Clinician Alert: Monkeypox in Europe and North America

May 23, 2022

Requested actions

• Be aware that multiple outbreaks of monkeypox have been detected in Europe and North America during the month of May, including a case diagnosed in a Massachusetts resident last week.
• Recognize the clinical syndrome and rash features of monkeypox.
• If you see a suspected case, promptly institute standard, contact, droplet and airborne precautions and notify the Health District immediately at (425-339-3503).  
• Collect at least 2 specimens as directed in the attached CDC Health Advisory, but please note the following:  one specimen should be collected from a dry lesion, and placed into a sterile specimen container with no viral or transport media; a second should be collected from any stage of lesion, and placed into a separate sterile specimen container with no viral or transport media.   Refrigerate (2–8°C) or freeze (-20°C or lower) specimens within an hour after collection. Coordinate specimen submission with the Health District.
• Wear personal protective equipment (PPE) utilizing contact, droplet, and airborne precautions (including gown, gloves, eye protection, and fit-tested respirator) when providing care to and collecting specimens from patients with suspected monkeypox virus infection. 

Background

• Monkeypox is a zoonotic orthopoxvirus endemic in central and western Africa with a clinical presentation similar to but milder than smallpox. The sylvatic reservoir is not specifically defined, but rodents and non-human primates have been implicated in transmission. 
• During the month of May 2022, multiple western European countries have reported confirmed cases of monkeypox, many of whom had not travelled or had contact with anyone with a relevant travel history.  Last week, monkeypox was confirmed in a Massachusetts resident who had recently returned from travel to Canada.  A substantial but unspecified proportion of these cases have been among men who have sex with men, some of whom presented to sexually transmitted infection clinics for genital-or-perianal skin lesion as their sole presenting symptom.

Source: European CDC, May 23, 2022

Clinical Information

• A high index of suspicion for monkeypox is warranted when evaluating people with the characteristic rash, particularly for the following groups: 
  1. men who report sexual contact with other men and who present with lesions in the genital/perianal area, 
  2. people reporting a significant travel history in the month before illness onset, or 
  3. people reporting contact with people who have a similar rash or have received a diagnosis of suspected or confirmed monkeypox.
• Presenting symptoms typically include fever, chills, headache, weakness and lymphadenopathy followed by the typical rash.  However, onset of perianal or genital lesions in the absence of subjective fever has been reported. The rash associated with monkeypox can be confused with other diseases (e.g., varicella, herpes zoster, measles, herpes simplex, secondary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, molluscum contagiosum, and contact dermatitis).  It is not necessary to exclude each of the listed entities in order to classify a case as suspected, but they should be considered and tested for in parallel when indicated.
• Typical monkeypox lesions involve the following: deep-seated and well-circumscribed lesions, often with central umbilication; and lesion progression through specific sequential stages:  macules, papules, vesicles, pustules, and scabs. Synchronized progression occurs on specific anatomic sites with lesions in each stage of development for at least 1–2 days. The scabs eventually fall off. Lesions can occur on the palms and soles, and when generalized, the rash is very similar to that of smallpox including a centrifugal distribution.
• Complications in endemic countries have included encephalitis, secondary skin bacterial infections, dehydration, conjunctivitis, keratitis, and pneumonia.
• Treatment is primarily symptomatic and supportive (alleviation of fever and pruritus, hydration), including prevention and treatment of secondary bacterial infections. Antivirals (e.g., cidofovir, brindcidofovir, tecovirimat) and vaccinia immune globulin are potential options for severe cases.
• The incubation period is generally 7-14 days with a maximum range of 5-12 days.
• Duration of infectiousness is from the onset of the prodromal illness until all scabs have fallen off and the underlying skin has healed over several weeks later.  
• Monkeypox does not spread easily between people. Between humans, the virus can be transmitted by respiratory droplets during direct and prolonged face-to-face contact. In addition, monkeypox virus can be transmitted by direct contact with body fluids of an infected person, contact of mucosa or non-intact skin with open rash lesions or with virus-contaminated objects, such as bedding or clothing. Sexual transmission of monkeypox also has been described and appears contributory for at least some of the cases in the current context.
• Because monkeypox virus is closely related to the virus that causes smallpox, the smallpox vaccine can protect people from getting monkeypox when used as post-exposure prophylaxis and given within four days of last exposure (efficacy of at least 85%).

Additional Resources

• What Clinicians Need to Know About Monkeypox. Centers for Disease Control and Prevention (webinar scheduled for Tuesday, May 24, 2022, 11:00AM-12:00PM; may be archived for later viewing).
• Monkeypox Multi-Country Outbreak.  European Centre for Disease Prevention and Control (accessed May 23, 2022).
• Monkeypox: Information for Clinicians. CDC (accessed May 23, 2022).