Related to smallpox, but monkeypox virus is far less fatal. It's less transmittable and only occasionally seen in the United States - UMC EMS ...
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Monkeypox Related to smallpox, but monkeypox virus is far less fatal. It’s less
transmittable and only occasionally seen in the United States.
On July 16, 2021, a single case of monkeypox was
discovered in Dallas, Texas. This then led to health
Typically 6 to 13 days, but can authorities monitoring over 200 individuals in the United
range from 5 to 21 days. States who had contact with this infected person. The
question comes up: How worried should we be about it?
Two to four weeks. The infected individual acquired monkeypox while in Lagos,
Nigeria and flew to the United States, entering at Atlanta
before the plane continued its journey
to Dallas’ Love Field. He didn’t develop
Droplets. These can originate the rash until four days later and when it
from oral secretions, blood, appeared, he sought medical care at a
respiratory secretions, or from Dallas hospital. He was isolated at that
infected skin lesions. time to prevent further spread of the
disease.
Gloves, eye protection, N95 With international travel comes an
mask, and gown. The patient increased risk of seeing exotic
can be contagious before the pathogens brought to our soil. Since
rash develops. monkeypox was discovered just a half
day’s drive from us, it’s worth learning
about the signs, symptoms, and Lagos, Nigeria is a huge, modernized city in
Since the wet or dry skin Africa with a population of over 14 million.
lesions can transmit the virus,
any equipment in contact by
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the patient or healthcare
provider’s contaminated
gloves needs to be disinfected
with a high-level hospital-
grade disinfectant.
infectivity of this virus. While it’s not smallpox or chicken pox, it can look a lot like it and carries similar
precautions to prevent further spread of the disease.
Monkeypox is closely related to smallpox but is nowhere near as deadly. They share the same genus
(Orthopoxvirus) but the viruses themselves are distinctly different. For example, the smallpox fatality rate is over
30%.1 The estimated fatality rate from monkeypox is much less, ranging from 1 to 10% and mostly affecting
young people.1 The usual cause of death is from complications such as secondary infections.
The variant carried by the Dallas patient was one of
the least fatal ones (about 1%). In conjunction with
mandatory mask use on flights, the suspected
infection risk to other airline passengers was very
low. This virus is usually spread by large respiratory
droplets where most can be blocked by layers of
fabric.
There is potential for airborne release, which is why
N95 masks are recommended for healthcare
providers who care for these patients. The other
common mode of transmission is contact with the Monkeypox infection in Somalia. The respiratory droplets,
fluid or dried scab from blisters on the skin. blister fluid, and dried scabs all contain infective material.
In 1958, two outbreaks of a pox-like illness with blisters, fever, and other
symptoms were discovered in colonies of monkeys kept for research. This
virus was noticeably different from the usual primate diseases and so was
named “monkeypox”.
Human infection wasn’t reported until 1970 during efforts to eliminate the
closely related and more injurious smallpox virus. During this time, healthcare
providers discovered a nine year old boy with a pox-like disease, but it wasn’t
smallpox.1 The tell-tale sign: His lymph nodes were swollen
(lymphadenopathy). This sign is not found with smallpox but is very common
with monkeypox.
Image: Rhesus monkey infected Today, monkeypox is usually found in the rural, rainforest regions of the Congo
with monkeypox. Basin, particularly in the Democratic Republic of the Congo.1
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Monkeypox occasionally slips into the United States through
international travel or by importing certain animal species such as
rodents. While it presents a lot like smallpox, the lymphadenopathy
is a key distinguishing feature. The virus is not as easily transmitted
compared to smallpox and the disease itself is a lot less fatal.2
Smallpox is different from monkeypox and shouldn’t be described as
the same exact disease when educating patients. The last known
natural case of smallpox was found in Somalia in 1977. Since then,
the only known cases were caused by a laboratory accident in 1978
in Birmingham, England, which killed one person and caused a
limited outbreak.1 Smallpox was officially declared eradicated in
1979 although samples remain in two highly-secured global
laboratories (one in the US) for research needs.1
Image: Lymphadenopathy (swollen lymph
nodes) in a child with early monkeypox.
The fatality rate from monkeypox ranges from 1 to 10%. This wide range is attributed to the existence of two
known, distinctly different genetic clades (variants) of the virus: The Congo Basin and the West African clades.
The Congo Basin clade is more virulent, easily transmitted, and carries an overall higher fatality rate. The West
African clade is less problematic. It has a low fatality rate, is not as easily transmitted to others, and fortunately
for us is the one that infected the traveler from Nigeria. In Africa, the geographical dividing line between the two
clades is thought to be in Cameroon as this is the only country where both monkeypox virus clades have been
detected. 1
Most cases of monkeypox resolve on their own within 2 to 4 weeks. However, severe cases can occur and usually
affect children more often than adults. Severe complications are usually related to the extent of virus exposure,
patient health status, and nature of the
complications.1 Secondary skin infections,
respiratory bronchopneumonia, sepsis,
encephalitis, and infection of the cornea with
ensuing loss of vision are known complications
associated with monkeypox.1
Besides the risk to public health, these
complications offer another reason to
transport the patient directly to the hospital
with appropriate PPE and minimizing contact
with others. These are not the patients to
punt to triage or refer to a clinic the next day.
If for some reason the patient refuses
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transport, medical control should be contacted as this is a public health concern and a reportable disease to the
health department.
In Africa, most cases are through animal-to-human transmission. The person directly contacts blood or body
fluids of infected animals or eats their undercooked meat. Infected animals include rope squirrels, tree squirrels,
Gambian pouched rats, dormice, different species of monkeys, and other
mammals.1 The natural reservoir of monkeypox has not yet been identified,
though rodents are the most likely.1
Secondary transmission (human-to-human) is more limited.
Infection can occur through close contact with respiratory
secretions, touching the skin lesions or blisters of an infected
person, or through contact with recently contaminated
objects such as medical equipment.
Transmission through respiratory droplets usually requires close
Image: A Gambian pouched rat. It is not a
true rat, but a native African rodent. A contact, so family members tend to be at higher risk of contracting
Gambian pouched rat infected with the monkeypox. In some close-quartered settings such as an
monkeypox virus was imported into the US in ambulance, this puts healthcare providers at greater risk as well.
2003. It was shipped with prairie dogs bred The longest documented chain of transmission in a community was
as pets, infected them, and they caused six successive person-to-person infections. Transmission can also
several human infections in the end.
occur via the placenta from mother to fetus (congenital
monkeypox).1
The incubation period (time from exposure and infection to the onset of symptoms) is usually from 6 to 13
days, but usually ranges 5 to 21 days. A person infected with monkeypox usually displays one or more of the
following signs and symptoms:
• Fever
• Headache
• Myalgia (muscle aches, particularly back pain)
• Lack of energy
• Swollen lymph nodes, a key finding
• The rash usually appears later, as described on the next page.
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The fever, headache, and muscle aches form the
initial clinical signs of monkeypox, which is then
followed by swollen lymph nodes and a rash within
one to three days. The rash starts flat but quickly
blisters; It may only have a few vesicles or extends to
several thousand of them that cover the entire body.
During the peak of infection, monkeypox blisters
usually concentrate on the individual’s face in about
95% of people1 and the hands and soles of the feet in
75% of the infected population.1 However, the
blisters and rash can exist anywhere and everywhere. Image: The rash starts flat and red as shown above. It
soon evolves with raised, fluid-filled blisters.
The monkeypox rash changes its appearance with
time. It starts off as patches of flat, red rashes that morph into papules (slightly raised firm lesions). The papules
then change into vesicles (lesions filled with clear fluid), then pustules (lesions filled with yellowish fluid), and
finally crusts. The crusts eventually dry up and fall off.1 The fluid in the blisters and even the scabs are infectious.
Image: Evolution of the monkeypox rash to vesicles, pustules, and finally scabs.
Images are from individual, unrelated patients.
Monkeypox is initially suspected by the signs and symptoms, but its similarities to other pox diseases requires
further testing. Polymerase chain reaction (PCR) is the preferred laboratory test on skin lesions given its accuracy
and sensitivity, particular for public health needs. Specimens collected at the hospital are sent to a biosafety
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level-two or more stringent level-three testing facility.1,3,4 This is not a lab test performed at the hospital or a
standard testing facility.
Mass vaccination efforts in Africa to eliminate smallpox also
prevented monkeypox infections in these individuals. While
the peak of vaccination was completed a long time ago in
Africa, our US military continues to vaccinate selected
Smallpox vaccines should not be given to
personnel for smallpox due to the greater risk of contracting
those with eczema or a compromised
this disease in a potential bioterrorism attack and their
immune system. The risks include:
international deployments.
The live vaccine does not use actual
Eczema vaccinatum is a smallpox
smallpox viral material... that would
vaccination complication that can occur
be too risky. Instead, it uses a pox
in persons with a history of eczema
strain that may have been originally
and/or atopic dermatitis. The vaccinia
derived from horsepox based on virus causes an extensive rash and
genetic analysis of early 20th century systemic illness.
smallpox vaccines.5 The vaccine
affects most poxes of the
Orthopoxvirus genus.
Since smallpox has been eradicated to the best of our
knowledge, routine vaccination is not recommended for the
general public or most healthcare providers. Although there
are FDA-approved smallpox vaccines used in the United States
(ACAM2000™, JYNNEOS TM™) made from the live vaccinia
virus (not the virus that causes smallpox), they still have risks. Progressive vaccinia is rare, severe, and
often fatal. It occurs when a vaccination
site fails to heal and live vaccinia virus
It is a live attenuated vaccine, so can cause problems in
replication persists. The skin surrounding
individuals with a compromised immune system the vaccination site becomes infected
(neonates/fetuses, patients with cancer, autoimmune with vaccinia virus and the lesion
disorders, HIV, some forms of eczema, etc.).6,7 Some of these continues to grow. This occurs in
risks include developing very rare forms of eczemaforms of immune-compromised individuals.
vaccinatum
eczema and progressive
vaccinatum vaccinia.vaccinia.
and progressive While extremely
While ext
uncommon, both conditions are potentially disabling or
even fatal.7
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Since vaccination is not recommended for most healthcare providers and the general public, preventing viral
transmission in the first place now becomes the primary method of preventing monkeypox spread. This includes
avoiding contact with blisters or even dried lesions, thoroughly disinfecting all
equipment such as door handles, stethoscopes, blood pressure cuffs, and even
stretcher straps in contact with the patient using an EPA-registered hospital
disinfectant8 such as Cidex™ 9, and just as importantly, donning appropriate
PPE.
Monkeypox is a respiratory droplet precaution disease, so PPE would
include gloves, gown, eye protection, and preferably an N95 mask instead of
a surgical mask.8 If the patient can tolerate a surgical mask, consider
applying it to reduce the risk of viral transmission through a cough or
sneeze. Blistered areas of the skin such as arms and legs should be kept
covered with an impervious sheet (if available) to prevent accidental,
unprotected wet contact by other healthcare providers. The hospital
should direct the patient to a negative pressure room as a precaution,8
so early notification to the receiving hospital is important.
10
Clinical Characteristic: Smallpox: Monkeypox:
Incubation period 7 to 19 days 5 to 21 days
Yes. Occurs before the Yes. Occurs before the
Fever
onset of skin lesions. onset of skin lesions.
Malaise Yes Yes
Headache No Yes
Lymphadenopathy No Yes
Animal-to-human or
Transmission Human-to-human only
human-to-human
Chart adapted from McCollum AM (2019)
In conclusion: You may never encounter a patient with monkeypox while working in the United States. It’s that
uncommon. However, the recommendations and complications associated with monkeypox can be applied
towards other more common pox-like diseases such as chickenpox or shingles. Remember that complications are
possible, PPE will be your friend, and disinfect *everything* that contacted the patient or that you touched as a
provider. You never know if your next patient on the ambulance will have an autoimmune disorder or other
compromise to his or her immune response. If an effort to help as a healthcare provider, you could cause more
harm and we want to avoid that with those few extra minutes in preparation and disinfection.
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1 Smallpox. World Health Organization. Web page: https://www.who.int/news-room/fact-
sheets/detail/monkeypox. June 28, 2016. Accessed: July 25, 2021.
2 About Monkeypox. Centers for Disease Control and Prevention. Web page:
https://www.cdc.gov/poxvirus/monkeypox/about.html. Last reviewed: July 16, 2021. Accessed: July 25,
2021.
3 Alakunle E, Moens U, Nchinda G, et al. Monkeypox Virus in Nigeria: Infection Biology, Epidemiology, and
Evolution. Viruses. 2020;12(11):1257. Published 2020 Nov 5. doi:10.3390/v12111257
4 Monkeypox: Laboratory Procedures - Routine Chemistry, Hematology, and Urinalysis in Hospitals or Clinical
Laboratories. Centers for Disease Control and Prevention. Web site:
https://www.cdc.gov/poxvirus/monkeypox/lab-personnel/lab-procedures.html. Last review: May 11, 2015.
Accessed: July 27, 2021.
5 Schrick L, Tausch SH, Dabrowski PW, et al. An Early American Smallpox Vaccine Based on Horsepox. N Engl J
Med. 2017;377(15):1491-1492. doi:10.1056/NEJMc1707600
6 Kantele A, Chickering K, Vapalahti O, et al. Emerging diseases-the monkeypox epidemic in the Democratic
Republic of the Congo. Clin Microbiol Infect. 2016;22(8):658-659. doi:10.1016/j.cmi.2016.07.004
7 Petersen BW, Kabamba J, McCollum AM, et al. Vaccinating against monkeypox in the Democratic Republic of
the Congo. Antiviral Res. 2019;162:171-177. doi:10.1016/j.antiviral.2018.11.004
8 Monkeypox. Infection Control: Hospital. Centers for Disease Control and Prevention. Last reviewed: May 11,
2015. Web site: https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-hospital.html.
Accessed: July 27, 2021.
9 FDA-Cleared Sterilants and High Level Disinfectants with General Claims for Processing Reusable Medical and
Dental Devices. U.S. Food & Drug Administration. Updated: September 2015. Web site:
https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices-information-
manufacturers/fda-cleared-sterilants-and-high-level-disinfectants-general-claims-processing-reusable-
medical-and. Accessed: July 28, 2021
10 McCollum AM. Centers for Disease Control and Prevention. Smallpox & Other Orthopoxvirus-Associated
Infections. Last reviewed: June 24, 2019. Web site: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-
related-infectious-diseases/smallpox-and-other-orthopoxvirus-associated-infections. Accessed: July 27, 2021
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Rhesus monkey with monkeypox infection on page2: Non-Human Primate Models of Orthopoxvirus Infections -
Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Monkeypox-virus-
infected-Macaca-mulatta-M-mulatta-with-multifocal-severe-papular_fig1_294426060. Accessed: July 28, 2021.
Lymphadenopathy on page 5: Monkeypox Clinical Presentation. Medscape. Last updated: September 26, 2019.
Web site: https://emedicine.medscape.com/article/1134714-clinical#b2. Accessed: July 28, 2021.
Evolution of rash on page 5: Monkeypox. Public Health England. Last updated: December 5, 2019. Web site:
https://www.gov.uk/guidance/monkeypox. Accessed: July 28, 2021.
Eczema vaccinatum and progressive vaccinia on sidebar of page 6: Vaccine Adverse Reaction Images. Centers for
Disease Control and Prevention. Last reviewed: December 5, 2016. Website:
https://www.cdc.gov/smallpox/clinicians/vaccine-adverse-reaction-images.html. Accessed: July 28, 2021.
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