Monkeypox Going Viral! What You Need To Know

Maggie Aime, BSN, RN

An outbreak of monkeypox has recently been confirmed in several countries in Europe, in Canada, and in the United States; these are countries where the disease does not naturally occur and is not typically reported. It's not known how the infected individuals contracted the disease as they did not report recent travel to Central or West Africa where monkeypox is prevalent. Monkeypox is not a new virus and it has been studied over several decades; however, the current outbreak is very concerning to public health officials as the disease has never been found simultaneously in different countries/continents where it is not endemic.

What is Monkeypox?

Monkeypox is a disease caused by the monkeypox virus which is a zoonotic virus (a virus that is transmitted to humans through close contact with infected animals). This virus was discovered in 1958 with the first human case diagnosed in 1970. It is endemic to Central and West Africa where it is found primarily in non-human primates and rodents.

Two different strains of monkeypox have been studied: The one from West Africa is less severe with a fatality ratio of 1% and is usually self-limiting. The other strain, from Central Africa, causes more severe illness with a fatality ratio of up to 11%.

According to the World Health Organization (WHO), between May 13, 2022 and June 2, 2022, a total of 780 confirmed cases of monkeypox have been reported in non-endemic countries. As of June 6, 2022, there are 31 confirmed monkeypox cases in the United States (CDC).

Modes of Transmission

Human-to-human transmission of monkeypox occurs primarily through:

Close and prolonged contact with the respiratory secretions of an infected person.
Skin-to-skin contact with the mucous membranes, skin lesions, or bodily fluids of an infected person.
Contact with contaminated objects belonging to an infected person.

The Centers for Disease Control and Prevention (CDC) reports individuals at a higher risk of being infected with monkeypox include anyone who:

Had close physical contact, kissing, hugging an infected person or someone who has symptoms.
Had contact with objects (including clothing, linen, etc.) or other personal items belonging to someone who is infected or has symptoms.
Traveled abroad to a country where monkeypox has been reported or where monkeypox is prevalent.
Had contact with wild or exotic animals (dead or alive), this includes contact with their meat or byproducts.
Ate raw or inadequately cooked meat of infected animals.

While monkeypox is not known to be a sexually transmitted infection, the CDC says that, with the current outbreak, many of the reported cases involve individuals who had sex with an infected person and men who had sex with men. It is known, though, that contact with monkeypox skin lesions during sexual relations can cause an infection.

An individual is considered infectious from the onset of symptoms until the scabs have crusted over and fallen off.

Signs and Symptoms

According to the CDC, monkeypox infection follows a clinical course like that of smallpox. Once infected, there is an incubation period of approximately 5 to 21 days, after which the initial symptoms of fever, headache, muscle aches, sore throat, cough, weakness develop.

In addition, people infected by monkeypox will also develop lymphadenopathy (swelling of the lymph nodes) in the neck, axilla, and/or groin which is a symptom that is not typical of smallpox.

About 1 to 3 days after the initial symptoms, a rash will develop with lesions that first look like macules. These macules will then progress to become papules, then vesicles, then pustules, and eventually scabs that will fall off, after which the person is no longer considered contagious.

At-a-glance: Stages of Monkeypox Lesions (CDC)

Type of lesion	Last about...
Macules (flat lesions usually on the face, arms, legs, hands, feet including palms and soles, look like chickenpox but larger)	1 to 2 days
Papules (raised lesions)	1 to 2 days
Vesicles (sacs filled with clear or yellow fluid)	1 to 2 days
Pustules (filled with an opaque fluid resembling pus)	5 to 7 days
Scabs	7 to 14 days

The CDC reports that, with this current outbreak, they have noted common initial symptoms of genital rash or rash around the orifice. In some cases, patients developed pustules before developing constitutional symptoms. These are different from the typical presentation of monkeypox.

Diagnosis

Monkeypox is best diagnosed by polymerase chain reaction (PCR) testing with samples taken from the roof or fluid from skin lesions. A biopsy may also be performed. The WHO reports that PCR blood tests are typically inconclusive and should not be routinely performed.

Treatment

Currently, there is no targeted treatment for monkeypox. Antivirals that are used to treat smallpox can be used for monkeypox. Individuals who have been exposed are asked to monitor themselves for the development of symptoms for 21 days after their last exposure. Post-exposure prophylaxis (PEP) with smallpox vaccine has been shown to offer protection against monkeypox.

Most cases of monkeypox resolve on their own; however, medical complications from monkeypox infection have been reported especially in the young and in people who are immunosuppressed.

Patient Care and Precautions

Patients with monkeypox and those suspected to have the virus should be isolated in a private room with the door closed. Currently, the CDC does not recommend a negative air pressure room for patient placement; however, procedures like intubation, extubation, and those that can spread respiratory secretions must be done in an airborne isolation room.

Transport and movement of infected patients should be kept to a minimum and, if necessary, patients should wear a surgical mask that fits well over their nose and mouth, and all skin lesions should be covered with a sheet to prevent aerosolization or contact with the lesion.

Healthcare providers are instructed to consult their state health department immediately for any suspected case of monkeypox.

Precautions for Healthcare Personnel

When caring for an infected or potentially infected patient, healthcare personnel must follow standard, contact, and droplet precautions:

Wear personal protective equipment (PPE) to include a gown and gloves.
Make sure eyes, nose, and mouth are fully covered with a face shield.
Wear a fit-tested NIOSH-approved N95 mask or higher-level respiratory protection.
Use dedicated or disposable equipment.
Practice good hand hygiene.

Pre-exposure prophylaxis (PrEP) with smallpox vaccine is available to protect certain designated healthcare employees.

Education for the Public

As nurses and healthcare providers, we have a duty to educate the public about prevention measures and what to do if exposed to monkeypox or if symptoms develop:

Avoid contact with people who have symptoms or are confirmed to have monkeypox.
Avoid contact with wild or exotic animals (dead or alive).
Do not eat raw or inadequately cooked meat of exotic animals.
Monitor for symptoms if recent travel to an area where monkeypox has been reported.
Contact a healthcare provider immediately if suspected infection or if symptoms develop.
Stay in a room separated from others if suspected infection or if symptoms develop.
If infected, wear a mask and keep lesions covered with long sleeves and pants to avoid contaminating others.
If infected, avoid contact with pets as they are susceptible.
Keep any infected person in the household in a separate room with the door closed.
Wash hands frequently.
Wear a medical mask and use gloves when caring for an infected person at home.
Avoid contact with the skin lesions of infected individuals.