CHICAGO — Monkeypox cases in some large U.S. cities appear to be declining, matching trends seen in Europe, and experts are cautiously optimistic the outbreak may have peaked in places hit hardest hit by the virus.
The World Health Organization earlier on Thursday said monkeypox cases reported globally declined 21% last week, after a month-long trend of rising infections, but noted that U.S. cases continued to rise.
Nevertheless, some U.S. experts believe cases are starting to decline based largely on immunity from prior infection and behavior changes as awareness of the disease has grown. That does not mean the disease will be contained, they cautioned.
Since late May, the United States has recorded nearly 17,000 monkeypox cases. The outbreak, which so far has reached 80 countries outside of Africa, where the virus is endemic, is largely being transmitted among gay and bisexual men.
Monkeypox, which is spread through close contact with an infected individual and the pus-filled sores common to the disease, is rarely fatal.
Rollout of Bavarian Nordic’s Jynneos vaccine has been slow because of low supplies of the shot, which is also approved to prevent smallpox. But heightened awareness of the risks and increased immunity appear to be slowing the spread.
“It’s very likely that the epidemic peaked as of last week,” said Dr. Gerardo Chowell, an infectious disease modeler at Georgia State University School of Public Health.
Chowell’s latest model, released on Thursday, forecasts a continued slowdown in new infections in the United States over the next four weeks. The declines may not be enough to extinguish the outbreak, but should bring infections to “very low levels,” he said.
The U.S. Centers for Disease Control and Prevention (CDC) did not respond to requests for comment about the apparent trend.
Dr. Celine Gounder, an infectious disease epidemiologist and an editor-at-large at Kaiser Health News, said she believes behavior change is driving down monkeypox transmission, but cautioned that “people get fatigued by behavior change” and transmission may go up again.
“I suspect behavior change will stick only until folks get two doses of the Jynneos vaccine,” she said.
For the moment, cases appear to be dropping in some large U.S. cities hardest hit by the outbreak.
New York City’s health commissioner, Dr. Ashwin Vasan, in a tweet on Thursday acknowledged the declining cases. “We are cautiously optimistic about this data, but will be closely following to ensure it is a sustained trend.”
Likewise, data tracking monkeypox infections in San Francisco and Chicago show cases starting to drop over the past few weeks.
Chicago Department of Public Health spokesman James Scalzitti said the city may be turning a corner but that more data is needed to confirm a downward trend.
There are other signs as well. According to data on the CDC’s website, the percentage of positive tests in public health and some commercial labs – an indicator of transmission rates – has fallen sharply, from 55% positive on July 16 to 24% on Wednesday.
“I think there likely has been some bending of the curve,” said Dr. Amesh Adalja, a senior scholar at Johns Hopkins Center for Health Security.
He too attributes the change to a combination of increased immunity, particularly among high-risk individuals who got infected early in the outbreak, behavior changes and increased awareness.
Howard Brown Health, a system of 10 federally-funded clinics in Chicago that has treated a third of Illinois’ monkeypox cases, has seen decreases in both the number of cases and percentage of positive tests.
“I think that reflects a true decrease in incidence,” said Laura Rusie, Howard Brown’s director of epidemiology. “It’s hard to say it’s going to stick, but it’s promising.” (Reporting by Julie Steenhuysen Editing by Caroline Humer and Bill Berkrot)
Every 22 minutes, a woman in Canada dies of a heart attack.
But the majority don’t have to, experts say, warning that more women will die unnecessarily if the medical community doesn’t tailor care to their needs.
“We have one of the best health-care systems in the world, and we’re not serving women,” said Dr. Paula Harvey, a cardiologist and head of the department of medicine at Women’s College Hospital in Toronto. “We have to do better.”
Heart disease is a top killer of women in Canada, and the push to change that is more urgent than ever. Harvey says more younger women are presenting with classic high risk factors for heart disease: high blood pressure, diabetes and obesity.
“There’s this trend to cardiovascular risk factors starting to be a problem at an earlier age, and I find that disturbing,”said Harvey.“I never used to see a woman in her 40s with high blood pressure. I’m starting to see that, and that’s going to mean that we’ll have more premature heart disease.”
Lifestyle factors play a role in the trend, but the threat itself is broader — the majority of Canadian women have at least one risk factor for cardiovascular disease. Women with diabetes and those who come from certain racial or ethnic backgrounds are at higher risk, but fluctuating hormones can wreak havoc with any woman’s heart health, especially as they enter menopause and levels of the heart-protecting hormone, estrogen, start to drop.
That transition starts when women are in their 40s and can catch many off guard, Harvey said.
“I do think that a lot of that comes from the fact that women are still not being educated, they’re not being counselled, they don’t understand the impact of our changing biology with age that puts them at cardiovascular risk.”
Heart disease kills 5 times more women than breast cancer
According to the Canadian Women’s Heart Health Centre, at the University of Ottawa Heart Institute, 24,000 Canadian women die of heart disease every year. That’s nearly five times more deaths than from breast cancer.
Yet when it comes to heart health, experts say it’s still largely a man’s world: Women remain underdiagnosed, undertreated and unaware.
“It is a glass ceiling. It’s a glass ceiling for awareness, it’s a glass ceiling for research and for how we provide care,” said Karin Humphries, an associate professor at the University of British Columbia whose has researched gender and sex differences in the diagnosis, treatment and outcomes of patients with cardiovascular disease.
The basic medical model is still male-dominated and contributes to a general lack of awareness among women and health-care providers, Humphries said. And while awareness is growing, it’s not growing fast enough, she said.
“Everything in our culture emphasizes that cardiovascular disease is a man’s disease. I mean, think of Hollywood. Every time you see a heart attack, it’s on the male, right? You’re not watching a woman in a Hollywood movie having a heart attack.”
Heart attack symptoms more subtle in women
Part of the problem is that women’s symptoms can be different than those of men and can be attributed by both doctors and women themselves to stress and busy lives. For example, months before a heart attack, women may experience unusual fatigue, trouble sleeping, indigestion and anxiety.
Even during a heart attack, the symptoms can be subtle. Women are more likely to have chest discomfort, shortness of breath and even neck, jaw or back pain.
“I was still, you know, two months after my event, still reeling from that shock,” said Risa Mallory, who had a heart attack four years ago at age 61.
Mallory had been experiencing discomfort in her chest for several days, she said, but it came and went and didn’t seem so bad — until it suddenly was.
“On the fourth day, I experienced chest pain. It had changed. It was much more severe. I was feeling nauseous and I had this sense of fight or flight,” she recalled. “I remember sitting in the car, rocking, and saying, ‘We gotta go, we gotta go, we gotta go.'”
Mallory ended up in the emergency room and got help in time. But it was a close call. Heart disease runs in her family, she was aware of her own risk, but she still almost missed the warning signs.
WATCH | Why heart disease is often missed in women:
A woman in Canada dies of heart disease every 22 minutes, and most don’t have to. CBC’s Ioanna Roumeliotis explores why so many women are underdiagnosed and what they can do to protect themselves.
“What it tells us is that there are still a lot of inequalities and biases at the community level and the health-care provider level,” said Dr. Thais Coutinho, a cardiologist and chair of the Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute.
Many women are in the dark, Coutinho said, in large part because much of the medical community is too.
Most cardiac research done with male patients
Even now, the majority of heart disease research is conducted on men — despite important physiological differences, she said. Women’s hearts and arteries are smaller, and plaque builds in different ways. Standard diagnostic tests like angiograms and stress tests are often not sensitive enough to detect heart disease in women.
“That assumption still permeates through the cardiovascular research community that women are small men,” Coutinho said. “I do a lot of sex- and gender-based research, or women-specific cardiovascular research, and it’s amazing the differences that you find if you look. All of the gaps that we know exist from awareness, diagnosis, treatment, care, rehabilitation, education, everything — it starts with knowledge.
“So if we don’t even know what the differences are, we don’t know how to manage them.”
‘There’s something wrong with my heart’
Samia Janna was 48 when she first went to her doctor in 2018 because of shortness of breath. The Ottawa-area woman was prescribed anti-anxiety medication and told to take it easy. But the symptoms persisted.
Janna went back to her doctor twice more, only to be given the same advice.
“At that time, I said, ‘No, I know it’s not anxiety,'” Janna says. “I know myself. There’s something wrong with my heart.”
Blood tests didn’t flag anything, but Janna insisted on an ultrasound to check her heart. It revealed Janna’s heart was enlarged and causing damage to her heart valves. She ended up having two open heart surgeries.
Janna says it was hard to let go of her anger about the fact that her concerns were initially dismissed. She joined a cardiac rehabilitation program and says it helped her regain her physical and emotional strength. “If it wasn’t for them. I would have been in a different place now, in a very dark place.”
Research finds women are up to 50 per cent less likely than men to attend cardiac rehab programs, often because they don’t get referred to one or face other barriers to follow-up care, including a tendency to minimize their own needs.
Harvey says research is beginning to uncover the biological, medical, and social reasons for this — and the hope is that new knowledge will lead to advances in tailoring prevention and treatment to women’s needs.
But she points out, 80 per cent of heart attacks can be prevented and women can decrease major risk factors by managing high blood pressure, not smoking and sticking to a healthy weight. Harvey says women should also urge their doctors to check their hearts.
“We need to be empowered,” she says. “Knowledge is power. Advocacy is power. And do what you can so that you are aware of cardiovascular risk.”
And though prevention is key, Humphries says women should not hesitate to get help if they feel something is wrong.
“Call 911 and ask for help. Don’t worry about, you know, taking up time for health-care providers. They’re there to help you. And if you find out there’s nothing wrong with you, that’s wonderful. But absolutely do not hesitate and call 911.”
A new study says reduced access to HIV services during early COVID-19 lockdowns in British Columbia was associated with a “sharp increase” in HIV transmission among some drug users.
The study by University of British Columbia researchers says that while reduced social interaction during the March-May 2020 lockdown worked to reduce HIV transmission, that may not have “outweighed” the increase caused by reduced access to services.
The study, published in Lancet Regional Health, found that fewer people started HIV antiretroviral therapy or undertook viral load testing under lockdown, while visits to overdose prevention services and safe consumption sites also decreased.
The overall number of new HIV diagnoses in B.C. continues a decades-long decline. But Dr. Jeffrey Joy, lead author of the report published on Friday, said he found a “surprising” spike in transmission among some drug users during lockdown.
Joy said transmission rates for such people had previously been fairly stable for about a decade.
“That’s because there’s been really good penetration of treatment and prevention services into those populations,” he said in an interview.
B.C. was a global leader in epidemic monitoring, which means the results are likely applicable elsewhere, Joy said.
“We are uniquely positioned to find these things,” he said. “The reason that I thought it was important to do this study and get it out there is (because) it’s probably happening everywhere, but other places don’t monitor their HIV epidemic in the same way that we do.”
Rachel Miller, a co-author of the report, said health authorities need to consider innovative solutions so the measures “put in place to address one health crisis don’t inadvertently exacerbate another.”
“These services are the front-line defence in the fight against HIV/AIDS. Many of them faced disruptions, closures, capacity limits and other challenges,” Miller said in a news release.
“Maintaining access and engagement with HIV services is absolutely essential to preventing regression in epidemic control and unnecessary harm.”
The Health Ministry did not immediately respond to requests for comment.
Researchers said the spike among “select groups” could be attributed to a combination of factors, including housing instability and diminished trust, increasing barriers for many people who normally receive HIV services.
British Columbia is set to become the first province in Canada to decriminalize the possession of small amounts of hard drugs in January, after receiving a temporary federal exemption in May.
Joy said this decision, alongside measures like safe supply and safe needle exchanges, will make a difference preventing similar issues in the future.
“The take-home message here is, in times of crisis and public health emergency or other crises, we need to support those really vulnerable populations more, not less,” he said.
“Minimally, we need to give them continuity and the access to their services that they depend on. Otherwise, it just leads to problems that can have long, long-term consequences.”
4:42 Health Matters: COVID-19 patients developing autoimmune diseases
One author reports receiving speaker and consultant fees from Bayer and Janssen for work unrelated to this study. Walli-Attaei and the other authors report no relevant financial disclosures.
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The magnitude of associations with major CVD for most risk factors are similar in women and men, despite sex differences in risk factor levels, according to an analysis of the PURE study.
In a comprehensive overview of the prevalence of metabolic, behavioral and psychosocial risk factors for CVD in women and men globally, researchers also found that diet was more strongly associated with CVD in women than in men. However, high concentrations of non-HDL and related lipids and symptoms of depression were more strongly associated with risk for CVD in men than in women. Patterns remained consistent across countries regardless of income level.
“Existing studies, mostly from high-income countries, have reported that hypertension, diabetes, and smoking are more strongly associated with cardiovascular disease in women than in men,” Marjan Walli-Attaei, PhD, a research fellow at the Population Health Research Institute of McMaster University and Hamilton Health Sciences, and colleagues wrote in The Lancet. “Such findings would imply that women would benefit to a greater extent in reducing cardiovascular disease risk from control of these risk factors than would men. However, the burden of cardiovascular disease is greatest in low-income and middle-income countries, for which prospective data on the association of risk factors with cardiovascular disease are sparse, with a paucity of analysis by sex.”
Walli-Attaei and colleagues analyzed data from 155,724 adults aged 35 to 70 years at baseline without a history of CVD enrolled in the PURE study, which included participants from 21 high-, middle- and low-income countries, and followed them for approximately 10 years (58% women; mean baseline age, 50 years). Researchers recorded information on participants’ metabolic, behavioral and psychosocial risk factors; all participants had at least one follow-up visit. The primary outcome was a composite of major CV events, defined as CV death, MI, stroke and HF. Researchers reported the prevalence of each risk factor in women and men, HRs and population-attributable fractions associated with major CVD.
As of the data cutoff of Sept. 13, 2021, researchers observed 4,280 major CVD events in women (age-standardized incidence rate, 5 events per 1,000 person-years) and 4,911 in men (age-standardized incidence rate, 8.2 per 1,000 person-years).
Compared with men, women presented with a more favorable CV risk profile, especially at younger ages. HRs for metabolic risk factors were similar in women and men, except for non-HDL, for which high non-HDL was associated with an HR for major CVD of 1.11 in women (95% CI, 1.01-1.21) and 1.28 in men (95% CI, 1.19-1.39; P for interaction = .0037), with a consistent pattern for higher risk among men than women with other lipid markers.
Researchers also observed that maintaining a diet with a PURE score of 4 or lower (score range, 0-8) was more strongly associated with major CVD in women than in men, with HRs of 1.17 (95% CI, 1.08-1.26) and 1.07 (95% CI, 0.99-1.15; P for interaction = .0065), respectively.
In contrast, symptoms of depression were more strongly associated with CVD in men than in women, with the HRs for symptoms of depression being higher in men than in women (P for interaction = .0002). “The HRs of other behavioral and psychosocial risk factors, as well as grip strength and household air pollution, were similar among women and men,” the researchers wrote.
The total population-attributable fractions associated with behavioral and psychosocial risk factors were greater in men than in women (15.7% vs. 8.4%) mostly due to the larger contribution of smoking to population-attributable fractions in men (10.7%) vs. women (1.3%).
“Our results emphasize the importance of a similar strategy for the prevention of cardiovascular disease in both sexes,” the researchers wrote. “However, the increased risk of cardiovascular disease in men might be substantially attenuated with better reductions in tobacco use and lipid concentrations.”
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