SirBillybob

From surveillance in Africa, particularly tracking MPOX in Zaire 1980-85, albeit very rare incidence, it is well established that the attack rate is much lower among those with Smallpox vaccination, but breakthrough Monkeypox disease can occur among those with the telltale Vaccinia scarification that designates a history of Smallpox vaxx uptake. Age at infection is less relevant because that tracking occurred not as long following global Smallpox vaccination rollout cessation, in contrast to how we stratify it by age in the developed world many decades later. The incidence was too rare to meaningfully establish an association between time from vaccination and level of susceptibility. Susceptibility was mostly based on presumed animal-to-human transmission, and secondary attack rate, eg household transmission, was extremely uncommon. Now we tend to view it in terms of routine SPOX vaccination cut-off, naturally translating to the age-split variable. It follows that all that can be said is that Smallpox vaccination may offer some degree of cross-protection against today’s Monkeypox. It is viewed as an age variable although the historical evidence for partial protection, where actual infection is tracked, is not age-based.

First stab at post-exposure vaccination efficacy. It’s not randomized assignment so I assume it will follow subjects that themselves decided on MVA-BN uptake following exposure to confirmed case. Perhaps cases that emerge would then generate ongoing recruitment, ie, their contacts. https://www.clinicaltrials.gov/ct2/show/NCT05438953?term=Mva&cond=Monkeypox&draw=2&rank=1#contacts

I’m not sure why you started a new thread. Your question fits the central thread. Anyway, here’s a poster on MVA-BN (aka Jynneos USA). It seems that 2 weeks following a single dose is fine. Additionally, an article on those with Smallpox vaccination history suggests the Smallpox immunity boost of a single dose of MVA-BN after 2 weeks is similar to that of the boost 2 weeks following a 2nd dose given after the 28-day interval. https://www.bavarian-nordic.com/media/290229/astmh2019-smallpox-monkeypox.pdf

The sluggish uptake seems to be specific to Montreal, perhaps also other Canadian locations. Supply more than adequate but the target population has plateaued, in terms of seeking vaccination, relative to expected GBMSM demographics. However, about 7 weeks of availability has passed and diminished returns on urging pursuit of MVA-BN might be an eventual broad trend. Mid-morning today about 20 bored staff at the walk-in Montreal location but no takers in sight.

2nd Imvamune dose in Quebec province is not offered at this time. Even though some recipients of the 1st dose have reached or exceeded 28 days.

Re: Escort game-playing … His pit bull must have eaten the certificate.

There is very little research on Smallpox vaccination and it’s potential for protection against Monkeypox disease presentation. This should be tracked currently. I hope it is and I hope it is well organized. We need to know the relation between symptomatic Monkeypox and Smallpox vaccination history in order to estimate the latter’s effectiveness in the current context. Paradoxically, the window for determining this reduces with MVA-BN uptake, that uptake being something we want to increase as much as possible. Therefore, it would be very remiss if case documentation in the past months has neglected this key factor. Beyond lab-based immunogenicity research, what we do have is an estimate of the association between Smallpox vaccination history and susceptibility to Monkeypox disease presentation. However, it is based on very low Monkeypox incidence in Zaire in the early 1980s. Merely 91 cases over about 5 years, annual incidence of about 1 person in 16,000. Isolated cases, mostly zoonotic (jump from animal to human), little secondary human transmission. The attack rate is considerably higher among those without Smallpox vaccination. The research group’s article abstracts suggest 85% protection but the absolute effectiveness extrapolating from a secondary article of that group suggests about 97% protection, or 40-fold susceptibility to Monkeypox for those without Smallpox vaccination. I cannot access the full texts to try to understand the contradictions. However, the incidence rate is so low that the difference between 85% and 97% may be moot given the extremely broad confidence intervals expected to surround those absolute metrics, owing to the rarity of Monkeypox in that population at that time. About 11% of the cases had a history of Smallpox vaccination but I cannot determine the ratio of vaccination for the population denominators. What was most purposeful for this dated research was to assess the need for reducing Smallpox vaccination population uptake shortfall in Zaire given Smallpox virtual eradication yet the rare occurrence of Monkeypox and it’s 10% mortality in that population at the time. The duration between original Smallpox vaccination and Monkeypox incidence in that population years ago may also be generally much shorter than for the elders among us with Smallpox vaccination several decades ago, leaving questions about antibody and cell-mediated immunity durability over time, for what is now an orthopox relative of Smallpox. I would assume breakthrough infection would be possible, of unknown severity; hence, the importance of generating revised immunity utilizing MVA-BN. Personally, I would not consider a history of Smallpox vaccination as meaningfully substituting in any way for the opportunity of a MVA-BN dose. I would avoid known risks until able to access a dose followed by a few weeks of immunogenic development.

On July 11th, Toronto Public Health answered a question on Twitter regarding a 2nd Imvamune dose. It responded that only the single dose was planned. As Indicated, I will report back in two days regarding Montreal’s playbook. Other than dosing, I can say that a local Infectious Diseases physician … coincidentally he was the first to prescribe HIV PrEP to me a few years ago … is unhappy about the level of Imvamune uptake, especially as we are closing in on Montreal Pride and the International AIDS Conference hosted here. He is consulting on cases that he believes could have been prevented since vaccination has been accessible for at least 6 weeks. Additionally, 4 Simian Pox hospitalizations are reported here; two with obstructed airways, one with eye involvement, and one with myocarditis. I don’t think they are older fellows.

Here’s the thing: I was among the first getting Imvamune in Montreal, June 9th, and was instructed to return in 4 weeks for 2nd dose but I had decided there’s no rush due to childhood inoculation history. There has been nothing in the news about 2nd dose uptake here. Also, the online booking portal only references scheduling a dose, but has not stratified bookings according to 1st versus 2nd. This contrasts with COVID vaxx bookings on the same portal, where particular doses in sequence are delineated. That said, I think the lack of clarification is an oversight. My assumption is that one can pursue the 2nd dose if desired. I will swing by the walk-in location this Friday 22nd, due to another errand in the neighbourhood, and inquire. —— It appears that British Columbia has explicitly decided on the single Imvamune dose for those with Smallpox vaccination history.

Coulda told ya. I live there. But I’ve been criticized for my less than impressed perceptions. Maybe your weekend will see an improvement. I’m currently elsewhere and just completed a perfectly paced (for me) 8 full sex dates with as many different jaw-dropping muscle gods for a grand total of $USD375, some of that amount discretionary tipping. They are very forward when they zone in on you in the specific curated settings. Each had at times needed to move on to tempt other other bar customers, until I could eventually catch up to them throughout the visit duration. But I fit in every one I wanted save one or two. Fortunately, they just show up regularly, including weeknights, enabling a bypass of FOMO, and there are usually no games or delays sealing a deal. I reside in the wrong city.

Marge?!

Yes the primary MVA-BN vaccination schedule is two doses. There are no efficacy data, only safety and immunogenicity data. The correlation between antibody titre thresholds and true immunity is unknown. True immunity is not guaranteed. The second dose is predicated on the observation of a boost in antibody titres, a kind of ‘better safer than sorry’ mindset. This boost in antibody titres can apparently occur with a delay in the second dose application. All of this needs to be considered in the context of supply and demand against the backdrop of incidence metrics. Those with a smallpox vaccination history demonstrate similar geometric mean antibody titre values irrespective of one or two MVA-BN doses in the present scenario, established in research prior to the emergence of the current outbreak. That is the basis of exercising discretion in terms of a second dose a month following the first. This level of discretion may be less applicable to special populations, eg, immunosuppressed.

It is so simple for GBMSM to access a dose of MVA-BN in Montreal that if anyone is denied, deemed ineligible, what have you, then they must have somehow self-sabotaged.

Again … Scroll back in the thread to June 13th, and to June 16th. I took medium pains to research and grasp the nuances: many would not be in need of a second MVA-BN dose. I won’t pursue a follow-up dose myself, even if there is flexibility in operationalizing a second dose option (ie, if a second dose is considered to superfluous and/or harmless; such rollout does not erode supply status, etc). If ambitious, read and interpret yourself the guidance that I linked.

Details sometimes get buried as threads get longer, but I posted here in this thread, on June 16th, that anybody, Québecois or not, Canadian or not, could get Imvamune in the walk-in Gay Village vaccination clinic in Montreal. Since then, booking-based clinics have emerged throughout the city and the walk-in clinic has the online bookability as well (though no real point as walk-in option is easy). Again, the product is MVA-BN … trade name Jynneos USA, Imvamune Canada, Imnavex EU, in case visitors wonder why their certificate is labelled Imvamune when accessed in Canada.

Quebec is unique. Latency age children or bullfrogs can manage strip clubs. Hence, the name Taboo a play on this dynamic. Seriously, though, it might lead to improvement.

UK’s latest public health technical briefing puts doubling time at 2 weeks, with a high degree of modelling confidence, majority of cases in England and about 75% of those London. 1,500 cases early July from one-quarter-ish that count early June does not portend a “losing battle” UNLESS growth is expected at the rates heretofore observed. Early low cumulative numbers appear as minor skirmishes. Month to month, though not necessarily a linear trajectory, unchecked transmission would yield 6,000; 24,000; 96,000 by early October, with likely incursions from GBMSM subgroup predominance into the broader community. If merely half of cases miss ascertainment, that early October amended figure suggests roughly 200,000 infections by that point. Granted, a levelling off could occur as it is unlikely that a few hundred thousand men fit the epidemiological profile worked up to date, but it remains to be seen what secondary transmission patterns will emerge with higher case accumulation. Anyway, that is but one fairly circumscribed geographic location and illustrative of spread potential. Bavarian Nordic closed its facilities, not long before the current orthopox infection pattern, for a few months to upgrade, reno, etc. Labelling epidemiological warning bells and associated language descriptors/analogies as premature hysteria is misguided. The tone, if in fact worried alertness, of personal and collective response will have been unwarranted IF spread ceases. Only then would a current finger-pointing of hyped reactivity prove to be retrospectively on the mark. Absolute incidence measurement is not alone the key marker of situation gravity. ‘Exponentiality’ is a tricky phenomenon and cares little about where anyone sits on a continuum from overreaction to denialism.

In Montreal I received a paper record, the standard, but the nurse accommodated my request to add, stamp, and sign the same info in my immunization booklet. I think you just ran up against policy rigidity, problem-solving paralysis in the face of nuance.

If there could just be a course correction and stop avoiding that the incidence pattern is largely confined to the MSM community and that is where the metrics mostly apply as well as how to conceptualize management. As such, the crudely equivalent rolling Canadian incidence within this population subset is consistent with the average rolling incidence of SARS-CoV-2 in Canada for the first 6 months for the broader general population Mar-Sept2020. Morbidity/mortality and speed of cumulative case incidence comparisons aside, there would have been hell to pay had there been dawdling in the serious pursuit of a viable and accessible vaccine for COVID at that time.

You are conflating higher risk in terms of susceptibility, by virtue of subgroup membership, with susceptibility according to a gradient of behavioural risk. However, low level physical contact is itself a risk factor. Smallpox vaccination historically was never predicated on a hierarchy of promiscuity, for want of a better term. If you are proposing both relative celibacy, not a terrible idea in scientific principle as far as breaking transmission cycles, and dissociating from others that pose secondary transmission potential (as if we have the capacity to be assortative in this way) then we are getting into the realm of the absurd in terms of containment. AFAIK many MSM pursuing MVA-BN are not substituting protective inoculation for the prevention conferred by harm reduction, the latter itself an obvious no-brainer strategy for attenuating the prospects of catching this virus, as you correctly identify.

I hear you. I don’t entirely disagree about the hyperbole of reality descriptors. Sadly, such terms may be applicable to fellows less rational than you. However, you can always on your own time investigate the science regarding transmission reproduction metrics and how these point to lack of containment even amongst non-index cases (ie, not high risk settings). It’s a slow burn that merits close surveillance and not dilly-dallying regarding prophylaxis. In a perfect world the prevention solution would be largely behavioural. A huge proportion of the population is non-immune viz orthopox viruses and cannot rely on behavioural containment.

You are missing a key fact about transmission and not decoupling it from, say, SARS-CoV-2 that targets indiscriminately. Cases are TRACEABLE to these high risk MSM settings, meaning that secondary transmission to contacts outside of these settings, in completely non-sexual contexts, accounts for a subset of new case incidence, essentially moving progressively more towards indiscriminate selection. You must have missed the post about the Chicago physician serving predominantly the gay male community. It is true, though, that the ‘circuit-breaker’ of transmission is most aptly situated in the high-risk settings. Additionally, the per capita incidence denominator makes it seem that incidence potential is negligible. The more appropriate incidence denominator is a small proportion of the general population. I arbitrarily set it at 1% of the gen pop, but specific to Canada rolling incidence count. Given contagion period, not adjusting for ascertainment bias of undercount that perhaps should be incorporated into a risk algorithm, the probability of minimally one case of Simian Pox in a high-risk cluster of 25 men is about 2%; in a cluster of 100 men about 7%. The metric changes if one stratifies the high-risk subset as a different percentage.

About a dozen cases reported to date. You cannot access MVA-BN there.

I drew a green circle representing the distance to Papineau Metro and Taboo. The inner blue circle is the distance to Beaudry Metro. A very popular restaurant in the city’s top-rated guides, Le Mousso, is at or near the blue circle, Ontario St. O-Thym near the hotel is not in Time Out’s top 50 but is fairly good. Many top restaurants reside within or very close to the area within the green circle, for me no more than 10-15 minute walk equivalency. If you would be fine walking a distance no greater than Papineau you would be within striking distance of a few great spots to dine. But you cannot just show up and you may need to book on an app such as Open Table. Singles do not fare well on busy nights in fine dining. You might want to seek a place, in that event, with bar seating that doubles as place setting. Le Bouillon Bilk is one such option, again, walkable right by St-Laurent Metro. Tiradito is outside the green circle but not by much; very good well-rated Japanese-Peruvian fusion and ample feeding at their bar if no table. This is not so much for you as it is for those less familiar. You yourself are able to find choice establishments while eye-candy drips off your arm. LOL

* in case seekers are coming to Montreal be aware the vaccination sites close early on 24 June and 1 July, 15:30