Monkeypox: An Overview

PracticeUpdate: Could you give an overview of monkeypox?

Dr. Temte: Monkeypox arrived in the United States in middle of May 2022, and over the ensuing months, it has grown up to over 15,000 cases. This is really of concern because this is the largest outbreak ever noted of monkeypox. And the last time we had monkeypox in the United States was all the way back in the early 2000s, when a total of 42 cases were identified. The current epidemic had exponential growth for the first eight to nine weeks, with a doubling time of every seven to eight days. The good news at this point in time is that it appears to have slowed down and is no longer doubling at quite that rate.

As of today, most of the cases have been largely within males and particularly in gay and bisexual men and men who have sex with men. That does not imply, however, that this is a gay or bisexual or disease confined simply to men who have sex with men, because we have seen many cases outside that group, as well. The common denominator is close skin-to-skin contact. And so this is where education is of the most important, or education is of utmost importance.

Signs and symptoms

There are some classical signs and symptoms of monkeypox that I can provide, but with a caveat that, in the current outbreak, we're seeing a lot of atypical presentation. The classic case of monkeypox will have an incubation period of approximately seven days. And that's during a time that a patient or an individual has been exposed, to the time that they have the first symptoms. The first symptoms tend to be very generalized and not particularly helpful, except if one has had a recent exposure. And these tend to be headache, fever, fatigue, swollen lymph nodes, sometimes muscle ache.

Usually, within a day or two of the onset of these prodromal symptoms, patients will develop characteristic rashes, which will start as a spot, progress into firm papule, then evolve into a vesicle with evolution to scabbing, and eventually the sloughing of the scab. It is during the prodromal time, and especially during the rash phase, that people are contagious. And in fact, most of the transmission occurs from bodily fluid or from direct contact with a lesion.

Once that lesion is healed, once the crust has come off, a patient is considered past the point of contagiousness, with a caveat: This has to apply to the very last lesion to scab over and be replaced by normal tissue. This entire period may take anywhere from three to four weeks. The other thing to keep in mind is the lesions can be exquisitely painful. Where this becomes a little typical is, during the current outbreak, many individuals have had fewer lesions than in a classic monkeypox. They might only have two or three, as compared to dozens to hundreds. Occasionally, the only lesions noted could be in the rectum and it makes it more difficult to diagnose. So I think it's really important for clinicians to be aware of not only classic presentation, but some of the atypical presentations, as well.

PracticeUpdate: What regions have the highest prevalence of monkeypox?

Dr. Temte: Across the globe, the highest number of cases has actually occurred in the United States. This current outbreak can be dated all the way back to 2017 in Nigeria, and continue to have chains of transmission now over five years, but really erupted this past spring in Europe. And so some of the European countries, particularly Spain, Portugal, France, Germany, have had a number of cases, but the US actually leads the world in total number. Across the globe, however, cases all appear very similar with this outbreak. And so we're just monitoring and, again, this is where having good education is very important.

Monkeypox treatments

And now we are also seeing the availability of two vaccines and one antiviral that can be effective for monkeypox. The two vaccines, if provided in the first four days after exposure, can prevent monkeypox. If provided in the first 14 days, may have some effect in reducing the symptoms, even if somebody does have monkeypox. But more importantly, this can be provided to people who are at high risk and largely prevent monkeypox. The one medication we do have is effective for treatment, if provided early in the course.

PracticeUpdate: Are there any treatment side effects that primary care physicians should be aware of?

Dr. Jackson: Well, I think the most important thing for clinicians to be aware of is that we have two options for a vaccine. One is called JYNNEOS, which is a live virus, but a replication-deficient virus, so it will not reproduce. This is a vaccine that's given in two doses, 28 days apart, and is very, very low risk. The other vaccine, ACAM2000, is a live replicating pox virus and needs to be used with caution, particularly in individuals with significant skin conditions, such as eczema or with people who are immunocompromised. So I think that's the largest. The tecovirimat, which is the antiviral, has a fairly reasonable side effect profile and is pretty well tolerated.

PracticeUpdate: What advice do you have for PCP regarding monkeypox?

Dr. Temte: Well, I think it's really important, even outside the context of monkeypox, for primary care physicians who have good relationships with their patients to early on, when establishing a new patient role, getting a detailed sexual history. And this is something that I find is deficient in many, if not most, of our practices. But these are things that can go a long ways in terms of helping us out, solve questions, help us provide the best care we can for our patients.

That being said, we have to be very open to our patients when they come in saying they think they have monkeypox or they've been exposed. And because we're seeing atypical symptoms, atypical presentations, being very, very open to providing treatment, providing testing to patients. There's a whole litany of stories out there of patients who have been turned down for testing because they didn't have classic symptoms. People been turned down for vaccination and so on.

And I think these are things that we have to be very proactive with our patients. Again, I think it's really imperative for clinicians to be up to date with information, up to date with presentation, up to date with the diagnostic approaches for monkeypox, and being up to date with the preventive and therapeutic measures we can take.

PracticeUpdate: What resources do you recommend for staying updated on monkeypox?

Dr. Temte: There are really very good services of information available on the CDC website that provide excellent photographs of monkeypox lesions provide background on symptoms, provide detailed information on appropriate samples to collect, clinically, for diagnosis, provide information on the vaccines and provide treatment, or advice on treatment. So I would have clinicians be familiar with the CDC resources. As with anything, you can always go on Google and just type in CDC monkeypox and it will take you there.

The other thing, which is really, really so very key is to communicate early and broadly. So if you think you have a case coming in, be in touch with your front desk staff, with your nursing staff, with your medical assistants and so on. These are patients that should be seen in a secure room, in isolation room, if possible. You need to use PPE. Typically, gloves and gown and an N95 mask. This is probably overkill, but it does provide that protection to the clinician and other staff who are seeing this patient. The other really key group to be in touch with is your state or local public health agency for the best information on access to vaccine, on where to send a specimen which you've collected it, and doing this in coordination with your professionals in public health is really key here.