After recently hosting their 10th COVID-19 forum, ACP and Annals of Internal Medicine gave another infectious disease the spotlight at the latest virtual forum on Oct. 11.
“This is the same kind of framework but a totally different subject … that none of us anticipated talking about even a few short months ago,” said forum moderator Deborah Cotton, MD, MPH, FACP, deputy editor of Annals and professor of medicine emerita at the Boston University Chobanian and Avedisian School of Medicine.
In August, HHS declared monkeypox a public health emergency. As of Oct. 18, there were more than 27,500 cases and three related deaths in the U.S., with more than 73,500 cases globally.
During the forum, which is available for replay as a video recording on Annals' website, an expert panel provided five key takeaways about monkeypox during three clinical vignette presentations and audience polls.
1. Test for monkeypox only if skin lesions are present.
In the first clinical vignette, a sexually active but asymptomatic male patient with no skin lesions presented with concern that he might have monkeypox. He reported having sex with a man about two weeks ago and has since learned that his partner had had other sexual encounters.
Based on this information, the clinician would have to assume the patient does not have monkeypox, said panelist Roy (Trip) M. Gulick, MD, MPH, adding that it typically takes between three and 17 days for monkeypox to manifest after an exposure. To date, the FDA has issued emergency use authorization (EUA) for two polymerase chain reaction tests to detect monkeypox DNA using lesion swab specimens.
“Many of you voted to test him for monkeypox. But remember, the current tests are only valid for skin lesions, and he has no skin lesions,” Dr. Gulick said. “Some of you wanted to do an anal swab for monkeypox—that's actually not been validated for the current tests that we have.”
2. Vaccines to prevent monkeypox are available.
Currently, clinicians can use two vaccines to prevent monkeypox, JYNNEOS and ACAM2000. The former, a nonreplicating vaccine, was FDA approved in 2019 as a subcutaneous injection for the prevention of smallpox and monkeypox disease, while the latter, a replicating vaccine, is approved to help protect against smallpox and is available for use against monkeypox under an expanded access protocol. (An alternative JYNNEOS regimen involving intradermal administration may be used under an EUA.)
“The ACAM2000 vaccine … [is] associated with more side effects, so JYNNEOS is the preferred, and that's the one that's been rolled out so well nationally,” said Dr. Gulick, who is the Rochelle Belfer Professor in Medicine and chief of the division of infectious diseases at Weill Medical College of Cornell University in New York City.
In the absence of a known exposure, the patient in the first vignette would not be a candidate for postexposure prophylaxis (PEP); however, “Over 90% of people who have monkeypox cannot identify a previous partner with monkeypox,” he noted.
In such situations where monkeypox may have been transmitted but no definite case was identified, the CDC's expanded PEP approach, also called PEP++, is another potential prevention strategy, he noted. PEP++ focuses on vaccinating people at high risk for monkeypox exposure in the absence of a known exposure. “[This patient] would qualify for a vaccine under the PEP++ way of thinking,” Dr. Gulick said.
The CDC initially restricted eligibility for the JYNNEOS vaccine due to short supply but now allows local jurisdictions to liberalize eligibility criteria, Dr. Gulick said. “The good news is that much more of the vaccine is now available,” he said. “Over a million doses of vaccine are available, and more than 800,000 doses have been administered across the country.”
Dr. Gulick added that for patients who have monkeypox or who had prior infection with the virus, the current recommendation is not to receive the vaccine. “The thinking there is that people will develop immunity to monkeypox,” he said.
3. The main risk for monkeypox transmission is close physical contact with an infected person.
In the second clinical vignette, a mother asked whether using a shared laundry facility would put her college-age daughter at risk for monkeypox. More than 80% of the audience voted for the answer that using shared laundry facilities does not present high risk for transmission, especially if hot water and a dryer are used.
“I would agree with the respondents in this case. … We know that the primary method of transmission of monkeypox is close contact, primarily direct skin-to-skin contact,” said panelist and infectious diseases physician Cassandra M. Pierre, MD, MSc, an assistant professor of medicine at Boston University School of Medicine.
Monkeypox can remain stable on surfaces like linens and bedding, especially in cooler, dark environments, she noted. That's because the proteins that make up the outer envelope of the virus make it hardy in the environment, said panelist Stuart N. Isaacs, MD, an associate professor of medicine at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
But a washing machine or dryer is not the virus' ideal place to hang out, he noted. “In the laboratory, we heat specimens up to 60 °C and are able to inactivate the virus,” said Dr. Isaacs, adding that detergent is also a very good disinfectant.
Even health care workers exposed to patients with monkeypox during this outbreak appear to have low risk of acquiring it, according to a report published in the Sept. 23 MMWR. Of 313 Colorado health care workers exposed to patients with the virus, with varying use of personal protective equipment (PPE), none acquired monkeypox.
“Less than 25% were wearing appropriate PPE … which, as an associate hospital epidemiologist, I was alarmed to read,” Dr. Pierre said. “But still good to know there were no health care worker infections.”
The case raises the question of whether a sexually active 18-year-old woman should get the monkeypox vaccine, Dr. Gulick noted. “There's a lot of worried well out there right now. … The vast majority of cases—more than 95% in the country—are confined to men who have sex with men. Turns out that's true worldwide, so there's been very little spread to other populations right now.”
Because of this, the CDC advises against all sexually active people getting the monkeypox vaccine at this time. However, vaccination should be considered if the college student in the case was the partner of an individual who was at higher risk due to sleeping with both men and women, Dr. Pierre noted.
4. Treatment is available, but more research is under way.
The FDA approved tecovirimat (TPOXX) to treat smallpox in adults and children in 2018. The oral antiviral is not FDA approved to treat other orthopoxvirus infections, including monkeypox; however, it is being made available for the treatment of monkeypox disease through the CDC under an expanded access protocol.
In the third clinical vignette, a patient tested positive for monkeypox eight days ago at a local ED but declined antiviral treatment at the time because he felt well despite the single oral lesion. However, the patient now presents with a fever, several oral lesions, and about a dozen skin lesions involving his upper back, arms, and perianal region, which are painful.
More than half of the audience (54%) voted to arrange for administration of analgesics and tecovirimat, and Dr. Isaacs agreed. “The analgesia for the pain is important, as well as stool softeners for the perirectal pain because some of that could really advance and cause some bad GI issues,” he said.
Of special concern in this case are the patient's painful oral lesions, since it is recommended to administer tecovirimat with 25 g of fat to achieve target drug exposures, noted Dr. Isaacs, who is also an attending physician in infectious diseases at the Philadelphia Veterans Affairs Medical Center.
“[For] someone with oral lesions, who may not be that interested in eating the cheeseburger or a milkshake … you may be treating yourself by giving them tecovirimat pills, where they're really not absorbing it and therefore not going to get the full benefit of the drug,” he said.
In these cases, the FDA-approved IV formulation of the drug may be helpful, Dr. Isaacs said. “Certainly, if this patient turns out to be HIV positive with no CD4 counts, [he] may be a patient that should be admitted to the hospital and initiated on IV tecovirimat.”
Dr. Gulick pointed out while tecovirimat is currently recommended for patients with severe monkeypox, it's unknown how well it works in those with milder disease. The federally funded STOMP trial was recently launched to examine this and other questions.
“People should look into that to see if there's anything in your immediate neighborhood to refer patients to,” Dr. Gulick said. “We need that data because we really need to know how efficacious is it, what's the risk of resistance with this drug, … and how frequent are recurrences.” (See sidebar for more information.)
5. Don't forget to test for HIV and other sexually transmitted infections (STIs).
While being on the lookout for monkeypox, clinicians shouldn't lose sight of STIs, Dr. Isaacs said. “Monkeypox isn't the only … infection occurring during sex that these patients are at risk for, and co-infections are being frequently seen with chlamydia, gonorrhea, syphilis, herpes,” he said.
Of nearly 2,000 individuals with monkeypox in the U.S., 38% had HIV infection and 41% had an STI in the preceding year, according to a Sept. 9 MMWR report. In addition, the CDC issued a health advisory on Sept. 29 alerting clinicians that individuals with HIV-associated immunocompromise are at risk for severe manifestations of monkeypox.
That's why HIV testing is of crucial importance in this population, Dr. Isaacs said. “Some of the most serious and potential deadly outcomes, which have been very few, have been in severely immunocompromised patients,” he said.
Ultimately, talking to patients about monkeypox risk prevention presents an opportunity to talk about STI prevention, including pre-exposure prophylaxis for HIV, Dr. Pierre noted. “We want to make sure we're safeguarding the whole health of our patients as much as possible.”