Monkeypox: What Healthcare Workers Need To Know
By Zack Janiel
Monkeypox has become a global outbreak after several cases were identified outside countries where the disease is endemic. The number of confirmed monkeypox cases is skyrocketing across the United States and worldwide.
As we recover from the recent COVID-19 pandemic, many people wonder if this new outbreak will cause lockdowns and bring the same havoc as COVID-19.
To fully understand monkeypox, the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have provided important information about the current situation.
This article covers information that can help you understand monkeypox, like how it started, what kind of virus it is, the signs and symptoms, and what monkeypox vaccines are available.
What’s in the Article?
What Is Monkeypox?
When Did Monkeypox Start?
What Is A Monkeypox Virus?
What Is The Difference Between Monkeypox and Smallpox?
How Does Monkeypox Spread?
What Are The Signs And Symptoms Of Monkeypox?
How Is A Monkeypox Diagnosis Confirmed?
What Is Monkeypox?
How Is Monkeypox Treated?
What Are The Available Monkeypox Vaccines?
Final Thoughts
What Is Monkeypox?
Monkeypox is an infectious disease caused by the monkeypox virus. This virus is similar to the variola virus that causes smallpox. Monkeypox is a zoonotic disease that first appeared in monkeys in 1958, but experts are still conducting studies to trace its natural source. Several animal species, such as squirrels, hedgehogs, and prairie dogs, are also susceptible to this disease.
Monkeypox virus spreads through close contact with infected people, animals, and contaminated materials. This pox-like disease causes itchy skin rashes that look like blisters. The monkeypox incubation period is typically three to 17 days, and the infection usually lasts for two to four weeks. Monkeypox vaccines are now widely used to prevent the disease.
When Did Monkeypox Start?
The first human transmission happened in the Democratic Republic of the Congo in 1970. Since then, monkeypox cases have been identified in several African countries. Monkeypox has become endemic in Western and Central African countries such as Cameroon, the Republic of the Congo, and Nigeria.
In 2003, the first human monkeypox outside Africa was confirmed. Six U.S. states reported a total of 47 confirmed and probable cases who had contact with infected pet prairie dogs. The imported animals from Ghana were said to be the source of the monkeypox virus. After the importation, they were housed near prairie dogs that were sold as pets.
In July 2021, a human case of monkeypox was confirmed in Texas, and the patient had a recent travel history from Nigeria. Health officials monitored 200 people for possible exposure, but no additional cases were identified. In November 2021, another travel-related case was confirmed in Maryland in a patient who recently returned from Nigeria.
The 2022 monkeypox outbreak first began in the United Kingdom. In May 2022, the first case was detected in a person with a recent travel history from Nigeria. Since then, patients have been identified in countries where monkeypox is not endemic. In the U.S., the first case of monkeypox was confirmed in Massachusetts. Currently, there are more than 17,000 monkeypox cases in the country.
What Is A Monkeypox Virus?
The monkeypox virus is an enveloped double-stranded DNA that belongs to the Orthopoxvirus genus. Both smallpox and monkeypox viruses are members of the same virus family called Poxviridae.
The monkeypox virus has two distinct genetic clades. These are the West African clade and the Central African clade, also called Congo Basin, which is said to be more severe and contagious. So far, these two clades have been found only in Cameroon.
According to CDC, poxviruses like monkeypox live on surfaces. They can survive longer in porous materials like clothes than in non-porous ones like glasses and metals. Poxviruses also live in dry places with low temperatures.
What Is The Difference Between Monkeypox and Smallpox?
Monkeypox has similar symptoms to smallpox, but it is less severe. Since these viruses are related, the smallpox vaccine can be used to prevent monkeypox.
Both viruses can spread from person to person, but smallpox is highly contagious. Patients can experience similar symptoms like headache, fever, skin rashes, and other flu-like symptoms. However, swelling of lymph nodes is distinct in monkeypox.
How Does Monkeypox Spread?
Monkeypox can be transmitted through close contact with infected individuals, specifically those with a monkeypox rash. Close contact can mean face-to-face contact (such as talking or breathing close to a symptomatic patient), skin-to-skin contact (such as touching or vaginal or anal sex), mouth-to-mouth contact (such as kissing), or mouth-to-skin contact (such as oral sex or kissing the skin).
Monkeypox can also be indirectly transmitted through fomite transmission when a person touches contaminated surfaces (such as clothing or electronics) and then touches their eyes, nose, or mouth. Congenital monkeypox can also occur when the virus spreads via the placenta of a pregnant person. Monkeypox can also be transmitted during or after birth through skin-to-skin contact.
Monkeypox transmission via aerosols is still uncertain, but studies are currently underway to determine if monkeypox spreads in the air. Scientists are also still researching if an asymptomatic patient can spread the virus.
Though there are elevated cases of monkeypox among gays, bisexuals, and other men who have sex with men, there is currently no evidence that monkeypox is a sexually transmitted disease. Scientists are still determining whether monkeypox spreads through semen or vaginal fluids. However, since prolonged close contact is maintained during sexual activity, a person having sex with an infected person with an active rash raises their risk of contracting monkeypox.
People with close contact with infected people or animals prone to infection are considered high risk. Children, infants, and people with weak immune systems are also susceptible to the disease and may experience severe symptoms.
What Are The Signs And Symptoms Of Monkeypox?
The most common symptoms of monkeypox are fever, severe headache, lymphadenopathy, exhaustion, backaches, and muscle aches. These symptoms are usually followed by or accompanied by skin rashes that last two to three weeks. While some patients experience flu-like symptoms at the start of the infection, not all cases present these symptoms. Some develop flu-like symptoms after they develop skin rashes, and others do not present with flu-like symptoms at all.
Skin rashes may appear on the face, hands, feet, genitals, anus, and oral mucous membranes. They can also be present on conjunctivae and cornea. Patients usually described them as painful and itchy. While many photos of monkeypox show patients with numerous rashes on their hands and feet, the number of sores in monkeypox cases can range from only one to several thousand.
Sores on the skin begin as flat lesions called macules. They will then become raised (papular phase), fill with clear fluid (vesicular stage), and become pustular before they crust over and dry up (scabbing). The crusted sores usually fall off, with a new layer of skin forming underneath it. Once all scabs have fallen off, the infected person is no longer contagious.
The incubation period of monkeypox is typically 3-17 days, where the person may feel fine and show no symptoms. Monkeypox is generally self-limiting, and patients can recover within two to four weeks.
How Is A Monkeypox Diagnosis Confirmed?
Monkeypox is confirmed through a PCR test that detects monkeypox virus DNA in lesion specimens.
Skin rash diseases, such as chickenpox, measles, allergies, and scabies, must be considered in a clinical differential diagnosis for monkeypox. The appearance of swollen lymph nodes distinguishes monkeypox from other rash-presenting diseases.
Healthcare personnel will collect specimens directly from the skin lesions to test a suspected monkeypox patient. Personal protective equipment (PPE) must be worn when collecting lesion specimens. Two swabs are collected from lesions that are preferably from different locations on the body or from lesions that differ in appearance. Generally, with vigorous swabbing, sufficient monkeypox virus DNA is present on the lesion's surface. De-roofing or aspirating the lesion is unnecessary and not recommended by the CDC, as this raises the risk for sharps injury.
How Is Monkeypox Treated?
Currently, there is no specific treatment for monkeypox. Treatment may also vary depending on the patient’s condition. People with weak immune systems or severe symptoms may need hospitalization. Patients with mild symptoms can recover within weeks without medical treatment.
In addition to standard precautions, healthcare personnel handling suspected or confirmed monkeypox patients should implement additional infection control precautions, as outlined by the CDC.
Activities that can resuspend dried materials from lesions (such as using fans, dry dusting, sweeping, etc.) should be avoided. Wet cleaning procedures are preferred.
Suspected and confirmed monkeypox patients should be placed in a single-person room with its own bathroom. When transporting patients, they should be wearing a medical mask and gown or sheet to cover their lesions.
Healthcare professionals should wear PPE, such as gowns, gloves, eye protection, and NIOSH-approved respirators when caring for a monkeypox patient.
Healthcare personnel should follow the U.S. Department of Transportation (DOT) Hazardous Materials Regulations. Waste management includes proper disposal of PPE and patient dressings.
Standard cleaning and disinfection should be performed with an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim.
According to CDC, patients with a suspected monkeypox infection should have the recommended isolation precautions until a monkeypox infection is ruled out. On the other hand, patients with a confirmed monkeypox infection should have the recommended isolation precautions until all lesions have crusted and fallen off.
What Are The Available Monkeypox Vaccines?
JYNNEOS and ACAM2000 vaccines can be used to prevent monkeypox. The two-dose JYNNEOS vaccine is preferred, and the ACAM2000, a single-shot vaccine, can be an alternative. While these vaccines can be used for monkeypox prevention, CDC is still conducting further studies to understand their effectiveness and risks.
JYNNEOS Vaccine
The U.S. Food and Drug Administration (FDA) approved the use of JYNNEOS vaccines against monkeypox through an Emergency Use Authorization (EUA).
JYNNEOS is a third-generation vaccine based on Modified Vaccinia Ankara (MVA), a live virus that cannot replicate in the human body. JYNNEOS is also called Imvamune or Imvanex in other countries.
Two doses of the JYNNEOS vaccine are recommended; the second should be given 28 days after the first dose.
Those 18 years and older should receive the vaccine on their forearm (intradermal injection). At the same time, those under 18 or with a keloid scar history should be vaccinated on their upper arm (subcutaneous injection). Infants under 12 months old who are at risk should receive the vaccine on their thighs. Still, pediatric vaccination should be coordinated first with CDC.
According to CDC, the JYNNEOS vaccine and COVID-19 vaccine cannot be given simultaneously. If the JYNNEOS vaccine is first administered, the patient should wait for four weeks before getting the COVID-19 vaccination.
Some people who get vaccinated on their forearms have experienced persistent swelling and redness at the spot of injection. Headache, chills, nausea, itching at the injection site, exhaustion, and muscle aches are some of the most common side effects of the JYNNEOS vaccine. However, not all can experience these side effects.
People who have experienced severe allergic reactions after the first dose should not be given the second dose of the vaccine. In this case, healthcare workers should determine if the patient is allergic to antibiotics like gentamicin, ciprofloxacin, or chicken or egg protein.
ACAM2000 Vaccine
ACAM2000 is a second-generation vaccine based on the Vaccinia virus, a live virus that can replicate in humans.
This vaccine is not approved by the FDA for emergency use against monkeypox. However, it has been made available under FDA’s Expanded Access Investigational New Drug (IND) mechanism, which requires informed consent and other requirements. With this, authorities that want to administer this vaccine should coordinate with the CDC to analyze the eligibility of people who will get the vaccine.
ACAM2000 is given through multiple pricks on the skin using a bifurcated needle. A lesion called “take” will form at the injection site after the vaccination. Patients should understand that this is not monkeypox or smallpox but the Vaccinia virus. Vaccinia can spread to other parts of the body or to other people. Proper care for the lesion is required to prevent its transmission. It can take four weeks or more until it is completely healed.
People who have been given the ACAM2000 vaccine should wait until 28 days before getting other vaccines, such as the live injectable vaccine or varicella vaccine. COVID-19 vaccine should be given four weeks after ACAM2000 vaccination.
CDC has stated that ACAM2000 shows more side effects than the JYNNEOS vaccine. Fever, lymphadenopathy, skin rash, headache, exhaustion, and muscle aches can occur after the vaccination. According to FDA, it can also cause myocarditis and pericarditis.
People with a weak immune system, heart ailment, skin condition, or eye disease treated with topical steroids are not eligible for ACAM2000 vaccination to avoid the increased risk of side effects. Those who have allergic reactions to its components can also not get the vaccine. ACAM2000 vaccine should not be given to infants under 12 months.
Vaccination Strategies
Multiple federal government agencies, such as CDC and FDA, are responsible for implementing the below monkeypox vaccination strategy.
Post-exposure prophylaxis (PEP).
Eligible people should be vaccinated within four days after exposure to potential or confirmed cases to prevent the onset of the monkeypox symptoms. The vaccine may be less effective if received after four to 14 days or after the appearance of symptoms. However, in some cases, it might still reduce the risk of severe symptoms when received 14 days after the exposure.
Expanded Post-Exposure Prophylaxis (PEP++).
Vaccines can also be administered to people at high risk or with a recent experience of a possible monkeypox exposure. Men who have sex with men, people with multiple sex partners, or those who engaged in group sex within the past 14 days can be considered for vaccination under this strategy.
Pre-Exposure Prophylaxis (PrEP).
This strategy allows people at risk of occupational exposure to monkeypox, such as healthcare workers and laboratory testers, to be eligible for vaccination.
PEP is the top priority over other strategies. Due to the limit of the JYNNEOS vaccine supply, the PrEP vaccination strategy may not be possible in some areas. While many cases are still occurring across the U.S., the CDC is not encouraging a mass vaccination for any group of people.
Final Thoughts
In the past years of our fight against COVID-19, we’ve learned how important healthcare workers are in saving lives and preventing diseases. Facts and information can help them to respond properly in any given situation. With this in mind, it is very crucial for all healthcare workers to be knowledgeable and updated about the current outbreak.