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Red Book Online Outbreak: Monkeypox Virus Outbreak

August 15, 2022

Summary

The Centers for Disease Control and Prevention (CDC) is tracking an outbreak of monkeypox infections in the United States. As of August 12, 2022, there have been 11,177 confirmed cases of monkeypox in the United States. This outbreak is part of a larger global outbreak (>31,700 cases) that is occurring in 89 locations (countries, territories, and areas) and is caused by the West African clade of monkeypox. The risk of children getting infected with monkeypox virus is low. As of August 10, two pediatric cases have been confirmed in the United States (<0.1% of all cases). Children and adolescents are more likely to be exposed to monkeypox if they live in or have recently traveled to a community with higher rates of infection. The CDC has summarized the epidemiology and characteristics of the monkeypox cases in the US from May 17 – July 22, 2022 in this report

 

Clinical Guidance

  • Presentation: Monkeypox should be suspected in patients presenting with a rash consistent with monkeypox (https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html), especially (but not solely) in patients with exposure to someone known to have or suspected to have monkeypox. Clinical judgement and consultation with your local public health department are required in determining who needs testing, as the overwhelming majority of children who present with a rash will have an alternative etiology.
    • The rash associated with monkeypox produces macules that progress to papules, vesicles, and then pustules that are deep-seated, firm or hard, and well-circumscribed; the lesions may umbilicate or become confluent and progress over time to scabs. Rash may spread to other parts of the body. In classic monkeypox, lesions on a particular body part are in the same stage. This has not always been the case in the current outbreak, with lesions in varying stages of progression being seen in many patients in the US currently, and lesions may be few in number, and limited to one area.
    • Presenting symptoms typically include fever, chills, malaise, sore throat, headache, and new lymphadenopathy, followed by the distinctive rash. In the current outbreak, onset of perianal or genital lesions in the absence of subjective fever or other systemic symptoms or concurrently with systemic symptoms also has been reported. Other symptoms include difficulty swallowing or cough when oropharyngeal lesions are present. Ocular lesions may present with eyelid swelling or crusting.
    • The rash associated with monkeypox can be confused with other diseases that are more commonly encountered in clinical practice (eg, syphilis, herpes simplex virus [HSV], chancroid, varicella zoster, and molluscum contagiosum). In addition, some patients have been coinfected with syphilis or HSV and monkeypox. A high index of suspicion for monkeypox is warranted when evaluating patients with a new onset of clinically compatible rash, who present with lesions in the genital/perianal area or for patients who had contact with a suspected or known case of monkeypox.
  • Diagnosis: If a patient is suspected of having monkeypox, the clinician should contact the health department to discuss testing or may use one of the commercial laboratories discussed below. Monkeypox virus can be detected through an orthopoxvirus PCR test (diagnostic process for monkeypox virus testing) at a designated laboratory response network (LRN) laboratory or at one of the commercial labs below. A positive orthopoxvirus PCR in a patient suspected of monkeypox is sufficient to consider the patient as having monkeypox, and public health officials will initiate an investigation and provide recommendations. The LRN laboratory will send the specimen to CDC for characterization. Five commercial laboratories are currently performing orthopox PCR testing, including Sonic Reference Laboratory (www.sonichealthcareusa.com), Aegis Sciences (https://www.aegislabs.com/our-services/monkeypox/), Labcorp (http://www.labcorp.com/monkeypox), Mayo Clinic Laboratories (https://news.mayocliniclabs.com), and Quest Diagnostics (https://www.questdiagnostics.com/healthcare-professionals/about-our-tests/infectious-diseases/monkeypox). Clinicians may order testing at commercial labs without prior authorization from public health authorities. Testing is performed on skin lesion material (dry swab, swab placed in viral culture media, or crusts) or mucosal lesion material. Requirements for specimen collection may differ by laboratory and clinicians should confirm requirements before obtaining a sample. Testing on blood or other body fluids is not available. For information on testing specimens that will be sent to an LRN laboratory see Preparation and Collection of Specimens | Monkeypox | Poxvirus | CDC.
  • Complications: Patients with monkeypox can develop a variety of complications, including encephalitis, pneumonia, sepsis, hemorrhagic disease, other conditions requiring hospitalization, blindness (secondary to ocular infection), and bacterial skin infections. If the patient is pregnant, there may be complications, including preterm delivery, fetal death, or congenital disease. For more information: Monitoring People Who Have Been Exposed | Monkeypox | Poxvirus | CDC
  • Precautions: Monkeypox spreads person to person primarily through contact with infectious rashes, close face-to-face contact, or items that previously touched the infectious rash or body fluids. Standard precautions should be applied for all patient care, including for patients with suspected monkeypox. If a patient seeking care is suspected to have monkeypox, infection prevention and control personnel should be notified immediately. In the inpatient setting, persons with suspected or confirmed monkeypox should be placed in a single patient room with a dedicated bathroom. Special air handling is not required except during aerosol-generating procedures. Intubation, extubation, and any procedure likely to spread oral secretions should be performed in a negative pressure isolation room. In ambulatory healthcare settings, the lesions of patients with suspected or confirmed monkeypox should be covered and patients who are at least 2 years of age should be masked. Patients should be put in an exam room promptly. In both inpatient and ambulatory settings, the PPE used by healthcare personnel who enter the patient’s room should include a gown, gloves, eye protection (ie, goggles or face shield), and a NIOSH-approved particulate respirator equipped with N95 filters or higher. For more information, see How it Spreads | Monkeypox | Poxvirus | CDC.
  • Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim. Products with Emerging Viral Pathogens claims may be found on EPA’s List Q. Follow the manufacturer’s directions for concentration and contact time. Activities that could resuspend dried material from lesions (eg, use of portable fans, dry dusting, sweeping, or vacuuming) should be avoided. Waste contaminated with the West African clade [PDF – 4.06 MB] of monkeypox virus, including disposable PPE,  should be managed as UN3291 Regulated Medical Waste (RMW) in the same manner as other potentially infectious medical waste (e.g., soiled dressings, contaminated sharps). Waste from individuals who have risk factors for the Congo Basin clade of monkeypox eg, history of travel to the Democratic Republic of the Congo, the Republic of Congo, the Central African Republic, Cameroon, or Gabon in the prior 21 days) must be managed as Category A waste pending clade confirmation.
  • Risk Mitigation: Children and adolescents with monkeypox who do not require hospitalization should be isolated at home. Infected persons should avoid contact with uninfected people and pets until the rash has resolved, the scabs have fallen off, and a fresh layer of intact skin has formed. When
    possible, the number of caregivers should be limited to one person who has been educated about infection prevention strategies. Caregivers should wear a respirator or well-fitting face mask, cover areas of broken skin with bandages and clothing to the extent possible and avoid direct skin-to-skin contact with the rash. During interactions with uninfected caregivers, children over 2 years of age with monkeypox should wear well-fitting source control (eg, a medical mask) when possible. Caregivers assisting with changing bandages or clothes covering the rash should wear gloves to avoid infection, dispose of gloves after use and perform handwashing.
    • Decisions regarding discontinuation of isolation precautions at a healthcare facility and at home should be made in consultation with the local or state health department. For individuals with monkeypox, isolation precautions should be continued until all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed. For more information: Isolation and Infection Control: Home | Monkeypox | Poxvirus | CDC
      • CDC recommends that people whose jobs (clinical or research laboratories and certain healthcare and public health team members) may expose them to orthopoxviruses, such as monkeypox, get vaccinated with JYNNEOS or ACAM2000 to protect them from an orthopoxvirus infection. At this point, vaccination is not recommended for most healthcare providers. For more information: Monkeypox and Smallpox Vaccine Guidance | Monkeypox | Poxvirus | CDC
      • Public health officials may recommend vaccine for contacts of monkeypox cases, especially those that are found to be at high risk. Healthcare providers who have unprotected, high risk contact with patients with monkeypox may be eligible for post-exposure prophylaxis in consultation with public health authorities.
      • JYNNEOS vaccine may be recommended for and given to children <18 years of age  for post-exposure prophylaxis under a single patient expanded access investigational new drug (IND) protocol through CDC (IND Applications for Clinical Treatment (Expanded Access): Overview | FDA). Clinicians should discuss use of vaccine in a child as post-exposure prophylaxis with the state or local health department and CDC.
      • Vaccinia immune globulin is available through an IND protocol for the potential prevention of monkeypox, but its effectiveness is unknown. Vaccinia immune globulin is an alternative to vaccine for post-exposure prophylaxis, especially in children <6 months of age.
      • Tecovirimat may be considered for post-exposure prophylaxis when vaccine is contraindicated; its effectiveness is unknown.
  • Treatment: Monkeypox is typically a self-limiting condition. Some patients are at higher risk for severe disease and should be considered for treatment on a case-by-case basis, including immunocompromised patients, pregnant or breastfeeding persons, children under 8 years, and those with atopic dermatitis or an exfoliative skin condition. In addition, those with complicated or severe disease, or lesions in the eye, mouth, genitals, or anus/rectum should be considered for treatment. For more information, see https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html. Consultation with an infectious disease expert is recommended. State or local public health officials can facilitate consultation with CDC and access to antiviral therapy. There is no treatment approved specifically for monkeypox virus infections. However, antivirals developed for use in patients with smallpox may prove beneficial against monkeypox. The following medical countermeasures are available from the Strategic National Stockpile (SNS) as options for the treatment of monkeypox:
    • Tecovirimat (also known as TPOXX, ST-246), developed for treatment of smallpox, is  being used as a first-line treatment  for patients weighing 3 kg or more through an expanded access protocol for monkeypox (see package insert: label [fda.gov]). Oral dosing is most feasible for children who weigh at least 13 kg and can take capsules, or the contents of a capsule mixed with soft food. The drug should be administered with a fatty meal to increase absorption. Because accurate oral dosing of children < 13 kg is challenging, intravenous therapy is recommended when tecovirimat is indicated. Renal immaturity in patients < 2 years of age may result in higher exposure to hydroxypropyl-β-cyclodextrin, an ingredient in intravenous tecovirimat. In animal studies, hydroxypropyl-β-cyclodextrin demonstrated the potential for nephrotoxicity at high levels. At least weekly monitoring of renal function is indicated in children and adolescents receiving intravenous tecovirimat. Tecovirimat has not been studied in children to date. Evidence of efficacy in the treatment of monkeypox is based largely on animal studies. The potential risks and benefits should be considered prior to initiating therapy.
    • CDC has an expanded access protocol for Vaccinia Immune Globulin Intravenous (VIGIV) in the case of a monkeypox outbreak (download [fda.gov]). Effectiveness is unknown.
    • The use of antiviral medications cidofovir and brincidofovir may also be considered, but these should be used with caution due to potential toxicity.
      • Cidofovir (also known as Vistide), which is approved for CMV retinitis, has an expanded access protocol for treatment of monkeypox (FDA VISTIDE cidofir injection).
      • Brincidofovir (also known as CMX001 or Tembexa), which is approved for smallpox treatment (FDA TEMBEXA brincidofovir) is not yet available in the SNS, but an expanded access investigational new drug protocol is being developed for use for monkeypox by CDC.

 

Special Populations

Management of Exposed Newborns
Neonates infected with Monkeypox virus are thought to be at risk of severe disease. Infants born to individuals with confirmed or suspected monkeypox should undergo early bathing before vitamin K or vaccines are administered, or other procedures are performed. Post-exposure prophylaxis should be considered for exposed neonates in consultation with public health authorities. The optimal therapy for post-exposure prophylaxis of neonates is not known.

As of July 29, 2022, screening tests for evaluation of exposed, asymptomatic newborns are not available. Infants should be monitored for symptoms of monkeypox, including fever, lymphadenopathy, and rash. At a minimum, exposed infants should have daily temperature checks and complete skin exams. These can be performed by a caregiver or a healthcare provider. Exposed infants who develop a rash should undergo prompt testing for monkeypox.

Caregivers or family members who do not have suspected or confirmed monkeypox can provide routine care to an uninfected neonate who is born to a person with monkeypox. Separation of a newborn from an infected parent is recommended as the best way to prevent transmission.

The infected parent should be counseled about the risk of transmission and the potential for severe disease in newborns. If the parent chooses to have contact with the newborn during the infectious period, strict precautions should be taken, including the following:

  • Avoid direct skin-to-skin contact.
  • During contact the newborn should be fully clothed or swaddled and after contact occurs the clothing or blanket should be removed and replaced.
  • Gloves and a fresh gown should be worn by the infected parent at all times, with all visible skin below the neck covered.
  • Soiled linens should be removed from the area.
  • The infected individual should wear a well-fitting source control (eg, medical mask) when in the same room as the newborn.

Precautions should be continued until criteria for discontinuing isolation have been met (ie, all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed).

It is not yet known if monkeypox virus can be transmitted via breastmilk. Breastfeeding should be delayed and expressed breastmilk from a person who is infected or isolated should be discarded until the criteria for discontinuing isolation has been met.

Hospitalized neonates exposed to monkeypox should be isolated for the duration of the incubation period (21 days). Care should be provided in a private room and PPE used by healthcare providers should include gown, gloves, eye protection (ie, goggles or face shield), and a NIOSH-approved particulate respirator equipped with N95 filters or higher.

Discharge planning should take into account the duration of isolation, ability to strictly adhere to recommended isolation precautions, and availability of alternative caregivers.

 

Resources

 

Pediatric Practice Tools and Info

AAP News: AAP experts answer pediatricians’ questions on monkeypox

CDC: Information For Healthcare Professionals

CDC: Clinical Considerations for Monkeypox in Children and Adolescents | Monkeypox | Poxvirus

CDC: Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding

 

Public Health Resources

CDC case count: 2022 US Monkeypox Outbreak: Situation Summary | Monkeypox | Poxvirus

CDC US map of cases: 2022 US Map & Case Count | Monkeypox | Poxvirus

CDC global map of cases: 2022 Monkeypox Outbreak Global Map | Monkeypox | Poxvirus

CDC health department: 2022 Monkeypox: Information for Health Departments | Monkeypox | Poxvirus

 

Infection Prevention and Control Resources

CDC: Infection Prevention and Control of Monkeypox in Healthcare Settings | Monkeypox | Poxvirus

AAP: Project Firstline

 

Information for Patients and Caregivers

AAP HealthyChildren.org: What is Monkeypox? | Spanish: ¿Qué es la viruela del mono o viruela símica? ¿Debo preocuparme?

CDC: Monkeypox factsheet for adolescents and young adults

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