Monkeypox Outbreak: What Infection Prevention Professionals Need to Know

Author: David Weber, MD, MPH, FSHEA, FIDSA, FMSM (London)

 In the midst of rising numbers of Monkeypox cases, and the Centers for Disease Control and Prevention (CDC) urging alert, all hospital and healthcare professionals need a fundamental understanding of what the virus is, how it’s transmitted, and importantly, the best practices for patient and staff safety.

A Brief History and Progression

Endemic in West and Central Africa, Monkeypox has been an uncommon orthopoxvirus viral disease, that was first recognized as an outbreak in primates in 1958, and first observed in humans in 1970^1-3.  Over the past few decades, we have seen an increase in cases of the virus in Africa, most likely due to decreased smallpox immunization, which also has protection against Monkeypox. The first reported Monkeypox viral outbreak outside of Africa was in 2003, with 47 confirmed cases in six states across the U.S⁴. These cases all originated through contact with animals from Africa, and no human-to-human transmission was reported. More recently, in 2021, there were two cases reported in the U.S. which stemmed from a person traveling to Nigeria. First recognized in Europe in May, the current 2022 outbreak of Monkeypox has been gaining some traction and has now spread across a wide geographic area. As of July 19, 2022, there were 14,511 cases reported worldwide from 70 countries; and 2,108 cases reported in the U.S. from almost all states⁸. Fortunately, to date most cases have been mild and no deaths have been reported.

Transmission

In studying the virus over the years, we’ve learned that animal-to-human transmission occurs from direct contact with the blood, bodily fluids, or lesions of infected animals⁶. And human-to-human transmission results from close contact with respiratory secretions, skin lesions of an infected person or recently contaminated objects⁶. Transmission via droplets of respiratory particles usually requires prolonged face-to-face contact, which puts health personnel, household members and other close contacts of active cases at greater risk. In addition, direct transmission from sharing utensils and contaminated clothes/bed linens has also been reported and raises additional concern about spread within healthcare facilities.

Symptoms

According to the CDC, early symptoms of Monkeypox generally develop one to two weeks after infection and can include fever, chills, and swollen lymph nodes⁵. A few days later, a rash typically develops which progresses through several stages from blister-like lesions to scabs, each lasting one to two days. Once scabs fall off, usually two to four weeks after symptoms begin, the individual is no longer infectious. Most reported cases have been mild, however, complications such as skin infection, nausea/vomiting, diarrhea, dehydration, and other effects can occur. The severity of Monkeypox really depends upon previous vaccination status, initial health status, concurrent illnesses, and comorbidities. Although, death has been reported in1 to 10 percent of cases of Classic Monkeypox, no deaths have yet been reported with this current outbreak.

It’s important for healthcare personnel to note that with this current outbreak there have been frequent atypical presentations and symptoms, such as: 1) only a few or even just a single lesion; 2) no skin lesions in some cases, with anal pain and bleeding; 3) lesions in the genital or perineal/perianal area which do not spread further; 4) lesions appearing at different stages of development; and, 5) the appearance of lesions prior to a fever, fatigue, and other symptoms.

Diagnosis and Therapy

A Monkeypox diagnosis is made by performing a PCR test on material obtained from underneath a scab and swabbing the underlying area. Samples can be sent to the CDC via state laboratories, or more recently, to commercial laboratories.  Most people with Monkeypox have a mild, self-limited infectious course and do not need a specific therapy. Treatment should be considered for individuals with severe illness (e.g. exhibiting hemorrhagic lesions) or at high risk for it, including those who are:

• Pregnant
• Immunocompromised
• Less than eight years of age
• Experiencing active exfoliative skin conditions
• Experiencing active complications (such as secondary bacterial infection).

Today’s treatment options include tecovirimat, cidofovir, and vaccinia immune globulin; all of which are only available via the state health departments. FDA-approved and CDC-recommended vaccines (such as the JYNNEOS vaccine) are also available.

Infection Prevention in Healthcare Settings

Although transmission in healthcare settings has been rarely found, there are several important safety procedures that all staff should adhere to, including:

• Isolating a patient with known or suspected Monkeypox in a private room with a bathroom
• Wearing personal protective equipment by healthcare personnel
• Thorough cleaning and disinfection procedures using an EPA-registered disinfectant with an emerging viral pathogen claim
• Diligent hand hygiene, including use of alcohol-based wipes
• Proper laundry procedures for soiled bedding, towels, personal clothing, including avoiding contact with any lesion material
• Wet cleaning materials, rather than dry dusting, sweeping, or vacuuming

Reducing the spread of Monkeypox, as with all serious viruses, is crucial for protecting the health and safety in and out of healthcare facilities.