Monkeypox is a viral zoonotic disease caused by the Monkeypox virus, a member of the Orthopoxvirus genus.
In addition to transmission from animals to humans, the monkeypox virus can be transmitted from one person to person through direct skin-to-skin contact, indirect contact / fomite transmission through contaminated linen and eating utensils can also occur. Respiratory droplet transmission also can happen, but requires prolonged exposure. Monkey virus can be transmitted through close contact during sex. It is unknown at this time if the virus can be transmitted through semen or vaginal fluid. There is risk of vertical or congenital transmission, which may lead to fetal demise.
The current 2022 outbreak is the largest monkeypox outbreak ever recorded. The estimated reproductive number (Rho) for monkeypox virus is ~1.3. This disease is unlikely to be spread as easily as COVID-19 (Rho value for omicron is 8-10).
Understanding this condition can help you proceed if you believe your patient was exposed to monkeypox or needs treatment.
Diagnosing Monkeypox
If you believe your patient has monkeypox, you can do a polymerase chain reaction (PCR) test to confirm the diagnosis. Your protocol for an in-office visit and PCR test should include the following:
- Upon arrival, immediately escort the patient to a private room separate from the general waiting room.
- Ensure the patient is wearing a tight-fitting mask and has their rash covered with long sleeves and pants or dressings.
- When entering the patient’s room, providers should wear personal protective equipment (PPE), including a gown, gloves, eye protection and an N95 respirator.
- Get the patient’s complete medical and sexual history to help determine exposure and rule out the possibility of any sexually transmitted diseases.
- If monkeypox is suspected, arrange for or conduct a PCR test by swabbing the patient’s rash or lesion; also test for other diseases that present similarly (e.g., herpes, syphilis and shingles).
- If the patient does not require hospitalization and monkeypox is suspected, inform them of the suspected diagnosis and instruct them to maintain isolation precautions.
- Provide the patient with discharge instructions for isolation.
Monkeypox Symptoms
Most patients in the current outbreak have atypical symptoms compared to the classic outbreak.
The majority of cases are seen in men who have sex with men, but anyone can get monkeypox. This disease is not limited to this subgroup of the population.
The incubation period for monkeypox is typically 5 to 14 days but can last up to 21 days. Initial symptoms may include fever, headache and body aches, swollen lymph nodes, fatigue or flu like symptoms.
A rash usually presents within 1 to 3 days of initial symptom onset, often affecting the face, hands, feet, mouth and genitalia. The skin rash progresses through different phases and eventually the scabs fall off. Some people get the rash first, followed by other, flu like symptoms, while some experience only a rash. Infected individuals should isolate until the entire rash has healed and a fresh layer of skin has formed. This process usually takes 2 to 4 weeks but can take longer. A small portion of the people can have complications including proctitis, which can progress to become severe and debilitating. Lesions in certain anatomical sites, such as the anal or genitourinary tract, can lead to scaring and stricture formation with permanent sequelae.
The current 2022 outbreak is caused by the West Africa clade, which typically causes less severe disease. Historically, the mortality rate associated with this clade is less than 1%. Based on information around the world, pregnant people, children under 8 and those with immunocompromised status are at risk for severe outcomes.
Monkeypox Treatment Options
Tecovirimat (TPOXX)
Tecovirimat (TPOXX) is an antiviral medication used for the treatment of smallpox, and is now being used to treat monkeypox infection under an Expanded Access Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. It is available for children and adults as an oral capsule and IV formulation.
- Tecovirimat is indicated for patients with a positive test result (or patients for whom specimens have been submitted for testing and have a clinically compatible illness) and have:
- Severe disease that may manifest as hemorrhagic disease, sepsis, or encephalitis
- Lesions in anatomical areas at special risk of scarring or stricture, such as those near or directly involving the eye, mouth, rectum, or urethra
- Complications, such as urethritis and proctitis, particularly with tenesmus, challenges in pain control, or rectal bleeding
- High risk of severe disease such as those who are immunocompromised, pregnant, have a history or presence of atopic dermatitis or other active exfoliative skin conditions, and children
If your patient needs treatment with antivirals, please contact the Inspira Health Research Office at (856) 641-6989 or the Infectious Diseases physician on call, so that this medication can be arranged through protocol.
Information on this protocol is available at: https://www.nj.gov/health/cd/documents/topics/Monkeypox/LINCS_Tecovirimat_7_22_22.pdf
Vaccinia Immunoglobulins
Vaccinia Immunoglobulins is also an option for patients with severe symptoms, please contact Infectious Diseases for assistance with this drug. Also discuss vaccine availability with your patients to prevent disease among their contacts.
The JYNNEOS vaccine for monkeypox is available through the New Jersey Department of Health (NJDOH), but current supplies are limited. This is an attenuated non-replicating smallpox and monkeypox vaccine that elicits humoral and cellular immune responses to orthopoxviruses. This virus can not cause monkeypox or smallpox or any other disease.
Currently, the CDC recommends vaccinating close contacts and those at risk for contracting the virus, including those who have had multiple sexual partners in the last 14 days in an area with high monkeypox transmission. Vaccine eligibility requirements may change as the vaccine supply improves.
If your patient has known contact with someone who tested positive for monkeypox, or if they are at very high risk for exposure, talk to them about scheduling a vaccine appointment at one of the designated locations throughout the state.
