Transcript: Monkeypox for Nurse Practitioners - Part 1

Liz Rohr:
I first want to start by saying that monkeypox is a global outbreak, which sounds extremely scary and so many patients are worried about it. I just want to start by saying, this is a mild self-limiting illness that does not require treatment in the vast majority of cases. And it is far, far, far, far, far less transmissible than coronavirus. So without further ado, let's hop in.

Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Liz Rohr:
This week's episode is about monkeypox. Monkeypox is I think really concerning for a lot of patients, clinicians, and it can feel especially unnerving because we're still on the heels of the coronavirus pandemic, SARS-CoV-2. In this episode, though, I hope I can answer some questions. There's actually a lot of information. So I'm going to be recording two different episodes. The first one, which is today, right now, is about important background information about the virus, signs and symptoms and diagnosis, transmission, as well as an overview of treatments and some points about infection control and isolation, things like that.

Liz Rohr:
The next episode is going to focus more on the treatments, because there's just a lot to say in an episode, but yeah, that's how it's going to go. I actually am going to also do a third episode that is for patients specifically, and I want to post that to the YouTube channel specifically for patients to find, but I'm also going to share it on the podcast for clinicians in case it is helpful for you to listen to how I would talk to a patient and have those conversations and answer those common questions that patients may have.

Liz Rohr:
First off, let's jump in with some really important background. So what is monkeypox virus? So it is a virus, of course by the name, in the Orthopoxvirus family. So the other virus that we are familiar with in that category is smallpox. So it is a zoonotic virus, meaning that it originated in animals and has both animal-to-human transmission, as well as human-to-human transmission. It was first detected in the 1950s in monkeys. And so hence the name of monkeypox. However, the original reservoir is unknown and it's actually far more common in rodent animals, rats and deer rats, I believe. I can't remember what they're called, but yeah, those are the original sources. So 1970s was the first time that it was detected in a human. So this is not a new virus. There's been a little bit of a change, but this is not a new virus. This is detected in humans in the '70s.

Liz Rohr:
Originally there were two strains. I believe it's the West African clade, is one of them. And then the other one is Democratic Republic of Congo I believe. Don't quote me on those names, but there are two strains and they were found originally in a few countries in Africa and now have become endemic, meaning it is a virus that just kind of hangs out there. There are occasional outbreaks in other countries within the continent of Africa and the most recent kind of global outbreak that was declared by the World Health Organization around May of this year is because it has spread not just to the endemic area or to countries close by with smaller outbreaks. It's like a much larger outbreak that's worldwide.

Liz Rohr:
I'm going to give you some stats. Hopefully that'll help you and your patients feel more comfortable. These are from, I believe, June. And so there may be some more updated numbers, but these were the most recent ones that I could find. There are about 18,000 cases worldwide in 78 countries, as of Mayish, Junish. 70% of those cases were actually located in European countries, and then 25% were located in the Americas. Of those 18,000 people, five deaths were reported. So I just want to let that sink in. Hopefully those numbers can help you feel a little bit better. 10% of patients, of those 18,000, were admitted to the hospital. The reasons for hospitalization were complications, which we'll talk about, but also because of pain control. There were also a handful of patients that needed treatment because of immunocompromised. And then there also were patients that had infections on top of the lesions, like [inaudible 00:04:47] superinfections, things like that.

Liz Rohr:
So far in terms of who's being affected, I just want to start by saying, there is no virus that's going to specifically go for a type of person, regardless of any of their characteristics really. I mean, I guess there's some caveats about specificity there, but anyway, the current outbreak, about 98% of them have been detected in men who have sex with men. And I want to say just on the record, there's no such thing as a gay disease and this is... I want to dispel any myths there. That number one, this is not sexually transmitted. Sexually transmitted means that it's like transmitted through the sexual fluids between partners. As we understand right now, it is not spread that way. There's an article that came out recently in the Lancet saying that there was monkeypox DNA detected in semen, but it is not thought that it actually is transmitting, which is a little bit of a complicated nuance there. But as we understand right now, it is not sexually transmitted, does not have an affinity for any specific type of person.

Liz Rohr:
The way that a lot of diseases spread, especially in outbreaks is by social clusters and patterns of behavior in close proximity. And so I think it's really important to stress to patients that this can affect anybody. And if there's any stigma around testing, diagnosis and treatment, it's going to make the outbreak worse and go on longer. For example, another example we can talk about is if the original case was in somebody who was on a wrestling team, all of the wrestlers on the team would likely get exposed. And there is no virus that's going to go for a wrestler, just it's a wrestler specific virus. That doesn't exist. Hopefully that's a helpful example to share with your patients and to help understand yourself.

Liz Rohr:
Next, I want to talk about symptoms as well as transmission. Let's talk about symptoms first. So you may have seen these pictures on the internet. Down below, I have some links. There were some requests for the different appearances of different types of lesions, especially in varying skin tones of patients and various body areas. So I have a link down below, so check that out. But basically what happens, the core of it is that there are these very extremely painful lesions, skin lesions. So the progression of these very painful lesions is that they are first a maculopapular rash. So they're they're groups of, or solitary maculopapular lesions. And they can be in a what's called a centrifugal pattern, which I think is so cool. That terminology, not the rash. But it can start more on the outside of the body than the central location. So it can be in the anal, genital region. It can be in the mouth, the palms, the soles, more of the distal extremities and less in the center. And so there can be a cluster of lesions that also can be a little bit more diffuse, whereas maybe before it may have been a lot more diffuse, but that's the presentation that we are seeing now.

Liz Rohr:
So there's a progression though. It's a maculopapular lesion in a cluster, quite painful. They're deep seated, meaning like chickenpox varicella for example, is very superficial. This is a very deep, deep lesion underneath and it's rubbery and it's circular. They progress then to vesicles. And then after that they become pustules. And then after that, they finally scab over. Like I said, they are quite painful. And what happens is it takes almost about six weeks from the original development of the lesion to the healed scabs, to fall off and have new skin, which is important, because we're talking about transmission in a second. So keep that in mind, six weeks to heal those lesions. So the lesions themselves are the contagious part. Hold that thought.

Liz Rohr:
Prodrome. The prodrome is that typically there's a classic case, and then there's a mild or non-existent case, where patients can have headache and fatigue, like a pretty significant headache and fatigue to start. And then a couple days later, I believe up to three to five days later, they will start to get the lesions, like maybe one to five days... Don't quote me on that, but just a couple of days, they will get the lesions. The other thing that they can have is a fever and lymphadenopathy. So we're seeing a little bit more of that than previous monkeypox that has been seen globally was more of just like a headache and fatigue. And so an important note about that is that when patients come in with headache, fatigue, fever, and lymphadenopathy, that could be a whole bunch of stuff. So just something to keep in mind in your differentials before they have lesions. And then the other thing to keep in mind is that they're actually contagious once they start having symptoms.

Liz Rohr:
Let's talk about the whole life cycle though and transmission. Basically what happens is that the way that this is spread is through the lesions themselves. Even if they don't have visible pus, even if they're those deep-seated papules, can still transmit. So anything touching a lesion can transmit. The caveat there is that it's not necessarily one touch and then you have the virus yourself. What they're using for language is more prolonged contact. So physical, intimate contact, whether it's again, a wrestling match, if it's sexual intercourse with somebody, if it's somebody that lives in your house like close contacts, that's a possibility too. So someone just who's in close, prolonged proximity and could be touching the lesions at any point.

Liz Rohr:
Another route is droplets. So respiratory droplets within three feet of another person with coughing, talking, sneezing for a prolonged period. So we don't have great numbers right now. I love specifics, but it's not nearly anywhere as contagious as say SARS-CoV-2 or COVID-19. So it's prolonged respiratory droplets, meaning like 15 minutes or more longer time. We don't have hard facts and numbers about that, but just know that it's not like you touch it one time and then you get monkeypox. Someone is close to you for just a moment in the grocery store, you're going to get monkeypox. It's not like that.

Liz Rohr:
The last one I want to mention though, is for mite transmission, which I love that word, it's the contact with objects. And so what we're talking about here is lesions that have come into contact with the clothing of an individual or bedsheets or towels, for example. For example, patients who were admitted to the hospital, it was detected on a number of different surfaces in their bedroom. But again, just because it's there, a brief contact does not necessarily mean that there's enough virus in that single touch to cause an overall infection for that person.

Liz Rohr:
The unfortunate part... So now we're talking a little bit more about transmission. The unfortunate part is that the life cycle is that when you get exposed to monkeypox and significant enough close, intimate exposure, it takes about one to two weeks to get symptoms, to get the prodromal symptoms of that fever, headache, lymphadenopathy, fatigue. And so in that time period... It doesn't sound like people are infectious during that time period. However, the main way that we're going to be reducing this outbreak is through contact tracing. So that's like a real, real unfortunate part of this virus.

Liz Rohr:
Anyway, the life cycle is that one to two weeks after exposure, we'll develop symptoms or a couple of days. Will get to be the sequential rashes; maculopapular to vesicles, to pustules, which will then scab over and fall off and there's new skin. That unfortunately takes between two and six weeks. So that's a real unfortunate part of this illness if people get it, is because really you're supposed to be isolating until the scabs have fallen off and there are no more scabs. Because like I said, even if there's no pustules or visible fluid coming out, you're still going to get virus shedding.

Liz Rohr:
One more thing I wanted to add about the lesions is that they can also have a central umbilication, which is just the most fun medical word, which can be confusing with molluscum if you're familiar with that virus. But it can have that little dot in the center of the pustule or the papule.

Liz Rohr:
Couple of differentials actually I want to throw in there. I didn't say I was going to talk about them, but I do want to throw out some now that I've mentioned molluscum. So couple of ones to keep in mind. Varicella, hand, foot, and mouth, because you also have the oral lesions and you may have the extremities as well. Measles, scabies, molluscum, herpes, syphilis, allergic skin reactions and drug eruptions as well. So those are the main things to keep in mind, but hopefully... I mean, hopefully you don't see this at all, but if you did see it, hopefully you would have some precautions in place to prepare.

Liz Rohr:
Let's talk about diagnosis. Currently as it stands, the way it's gone in this outbreak so far is that it is handled by the Department of Public Health. This is not a routine infection that we send somebody to the lab for, and then we test for it. So the majority of this, and again, check with your... Actually, I didn't say this yet, but check with your supervisor about testing and treatment and the protocols at your clinic. So hopefully your clinic has developed a protocol of how to prepare for these potential patients, protective equipment. Again, if it's a by touch transmission, as well as droplet, we want to consider personal protective equipment that is both contact and droplet in the clinic setting. But yeah, when it comes to the testing and the treatment part, we do want to collaborate with our supervisors, the people running the clinic, as well as the Department of Public Health.

Liz Rohr:
The way that we're testing for it if we have a suspected contact, step number one is let somebody know. Let your supervisor know, let the Department of Public Health know. And actually down below this episode, I have a link to the contact information for every state, for your Department of Public Health. Phone number to call. And that is how you will arrange for testing as well as potential treatment. Not everybody gets treatment, by the way.

Liz Rohr:
The testing is a PCR swab test. It's through a swab of the lesion and it's sent off to typically the Department of Public Health lab. I've heard that there are some commercial labs doing this test, but vast majority at the time of this recording, you're going to be working with your particular clinic, your particular state department of public health. And how you collect the swab according to CDC, is that it's act it's one of those cotton or dacron around swabs, like a typical wound culture... Anyway, talk to your supervisor, but that's typically what it looks like. Unfortunately it's like a vigorous scrubbing of the lesion, even if it doesn't have visible discharge. And I say, unfortunately, because apparently they are quite painful. So just do your very best to obtain those, again, with guidance. You'll likely have guidance if this is actually happening to you, but it's a vigorous swab of a lesion sent to that specific lab and it's a PCR test. And so because it's a PCR test, you shouldn't need to have too much sample for them to be able to run it.

Liz Rohr:
I just want to briefly talk about approach to treatment. So this is a mild... I probably should have started with this comment, but it's a mild self-limiting illness for the vast majority of patients. Vast majority of patients will not need treatment of any kind and it will self-resolve. I should have said that at the beginning, but most patients are not going to get treatment. So there's basically two camps of management if it gets to that point of treatment. And you are not going to be doing this alone, you're going to be doing this with a supervisor and again, the Department of Public Health.

Liz Rohr:
The brief overview is that there's two main categories. One is vaccine. And then the second one is antivirals. So for vaccines, these are the smallpox vaccines. And these are primarily for preexposure prophylaxis for certain healthcare workers, for certain lab, people who work in a lab processing the specimens. Please check the CDC recommendations about who should get that at this time, at the time you're watching this or listening to this. And so that can be for preexposure prophylaxis or post-exposure prophylaxis. So for patients who have a known exposure to monkeypox, those patients can get a smallpox vaccine, not a monkeypox vaccine. It's a small pox vaccine. Again, I'll talk about that in the treatment episode, but it's has this emergency use authorization to be used for monkeypox because they're in the same family of viruses.

Liz Rohr:
And then the people who require treatment are those who have severe symptoms. So people who should get treatment again, this is in conjunction with your supervisor and the Department of Public Health. This is not available at a commercial pharmacy. This is specifically obtained. Persons with severe disease, so hemorrhagic disease, many, many, many confluent lesions, people who have complications of sepsis or encephalitis, as well as other conditions requiring hospitalization. If they had that superinfection, if they were immunocompromised, things like that. So people who are at high risk for severe disease and are not hospitalized, those patients are immunocompromised patients with things like HIV. Pediatric populations, especially those less than eight are at higher risk for more severe illness. People who are pregnant or breastfeeding. People who have really extensive skin underlying conditions already. So if you had severe atopic dermatitis or other active exfoliative other skin conditions, those patients are at risk for it being a lot worse.

Liz Rohr:
So again, I'm going to talk about the treatments in that episode, but I guess just as a quick take home, these are all available through emergency use authorization by the FDA. They're all FDA-approved medications and vaccines, but they're all for other illnesses that are not monkeypox specifically. And so because of that, they are located in the... In the US, all I can speak to is the US, unfortunately. They're located in the strategic national stockpile of medications to be used in an outbreak. So there are special procedures to actually get those treatments. And so you're never going to make that decision yourself of like, do they need treatment or not?

Liz Rohr:
Hopefully this episode is helpful and helps answer a lot of questions that you might have. Please let us know what questions you have further and definitely check out the links down below about the contact number for the Department of Public Health in your state, as well as some other CDC recommendations and resources and images for diagnostic purposes.