Hello. I’m Paul Auwaerter with Medscape Infectious Diseases, speaking from the Johns Hopkins University School of Medicine.
Monkeypox joins the legion of occasional emerging infectious diseases that, as an infectious diseases consultant, we have to become at least familiar with, even if we’ve never seen it personally, and consider it when the occasion arises.
Monkeypox is a member of the orthopoxvirus family, which is the same as smallpox. It is generally a milder infection that causes very similar diseases, which I’ve never seen clinically, with the exception of one laboratory-acquired case of generalized vaccinia in a lab worker many years ago that we diagnosed by electron microscopy.
The current situation with monkeypox has certainly been in the news following an outbreak that, as of late May, has at least 260 cases in 19 countries, including many European countries, Argentina, and Australia, and also here in the United States, with at least 6 states reporting infections, including California, New York, Massachusetts, and Florida.
Monkeypox is something that we’ve seen before in the US. In 2003, there was an outbreak of 71 suspected or confirmed cases that were traced to the importation of Gambian giant rats, squirrels, or dormice that had spread to prairie dogs that were subsequently sold as pets. In all, 18 people were hospitalized, but there were no deaths, certainly suggesting a milder illness and that a higher mortality is seen with smallpox.
We don’t know much about monkeypox. Although it can reside in monkeys and be transmitted by that pathway, the thought is it probably has a reservoir more frequently seen in rodents. Acquisition to humans could be from handling infected animals or transmission through skin or mucous membranes, but it is mostly thought to be large droplet–related, because this is a large DNA virus and probably not prone to aerosolization.
The current outbreak here, in 2022, isn’t exactly clear, but there have been descriptions in Europe that certain social networks — such as, for example, men who have sex with men — may be contributing to the spread. Therefore, it needs to be considered also in the spectrum of, perhaps, a sexually transmitted disease (STD) when we’re evaluating patients.
From acquisition to acquiring symptoms can range from 5 to 21 days, with a 1- to 2-week average. The initial infection is, indeed, just a viral-like prodrome: sometimes a sore throat or lesions, with a rash that typically begins 1-3 days later, initially a viral-type exanthema that’s not specific. Flat or macular to papular lesions subsequently become nodular, umbilicated, or pustulovesicular before crusting. They classically occur on the face and then spread elsewhere to the body, with involvement of the palms and soles, which certainly makes it different from other things that might be on your differential, such as chickenpox. You may have some lymphadenitis as well.
The differential diagnosis, of course, comes up with primary infection with varicella, but other pox infections — cowpox, or smallpox if there’s a bioterror event — maybe should be considered if you’re thinking of measles or sexually transmitted infections (STIs), such as syphilis, herpes simplex virus (HSV), or chancroid.
How to diagnose it is, unfortunately, not straightforward. Neither a commercial laboratory nor your health system laboratory will be able to make the diagnosis, so you need to contact your local or state health department. There are links below this video for the CDC’s monkeypox site, where there is specimen collection information for obtaining direct skin lesion material for PCR analysis that can help confirm.
Generally, the skin is where you see most of this infection. Occasionally, if it’s severe, in patients with elevated fever or more than 100 lesions, especially in children, it can be quite awful and include pneumonitis. You may need to also consider proctitis if there is sexual transmission.
In terms of treatment, there are no approved treatments and most have been lifted from smallpox. There are now two FDA-approved oral drugs that seem to have broad in vitro poxvirus activity, including tecovirimat, which is FDA approved for smallpox in adults and children, and brincidofovir, a variant of cidofovir, which also can be used in people as young as the neonatal age range.
Other modalities could include a vaccinia immunoglobulin, hoping that there’s cross-reactivity. In terms of prevention, there is the smallpox vaccine available on limited supply, and also a modified vaccinia that has fewer side effects than typical vaccinia virus that goes by the trade name Jynneos. It’s available in very limited supply, but if you have a case with potential contacts, it might be considered, or it may be considered as adjuvant therapy for someone who’s infected.
There’s nothing well known or described. There’s a handful of case reports and a nice study out of the UK summarizing experience with monkeypox and some of these newer treatments, but it is uncertain whether they had an impact on outcomes or quicker resolution of illness, given the limited number of data points.
These are all things that I think will continue to evolve. Certainly, it sounds like this is the largest outbreak of monkeypox to date and it bears watching. Many have opined that they don’t think this will become significant from a public health standpoint, but it certainly bears watching and consideration by infectious disease consultants when evaluating certain patient types.
Thanks so much for listening. I hope this is helpful. Please see the background information if you need more. Thank you.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
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