Public Health Expert Fields Monkeypox Questions (aafp.org)
Q&A With Jonathan Temte, M.D., PhD., M.S.
Public Health Expert Fields Monkeypox Questions
July 13, 2022, 3:15 p.m. David Mitchell — As of July 12, 929 confirmed monkeypox/orthopoxvirus cases from 40 states, the District of Columbia and Puerto Rico had been reported to the CDC. The AAFP recently launched a webpage offering up-to-date tools and information for family physicians regarding the outbreak, including guidance related to recognizing the signs and symptoms of the disease, appropriate use of antiviral medications, vaccines and more.
To summarize key points about the outbreak, AAFP News recently spoke with Jonathan Temte, M.D., Ph.D., M.S., associate dean for public health and community engagement and a professor in the Department of Family Medicine and Community Health at the University of Wisconsin-Madison School of Medicine and Public Health. Temte is a past chair of the CDC’s Advisory Committee on Immunization Practices and currently serves on the agency’s Board of Scientific Counselors. He also serves as medical director for Public Health Madison and Dane County.
This is a summary of that conversation.
Q: It’s been suggested that testing for and reporting cases of monkeypox to date have been insufficient. Are you concerned that the current U.S. case count might actually be higher? Do you expect it to go significantly higher? How do we make sure primary care physicians and patients have this on their radars without causing panic?
A: I look at this like we’re poised somewhere between COVID-19 and the Ebola outbreak we saw in 2014-16. If you went back to the first several months of Ebola, people were panicking, although we had just a handful of cases in the U.S. total. This is in between those two events.
Regarding the question of, “Is the case count going to be significantly higher?” Yeah, absolutely it’s going to be higher. It’s a big country. We have 330 million people. We have cases out there, and we don’t have the ability to detect and report every case. The question becomes, “At what level would one start panicking?” And I would say, if it’s 1,400 cases, I’m not panicking. If it’s 70,000, I would be, but we’re not there.
Q: One of the other differences between this outbreak and Ebola is that those cases were largely imported, whereas monkeypox is likely being spread here.
A: That’s the case. On the other hand, I would argue that monkeypox spreads more like Ebola than it does like COVID, so it really requires close contact, prolonged time, lack of distance, and because of that, from an epidemiological standpoint, I’m feeling much more comfortable with this than COVID.
Q: From an infection control perspective, how do you deal with patients with suspected cases when they’re in your clinic?
A: The good news here is we have had a crash course in PPE over the past two years. Gloves are important. Gowns? Probably. Do you need an N95? No, a surgical mask is fine. Those are the things to consider, but it’s a step down from what we do for COVID.
Q: Is it important for your scheduler to know what questions to ask? If you have online scheduling, should you try to determine why someone is coming in before they get there?
A: I would be more concerned if it were somebody with a new-onset rash. I might ask a few more questions. On the flip side, I have to say that during Ebola I got really tired, every time I called my clinic, of getting the question, “Have you been to West Africa?” That went on for a very long time. Maybe if nothing else, you let your front desk staff or schedulers know that if it’s a new-onset rash, they might want to ask more questions about that.
If it’s a new-onset rash in somebody who has recently been traveling, and it started out with a high fever and now the person has a reddish rash that’s extending peripherally and has not been vaccinated for measles, that person is going to a negative airflow room on arrival, and they have to be masked.
Somebody with monkeypox could sit in my waiting room for quite some time, and I wouldn’t have a whole lot of concern. The level of contagiousness is really important here. It’s worthwhile to ask those questions upfront. But at the same time, know that we’re (not) putting other patients in our waiting rooms, our front office staff, our rooming staff, our nurses, our medical assistants at high risk (by) doing the things that we normally do.
I’m not sure where we are across the country regarding masks, but in my neck of the woods, I have a mask on every time I step foot in the clinic. With that alone, I would say that I’m pretty protected from this. Even though this is not highly contagious, we recommend using appropriate PPE. The good news is that currently, CDC considers close contact with an individual as being within 6 feet of somebody for at least three hours without wearing a mask.
Q: A lot of the symptoms of monkeypox are also seen with other conditions. How do you recognize the symptoms and differentiate them from something else? Is recognizing the rash the most important thing?
A: There are two components, and it goes back to the current guidance out there in terms of clinical cases and epidemiologically linked cases. For the clinical cases, what we know with monkeypox is it starts out as something that looks like a whole lot of other infections. You have these very nonspecific things. There can be this host of routinely seen things: fever, headache, back pain, tiredness and swollen lymph nodes. That doesn’t help us with diagnosis much. I see those symptoms all the time in my practice, and you certainly don’t want me to be thinking monkeypox every time.
However, if I had a patient who came in and said, “I have these symptoms, and I have this exposure” — all of a sudden, I’m raising my level of concern.
Something I’ve tried to emphasize throughout my career is putting everything in context. One of the things I try to train my family practice residents to do with routine acute respiratory infection symptoms is ask people, “Were you around anybody else with a similar symptom in the last few days?” That can help you a lot.
Beyond that, once patients start having these interesting lesions, that should be a red flag for anybody. I say that because my career has gone from seeing acute vesicular rashes in kids all the time to chickenpox now being a pretty rare disease. So, when we have somebody coming in with these characteristic lesions, that really does help us out a lot. Clinicians have to be aware of that progress from vague, nonspecific symptomatology of an acute infection to the development of a rash. And always in the background, keep these other questions in mind: Where were you? Who were you with? What was the time course for this?
Q: At what point do you test somebody, and what do physicians need to know about reporting a suspected case?
A: If you look at the number of cases in the country, most family docs will never see a case of this, so being prepared to know exactly what to do is not very useful. The reason I say that is we have to know so much about so many things that knowing exactly what to do when we see something this rare is difficult. I would emphasize communication. If you have a patient who you suspect has monkeypox — and that could be because of that epidemiological contact or history or because of the symptoms or rash — your first step should be contacting your local or state public health department. That’s really important.
Then think about getting a specimen. If you have somebody with a lesion, use a synthetic, not cotton, swab. Start with a sterile swab. If it’s a pustule or a vesicle, you can just rub over the surface. If it’s a scab, you can rub over the surface. You do not have to unroof the lesion, but you could if you wanted to. CDC currently recommends getting at least two specimens from different lesions if somebody has more than one. And that could be a clinical clue right there. If somebody has a sole lesion on the genitalia, you would still want to check, but that puts them more in the area of things like syphilis. Really think about getting specimens from two separate sites, and they can be sent in either dry or in VTM — viral transport medium. I think most clinics have that.
Then the question is, where do I send this? And this is where that communication is really important. It needs to be sent to a laboratory that is credible and equipped for monkeypox. That’s where communication with your local or state public health person is going to be key.
Q: What do you tell patients with a suspected case who don’t yet have test results back? What do they need to do in terms of isolation, masking, etc.?
A: First and foremost, from time of exposure until potential incubation is over is typically about 21 days. If you have somebody who has known exposure, you want to follow them out at least 21 days to make sure they’re not coming down with things.
Second, if they have a lesion, they are considered infectious until that lesion goes through the whole evolution to scab, the scab comes off and underneath that area you’re back to intact skin. In fact, the contagious period is probably from before you have any lesion — though the likelihood is lower at that point of time — until after that lesion has scabbed over and healing has occurred. During that time, those individuals should avoid close personal contact with anybody. Skin-to-skin lesion contact is very important to avoid. Hand hygiene is really important. Use disinfectant for surfaces if they’re in a shared living space. When they’re out and about, wearing a mask is going to be important.
I still cannot go into the grocery store locally without seeing maybe 10% to 20% of the people in my grocery store still masking due to COVID. It has become much more socially accepted to be masked, and it’s not a marker for, “Aha, this person has monkeypox.” The world has changed over the past two years.
Q: Initially, monkeypox vaccines were recommended only for people with confirmed exposures. Now that supply is expanding, who should receive the vaccine and how do people get it? Will vaccine be available in family medicine practices or do people need to go to public health departments?
A: We have two licensed vaccines, but neither is readily available. The best use is probably for the people who have known exposure to a case. In the first four days after exposure, providing the vaccine can be preventive. And we consider four to 14 days after exposure as not preventive but likely to reduce symptoms and perhaps duration.
At this point, we’re looking primarily at post-exposure prophylaxis. There are some individuals who could be interested in receiving preexposure prophylaxis, but those people are primarily laboratorians, people who will be handling specimens. That being said, a week and a half ago I presented at our annual Wisconsin virology conference, and the sentiment among the laboratorians is not many of them were interested in getting the preexposure prophylaxis.
The other consideration is the two vaccines are quite different. JYNNEOS is a live, nonreplicating viral vaccine that’s approved for monkeypox and smallpox. ACAM2000 is a live cowpox vaccinia virus vaccine. ACAM2000 has to be used with caution with anybody who is immunocompromised or has eczema, because of the potential for pretty severe side effects.
People who are older already had smallpox vaccinations as kids. One of the things to put in the back of your mind is that if somebody had a previous smallpox vaccination, they’re probably at least somewhat protected. In the U.S., we stopped that in 1972. It was a universal vaccine, and most people got it in childhood. People who are in their mid-50s or older are probably relatively protected compared to younger people.
The best way to handle this is if you have questions, talk to your local or state public health office. Right now, I think most of the supplies are being handled through that chain.
Q: There is no treatment specifically approved for monkeypox, so what are the options regarding antivirals?
A: Most cases of monkeypox are self-limited. It is reasonably well tolerated. Most people don’t require hospitalization or anything other than home supportive care. But there are a number of antivirals out there that are licensed, not necessarily for monkeypox, but they are licensed medications.
There’s tecovirimat, which is FDA-approved for use in smallpox. This is a medication you would consider for people who have evidence of monkeypox and who have really severe disease or are immunocompromised. As a family doc, I’m not going to write out a prescription for this antiviral and send it to the pharmacy. I’m going to do this in consultation with my public health department and probably with my favorite infectious disease doc. This is something we don’t handle routinely, and we will likely never handle. Again, this is where that communication aspect is really important.
When we talk about rare conditions like Ebola, monkeypox, or even COVID-19 when it was first emerging, it’s really important to have that communication channel open. This applies to things that we rarely see, like rabies. What happens if you have a kiddo who got bitten by a cat? Well, I can try and look stuff up quickly, or I can call my public health person. They almost always have somebody on call 24 hours a day.
Q: Are there other antiviral meds we should mention? Is tecovirimat preferred?
A: It gets more of the top billing. But there’s also vaccinia immune globulin that can be used, and two others: cidofovir and brincidofovir. Those are medications that are FDA licensed, not for use in monkeypox, but could be considered if you have somebody with severe illness or immunocompromise. Again, with all these, there would be consultation with your public health professionals and infectious disease specialists.
Q: Most cases of monkeypox in the current outbreak have occurred in men who have sex with men. How do you communicate the risk to that patient population without creating stigma and without minimizing the risk to other patient groups?
A: I would phrase it like this: If you’re a human being who has skin, you have the potential of coming down with monkeypox. It basically is a cutaneous-to-cutaneous exposure. Monkeypox doesn’t care if you’re gay, straight, trans. It doesn’t matter. People are susceptible.
It is most common right now in the gay community, in men who have sex with men, simply because this is where things emerged, and it looks like it traces back to large gatherings in Europe. There’s a real difference in terms of where something starts because of risk behavior and bad luck and where it eventually ends up. What I would do is not jump to any conclusions. Don’t have prejudicial approaches. Accept the fact that this is a transmittable disease that requires skin-to-skin contact and sometimes closer contact by way of large respiratory drops.
That gets back to the whole thing about being close to somebody for several hours. You have to take each and every case as is. This is your patient, and our job is to give the best care, do the diagnostic services, referrals, education and treatment.