Transcript: Monkeypox Treatment For Nurse Practitioners - Part 2

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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.

In this episode, I'm going to be talking about treatments and vaccines around the Monkeypox virus. So a couple of quick notes, this is intended for primary care providers and students who are yet to be primary care providers. So if you are not in that category, if you are a patient, please seek out additional guidance from your healthcare provider, as well as check out the video that I made on patient education, regarding this topic. So I made another episode about monkeypox, Monkeypox Part 1, where I covered the background information about the virus symptoms, important key background notes, transmission, testing, overall approach to treatment. So if you haven't checked that out already, definitely go back and do that before you watch or listen to this episode.

Another key point that I want to make that I sort of alluded to in the first episode is that, as it currently stands at the time of this recording, is that all of the testing and treatment is being governed by the Departments of Public Health, unique to each state, in collaboration with the Center for Disease Control. So that is within the United States. I, unfortunately, can't speak to the international communities addressing this, but the treatment principles are generally speaking the same. The access may be different, depending on where you practice, if you're outside of the US for that matter. So when we're talking about treatments though, all of these treatment decisions and vaccination decisions are going to be made in collaboration with the Department of Public Health. Important background is that there's something called the Strategic National Stockpile. And this is a collection of things like vaccines and medications that have been assembled by the Center for Disease Control in the US government organization to prepare for emergency medical outbreaks. And so, Strategic National Stockpile is where these treatments and vaccines are coming from. And so, that's why we're working in collaboration with Department of Public Health.

So a couple of key pieces. That's some foundational parts. Two main things about treatment. One is there's the vaccine approach. And then, the other one is the actual antiviral treatment approach. So I'm going to talk about the foundations for both of those things. And then, we'll talk about those specific options.

So going back to the Strategic National Stockpile for a second. So smallpox was a very dangerous virus that has been eradicated from the planet, a global eradication, as of 1980, declared, that way. And how we got there is that people used to be vaccinated for smallpox. So smallpox is in the same family as monkeypox. So that's important. So hold that thought.

So smallpox, people used to get vaccinations against that. 
And then, it got to the point where we stopped vaccinating routinely in the United States in 1970. And in 1980, it was declared to be eradicated, right? Smallpox is gone. However, because we want to be prepared as a nation. We have a Strategic National Stockpile of both treatments for and vaccines against smallpox because it was such a dangerous virus. So cut to today.

So monkeypox, as I mentioned in the previous episode about monkeypox, first detected in humans in 1970 in Africa. And it's since become an endemic virus, in a number of different countries. The unfortunate part is that there hasn't been a lot of funding or attention for monkeypox. And so, we don't have specifically targeted treatments or vaccines for monkeypox.

However, because monkeypox and smallpox are in the same family, what has happened is that these vaccines and treatments that we have for smallpox have been given emergency use authorization by the CDC in the United States. And similar things have been recommended by the World Health Organization, where if we're talking about international approaches, same approach, but different ways of getting there.

So yeah, so basically, we have this emergency authorization for vaccines and for medications. With that said, that's why there's a challenge sometimes with getting the treatments that are needed or the vaccines that are needed.

However, let's talk about some other points, like who needs treatment? And what are the treatment/vaccine options?

So in terms of treatment, I said this in the other episode, but basically, monkeypox is a mild self-limited viral illness. Vast majority of patients do not need treatment and they will get better on their own. So that is the reason, number one, I want you to really remember here is that, when patients come in and they're very frustrated, they're very scared. They're kind of freaking out. They're hoarding medications. "Where can I get stuff?" It's like, "Okay, hold on, take a breath." The reality is, this is a mild self-limited illness that is not as contagious as something like coronavirus.

And so, the moral of the story is that we need to treat the people who need to be treated, but that doesn't mean every single person that's ever existed in the whole world. So people with severe disease are people who are going to need treatment. So those are patients who are hospitalized with really broad diffuse confluent rashes. They have sepsis or encephalitis or bacterial infections of their lesions, like super infections on top of it. And then, also people who may be considered for treatment are patients with immunocompromised statuses, related to HIV or other causes. The other at risk populations that may need treatment, again, in collaboration with the Department of Public Health, are pediatric populations, especially any kids under the age of eight, pregnant and/or breastfeeding persons, people with multiple complications from the illness. So it's not just the kind of stock illness.

They're having multiple comorbidities going on with it, like nausea and vomiting and secondary bacterial infections that are not hospitalized, things like that.

So just so you know, just as a premise, those are the people who get treatment and it is not really up to us in the clinic setting to make that determination, at this point in time. So we just really need to be involved with the Department of Public Health and the CDC.

So let's talk about the individual options, so that you are aware of them. Again, as you go forward in this process, because number one, they're not available in a clinic. We don't stock the vaccines for smallpox. And number two, we don't stock the treatments for smallpox in commercial pharmacies, or any pharmacy really. So it all has to go through that venue.

So let's talk about vaccines first though.

So there's two vaccines for smallpox, and because they're in the same family as monkeypox, they've been studied against monkeypox in animal studies. However, it is unethical to do that study of efficacy in humans. And so, what's happened is the testing was done on healthy people and they did well with it. And now, we can use it as emergency use authorization.

Two vaccines.

Number one is Geneos is the name. So I have some references down below, but Geneos is a live attenuated non-replicating smallpox virus vaccine. So this was FDA approved back in 2019. So it's been around for a while. And now, again, it has expanded access use for monkeypox specifically.

So the other vaccine that we have is called ACAM2000. Very fancy name. So this was FDA approved in 2007 for, again, for smallpox use. And this is replacing the previous vaccine that people used to get when they were kids for against smallpox.

And so, this notably though, this is also a live virus, but it is a potentially replicating virus. So that's one potential consideration to think about between Geneos, non-replicating, and ACAM, which is replicating, which is there's a small risk of autoinoculation of the smallpox virus. So it's not like unsafe to use, but you just have to be more mindful in patients with immunocompromised, for example. And I'm not going to get into all of the little bits and pieces about each of them. I just want you to have an overarching picture of what the things are. So the deal with that is... I'll talk a little bit more about each of the vaccines, but what's the deal with vaccines? So the people who get vaccines are there's pre-exposure prophylaxis that has very limited narrow of options at this moment in time by the CDC.

So it's typically people who are handling lab samples of any of the orthopox viruses, as well as potentially the option for healthcare providers who are directly caring for patients with monkeypox. So in the hospital setting type of thing potentially. But it doesn't really have any further clear guidance. So the other context is in post-exposure prophylaxis. So patients who have a confirmed exposure to monkeypox, those patients are eligible for getting a post-exposure prophylaxis. The goal is to get them a vaccine within four days of exposure to prevent them from getting monkeypox. If it's administered between four and 14 days after exposure, it's going to hopefully lessen the symptoms for them, but it will not prevent them from getting it. So there's a newer note on the CDC website about post-exposure prophylaxis plus. It's like plus or something. Anyway, it's not super clear at this time, but there is starting to be more accessibility for patients who aren't necessarily confirmed exposure, but might be at more higher risk.

And so, there is some leeway there. And again, none of these are determined by us. So we're going to collaborate with the Department of Public Health to help us.

So a couple of quick notes though, so Geneos, which is the non-replicating but live attenuated smallpox vaccine, has two doses. There's day one, of course. And then, 28 days later is a second. And it's a subcutaneous injection. And after the second dose, it's 14 days until they're covered. So it's a significant chunk of time. And it's been used in previous outbreaks of monkeypox and it's been about 85% effective, both of the vaccines actually.

As opposed to ACAM2000. So fancy, I don't know if you've seen that either, if you've had it yourself or you've seen it on patients or family members, but it's like a little dot on their arm. 
And what it is, is that percutaneous technique of multiple punctures of the vaccine on the skin. And that's a one-time administration, it kind of forms a little sore. It scabs over and then, they're protected. And that's about four weeks later ish. So it's a little bit. It's one dose and it's a little bit faster immunity. So that's pluses and minuses there. So that's the deal with vaccines.

And so, patients may ask you a question of like, "is there a vaccine? And why can't I get one?" Hopefully, that fills in the answer for you.

But I think the main take-home point for people is not that we're hoarding medications and vaccines away from them, but truly the risk of morbidity and mortality is low enough that it does not warrant people to be getting those types of treatments and vaccines. 

Because all of our information is based on studies and it's not really drawing out that that would be beneficial in the big picture for them. So if we get to treatments, so again, I said the high-risk people are the ones that are at risk.

So you, definitely your role is to determine, number one, suspecting a case in testing, and then, educating about containment and connecting them with the Department of Public Health. And then, the next thing is kind of understanding what the next steps are, so that you can kind of help talk them through stuff. And just be informed, especially for other patients who are not coming in with it. But yeah.

So in terms of the treatment options, the main one is an antiviral, specifically for smallpox, which again comes from the Strategic National Stockpile, authorized use for monkeypox. And it's been studied in animals for efficacy. 
And then, it's also been tested on humans for other orthopox viruses. So it's determined to be a safe medication, but again, we have a limited stockpile of it. So we want to be mindful of who gets it. And they will help us decide.

So I'm really good at pronouncing things, as you may have noticed. But Tecovirimat, Tecovirimat. I do a lot of reading and I don't hear people say it. So I hope I'm saying that right.

TPOXX is one of the other brand names, as well as ST246. This is an oral or an IV antiviral that's taken for treatment. It can be used in pediatric patients as well. And it's kind of a more of a weight-based dosing type of thing.

So one of the next treatment options is IVIG for the vaccinia immunoglobulin. 
So that's the smallpox immunoglobulin's infusion. And so, some patients who are not eligible for the vaccines to help prevent post-exposure prophylaxis may be considered to use that. Again, this is for your informational purposes kind of only, because you're not going to be prescribing these.

Cidofovir is another antiviral. All of these are FDA-approved. They're just emergency authorized use for this indication. So Cidofovir is an antiviral used for cytomegalovirus in patients with AIDS previously. But it is thought to be supportive. It is kind of like that lower line, lower level line of efficacy though, because the TPOXX one is going to be a little bit more efficacious. So those are both Strategic National Stockpile sourced.

There is another antiviral. I'm not even going to try to pronounce it, but I'll put it in the show notes or the notes down below. That is kind of like a last line one and is not readily available.

I think even in the US was what I was trying to find was like, it seemed like it was available internationally, but maybe not.

So yeah, so those are the main things for treatment.

So hopefully this helps you feel more confident in those conversations with patients. And then, if you happen to have a patient with those symptoms and you need to connect them to treatment, you can hopefully help walk them through it. But yeah, please let us know what other questions you have about this topic. And hopefully, we can connect you to the right resources.

One other episode that I did, that I mentioned in the other video, is that I did a patient education-specific video. There are so many things and so many questions people have and so many things you can say, but I tried to highlight the main things that patients would want to know.

So hopefully, that would help you kind of explain to your own patients or maybe even refer them to watch, if that was supportive for them. But yeah.

Thank you so very much for watching. Hang in there. I'll see you soon.