cumulative MPX infections, at 26 cases for every 100,000 Black residents, while Latino residents and white residents had similar case rates, at 16 and 17 per 100,000, respectively.

Using the Healthy Places Index, or HPI — a measure that accounts for the overall public health level of a community, such as poverty and access to housing and education — county officials found that neighborhoods with the least resources have accounted for a larger share of the county's total MPX cases: about 70% as of early September.

"Over time, a higher proportion of cases have been in the two lowest HPI quartiles, or the least healthy communities," Singhal said. At the beginning of the outbreak, people living in communities with fewer resources for optimal public health made up roughly 30% of MPX cases, while those in communities with greater resources were initially more likely to contract the virus. But that flipped about two months later.

People of color have also disproportionately not received a vaccine against MPX, despite making up a majority of current cases, according to county data from last week. Latino residents make up 44% of MPX cases but only 32% of first-dose recipients; similarly, 12% of county cases are among Black residents, but only 9% of the administered first doses have gone to that demographic.

White Angelenos make up 40% of the county's first-dose recipients, though they account for less than 30% cases, the data show.

"To address the disparities in monkeypox case and vaccination rates among Latinx and Black populations, [the Department of] Public Health is working with community-based organizations to further define messaging and outreach for these populations," Singhal said. "We are meeting with stakeholders on a weekly basis to hear feedback from focus groups on how best to reach these populations."

Singhal also noted that only one-third of those eligible for a second dose of the MPX vaccine have received it, and she strongly encouraged people to get both shots to "optimize their immune response."

Barbara Ferrer, the county's public health director, said she is hopeful the agency's recent expansion of vaccine eligibility to include people who self-attest they may be at "risk for future exposure" will also help bring more people in for a shot.

Due to an initial shortage of doses, the county limited doses to those considered most at-risk to the virus — primarily gay and bisexual men or transgender people with certain sexually transmitted infections or multiple sexual partners — which she acknowledged could have been stigmatizing. Vaccine availability has since drastically increased, though officials are still not recommending widespread inoculations.

“We’ve changed our eligibility guidance to really make that much easier to people," Ferrer said Tuesday. “We’re trying desperately to listen to concerns residents are raising. ... We do have disproportionality; we need to pay a lot of attention to what people in our communities are saying would help reduce the barriers to getting vaccinated.”

Singhal also reported two MPX cases that have been confirmed in county jails and 81 among people experiencing homelessness, including seven in congregate housing, but she said there is "no evidence of spread in those settings." There have been six cases in children under the age of 18.

Throughout the entire outbreak, 66 people have been hospitalized for MPX, Singhal said, or about 4% of total cases. The person who recently died of MPX in L.A. County was "severely immunocompromised and had been hospitalized," Singhal said, and she urged those with MPX to seek medical care and treatment early, when possible.

Times staff writer Rong-Gong Lin II contributed to this report.

This story originally appeared in Los Angeles Times.


'I'm living from day to day': Isolating for MPX can put people out of work for weeks


Emily Alpert Reyes, Heidi Pérez-Moreno, Grace Toohey
September 12, 2022

Justin Bolding looks outside his West Hollywood apartment window where family and friends would talk to him while he suffered for three weeks with MPX. (Genaro Molina / Los Angeles Times)

When a doctor told Ivan that he needed to isolate himself and not share bedsheets to keep the MPX virus from spreading, he wondered: How?

"It would be absurd trying to isolate while sharing a bed," the Hayward, Calif., resident said in Spanish.

The 43-year-old man, who is gay, had been splitting a bedroom with a female friend to save money in the San Francisco Bay Area, where rents are steep. He was grateful when another friend offered him somewhere else to isolate, but then there was the money: Doctors warned that isolation might last weeks as his lesions healed, and Ivan was out of sick days at the grocery store where he works.


The virus racked him with pain and ultimately kept him away from work for three weeks — and that cost him almost $2,000 in income, said Ivan, who asked to go by only his first name to protect his privacy. Now rent is looming. A friend helped him cover his phone bill, but as of late August, he still needed $500 for a car payment.

"I just haven't gotten the money," he said.

The MPX virus has wreaked financial havoc for workers who have little paid time off to recover from illness. Healing from painful lesions can take weeks — much longer than the three days of sick leave that California generally requires from employers. Government guidelines aimed at stopping the spread of MPX — which is what the California Department of Public Health calls monkeypox — urge people to try to remain isolated at home.

“The best thing would be … for them to be able to stay home and to work remotely,” said Dr. Rita Singhal, chief medical officer for the Los Angeles County Department of Public Health. "But we know that that's not an option for everyone."

As the coronavirus sickened and sidelined Californians, state and local lawmakers set up programs that bolstered paid leave for people affected by COVID-19. In Los Angeles, for instance, which requires at least six days of paid sick leave annually for many employers, city officials decided to mandate additional COVID-19 leave for workers at large companies.

Across California, as of this year, some workers at bigger companies are eligible for up to 80 hours of paid leave if they are ill with COVID-19 or caring for a family member with the virus. But so far, state lawmakers have not set up similar programs specifically for MPX, despite an isolation period that can last as long as four weeks.

"No one should be forced to choose between complying with health orders and being able to feed themselves and pay their bills," said Samuel Garrett-Pate, managing director of external affairs at Equality California, which has advocated to extend more paid leave for people affected by the virus. "There's no reason that people affected by monkeypox — which requires a longer quarantine period — are any less deserving of that same relief than everyone who was affected by COVID-19."

Many California workers can also try to access payments for disability insurance — a program that can partially cover lost wages in the short term for Californians who are unable to work because of non-work-related illness — but that process can be cumbersome, Garrett-Pate said.

Restaurant worker Justin Bolding, who first realized he might have gotten the MPX virus when he felt unusually exhausted after a Sunday night shift, said he had phoned a state agency hundreds of times to get help with applying for the program.

“I’m still trying to get some money from losing three weeks of work,” Bolding, 37, said in August, shortly after he submitted a paper application.

Bolding had to isolate for weeks after the virus peppered his body with lesions from his head to the sole of his foot. One popped up on his nose, he said, which made him especially worried about protecting others from infection. Bolding counts himself as luckier than others who got infected, but he still had to dip into his savings as he went without his usual paychecks.

Even if workers can access them, "disability benefits don't pay your full salary, and folks are already living paycheck to paycheck," said Kathy Finn, secretary-treasurer for United Food and Commercial Workers Local 770, whose members include grocery and pharmacy workers.

California does require continued pay for healthcare workers who are exposed to some transmissible diseases on the job if a physician recommends they stay out of the workplace, which applies to MPX, said Stephen Knight, executive director of the nonprofit Worksafe.

But for others, "if public health requires workers to isolate for the general good ... then the public needs to compensate those workers to ensure that this is not a ticket to joblessness and homelessness," he said. "Otherwise people will not report they're sick."

Workers who need to take time off for MPX can also face stigma.

The virus has disproportionately affected gay and bisexual men and many cases have spread through intimate or sexual encounters, although health officials have emphasized that anyone can get the virus and that it can also be transmitted through other kinds of skin-to-skin contact.

“They don’t want to tell their employer they have monkeypox — it’s highly stigmatized. They don’t have any protected time off,” said Dr. Adam C. Lake, a physician who practices in Lancaster, Pa. And “even if you do, you have some explaining to do if you’re taking four weeks off.”

Marquiette, a 49-year-old construction worker, said that when he had to isolate for weeks after getting the virus, he quickly lost a job. “They were like, ‘You shouldn’t be taking off for so long,’” said the Los Angeles resident, who asked to use only his first name due to privacy concerns. “I had to tell them why I needed the time off — and that scared the company.”

Marquiette said a construction foreman quizzed him about how he got the virus. He said he didn’t know. “You have people looking at you crazy,” said the worker, who is heterosexual. “The first thing coming to their mind is something negative, and I couldn’t answer the questions that they asked me.”

As of late August, he had been out of work for almost three weeks, he said. “I don’t have gas to get around. I’m living from day to day. I’m having to go to pantries just to get food to survive right now.”

His landlord told him not to worry about being late on the rent. But Marquiette worries about when he will get hired again. Word of mouth travels in his field, he said.

“Now I’m blackballed and I can’t get hired nowhere,” he said.

Paul, 35, who works in the tech industry, said he “had the privilege of making up excuses” when he had to isolate, because he is supposed to come into the office only a few times a week.

“I kept getting asked, ‘When do you think you’ll be coming back in?’ " said the Los Angeles resident, who asked not to give his last name to protect his medical privacy. On video calls for work, he strategically chose clothing that would conceal his lesions and gritted his teeth through the pain, which he said was so severe that he was prescribed painkillers.

“If you had COVID, you could be honest about what’s going on,” said Paul, who is gay. But even though he works at an LGBTQ-friendly company, he didn’t want to tell co-workers he had MPX and feel them silently speculating about his sex life.

He had to isolate for 31 days as new lesions emerged and healed on his body. “Had I not had a job that allows flexibility,” he said, “I would have been screwed.”

The Centers for Disease Control and Prevention has stated that "ideally, people with monkeypox would remain in isolation for the duration of illness." The California Department of Public Health has warned that the virus can spread after symptoms begin and until all lesions are fully healed, with a new layer of skin having formed over the lesions.

Under state guidelines, people infected with MPX can return to the workplace after that happens and all other symptoms are gone for at least two days.

However, if their work does not involve physical contact or “settings of concern” such as schools, health facilities and homeless shelters — and virtual work is not possible — the state guidance says they can go back to work a few days after their fever or respiratory symptoms have disappeared, new lesions have stopped popping up for two days, and any lesions that cannot be covered are fully healed.

If they do so, they are still supposed to take precautions, including wearing a mask and covering any unhealed lesions with clothing or bandages.

Dr. Tomás Aragón, director of the California Department of Public Health, said that some MPX lesions may be in areas where there is no risk of exposing other people, and "we wanted to put together guidelines that are more practical for those situations." Before California set out its guidelines, many patients said they had gotten little leeway to exit isolation before all lesions had healed; some had been issued court orders to remain home.

In this global outbreak, the most common route of transmission has been "direct skin-to-skin contact with monkeypox lesions, and that's including sexual contact but not limited to that, as well as close contact with household or contaminated items," said Dr. Muntu Davis, county health officer for the L.A. County Department of Public Health. If lesions can be covered and someone doesn't have respiratory symptoms, "the risk should be much lower."

Aragón urged people to take advantage of any local programs that counties and others had already developed to support people amid the COVID-19 pandemic. Los Angeles County, for instance, is offering isolation housing in motels for people who are unhoused or have nowhere to safely isolate in their home during an MPX infection, according to its public health department.

In the Palm Springs area, C.J. Tobe said he knew of at least two people who had lost their jobs after getting the virus. DAP Health, the federally qualified health center where he serves as director of community health and sexual wellness, has delivered food to people unable to afford it and put up unhoused patients in hotel rooms as they wait out their isolation period.

"We're basically relaunching everything that we did through COVID to make sure that our patients, that our community members, are supported and safe," Tobe said.

Getting diagnosed with MPX "can and will be financially crippling for those without adequate financial support and/or paid leave," dozens of health and community groups warned in an August letter to state leaders.

They urged the governor to expand temporary eligibility under the state disability insurance program to cover workers who do not contribute to it, “in much the same way that eligibility for unemployment insurance was expanded during COVID-19.”

Gig workers, people working temporary jobs, and those who are self-employed are unlikely to be covered by the program as it stands, said Phil Curtis, director of government affairs for APLA Health, one of the groups that signed the letter.

The letter also urged state officials to consider providing financial relief for employers to extend paid leave to workers who need time off for MPX vaccination, testing or isolation.

When Juan fell ill with the virus, he decided not to use the five days of sick leave that his company provided because he knew he would need to isolate much longer. "I knew that if I took more than whatever sick days I had, then I would have to be short of that income and I could not afford that," said the Orange County resident, who asked to use only his first name to protect his privacy.

Instead, the 54-year-old worked from home. His doctor prescribed him painkillers, but Juan avoided taking them during the day, to avoid being groggy while working remotely. During video meetings, he shut off his camera so no one would see lesions on his face. When those meetings finally ended, he would soak in a tub to ease the pain.

"It was the only relief I really felt," he said.

Juan didn't lose out on income but had added expenses from getting groceries and other necessities delivered.

An MPX infection can be costly in other ways: Bolding, the restaurant worker, said he had to pay more than $300 out-of-pocket for a testing appointment, skin swabs and lab fees because he didn't have health insurance. And even after an infection wanes, some patients have been left with visible scars that can be costly to remove.

The financial and emotional burdens of isolating for weeks are one reason that some physicians have argued to expand access to Tpoxx, an investigational drug that has shown promise in sending lesions into retreat. Some researchers have also argued that isolation guidance is excessively strict if MPX is chiefly being spread through sexual contact rather than other forms of transmission, a question that has been the center of ongoing research and debate.

In Hayward, Ivan said that a clinic had helped him out with gift cards to try to soften the financial blow from having to stop working for weeks, but "the economic effect is huge."

Back at work, he wears a mask to protect himself, but also to hide the scars left over from the virus. As a newcomer to the country, Ivan has been frustrated with the ways it can fail workers who fall ill.

"They say that the United States is No. 1 in terms of resources," he said in Spanish. "But that's not true."

This story originally appeared in Los Angeles Times.