Monkeypox in the United States
By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The first 17 patients in the United States affected by the current monkeypox outbreak are described. Of note is the absence of reported fever in 10, and the frequent presence of lymphadenopathy, as well as of genital and perianal lesions.
SOURCE: Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox outbreak — nine states, May 2022. MMWR Morb Mortal Wkly Rep 2022; June 3. doi: http://dx.doi.org/10.15585/mmwr.mm7123e1 [Online ahead of print].
As of May 31, 2022, 17 patients with confirmed orthopox virus infection considered to be caused by the monkeypox virus had been reported from nine states. Fourteen of the 17 reported international travel to a total of 11 different countries during the 21 days preceding illness onset. All were adults, and 16 were men who have sex with men (MSM); only three were immunocompromised. Twelve had nonspecific prodromal symptoms before rash onset, which was present in all, was disseminated in all but one, and generally involved the face, trunk, and extremities; in eight patients, the rash had started in the genital or perianal area. Nine had lymphadenopathy. Of the 17 patients, 12 reported having chills, but only seven were recorded as having fever. At the time of this Centers for Disease Control and Prevention (CDC) report, all patients (one of whom received tecovirimat) were doing well.
Contacts were to be followed for 21 days, and postexposure vaccine prophylaxis was recommended for intermediate- and high-risk contacts. Examples of high-risk exposures included unprotected contact with skin or mucous membranes, lesions, or body fluids, while intermediate-risk exposures included being within six feet of an unmasked patient for more than three hours without at least a surgical mask. Patients are considered infectious “until all lesions have crusted over, those crusts have separated, and a fresh layer of healthy skin has formed under the crust.”1 Fomites also can be a source of infection.
Although of great concern, control of monkeypox transmission should be able to be accomplished with relatively straightforward measures. A person with monkeypox is considered to be infectious from the onset of illness until all lesions have crusted over, the crusts have separated, and a fresh layer of healthy skin has formed underneath the crust. Transmission from human to human occurs by direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions, typically with prolonged exposure. The CDC recommends patient isolation, use of effective hand hygiene and appropriate personal protective equipment by household members and home caregivers, and use of an appropriate Environmental Protection Agency (EPA)-approved disinfectant. Contact with pets or other animals should be avoided to prevent potential subsequent spread of the virus. Patients with symptoms who may have monkeypox should isolate and should avoid sexual activity. Of note is that a recent study identified monkeypox virus in seminal fluid of at least three of the four patients in whom this was examined.2
Currently, two vaccines are available, and these can contribute to the control of transmission. In addition to postexposure prophylaxis of intermediate- and high-risk contacts as described earlier, vaccination is recommended for individuals at risk of occupational exposure to monkeypox virus.1 These include laboratory personnel performing research on the virus, clinical laboratory personnel involved in diagnostic testing for orthopoxviruses, members of response teams, and healthcare personnel who care for patients infected with orthopoxviruses and/or administer ACAM2000 (Smallpox [Vaccinia] Vaccine, Live). The CDC indicates a preference for use of Jynneos over ACAM2000, since the former contains an engineered replication incompetent vaccinia virus, while the latter vaccinia is replication-competent and, thus, represents a potential risk.
Tecovirimat, which is approved for treatment of monkeypox, is available for treatment via a CDC Investigational New Drug (IND) application. Only one patient in this series received the drug, and no description of that experience was provided. It also is available in an expanded access program for postexposure prophylaxis of U.S. Department of Defense-affiliated personnel.3
- Rao AK, Petersen BW, Whitehill F, et al. Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for preexposure vaccination of persons at risk for occupational exposure to orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:734-742.
- Antinori A, Mazzotta V, Vita S, et al. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Eur Surveill 2022;27. doi: 10.2807/1560/07917.ES.2022.27.22.2200421.
- U.S. Army Medical Research and Development Command. NCT02080767. Tecovirimat (ST-246) treatment for orthopox virus exposure. https://clinicaltrials.gov/ct2/show/NCT02080767?cond=monkeypox&draw=2&rank=4
The first 17 patients in the United States affected by the current monkeypox outbreak are described. Of note is the absence of reported fever in 10, and the frequent presence of lymphadenopathy, as well as of genital and perianal lesions.
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