Monkeypox. Damn It.

Difficult answers to evolving questions. What we should and should not do at this time.

This is the first of a two post series.

Instead of writer’s block, I’ve been feeling writer’s avoidance. I’ve been reading about this outbreak of monkeypox, now a global health emergency, with a sense of reluctance and exhaustion. And so it is with a heavy heart that I present some of my thoughts and guidance in regards to what I’ve learned about monkeypox. This post is longer than most… there is just so much to consider. I’ll start with a quick review of the virus and disease. I’ll go over the efforts to contain it on a national and global scale, and why many fear it’s too late. There are ways to avoid getting monkeypox, and ways to treat severe cases. Monkeypox and coronavirus differ in important and somewhat reassuring ways, such that it is unlikely this newest outbreak will result in millions dead. And finally, in part 2, I’ll discourage learning about global health emergencies from sources like Ben Shapiro.

~Monkeypox Basics

You’ve probably learned the basics about this virus by now from many sources, so I’ll keep this part mercifully concise. Highlights from the CDC as of today include the following bullet points:

• Monkeypox is related to smallpox, but generally causes more mild syndromes, and is rarely fatal.

• The incubation period for monkeypox ranges from 5-21 days, with the CDC citing 1-2 weeks roughly between exposure and symptoms starting.

• Those symptoms may include fever, headache, muscle aches, swollen lymph nodes, chills, exhaustion, URI symptoms (like sore throat, nasal congestion, cough), and a rash.

• Severe syndromes may include secondary bacterial skin infections, gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration, and pneumonia

• The “typical” rash is proving to be quite tricky, as it can look different between cases. Most commonly we are seeing pimples or blisters that can show up on the face, inside the mouth, on hands, feet, chest, genitals, or anus. The rash can be excruciatingly painful, especially when it occurs in sensitive areas.

• The rash goes through different stages before healing completely. Monkeypox typically lasts 2-4 weeks. Symptoms usually precede the rash but not always.

• Most experts state that monkeypox is not contagious until an infected person has symptoms, or a rash.

• It can remain contagious for the entire duration of the illness, and CDC states that ideally someone infected should isolate for 2-4 weeks. They quickly concede how difficult this will be, and offer other ways to reduce transmission beyond a strict isolation period.

The above photos are of individual monkeypox lesions (image from the UK Health Security Agency). The photos below are zoomed out to show how these lesions might appear on the body.

The rash can look like shingles, chicken pox, herpes, chancroid, syphilis, and even folliculitis. Swabbing and testing are very important.

Commentary on the Basics

There are basically two types of monkeypox, and it’s fortunate that the less severe one is on the loose. It is also great that people are not thought to be contagious until they develop symptoms. Diagnosing the rash can be a problem from what I have read from infectious disease specialists posting on social media. It really can mimic a lot of other rashes, and is therefore going to cause doctors’ offices, urgent cares, emergency rooms, and labor and delivery to err on the side of caution when evaluating a rash. Some patients who are already frustrated with screening questions and protocols used to limit the spread of Covid in health care settings may have another reason to get angry. We are now asking about rashes, fevers, and potential exposures during scheduling. I am very concerned with the 2-4 week isolation period that is ideally recommended for those who are infected, and how long this disease can remain contagious. It may be our biggest Achilles’ heel.

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~Monkeypox Transmission

There is still a lot unknown about transmission. We don’t have a good sense of how easily this can spread, or what sorts of mutations are happening that have accelerated this outbreak in comparison to small prior monkeypox outbreaks. I’m going to quote the CDC:

Monkeypox spreads in different ways. The virus can spread from person-to-person through:

• direct contact with the infectious rash, scabs, or body fluids

• respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex

• touching items (such as clothing or linens) that previously touched the infectious rash or body fluids

• pregnant people can spread the virus to their fetus through the placenta

Commentary on Transmission

It could be worse; it could be a lot better. I don’t like contact modes of transmission. During the early days of Covid, we fastidiously washed our hands and wiped down groceries. And while contact precautions are still helpful in preventing Covid spread, we have learned that most transmission is via aerosols and the respiratory route. Having to tighten up our behaviors even more to avoid touching a virus that can survive on surfaces for weeks is going to be demoralizing. But so far the amount of contact does matter, and a nightmare of high contagiousness like Ebola is not occurring.

Monkeypox is not an STD per se, but close contact as in sexual activity involves many of the above means of transmission. Cases of monkeypox have been overwhelmingly occurring among men who have sex with men, but as the journal Nature stated all the way back in May: “…the most likely explanation for the virus’s spread among (men who have sex with men) groups is that the virus was coincidentally introduced into the community, and it has continued spreading there.”

One reason I worry about monkeypox spreading is this: little children. They regularly share secretions like saliva and mucous, are bad about keeping fingers out of their mouths, like to cuddle, wrestle, and horse around, and are cooped up in crowded schools and daycares for most of the day.

This version of monkeypox might be more severe in children. Previous limited experience with monkeypox has shown that children, especially under age 8, are at higher risk of severe illness. The several children in this country who have contracted monkeypox from close household contact are actually being treated with TPOXX. More about this later.

I am also concerned about pregnant women, and fetal transmission. This has been shown to cause stillbirths and fetal injury.

As spread continues (for now) mostly among one community, we might take a deep breath (but not too deep) that the monkeypox virus is unlikely to be transmitted through brief respiratory exposures. It’s not jumping out to everyone without close contact.

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~Monkeypox Containment, Vaccination, and Treatment

There is still hope that we can prevent a massive outbreak. Exhausted public health departments on the county, state, national, and global level are working overtime on contact tracing, ring vaccination of exposures, and voluntary vaccination of high risk groups with possible exposures, documented or not. The federal government has stepped up its sense of urgency lately, distributing over 300,000 vaccine doses to be used now, and is securing more vaccines (Jynneos) and treatments (TPOXX). The Biden administration is looking for an additional $7-8 billion according The Washington Post, but faces potential political resistance to spending more money. Testing capacity is also getting much more robust by the day, as major labs like Quest and Labcorp can now process samples.

Vaccines

There are two repurposed smallpox vaccines that can be used for preventing monkeypox, ACAM2000 and Jynneos. A deeper look at the details of each vaccine can be found here at CDC. Suffice it to say that Jynneos is the preferred vaccine, and the U.S. was fortunate to have 370,000 doses that it has mobilized. Another 786,000 doses should be delived by the end of the month. The federal government ordered another 2.5 million doses about a month ago from the manufacturer Bavarian Nordic, based in Denmark, with a total supply through next year of 6.9 million doses.

It is estimated that Jynneos works about 85% of the time, which is quite good for a vaccine, although clinical trials have not been completed during this outbreak. Many studies about everything monkeypox are getting off the ground or have already begun. CDC recommends that Jynneos be given within 4 days from exposure for the best chance to prevent onset of the disease. It can still be given up to 14 days after exposure, and will likely reduce severity of disease even if it does not totally prevent monkeypox.

Prior routine vaccination for smallpox, which ended in the U.S. in 1972 after eradication, probably adds some protection for older adults who got those jabs. Researchers studying 1980’s African outbreaks of monkeypox found up to 85% protection for those who had the smallpox vaccine. But the broader world, including Africa, stopped routine vaccination around 1982. Since routine smallpox vaccination has not been received by several generations since, some microbiology experts speculate Western countries, and particularly the younger generations, might be more susceptible in an epidemic. Other experts I’ve read think that older folks’ smallpox jabs were too long ago to provide any significant protection.

Treatments

There are no treatments specifically for monkeypox, but the FDA and CDC have loosened restrictions on using smallpox medications like tecovirimat, brand name TPOXX. This antiviral was developed and approved for treating smallpox, which as you know by now is a close, meaner cousin of monkeypox. The U.S. stockpiled some 1.7 million doses in case of a bioterrorism attack. TPOXX was shown to be very effective at stopping pox virus infections in animal models, and found to be safe in several hundred human subjects in terms of side effects and adverse effects. Anecdotally, I have also been reading infectious disease doctors’ stories on social media about TPOXX working phenomenally well in those patients treated. I listened to an interview on All Things Considered with an infected, suffering graduate student who reported:

Monkeypox is the worst pain I've had in my life. And especially because it was, like, an internal sort of pain, it was very - really hard to deal with… (he believes TPOXX helped him get better faster. Within two days of starting it…) I noticed that some of the pustules were actually shrinking in size, and some of them just kind of, like, disappeared back into my skin. So they didn't go through the normal progression that the lesions usually do.

There are other treatments available, but most have more side effects and other issues, so I’ll direct you to this CDC page for further reading if you want. Tecovirimat is the best treatment option we have at this time, and for the foreseeable future.

Most cases of monkeypox are not being treated right now. Many infections are running their course without becoming disfiguring, horribly painful, or life-threatening. But many do. And there are higher risk groups, just like with Covid. According to CDC, these higher risk groups should be considered and prioritized for treatment:

• People with severe monkeypox disease

• People who may be at high risk of severe disease:

  • People with immunocompromise (a large category including HIV, many cancers, organ transplant, chemotherapy and radiation, TNF inhibitors for autoimmune diseases like psoriasis, Crohn’s, and rheumatoid arthritis, high-dose corticosteroids, and more)

  • Pediatric populations, particularly patients younger than 8 years of age

  • People with a history of certain skin conditions that compromise the integrity of natural defenses (eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis, psoriasis, etc.)

  • Pregnant or breastfeeding women

  • People with one or more complications (e.g., secondary bacterial skin infection; gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; concurrent disease or other comorbidities)

• People with monkeypox virus lesions in the eyes, mouth, or other anatomical areas where monkeypox virus infection might constitute a special hazard (e.g., the genitals or anus)

Commentary on Containment, Vaccination, and Treatment

As a family doc, I am not on the front lines of treating this yet. But I have been busy educating myself and patients in the office, and perhaps readers here. I have targeted my most intense counseling towards patients with high risk behaviors. The gay male patients I have seen since this started have mostly been in monogamous relationships with average risk. Those at higher risk, because of behaviors and the present demographics of infection, have really been on board with educating themselves, proactively seeking vaccination, and supporting others.

I don’t think monkeypox will be completely eradicated from the world for a long, long time. Probably never. Monkeypox has been detected in ~80 countries so far. That number alone is terribly daunting, and undermines the notion that this problem will remain in one specific community. But it is still possible to suppress this current outbreak. Since it is transmitted primarily through physical contact, and therefore social networks, the usual tools of public health will work better than with airborne Covid.

That we have a pre-stocked vaccine this early in a public health emergency with an uncertain viral trajectory is AMAZING. I am hopeful that we can subdue and contain this outbreak. Ring vaccination and targeted vaccinations are so important right now. I am a realist, too. The cat is out of the bag now, and everyone is really tired of making sacrifices. I will be really concerned if this starts spreading in children. If we see that sort of transmission as the school year approaches, then we could be in for another pandemic sort of nightmare. I don’t expect that swimming pools will be a major factor in transmission, but it has crossed my mind. Their have been pool parties associated with this outbreak, and another poxvirus called Molluscum contagiosum has occasionally been suspected of transmission this way. But the CDC points out that other factors like pool toys or sharing a towel are more likely explanations of how molluscum could spread. I’m going to keep swimming at my local pool, because I think it is extremely low risk at this time, and the pool is one of my few remaining sources of joy.

That we have a prestocked treatment like TPOXX is also amazing. Tecovirimat is made by an American pharmaceutical company called SIGA technologies. They only sell TPOXX to governments right now, and American doctors must work with the federal government and public health distribution channels to get this medication for patients. Fortunately, restrictions have been eased in the past week to facilitate easier access to this important medication (details for healthcare providers here). The health care institution I work for has already held a virtual meeting for its providers on how to triage, coordinate, and handle this evolving potential mess. Hopefully treatment will start flowing more easily to those who need it, and we can be valuable partners with the county, state, and local departments of health in our common efforts to stop this train.

This concludes part 1 of this 2 part series. Take a deep breath and congratulations on making it through the hike so far! It was tiring for both of us, but was the view worth it? Stay tuned for the next installment.

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