What rheumatologists need to know about monkeypox

Between rapidly increasing case counts and a flood of misinformation reported online and in media, the facts surrounding the current monkeypox outbreak around the world and in the United States might indicate some cause for alarm.

However, understanding the virus, the way it is transmitted, and the ways infection can be prevented and treated, may prove to be the best weapon in combatting this latest disease outbreak.

The United States has now recorded more than 18,400 confirmed cases since May, according to the CDC. Moreover, on July 23, the WHO director-general declared the escalating global monkeypox outbreak a Public Health Emergency of International Concern, which is the same designation that was assigned to the SARS-CoV-2 virus in January 2020.

Multiple U.S. states have seen case numbers escalating, if not doubling, at rapid rates, and on Aug. 31 Texas officials announced the first death of someone in the United States with monkeypox. However, officials have not determined whether the disease was the person’s cause of death.

In addition, issues with the vaccines may make at least one of the products less than attractive for most individuals, and particularly concerning for patients with autoimmune diseases.

In addition, as with many newsworthy topics in the internet era, misinformation abounds. Speculation about how and where the virus is being transmitted, along with falsities about the two approved vaccine products — Jynneos (Bavarian Nordic A/S) and ACAM2000 (Emergent Product Development) — have worked their way from social media into some mainstream news outlets.

Healio sat down with Cassandra Calabrese, DO, assistant professor of medicine in the department of rheumatic and immunologic disease, and the department of infectious disease, at the Cleveland Clinic Foundation, to set the record straight.

Healio: Could you give some background on the virus itself?

Calabrese: The monkeypox virus is in the same family as smallpox, which is maybe why many people are concerned about it. Fortunately, though, the disease it causes is milder than smallpox, although the lesions can be quite painful. The lesions develop at the initial point of contact, which, at the moment, are occurring most frequently on the genitals and mouth. Usually there is a prodromal period which may include fever, lymphadenopathy, myalgia and headaches before the rash appears.

The rash itself evolves through several stages, including fluid-filled blisters that ultimately scab. Monkeypox is a milder disease than smallpox and is rarely fatal. Historically, it is endemic in parts of Africa, and has been for decades there. However, it is rarely seen outside of Africa, which is why there has been concern about the recent outbreak.

Healio: Besides the lesions, what other symptoms can patients have?

Calabrese: Fever and swollen glands are common, along with myalgia.

Healio: How is monkeypox transmitted?

Calabrese: It is spread through close contact, usually skin to skin. It is not a disease that can be transmitted through the air. Because it requires such close contact, one of the misconceptions is that it is a sexually transmitted infection (STI). Although it is not technically an STI, at present its main mode of transmission is through sexual contact. A significant amount of virus must be present for infection, so while you can’t get it from touching a doorknob touched by someone who is sick, you could technically become infected through towels or bedding used by someone infected with monkeypox.

Healio: Is there anything else about transmission that is worth noting?

Calabrese: You need to have symptoms to spread infection, which is really important to consider in the context of COVID-19, which can be transmitted asymptomatically. Monkeypox cannot be transmitted asymptomatically.

Healio: Who is at risk for monkeypox?

Calabrese: At present, the virus is mostly circulating through social networks, which currently is in men who have sex with men (MSM), although there have been cases reported in women and children, albeit at very low numbers. More specifically, a large portion of the patients also have HIV. This is why, at the moment, the recommendations for the vaccine and post-exposure prophylaxis are largely targeted only to those groups.

Healio: Are there concerns that the virus will move beyond those specific social networks?

Calabrese: Although there is potential for more spread in the community, I think with the right public health measures it can be contained. This will rely on ease of access to vaccines and treatments for those who need it, which currently remains a bit of a challenge. The CDC has published recommendations, which include prevention modalities about minimizing skin-to-skin contact, being aware of partners within the last 2 weeks and any jobs that may put you at risk for monkeypox.

Healio: Can we talk about the vaccines?

Calabrese: Sure. The Jynneos vaccine is approved under Emergency Use Authorization for the prevention of monkeypox. It can also be used as post-exposure prophylaxis. However, it is in very short supply at the moment. The FDA is making an effort to increase available doses.

The ACAM2000 vaccine is approved for immunization against smallpox disease and made available for use against monkeypox under an Expanded Access Investigational New Drug protocol. It is a second-generation smallpox vaccine and is available in the Strategic National Stockpile. It is a live replicating vaccine and thus carries with it some risks, including acquisition of vaccinia virus infection — the virus contained in the vaccine, related to smallpox — as well as other significant adverse events, including myocarditis. Healio: Are there concerns about these vaccines in immunosuppressed patients?

Calabrese: Because ACAM2000 is a live virus vaccine, it is contraindicated in the setting of immunosuppression.

Healio: Could you talk a bit more about using Jynneos as post-exposure prophylaxis?

Calabrese: The current CDC guidance for vaccine as post-exposure prophylaxis are for the vaccine to be given within 4 days from the date of exposure. It is also possible to administer vaccine up to 2 weeks after exposure, which might reduce symptoms but may not prevent monkeypox infection.

Healio: How about treatments?

Calabrese: There is an investigational antiviral tecovirimat, also known as TPOXX or ST-246 (Siga Technologies), but there have been access issues with this, as well, which has frustrated physicians who are treating patients.

Healio: Are patients with autoimmune or inflammatory diseases at any particular risk?

Calabrese: I am not sure we know a lot about that right now. We do know that there are a lot of cases among people with HIV, but that presents its own challenges. The immune status of persons living with HIV can range from very healthy people with well-controlled disease to others who do have the virus less under control. So, at the moment, we do not have reason or knowledge to say that patients with our diseases would do any worse, but it is possible. But we are still learning. I can say that the JYNNEOS vaccine is safe to give immunocompromised patients or those with immune-mediated inflammatory diseases.

Healio: Is the vaccine safe for patients being treated with B–cell depleting therapies?

Calabrese: The vaccine is theoretically safe for all immunocompromised patients.

Healio: Any final thoughts or considerations?

Calabrese: I would like to reiterate that with appropriate public health measures, it seems that the spread of monkeypox will continue to decelerate.