Monkeypox Treatment for Nurse Practitioners - Part 2
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Show notes:
With the most recent global Monkeypox outbreak in May of this year, there’s been a lot of confusion among patients and providers about treatment options and vaccination.
With about 7,000 cases in the United States as of this recording, luckily the treatment options are starting to become more available. As I mentioned in the first episode of this series, thus far the treatments and vaccines have been only available through the Strategic National Stockpile, a government supply created to prepare for outbreaks. However, we’re starting to see more availability as the weeks go on.
If you haven’t already watched the last episode about Monkeypox Overview Part 1, definitely go back and check it out!
Monkeypox Treatment Options
In this week’s episode, we cover:
Who needs treatment (and who doesn’t)
The two main categories of treatments
What vaccines are available
Antiviral treatment options
Where to access treatments
Luckily, the vast majority of patients will have mild, self-limited illnesses, but it is helpful to understand all the treatment options out there so you can confidently answer patients’ questions and connect patients to treatment who need it.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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capable and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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podcast.
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In this episode, I'm going to be talking about treatments and vaccines around the
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monkey pox virus.
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So a couple of quick notes.
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This is intended for primary care providers and students who are yet to be primary care
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providers.
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So if you are not in that category, if you are a patient, please seek out additional
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guidance from your health care provider, as well as check out the video that I made
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on patient education regarding this topic linked below.
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So I made another episode about monkey pox, Monkey Box Part 1, where I covered the
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background information about the virus, symptoms, important key background notes, transmission,
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testing, overall approach to treatment.
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So if you haven't checked that out already, definitely go back and do that before
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you watch or listen to this episode.
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Another key point that I want to make that I sort of alluded to in the first
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episode is that as it currently stands at the time of this recording is that all
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of the testing and treatment is being governed by the departments of public health
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unique to each state in collaboration with the Center for Disease Control.
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So that is it within the United States.
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I unfortunately can't speak to the international communities addressing this, but the
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treatment principles are generally speaking the same.
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The access may be different depending on where you practice, if you're outside
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of the U.S. for that matter.
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So when we're talking about treatments though, all of these treatment decisions
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and vaccination decisions are going to be made in collaboration with the
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department of public health.
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Important background is that there's something called the strategic national stockpile.
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And this is a collection of things like vaccines and medications that have been
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assembled by the Center for Disease Control in the U.S. government organization
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to prepare for emergency medical outbreaks.
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And so strategic national stockpile is where these treatments and vaccines are coming
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from.
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And so that's why we're working in collaboration with department of public health.
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So a couple of key pieces.
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That's some foundational parts.
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Two main things about treatment.
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One is there's the vaccine approach and then the other one is the actual
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antiviral treatment approach.
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So I'm going to talk about the foundations for both of those things and then we'll
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talk about those specific options.
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So going back to the strategic national stockpile for a second.
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So smallpox was a very dangerous virus that has been eradicated from the planet.
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A global eradication as of 1980 declared that way.
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And how we got there is that people used to be vaccinated for smallpox.
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So smallpox is in the same family as monkeypox.
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So that's important.
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So hold that thought.
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So smallpox people used to get vaccinations against that.
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And then it got to the point where it stopped.
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We stopped vaccinating routinely in the United States in 1970.
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And in 1980, it was declared to be eradicated, right?
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Smallpox is gone.
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However, because we want to be prepared as a nation, we have a strategic national
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stockpile of both treatments for and vaccines against smallpox because it was such a
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dangerous virus.
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So cut to today.
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So monkeypox, as I mentioned in the previous episode about monkeypox, first
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humans in 1970 in Africa, and it's since become an endemic virus in a number of
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different countries.
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The unfortunate part is that there hasn't been a lot of funding or attention
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for monkeypox.
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And so we don't have specifically targeted treatments or vaccines for
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monkeypox.
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However, because monkeypox and smallpox are in the same family, what has
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happened is that when these vaccines and treatments that we have for
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have been given emergency use authorization by the CDC in the United States.
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And similar things have been recommended by the World Health Organization, where
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we're talking about international approaches, same approach, but different
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ways of getting there, right?
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So, yeah, so basically we have this emergency authorization for vaccines and
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for medications.
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With that said, that's why there's a challenge sometimes with getting the
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needed or the vaccines that are needed.
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However, let's talk about some other points, like who needs treatment and
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what are the treatment slash vaccine options.
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So in terms of treatment, I said this in the other episode, but basically
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monkeypox is a mild self-limited viral illness.
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Vast majority of patients do not need treatment and they will get better on
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their own.
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So that is the reason.
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Number one, I want you to really remember here is that when patients
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come in and they're very frustrated, they're very scared, they're kind of
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hoarding medications, where can I get stuff?
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It's like, okay, hold on, take a breath.
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The reality is, is a mild self-limited illness that is not as contagious as
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something like coronavirus, right?
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And so the moral of the story is that we need to treat the people who
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need to be treated, but that doesn't mean every single person that's ever
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existed in the whole world, right?
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So people with severe disease are people who are going to need treatment.
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So those are patients who are hospitalized with like really broad,
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diffuse confluent rashes.
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They have sepsis or encephalitis or bacterial infections of their lesions,
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like supra infections on top of it.
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And then also people who may be considered for treatment are patients
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with immunocompromised statuses related to HIV or other causes.
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The other at-risk populations that may need treatment, again, in
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collaboration with the Department of Public Health, are pediatric
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populations, especially any kids under the age of eight, pregnant and
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or breastfeeding persons.
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People with multiple complications from the illness.
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So it's not just the kind of like stock illness.
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They're having multiple comorbidities going on with it, like nausea and
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vomiting and secondary bacterial infections that are not hospitalized.
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Things like that.
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So just so you know, just as a premise, those are the people who get
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treatment, and it is not really up to us in the clinic setting to make
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that determination.
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At this point in time, so we just really need to be involved with the
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public health and the CDC.
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So let's talk about the individual options so that you are aware of
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them.
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Again, like as you go forward in this process, because number one,
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they're not available in a clinic, right?
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We don't stock the vaccines for smallpox.
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And number two, we don't stock the treatments for smallpox in
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commercial pharmacies or any pharmacy, really.
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So it all has to go through that venue.
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Okay, so let's talk about vaccines first, though.
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So the indication, so there's two vaccines for smallpox.
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And because they're in the same family as monkeypox, they've been
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studied against monkeypox in animal studies.
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However, it is unethical to do that study of efficacy in humans.
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And so what's happened is the testing was done on healthy people
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and they did well with it.
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And now we can use it as emergency use authorization.
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Two vaccines.
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Number one is Jynneos is the name.
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So I have some references down below.
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But Jynneos is a live, attenuated, non-replicating smallpox virus vaccine.
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So this was FDA approved back in 2019.
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So it's been around for a while.
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And now, again, it has expanded access use for monkeypox specifically.
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So the other vaccine that we have is called ACAM 2000.
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Very fancy name.
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So this was FDA approved in 2007 for, again, for smallpox use.
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And this is replacing the previous vaccine that people used to get when they were kids
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against smallpox.
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And so this, notably though, this is also a live virus,
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but it is a potentially replicating virus.
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So that's one potential consideration to think about between Jynneos,
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non-replicating and ACAM, which it is replicating,
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which is there's a small risk of auto-inoculation of the smallpox virus.
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So it's not unsafe to use, but you just have to be more mindful in patients
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with immunocompromised, for example.
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And I'm not going to get into all of the little bits and pieces about each of them.
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I just want you to have an overarching picture of what the things are.
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So the deal with that is, I'll talk a little bit more about each of the vaccines,
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but what's the deal with vaccines?
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So the people who get vaccines are, there's pre-exposure prophylaxis
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that has very limited narrow of options at this moment in time by the CDC.
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So it's typically people who are handling lab samples
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of any of the orthopox viruses, as well as potentially the option
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for healthcare providers who are directly caring for patients with monkeypox.
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So like in the hospital setting type of thing, potentially, right?
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But it doesn't really have any further clear guidance.
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So the other context is in post-exposure prophylaxis.
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So patients who have a confirmed exposure to monkeypox,
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those patients are eligible for getting a post-exposure prophylaxis.
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The goal is to get them a vaccine within four days of exposure
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to prevent them from getting monkeypox.
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If it's administered between four and 14 days after exposure,
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it's going to hopefully lessen the symptoms for them,
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but it will not prevent them from getting it.
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So there's a newer note on the CDC website about post-exposure prophylaxis plus.
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It's like a plus plus or something.
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Anyway, it's not super clear at this time,
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but there is starting to be more accessibility
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for patients who aren't necessarily confirmed exposure,
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but might be at more higher risk.
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And so there is some leeway there.
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And again, none of these are determined by us,
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so we're going to collaborate with the Department of Public Health to help us.
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So a couple of quick notes, though.
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So Jynneos, which is the non-replicating,
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but live attenuated smallpox vaccine, has two doses.
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There's day one, of course, and then 28 days later is a second,
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and it's a subcutaneous injection.
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And after the second dose, it's 14 days until they're covered.
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So it's about, you know, it's a significant chunk of time.
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And it's been used in previous outbreaks of monkeypox,
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and it's been about 85% effective, both of the vaccines, actually.
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As opposed to ACAM2000, so fancy.
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That one is actually, I don't know if you've seen that either,
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if you've had it yourself or you've seen it on patients or family members,
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but it's like a little dot on their arm.
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And what it is, is that percutaneous technique of multiple punctures
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of the vaccine on the skin.
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And that's a one-time administration.
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It kind of forms a little sore.
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It scabs over, and then they're protected.
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And that's about four weeks later-ish.
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So it's a little bit, it's one dose,
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and it's a little bit faster immunity.
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So that's, you know, pluses and minuses there.
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So that's the deal with vaccines.
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And so patients may ask you a question of like,
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is there a vaccine and why can't I get one?
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Hopefully that fills in the answer for you.
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But I think the main take-home point for people
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is not that we're hoarding medications and vaccines away from them,
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but like truly the risk of morbidity and mortality
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is low enough that it does not warrant people
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to be getting those types of treatments and vaccines, right?
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Because all of our information is based on studies,
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and it's not really like drawing out that that would be beneficial
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in the big picture for them.
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So if we get to treatments.
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So again, I said the high-risk people are the ones that are at risk.
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So you definitely, like, your role is to determine,
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number one, suspecting a case and testing,
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and then educating about containment
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and connecting them with the Department of Public Health.
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And then the next thing is kind of like understanding
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what the next steps are so that you can kind of like
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help talk them through stuff and just like be informed,
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especially for other patients who are not coming in with it.
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But yeah, so in terms of the treatment options,
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the main one is an antiviral specifically for smallpox,
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which again comes from the Strategic National Stockpile,
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authorized used for monkeypox.
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And it's been studied in animals for efficacy,
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and then it's also been tested on humans
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for like other orthopoxviruses.
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So it's determined to be a safe medication.
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But again, we have a limited stockpile of it.
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So we want to be mindful of who gets it,
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and they will help us decide.
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So I'm really good at pronouncing things,
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as you may have noticed.
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But TECORVIRAMAT, I do a lot of reading
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and I don't hear people say it,
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so I hope I'm saying that right.
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TPOX is one of the other brand names,
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as well as ST246.
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This is an oral or an IV antiviral
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that's taken for treatment.
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It can be used in pediatric patients as well,
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it's kind of like more of a weight-based
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dosing type of thing.
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So one of the next treatment options is IVIG
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for the vaccinia immune globulin.
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So that's the smallpox immune globulin's infusion.
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And so some patients who are not eligible
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for the vaccines to help prevent
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post-exposure prophylaxis
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may be considered to use that.
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Again, this is for your informational purposes,
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kind of only,
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because you're not going to be prescribing these.
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Sadafavir is another antiviral that is,
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all of these are FDA approved.
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They're just emergency authorized used
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for this indication.
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So Sadafavir is an antiviral used
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for cytomegalovirus in patients with AIDS previously,
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but it is thought to be supportive.
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It is kind of like that lower line,
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like lower level line of efficacy though,
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because the TPOX one
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is going to be a little bit more efficacious.
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So those are both strategic national stockpiles.
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There is another antiviral.
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I'm not even going to try to pronounce it,
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but I'll put it in the show notes
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or the notes down below.
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That is kind of like a last line one
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and is not readily available.
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I think even in the U.S.
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was what I was trying to find was like,
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it seemed like it was available internationally,
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but maybe not.
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So yeah, so those are the main things for treatment.
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So hopefully this helps you feel more confident
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in those conversations with patients.
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And then if you happen to have a patient
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with those symptoms
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and you need to connect them to treatment,
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you can hopefully help walk them through it.
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But yeah, please let us know
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what other questions you have about this topic
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and hopefully we can connect you to the right resources.
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One other episode that I did
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that I mentioned in the other video
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is that I did a patient education specific video.
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There are so many things
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and so many questions people have
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and so many things you can say,
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but I tried to highlight the main things
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that patients would want to know.
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So hopefully that would help you
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kind of explain to your own patients
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or maybe even refer them to watch
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if that was be supportive for them.
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But yeah, thank you so very much for watching.
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Hang in there.
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I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe,
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as many nurse practitioners as possible
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Thank you so much again for listening.
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Take care and talk soon.
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