Making sense of monkeypox
Two experts offered advice to hospitalists on their role in dealing with this latest infectious disease outbreak.
On Aug. 4, HHS declared the U.S. monkeypox outbreak to be a public health emergency. While learning the ropes for yet another infectious disease may seem daunting to hospitalists who just withstood a pandemic, rest assured that the human monkeypox virus is not another SARS-CoV-2.
For one, after a steep rise following the disease's first identification in the U.S. earlier this year (there have been more than 26,000 confirmed cases and two deaths as of Sept. 30, according to the CDC), cases are declining here. In mid-September, federal health officials announced that monkeypox cases were down nearly 50% since the start of August. In addition, unlike at the start of the COVID-19 pandemic, tools including real-time polymerase chain reaction (PCR) testing, an FDA-approved vaccine, and a treatment are all available.
U.S. health care workers have very low risk of acquiring monkeypox from exposure to patients, according to a report published in the Sept. 23 MMWR. Of 313 Colorado health care workers exposed to patients with monkeypox, with varying use of personal protective equipment, none acquired monkeypox.
The CDC has also provided recommendations for infection prevention and control of monkeypox in health care settings, which were updated Aug. 11. A patient with suspected or confirmed monkeypox infection should be placed in a single-person room with a dedicated bathroom, although special air handling is not required, and the door should be kept closed if possible, according to the recommendations.
(Of note, ACP and Annals of Internal Medicine held a forum with a panel of experts on Tuesday, Oct. 11, discussing challenging clinical questions related to monkeypox. A free recording will be available soon on Annals' website.)
To gather more guidance for hospitalists on monkeypox, ACP Hospitalist recently spoke with two experts. Raghavendra Tirupathi, MD, FACP, is the medical director of Keystone Infectious Diseases and chair of infection prevention at WellSpan Chambersburg and Waynesboro hospitals in Pennsylvania, and hospitalist Venkataraman Palabindala, MD, MBA, FACP, is the regional medical director of Optum in Seattle and an associate professor of medicine at the Elson S. Floyd College of Medicine in Spokane, Wash.
Q: What are you currently most concerned about regarding the monkeypox outbreak?
A: Dr. Tirupathi: The monkeypox outbreak currently going on in the U.S. and West was initially affecting certain communities like men who have sex with men, but more recently, sporadic cases have been seen in women and children. Transmission of this infection happens with prolonged close and intimate contact like kissing. There has been, thankfully, a downward trend in the incidence of new cases over the last few weeks due to concerted efforts of risk reduction, lifestyle modifications, increased awareness, and, most importantly, treatment with tecovirimat [and] quick and effective rollout of monkeypox vaccination among at-risk communities; however, there has been concern about emergence of drug-resistant strains in the recent past.
Q: At this point, how likely is a U.S. hospitalist to see a patient with monkeypox?
A: Dr. Tirupathi: It is very likely that monkeypox would be diagnosed in patients requiring hospitalization in the next few months. Severe oral lesions leading to odynophagia and dysphagia, as well as severe anogenital lesions, are one of the common indications for hospitalization and administration of IV or oral tecovirimat.
Q: What are the most important points for hospitalists to know about monkeypox?
A: Dr. Palabindala: Hospitalists need to be aware of the possibility of monkeypox as one of the differential diagnoses for patients presenting with vesiculopustular rash and fevers, especially if the patient belongs to an at-risk population. Prompt testing, isolation, and, if needed, treatment with tecovirimat should be pursued as necessary. Infectious diseases consultation and infection prevention should be involved in care of these patients.
Q: What do you recommend for symptom control?
A: Dr. Tirupathi: Supportive care and pain management is big in the management of monkeypox. For proctitis, symptom control includes appropriate hydration, stool softeners, and sitz baths. Acetaminophen and NSAIDs can help with pain, although oral gabapentin is anecdotally better for pain control. Opiates can cause constipation; if used, consider stool softeners or gentle laxatives. Topical lidocaine gel can also be used for comfort. If proctitis is associated with severe rectal bleeding, consider GI evaluation. For pharyngitis, saltwater gargles, pain relievers, and extra fluids are all helpful.
Q: Patients at high risk for severe disease from monkeypox include those with immunocompromising conditions. What is your advice for treating these patients?
A: Dr. Tirupathi: Immunocompromised patients need longer time to recovery, and that needs to be factored in while caring for these patients. Immunocompromised patients tend to have a protracted and more severe infection course. They might need more intensive clinical inpatient care, with needs including [nasogastric] tube feeds, oral care, and analgesic management. This may in turn lead to longer hospital stays. There is also discussion of extending duration of treatment with tecovirimat to 21 days instead of the recommended 14 days in this subset of patients.
Q: Should hospitalists currently be doing anything differently given this outbreak?
A: Dr. Tirupathi: I do not think that the current outbreak disrupts the hospitalist workflow like COVID did; however, hospitalists need to have a high degree of suspicion in patients with an appropriate risk profile presenting with a vesiculopustular rash or symptoms of proctitis, anogenital ulcerations, or pharyngitis with oral ulcerations. Prompt testing, alerting infection prevention for isolation, and expert consultation when indicated is very necessary for optimal short-term and long-term outcomes.
Testing via multiplex PCR is now available through multiple commercial laboratories, and most hospital and health care systems have arrangements made for the same. I would recommend hospitalists be aware of the testing arrangements at their health systems, as well as the turnaround time for those tests.
I would also recommend hospitalists make themselves familiar with the compassionate use or expanded access investigational new drug program of the CDC through which tecovirimat could be obtained currently. CDC has significantly streamlined the process to procure tecovirimat. Hospitalists, like other health care providers and clinicians, also need to encourage monkeypox vaccination in appropriate at-risk patients and guide them to necessary resources.
Q: Do you have any other advice for hospitalists on this topic?
A: Dr. Palabindala: With exhaustion from the COVID pandemic and stretched-thin resources, another panic outbreak alert is definitely painful for hospitalists as a frontline team. Because of the mode of transmission, transmission rates, and mortality rate, we want hospitalists to think of monkeypox differently [in terms of] resource optimization. Extra vigilance and awareness of the basic presentation is more than enough to deal with this pox, and keeping up with simple educational material like this.