I wanted to provide a monkeypox update. First, I wanted to reassure people that this seems to spread through sexual activity and prolonged contact with the droplets from vesicles or very close and prolonged exposure to respiratory droplets and saliva. Also, droplets in bedding, clothing and towels used by someone with monkeypox can also occur. The most common means of transmission in 95% of the patients is through sexual activity and hence the “vesiculopustular” lesions (like fluid filled blisters) and/or a rash occur in the genitals, anorectal lesions, and mouth lesions. The lesions are quite painful. Sometimes monkeypox may present as a single lesion and be mistaken for a Sexually Transmitted Infection (STI) such as herpes and syphilis and thus may be missed (in medical speak we say, “delay in detection.” Thus, any suspected STI should also be tested for monkeypox. Given syphilis often coexists with monkeypox, patients with monkeypox should be tested and treated for syphilis.
If symptoms are severe enough, such as for significant pain or a “superinfection” of mucosal surfaces (when a viral lesion becomes infected with bacteria), hospitalization may be required. However, most infections are “self-limiting” meaning they subside on their own.
From the Department of Health:
• If eligible, persons should especially consider getting vaccinated if they:
• Have had recent intimate contact with a partner who is showing symptoms of monkeypox, such as a rash or sores; or
• Had recent intimate contact with a partner met through an online application or social media platform (such as Grindr, Tinder, or Scruff), or at clubs, raves, sex parties, saunas or other large gatherings; or
• Have a condition that may increase their risk for severe disease (HIV or another condition that weakens your immune system, history of atopic dermatitis or eczema)
• CDC recommends the vaccine be given within 4 days of exposure in order to prevent the onset of disease. Given between 4-14 days after exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease.
• Potential vaccinees should be educated on the risks versus benefits of vaccination, as well as the potential adverse effects of the vaccine. The most common of these are redness, soreness, swelling and itching at the injection site and fatigue, headache, and muscle ache.
• People are considered fully vaccinated 2 weeks after their second shot of JYNNEOS. However, people who get vaccinated should continue to take steps to protect themselves from infection by avoiding close, skin-to-skin contact, including intimate contact, with someone who has monkeypox.
• The effectiveness of JYNNEOS against monkeypox is supported by animal studies; there is currently no data on the efficacy of JYNNEOS for PEP or pre-exposure prophylaxis (PrEP) for the current outbreak.
Monkeypox Treatment with Tecovirimat (TPOXX):
• CDC holds a non-research, expanded access Investigational New Drug (EA-IND) protocol that allows for the use of Tecovirimat for treatment of monkeypox in adults and children of all ages.
• Tecovirimat is only available through the federal Strategic National Stockpile and must be requested via the Connecticut Department of Public Health. Please email dph.monkeypox@ct.gov if you are interested in prescribing tecovirimat for your patients. Tecovirimat is being pre-positioned in the state to ensure rapid access for providers and their patients.
• Tecovirimat Treatment Considerations: For people infected with Monkeypox virus, CDC’s Guidance for Tecovirimat Use recommends treatment with TPOXX for those with:
• Severe disease, such as hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization
• Aberrant infections involving accidental implantation in eyes, mouth, or other anatomic areas where Monkeypox virus infection might constitute a special hazard (e.g., the genitals or anus)
• High risk of progression to severe disease:
• People with immunocompromising conditions (e.g., HIV/AIDS, leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient with hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component)
• Pediatric populations, particularly patients younger than 8 years of age
• Pregnant or breastfeeding women
• People with a history or presence of atopic dermatitis, people with other active exfoliative skin conditions
• People with one or more complication (e.g., secondary bacterial skin infection; gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; concurrent disease or other comorbidities)
• Any other complications not otherwise stated above (e.g., intractable pain) that a healthcare provider determines as warranting treatment
• Healthcare providers ordering TPOXX for patients should familiarize themselves with the protocol and list of required documentation.
• CDC released a Health Alert Network (HAN) earlier this week with additional updates on testing and treating patients with monkeypox.
Monkeypox Testing:
• Monkeypox testing at the State Public Health Laboratory (SPHL) no longer requires prior approval. Testing will be available on a first come, first served basis Monday through Friday with a daily cut-off time of 8AM. Specimens arriving after 8AM will be tested the next scheduled testing day; specimens received after 8AM on Friday will be tested the following Monday. To discuss urgent testing with DPH Epidemiology, call 860-509-7994 Monday-Friday 8:30-4:30, or 860-509-8000 after hours or on weekends.
• In addition to SPHL, Labcorp, Mayo Clinic, Aegis and Quest Diagnostics laboratories are now offering Monkeypox virus testing.
• Specimen submission requirements may vary by laboratory- please verify lab-specific sample and submission requirements before submission to avoid testing delays.
Monkeypox Infection Prevention:
• Healthcare Settings: A patient with suspected or confirmed monkeypox infection that requires hospitalization should be placed in a single-person room. If an aerosol generating procedure will be performed, the patient should be placed in a negative air pressure room. PPE used by HCP entering the patient’s room should include gown, gloves, eye protection, and NIOSH-approved N95 or higher-level respirator.
• Isolation at home: Healthcare Professionals should advise people with monkeypox who do not require hospitalization to isolate at home away from others until lesions have scabbed over and new skin is forming underneath. While isolation at home for the duration of illness is recommended and best for preventing further spread, that may not be possible in all situations. Prioritizing isolation and source control strategies helps prevent transmission while balancing the impact on the daily lives of people diagnosed with monkeypox.
