As of July, Washington DC residents accounted for the highest number of monkeypox cases per capita. The spike in infection numbers, which were reflected in recent data from the Centers for Disease Control and Prevention, has incited concern among DMV residents largely unfamiliar with the virus and its characteristics.
With vaccines in short supply, some clinics have had to enforce eligibility requirements to distribute doses to those considered most at risk. But what does that criteria entail? When should you get tested? What symptoms should you look for? And what are the best preventative measures?
To answer these questions and keep Virginians informed, we spoke with Dr. Jennifer Primeggia, an infectious disease expert with the Virginia Hospital Center Physician Group.
How much do we know about monkeypox and its history relative to other infectious diseases?
Primeggia: Unlike COVID-19, monkeypox is not a new virus. We already know quite a lot … and we have vaccines and treatments available.
Monkeypox was first isolated from a lab in Denmark in the 1950s. In subsequent years, outbreaks were observed in lab animals. It was not until the 1970s, however, when it was first identified in humans in the Democratic Republic of the Congo.
In the U.S., we have seen sporadic cases related to international travel to parts of Africa, where monkeypox is known to be endemic. Additionally, there was an outbreak of monkeypox across six states in the American Midwest associated with infected prairie dogs, which came from West Africa as part of exotic pet consignment. Through these cases, we learned quite a bit about the clinical presentation of monkeypox and risk of transmission with specific exposures.
We are far ahead of the curve in terms of knowledge, treatment and prevention.
How is monkeypox transmitted?
Primeggia: Person-to-person transmission, animal-to-person transmission and person-to-animal transmission have all been documented.
Animal-to-person transmission is usually acquired through contact with an infected animal’s body fluids or through a bite. It has also been reported in bushmeat preparation.
In person-to-person transmission, monkeypox is spread through direct contact with infectious sores, scabs and body fluids. Because of this, it usually spreads during periods of close personal contact with an infected person.
It also spreads through indirect contact with fomites — objects or materials that have been contaminated with the virus — such as clothing or linens. Finally, it is spread through respiratory secretions, though prolonged face-to-face contact is required.
Who is most susceptible? Are children at risk?
Primeggia: Monkeypox can affect anyone, no matter age or sexual orientation. As of August 21, the CDC reported 130 cases of monkeypox in those 20 and younger, including six cases in children 5 and under.
Those most at risk for severe outcomes from this virus are children under 8 years old, those with weakened immune systems — including immunocompromised and pregnant patients — and those with certain skin conditions, such as eczema and atopic dermatitis.
What are the symptoms of monkeypox to look for?
Primeggia: Traditionally, monkeypox has caused a flu-like illness — fevers, body aches — that precedes the development of a rash. However, with this outbreak, we have observed that not all patients experience flu-like symptoms before a rash.
Also, the appearance of the rash has been quite variable. The rash can look like bumps, pimples, or blisters. It can occur on the skin or on mucus membranes, such as inside the mouth, the rectum or on genitals.
Because of this, monkeypox can look like a lot of other infections — herpes, chickenpox, and syphilis, for example.
What is the best route for one to get tested?
Primeggia: There is no blood test for monkeypox at this time — patients can only be tested once they have developed a skin rash.
Testing, which is available through commercial labs and the Department of Health, involves vigorous rubbing of a swab across the rash. The specimen is then submitted for analysis to see if the monkeypox virus is detected.
At this time, and per CDC guidelines, specimen collection can only be performed by a healthcare professional. The best way to find a monkeypox test is for patients to contact their primary care provider or an urgent care center.
Have you seen patients with monkeypox cases? If so, what are some alarming manifestations of the virus?
Primeggia: We have seen cases at Virginia Hospital Center. Most bothersome to some patients is the degree of discomfort they experience, specifically pain and itchiness, and particularly when the lesions are on sensitive areas, such as mucus membranes.
The most alarming to me, especially early on in this outbreak, was the difficulty patients experienced in achieving an accurate diagnosis. We saw high-risk patients who presented to our ER for a second or third opinion after other providers told them their rash was not consistent with monkeypox and no testing was required.
What are the best preventative measures for those who may be susceptible?
Primeggia: Avoid close contact with anyone who might have the virus. A family member or household contact with monkeypox should self-isolate until no longer contagious.
Parties where there is minimal clothing and direct personal contact do pose a risk, so avoid touching any rashes noted on others and consider minimizing skin-to-skin contact. Do not share objects that pose a higher risk of transmission, like towels, toothbrushes, or silverware.
Vaccination is another important tool. The Jynneos vaccine is currently available to patients through local health departments and can prevent infection or lessen the severity of disease in those exposed to monkeypox.
If a test comes back positive, what treatment options are there? What measures should be taken to limit the virus’ spread?
Primeggia: For most patients, monkeypox is a mild disease. Full recovery usually takes place over two to four weeks without treatment.
For certain individuals who are at high risk for more severe disease and for those with lesions in sensitive areas, such as the mouth, the rectum, or near the eyes, the antiviral tecovirimat, or TPOXX, may be recommended. This medication was approved by the FDA for the treatment of smallpox, but animal studies have shown it to be effective in the treatment of other orthopoxviruses, such as monkeypox.
Patients with known or suspected monkeypox should avoid leaving their home — outside of seeking medical care. If around others, the skin lesions should be covered to minimize contact. In the home, the infected individual should wear a face mask — ideally, household members will as well.
Frequent hand washing should also be performed by household contacts and the infected individual. Soiled linens should not be shaken, as this could spread contaminated material in the air.
The WHO also recommends condom use for sexual activity for 12 weeks after recovery, as the virus can be found in semen and vaginal fluids. Persons with monkeypox are considered infectious until all scabs have fallen off and new skin has formed over the sites.
What is your perception of how Virginia has handled the outbreak?
Primeggia: With the resources it has been provided, the state has handled the outbreak well so far. Because the state already has gone through the process of establishing vaccination sites for COVID-19, Virginia has been able to mobilize the staff and resources quickly to implement vaccination for monkeypox.
However, it is the federal government that supplies Virginia with both vaccine and treatment, and early on in this outbreak, the response was slow. Many patients reached out to me as early as May in search of vaccine, as they knew they were part of a high-risk demographic.
It was disappointing that the vaccine was available in DC weeks before the surrounding jurisdictions. I have a number of patients who reside in Virginia and Maryland and spend a great deal of time in DC. They were clearly high risk for monekypox, but did not have access the vaccine. I would have liked to see the DMV as a whole recognized as an at-risk area.
Once a vaccine is available, what does that process entail? What is the vaccine’s efficacy?
Primeggia: I currently direct my eligible patients to the monkeypox information website of the health department for the county in which they reside. They then complete the monkeypox vaccine interest form and are contacted directly to arrange a vaccination appointment. Currently, public health authorities only recommend vaccination for select high-risk individuals and those exposed to monkeypox.
In Virginia, Jynneos is the vaccine currently being distributed. It comes as two doses taken a minimum of four weeks apart, and has been used for the prevention of smallpox and monkeypox.
Experts also believe that vaccination after monkeypox exposure may help make the disease less severe. The effectiveness of this vaccine against monkeypox was inferred from animal studies. As such, we do not yet have real world data regarding its effectiveness in this particular outbreak and on the duration of immunity.
Editor’s note: If you are experiencing symptoms consistent with Monkeypox, talk to your medical provider and fill out the online Monkeypox Vaccine Interest Survey. To learn more about monkeypox cases in Virginia, visit the Virginia Department of Health’s Monkeypox information page.
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