How to prevent, diagnose and treat monkeypox
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Clinicians should prepare now for the possibility of having to diagnose and treat cases of monkeypox, according to an opinion paper published in Annals of Internal Medicine.
“Physicians should be communicating [to patients] that if they have high-risk sexual contacts and have known contact with somebody who may have had monkeypox-like lesions, they should seek medical attention,” Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security and an adjunct assistant professor at the Johns Hopkins Bloomberg School of Public Health, told Healio.
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Specifically, physicians in primary care, urgent care, emergency medicine, dermatology and sexually transmitted infection (STI) clinics “may be most likely to identify new patients with monkeypox should they continue to appear,” Adalja and Tom Inglesby, MD, the director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health, wrote.
Monkeypox virus is in the same orthopoxvirus family as smallpox. The virus had not been detected outside of Africa before 2003, according to Adalja and Inglesby.
According to the Center for Infectious Disease Research and Policy, at least 226 cases of monkeypox have recently been identified in 21 countries, including the U.S., Canada and countries in Europe. The in the U.S.
“What distinguishes these cases — all of which are outside the endemic region of the virus — is that person-to-person transmission is occurring, with the majority of cases seemingly unlinked to travel from an endemic country and the appearance of multiple, as-yet unlinked clusters,” Adalja and Inglesby wrote. “This suggests that undetected chains of transmission have been occurring.”
Spread
While the CDC noted that there is a “theoretical risk” for airborne transmission of monkeypox, it is mainly spread from close contact with the skin or fluid of an infected person. In the past, the most consistent source of transmission was through contact with animals, according to Adalja and Inglesby. More recent cases seem to be congregated among men who have sex with men (MSM), and many new infections are being diagnosed at STI clinics, the authors reported.
Incubation of the virus ranges from 5 to 21 days, with a contagious risk occurring when symptoms begin. The mortality risk from infection ranges from 1% to 10%, depending on the availability of medical resources.
Diagnosis
Patients with new onset of febrile illness and rash should be evaluated for monkeypox, according to Adalja and Inglesby. The presence of lymphadenopathy is also a warning sign.
The top clues to watch out for with monkeypox are rash, fever and swollen lymph nodes. Attention should be paid to lesions as well as patients’ social histories due to the disproportionate prevalence of monkeypox among MSM, Adalja said.
Rashes usually start in the mouth before moving to the face and body “in a centrifugal pattern,” Adalja and Inglesby wrote. A PCR test of skin lesions or fluid can confirm a diagnosis. A high suspicion of infection warrants testing.
Treatment
Adalja and Inglesby reported that smallpox antivirals with poxvirus activity such as Vistide (cidofovir, Gilead Sciences), Tembexa (brincidofovir, Chimerix) and TPOXX (tecovirimat, SIGA Technologies Inc) may be used against monkeypox. No standard-of-care treatment for the virus currently exists and only anecdotal reports suggest benefit with antivirals.
“Most patients are not going to have severe enough infection to merit antiviral treatment, but it will be important to study the use of antivirals during this outbreak,” Adalja said.
Researchers behind a British retrospective observational study recently published in The Lancet Infectious Diseases evaluated the use of off-label antivirals administered to seven patients with monkeypox that were detected from 2018 to 2021. Three patients were treated with 200 mg of brincidofovir once weekly; all three patients developed elevated liver enzymes and were forced to suspend therapy. Meanwhile, one patient was treated with 200 mg of tecovirimat twice daily for 2 weeks. This patient experienced no adverse effects and had a shorter duration of viral shedding and illness.
The cohort in this study was too small to conclude any benefit or harm from antivirals for “this neglected tropical disease,” Hugh Adler, MB, BCh, BAO, MRCPI, DTM&H, of the Liverpool School of Tropical Medicine, and colleagues reported.
Overall, “the disease course of the patients ... were challenging and resource-intensive to manage, even in the high-income setting of the U.K.,” they wrote.
Prevention
The smallpox vaccine Jynneos (Bavarian Nordic) has an FDA indication for the prevention of monkeypox, and an older-generation vaccine (ACAM2000, Sanofi Pasteur Biologics Co.) may be used off-label for monkeypox, according to Adalja and Inglesby. Clinicians who administer either vaccine immediately after a suspected exposure can “abort infection or significantly attenuate it,” they wrote. For patients who cannot receive the smallpox vaccines, vaccinia immune globulin may be administered.
While researchers attempt to uncover what is driving this outbreak of monkeypox, clinicians should apply “enhanced case finding, isolation, contact tracing and postexposure vaccination,” the authors advised. Any new cases of monkeypox should be reported to a state or local health department immediately.
References:
Adalja A, Inglesby T. Ann Intern Med. 2022;doi:10.7326/M22-1581.
Adler H, et al. Lancet Infect Dis. 2022;doi:10.1016/S1473-3099(22)00228-6.
Multi-country monkeypox outbreak in non-endemic countries. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385. Published May 21, 2022. Accessed May 25, 2022.
Officials confirm 226 monkeypox cases in 21 countries. https://www.cidrap.umn.edu/news-perspective/2022/05/officials-confirm-226-monkeypox-cases-21-countries. Published May 25, 2022. Accessed May 26, 2022.
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