This digitally colorized electron microscopic (EM) image depicts monkeypox virus particles, obtained from a clinical sample associated with a 2003 prairie dog outbreak. It was a thin section image from of a human skin sample. On the left were mature, oval-shaped virus particles, and on the right were the crescents, and spherical particles of immature virions. (Photo by Cynthia S. Goldsmith, Russell Regnery and Hannah Bullock/U.S. Centers for Disease Control and Prevention)
WASHINGTON — College students are heading back to campus following more than two years of a pandemic that led many schools to empty out for full semesters and later move to hybrid schedules in a struggle to curb the spread of COVID-19.
But the attempt by colleges and universities to return to something resembling normal could be truncated by monkeypox, the virus that has steadily increased throughout the summer, challenging both the federal government and state and local public health officials.
Higher education plans for dealing with monkeypox appear opaque or nonexistent. Schools have begun sending students information about monkeypox through websites and newsletters, but large public colleges contacted by States Newsroom were unable to explain how they’ll help students isolate or keep up with their classes during the two to four weeks they’ll be contagious if they contract monkeypox.
Case counts throughout the United States began increasing after a Massachusetts man was diagnosed on May 17 and have since risen to more than 14,100 people in every state except Wyoming. The White House has declared this outbreak a national public health emergency.
American Public Health Association Executive Director Georges C. Benjamin said colleges should be preparing for the year by assuming they’ll have monkeypox cases on campus.
“My advice to universities is that, while we’re all trying to rapidly return to normal, the truth of the matter is they ought to have contingencies to provide support to students in a hybrid manner,” such as providing options for online study, he said in an interview. “Anybody who’s not making plans for that is going to find themselves deeply disappointed.”
Student health centers and health care providers that regularly treat college students should become extremely familiar with how the rashes and lesions are presenting in this monkeypox outbreak, he said.
“Rashes are high on the list of what people see in the student health centers,” Benjamin said. “The vast majority of those will be rashes for a range of other relatively benign conditions, but they want to make sure they’re really up to speed on the early phases of monkeypox.”
Preparation is key, he said. “There’s nothing to say they’ll have big outbreaks, but all schools should assume that they’re going to have somebody on their campus that has monkeypox,” Benjamin said. “The outbreak is just too widespread for that not to be the case.”
College responses vary
The virus, which is a cousin of smallpox, is characterized by a rash or lesions that can look like acne or mosquito bites. The virus can come with flu-like symptoms and painful muscle aches, though sometimes it can present with just the rash. No one in the United States has died in this monkeypox outbreak.
Unlike COVID-19, which is a respiratory virus that can spread somewhat easily from person to person, monkeypox is spread by direct physical contact with someone who has been infected. It can also spread by touching fabrics, such as bedding or towels, or surfaces an infected person has touched.
The current outbreak in the United States has spread predominantly among gay, bisexual and men who have sex with men, though cases have been diagnosed outside that population as well.
Among colleges and universities reviewed by States Newsroom, there’s no guidance about how students should address missed lectures, exams, labs, or work-study programs that might be critical for students’ financial aid. Colleges don’t offer insight on how students on academic or athletic scholarships might be affected if they miss a month of instruction, or practices due to monkeypox.
The university guidance also lacks information about how administrators will respond if several cases crop up in a dorm, or other on-campus housing.
In New Jersey, Rutgers University’s online guidance details what monkeypox is and how it spreads before telling students that “at this time, there is no need to take special precautions to avoid monkeypox unless you experience symptoms.”
Rutgers then directs students to the state health department and U.S. Centers for Disease Control and Prevention websites for more information.
A University of Maryland spokesperson shared websites run by the state health department, but said in a statement, “We don’t have any particular university’s plan. This is all general information that is provided for use by all Marylanders.”
The University of Georgia, where students are already back on campus ahead of the fall semester, says on its website the University Health Center’s “clinical staff are trained and fully prepared to identify any patient presenting with signs and symptoms consistent with monkeypox infection.”
The University of Iowa tells students who believe they have monkeypox to call the student health nurseline or seek care from their health care provider.
“Due to the length of the isolation period (2-4 weeks), students living in a residence hall will be expected to isolate off-campus until they are healed,” the website says. “In the rare event this is not possible, the University of Iowa will work with students to obtain alternative housing.”
Students at Iowa living off-campus should “take precautions to limit exposure to others living in the same household,” according to the university.
The University of Michigan’s webpage on monkeypox notes the “Public Health Response team has been closely monitoring the evolving situation with monkeypox — or MPV — and its potential impact on the U-M community.”
The University of Florida guidance, sent out this week, plainly tells students the “overwhelming majority of cases in the U.S. have been transmitted through intimate sexual contact.”
“It is important that you consider this in deciding how widely to engage in intimate activities,” it says.
A spokesperson for the University of Florida said the student health center plans to “increased promotion of health hygiene and safe sex messaging” to try to reduce spread.
Still working on plans
Rachel Mack, spokesperson for the American College Health Association, said in a statement that “many colleges are still working on their plans to prevent and manage monkeypox outbreaks.”
At the moment, she said, “there isn’t much guidance specifically for colleges and universities,” including on how to address “unique considerations” like isolating students, making academic accommodations for students who contract the virus, providing extra cleaning and administering testing.
Colleges are working to come up with the best way to communicate with students effectively, she said.
“Because currently the virus is primarily affecting gay, bisexual, and other men who have sex with men, some students may feel very fearful — or even stigmatized — while other students may mistakenly believe there is no risk to themselves,” Mack said.
Since anyone can contract monkeypox, Mack emphasized that colleges “should communicate it as a public health concern for all. However, campus communications can be tailored to different audiences to be most effective.”
Benjamin said student health centers need to understand how to access the antiviral drug Tpoxx that federal officials are using to treat monkeypox cases. At the moment, the federal government requires an “onerous” amount of paperwork to dispense the prescription medication for monkeypox patients, he said.
Universities, Benjamin said, will need to determine how they’ll isolate students who test positive and how they’ll ensure those students can keep up with their coursework.
Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health, said the current monkeypox outbreak has spread “further and wider than it ever had before” because the virus “found itself in a social/sexual network and really exploited those network effects.”
Colleges and universities, he said, should be able to keep cases at bay if they follow some best practices. That includes explaining the virus during orientation, preparing the student health center to test and get test results quickly, planning for the complicated process required to order the antiviral being used to treat monkeypox, providing a bridge between students and the health departments distributing the vaccine and having a plan in place to isolate students who test positive.
“It’s something that universities have to be proactive about because it’s likely that they’re going to have people that have cases on their campuses,” Adalja said. “And I think if they’re managed swiftly and competently, you won’t have much sustained spread.”
Mark O’Neill, press secretary for the Pennsylvania Department of Health, said in a statement that “while everyone should be aware of the presence of monkeypox, most individuals, including college students, are at low risk of contracting monkeypox as the disease does not spread easily between people.”
The CDC, he writes, “maintains that people who contract monkeypox typically have skin-to-skin contact, direct contact with body fluids, or prolonged face-to-face contact with someone who already has monkeypox.”
Those three things, however, could make up a typical Saturday night for some college students, especially if they don’t realize they have monkeypox.
Some states, though, are moving ahead on plans. Kevin Litten, spokesperson for the Louisiana Department of Health, said staff are meeting with “higher education leaders and student body presidents next week to provide an update on the monkeypox outbreak, our response and the latest guidance and a communications toolkit.”
“We see these materials as a starting point for their own education and awareness-raising efforts on campuses,” he said.
CDC Director Rochelle Walensky said this week that 98% of monkeypox cases are in men and that “among cases with known recent sexual history and gender, 93% of cases were among men who reported recent sexual contact with other men.”
Monkeypox is transmissible from the time symptoms begin through when the rash has completely disappeared and a new layer of skin has formed, a trajectory that typically lasts between two and four weeks.
That timeline, much longer than with COVID-19, could create significant problems for students, many of whom don’t have remote classes anymore and would likely miss much of their coursework.
College students also often live in crowded houses and apartments where completely avoiding contact with someone who tests positive or all the fabrics they may have touched could be especially challenging.
The federal government began the outbreak as the only entity allowed to test for monkeypox, but has since opened up testing to commercial laboratories.
Vaccine demand high
The U.S. Department of Health and Human Services began distributing the Jynneos vaccine, which requires two doses, to state health departments earlier this summer.
Guidance for who is eligible has evolved as cases have increased.
At the moment, the CDC recommends vaccination for people who are identified as a close contact of a person diagnosed with monkeypox. People who have had a sexual partner from the past two weeks test positive are eligible, as are people with multiple sexual partners in an area with monkeypox cases. Anyone whose job might expose them to monkeypox, such as a healthcare or laboratory worker, is also eligible.
But demand has far outpaced supply in many areas, leading the federal government to announce earlier this month that it would approve emergency use for injecting the vaccine just under the skin, or intradermally.
The move away from injecting the vaccine subcutaneously, below the layers of fat in the arm the way most people have experienced,, is expected to allow health care providers to get up to five doses out of each vial instead of one.
Benjamin said the United States is behind on distributing the vaccine.
“We have an inadequate number of vaccines, overall. Our pipeline is very thin,” he said, adding that “the manufacturer has already said they’re not sure they can keep up with the demand.”
Adalja was highly critical of the federal government’s response to monkeypox so far, saying “it should have been easier to get a handle on” the virus had there not been “systemic incompetence that you see in the government.”
“The federal response has been dismal from the very beginning, because what you’ve seen is a response that’s very reminiscent of the same mistakes that were made during COVID-19,” he said.
Adalja, however, is optimistic that colleges and universities have learned enough from their COVID-19 experiences as well as from meningitis outbreaks on campus to keep monkeypox from becoming widespread among students.
“I think that there’s a risk on college campuses, that there’s going to be cases and they may see some limited spread,” Adalja said. “But it’s not going to be a disruptive force in the way COVID-19 was on college campuses.”
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