By Vanessa Pomarico-Denino, EdD, FNP-BC, FAANP
First identified in 1970 in the Democratic Republic of the Congo, monkeypox is a disease endemic to the tropical rainforests of Central and West Africa. It became a disease of global public health concern and declared a public health emergency in the United States in 2022.
Viral transmission
Monkeypox is a zoonotic disease, with transmission possible between animals and humans. To date, most cases in this current outbreak have disproportionately affected gay men, bisexual men, and men having sex with men. However, cases have also been reported in providers not equipped with proper PPE who have been caring for patients with a suspected monkeypox infection.
A member of the orthopoxvirus genus in the Poxviridae family, monkeypox is rarely fatal. Transmission occurs via direct and indirect contact (respiratory droplets and fomites) and contaminated food and water. It can also be vector-borne.
Vertical transmission in pregnancy causes congenital monkeypox in utero, placing patients at risk for spontaneous pregnancy loss, fetal demise, and preterm delivery.
At-risk populations
Patients that have sexual contact with people outside of the nuclear relationship, especially transmasculine persons (assigned females at birth identifying as male) who are pregnant, having sex with, or have partners who engage in sex with assigned males at birth may be at a higher risk for infection.
Other at-risk populations include patients who are:
- Receiving chemotherapy, especially those diagnosed with leukemia or lymphoma
- Receiving alkylating agents
- On long-term corticosteroids
- Pregnant
- Chest-feeding
- Experiencing any dermatologic conditions causing denuding of the skin (psoriasis, eczema, atopic dermatitis)
Additionally, solid organ and stem cell transplant patients are considered high risk for contracting monkeypox.
Related: Monkeypox: Symptoms and Treatment
Clinical presentation
Clinical presentation includes a prodrome febrile syndrome that lasts 5-21 days, including malaise, chills, headache, and lymphadenopathy. A deep-seated vesicular or pustular rash is the hallmark occurring in over 98% of all patients infected with monkeypox. This rash starts centrally before spreading to the extremities and face.
Macules evolve into papules, then to vesicles, then pustules, before finally crusting. Patients are still considered contagious until all scabs fall off and there is evidence of new skin growth, which can take 7-14 days. It is important for patients to avoid picking at the lesions, as this may cause permanent scarring.
Approximately 40% of all cases involve the oral, genital, and perianal mucosa, resulting in dysphagia, tonsillitis, epiglottitis, proctitis, urethritis, and balanitis. Patients with perianal lesions may also experience some rectal bleeding and tenesmus. Conjunctivitis occurs in about 6% of all cases reported thus far.
Treatment options
Currently, there are no FDA-approved treatments for monkeypox. There are two medications that are being used under Emergency Use Authorization (EUA) including:
- TPOXX (tecovirimat)
- VIGIV (Vaccinia immune globulin intravenous)
Both medications are available through the Strategic National Stockpile (SNS) for compassionate use.
There are two vaccines currently available. Jynneous (Imvanex), a live replication incompetent vaccinia virus, and ACAM2000, a live replication second-generation competent vaccinia virus.
Two-dose Jynneous is administered subcutaneously or intradermally four weeks apart. Single-dose ACAM2000 is administered via a bifurcated stainless-steel needle covered with vaccine solution. The virus grows at the vaccination site and produces a pruritic pock formation within 3-4 days. This scab falls off within a few weeks and antibodies then forms, demonstrating successful vaccination.
Containing the spread, educating patients
Fortunately, the monkeypox virus does not spread as easily as COVID-19, allowing outbreaks to be more easily contained.
Like any other public health concern, the data on monkeypox changes quickly. Stay up to date with these changes through the CDC or the World Health Organization (WHO) websites.
