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Monkeypox: A Global Health Emergency

by Michael D. Cohen MD

The World Health Organization has designated monkeypox a global health emergency because it has suddenly and unexpectedly spread around the world via new modes of transmission that are not understood. It is an emergency because it is still spreading. But the numbers of people infected are still small, and it is not circulating widely in the population. People should be well informed about this new illness and how it may affect them. In this article I will summarize what is known about monkeypox and the current recommendations from public health agencies.

What is monkeypox?

Monkeypox is a disease that originatedin African monkeys. It is similar to smallpox, but monkeypox usually causes a milder illness that is rarely fatal. In the past, people who had contact with infected monkeys in certain parts of Africa were primarily those who got monkeypox, but in recent months a worldwide outbreak of monkeypox has occurred. There are already more than 11,000 cases in the U.S. alone. Recently, Cook County jail in Chicago reported the nation’s first incarcerated person with monkeypox. Monkeypox is still a rare disease. But it is important to be informed about symptoms, spread, and what to do if you are exposed.

What does the monkeypox rash looks like?

Monkeypox causes sores on the skin, often called a rash. The skin sores change over time. New ones appear as older sores scab over and heal. Monkeypox sores can look like a pimple: a bump with a light-yellow center and surrounding pink skin. The sores can look like chickenpox or herpes: a cluster of tiny clear blisters. Sores on the palms or soles are just small, flat, dark spots. Eventually each sore forms a scab, the skin heals from below and the scab falls off. Any unexpected or unusual sore on the skin may be monkeypox or another illness. If you have a rash, get health care.

How does monkeypox spread?

A person with monkeypox can spread it to others from the first appearance of the sores until the skin under the last sore has healed and the scab falls off. It usually lasts about three weeks.

Monkeypox spreads among people in several ways. The virus shed from the sores or in the breath of the infected person must come in close contact with another person to spread. It can spread by skin-to-skin contact and on shared clothing, towels, bedsheets, toothbrushes, toilet seats or other personal items. It can also spread by breathing the exhaled breath of an infected person. These are all different types of very close contact that can occur among people living together, having sex, or gathered in crowds.

There is a lot we don’t know yet about monkeypox. It is not known if monkeypox can spread from infected people who have no symptoms. It is not known how often it is spread by droplets in the breath, saliva while kissing, or being near a person with monkeypox who coughs without a mask. It is not known how often it is spread via semen, vaginal fluids, urine, or feces.

Why is monkeypox spreading all over the world now?

We don’t know why this is happening. It is new and unexpected. Some super-spreader events have been identified where large numbers of people gathered together, spread monkeypox among each other, then returned home and started spreading it there. But monkeypox must already have been circulating even before those events.

The monkeypox virus may have become more infectious recently. Perhaps it spreads more effectively via new routes. Sexual transmission through contact with male or female body fluids may be occurring. One of the unusual characteristics of this outbreak is that the sores are showing up more often on areas of the body that have direct sexual contact.

Perhaps airborne infection can occur in crowded, poorly ventilated rooms where people are dancing vigorously and yelling, such as raves, house parties, and nightclubs.

Monkeypox is not a “gay” disease. Although most of the U.S. cases have occurred among gay or bisexual men, there have been cases in women and children, too. Any network of people—gay or straight—who have casual sex with multiple partners can become a super-spreader event when monkeypox is circulating in that population.

What is it like to have monkeypox?

After exposure via close contact with an infected person, there is an incubation period of usually 8–14 days before disease symptoms start. The illness may begin with the rash described above. More often there are flu-like symptoms before the rash, such as fever, chills, fatigue, headaches, body aches, and swollen lymph nodes.

Monkeypox sores can be painful. Also, they may itch a lot, like chickenpox. Control of itching is important because scratching can damage the skin around the sores resulting in bacterial skin infections like strep (impetigo) or staph (MRSA). Full recovery occurs when the last sore loses its scab and there is heathy skin where the sore used to be. This takes 2–4 weeks.

What treatment is there for monkeypox?

Monkeypox is similar to smallpox but not as dangerous. Treatment for monkeypox is available because there are military stockpiles of vaccines and medicine to treat smallpox if it were used as a biological weapon.

Vaccines: There are two smallpox vaccines currently available in small quantities that have been authorized by the Food and Drug Administration (FDA) for emergency use against monkeypox.

The JYNNEOS vaccine is injected under the skin (“subcutaneous”). Two doses four weeks apart are required. To amplify the current supply by reducing the dose, the FDA has issued emergency authorization to inject it into the skin (“intradermal”). The skin test used for tuberculosis screening is injected into the skin in the same way.

The ACAM2000 vaccine is administered by placing a drop of vaccine fluid on the skin and pricking the skin under it with a special needle. This was the original approach to vaccination that was used to eliminate wild smallpox in the 20th century.

The vaccines can be used to prevent monkeypox among people who are at highest risk for severe disease, such as the immunocompromised; children under 8 years old; pregnant women; and the elderly. Vaccines are also being recommended to prevent monkeypox among people who are at highest risk of becoming infected in this outbreak, such as men who have sex with men, especially those who are active in sexual venues; have had more than four partners in the past 14 days; exchange money for sex; or have sex with anonymous partners. As monkeypox spreads into other social or sexual networks, eligibility for preventive vaccination may change.

Vaccines are also recommended to prevent disease among people who have had close contact with an infected person. When close contacts are vaccinated, they may not become ill at all, or they may have a mild case with very few sores and minimal other symptoms.

Antiviral medication: There is also an antiviral that can be used to treat smallpox or monkeypox called tecovirimat (brand name Tpoxx). Supplies of tecovirimat are limited. It was approved by the FDA based on animal studies alone and has not been widely tested in humans.

Pain Control: The sores of monkeypox can be painful. Numbing medicines used for “cold sores” on the lips or lidocaine gel can be applied to monkeypox sores. Numbing mouth wash can be used for painful sores in the mouth. Stool softeners have been used to reduce pain from anal sores.

Itching Control: Measures used to control itching are similar to management of chickenpox—pink calamine lotion, antihistamines like Benadryl, or steroid cream like hydrocortisone. An oatmeal bath can be soothing (for example, Aveeno brand).

Why are prisoners at risk for monkeypox?

There are several aspects of life in carceral facilities that put people at risk for exposure to monkeypox. There are no CDC guidelines for prevention or management of monkeypox specifically in these settings; prisons and jails have been subsumed within the guidance for congregate living settings like homeless shelters, group homes, residential drug treatment centers, college dormitories, etc. However, the risks for the incarcerated are unique and require specific guidance. For example:

• People are often held for hours or days in crowded, unsanitary, poorly ventilated units like police lockups, receiving rooms, court “pens” and similar areas.

• Too many people are often housed in small cells, especially lockdown cells, where close physical contact is unavoidable.

• Physical contact in fights, restraints, or sexual contact may spread monkeypox among prisoners or between prisoners and guards or other staff.

Additionally, administrative segregation for infection control can inhibit prisoners from seeking health care, as can copays for health care. Punitive sick leave policies can also inhibit staff from isolating when they are sick with monkeypox.

These risks specific to prisons and jails must be addressed directly to prevent introduction and control the spread of monkeypox within these facilities.

How do you protect yourself from monkeypox?

Try to stay well informed with accurate information from state or local public health agencies or the Federal Centers for Disease Control and Prevention (CDC).

People who were vaccinated against smallpox in the past are probably still resistant to monkeypox. If you were born in the U.S. before 1971 you were vaccinated against smallpox. If you traveled internationally before 1981 you were also required to have smallpox vaccination.

There are many things people can do to reduce the risk of exposure to monkeypox. Most of these are good personal hygiene practices in general, not just for monkeypox:

• Avoid contact with those with a rash/skin sores (and encourage them to get health care);

• Screen sexual partners by asking about fever, sores or rash;

• Avoid casual sex with multiple partners;

• Avoid sharing personal items such as towels, sheets, toothbrushes, etc.;

• Avoid prolonged face-to-face contact breathing another person’s exhaled breath;

• Avoid crowded rooms with poor ventilation, especially places where people are shouting or singing loudly; and

• Avoid direct skin contact with toilet seats or sports equipment others have used, cleaning them between users with disinfectant wipes, or place a toilet paper barrier on a public toilet seat if no wipes are available.

If you are exposed to monkeypox or have symptoms such as fever or rash, get health care.

What should carceral
facility managers do?

It is understood from the COVID-19 experience that jail outbreaks increase community spread of infectious diseases. According to Dr. Homer Venters, spread in carceral facilities can be controlled by reducing close contact, increasing monkeypox detection and treatment, and eliminating barriers to care.

Cook County jail in Chicago was well prepared for a new infectious disease when its first case of monkeypox was diagnosed. Because of prior experience with COVID-19, the jail had well-established liaison with the local Department of Public Health. When a patient was diagnosed, officials were able to initiate medical isolation, perform contact tracing and monitor close contacts for symptoms, and test people for infection.

These are things that facility managers can do to reduce the risk of monkeypox transmission among the incarcerated:

• Reduce overcrowding by releasing people from jails who do not need to be locked up for public safety reasons;

• Reduce risks due to housing by addressing crowding in holding areas such as receiving rooms, central bookings, police lockups, court pens, etc.;

• Reduce or eliminate the practice of housing two or more in cells designed for one;

• Reduce or eliminate overcrowding in dormitories;

• Establish good liaison with local and state public health agencies in order to obtain tests, vaccines, and treatment medicine;

• Isolate each person with monkeypox behind a closed door with a private toilet, and if patients must move out of isolation they should wear a face mask, long pants, socks, and a long sleeve shirt (it is best if the patient does not touch doors or handles);

• Manage regulated medical waste from a room where a patient with monkeypox is isolated, following Department of Transportation hazardous materials regulations;

• Equip health staff or others with appropriate personal protective equipment (PPE). Anyone who may have to enter patient isolation rooms or handle their laundry needs PPE, including gowns, gloves, eye protection, and masks;

• Have 60% alcohol-based hand sanitizer and disinfectant wipes available to clean hands and surfaces, especially in public toilets;

• Do contact tracing when a case is identified; and

• Provide a vaccine to exposed people, since access to vaccines is a crucial component of monkeypox control.

The CDC recommends that people who had close or intimate contact with an infected person do not need to isolate unless they have symptoms of monkeypox. But those exposed must be monitored for fever twice a day and daily for chills, newly enlarged lymph nodes (“swollen glands”), and rash. Exposed people should be isolated if fever or rash develop.

Reporting of symptoms also limits disease spread, as does eliminating copays for health care, or at least for fever or rash assessment. If a person with monkeypox is held in a single cell with a toilet, allow him or her to isolate there rather than on a separate unit for monkeypox disease.

Implementing flexible sick leave policies that are not punitive will allow staff who must isolate with monkeypox to stay home throughout their illness. This is crucial to prevent spread from sick staff to residents in congregate care facilities such as prisons and jails. Policies should not force sick employees to come to work and spread the disease.

Scientific studies of monkeypox spread in the U.S. are just beginning. As more is learned about how and why this global outbreak has occurred, PLN will provide periodic updates for our readers in prisons and jails. 

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