Management Of Monkeypox

MANAGEMENT OF MONKEYPOX

https://meditropics.com/management-of-monkeypox/

Rashmi Rajput

Assistant Professor, Department of Medicine, LHMC

 

INTRODUCTION

 Monkeypox was first discovered in 1958 in monkeys kept for research hence the name and the first human case was reported in 1970 from democratic republic of Congo. It is a zoonotic disease which has symptoms similar to smallpox, but less severe than the latter.

EPIDEMIOLOGY-

 It is a double stranded DNA virus belonging to Orthopox virus (poxviridae) family. It has two genetic clades –

  1. Central African (Congo basin) clade- it causes more severe disease and is more transmissible.
  2. West African clade.

HOST–  Natural reservoir is unknown. Certain rodents like squirrels, tree squirrels, Gambian pouch rat and non-primate humans are naturally susceptible to small pox.

INCUBATION PERIOD – It is generally about 6-13 days, but can range from 5-21 days.

PERIOD OF COMMUNICABILITY – It is from 1-2 day prior to appearance of rash and lasts till all scabs fall off.

 

MODES OF TRANSMISSION-

 Human to human transmission –

  1. Via large respiratory droplets (prolonged contact).  
  2. Direct contact with body fluids or lesion material.
  3. Indirect contact with lesion material such as through contaminated clothing.
  4. In utero transmission (from mother to fetus.

 Animal to human transmission-

  1. Bite or scratch of infected animals.
  2. Bush meat preparation.

 

CASE DEFINITION-

Suspected case-

A person with history of travel to affected country within last 21 days presenting with an unexplained acute rash AND one or more of the following-

  • Swollen lymph nodes.
  •  
  •  
  • Body aches.
  • Profound weakness.

Probable case-

A suspected case with an epidemiological link (face-to-face exposure, HCW without appropriate PPE, direct contact with lesion, contact with contaminated materials).

Confirmed case-

Laboratory confirmed case (by detection of unique sequences viral DNA by PCR or sequencing).

 

Diagnosis of Monkey-pox –

Healthcare personnel must be in PPE for collecting samples.

Criteria for sample collection-

  1. Asymptomatic travelers coming from endemic region- Observe them for 21 days. If signs and symptoms develop during this period, then collect samples as outlined for symptomatic patients.
  2. Symptomatic patient-
  3. Rash phase – Samples must be collected from multiple sites.
  • Lesion roof with scalpel or plastic scrapper collected in a plain tube.
  • Lesion fluid with intradermal syringe.
  • Lesion base scrapping with sterile polyester swab in a plain tube.
  • Lesion crust in plain tube.
  • Nasopharyngeal or oropharyngeal swab to be collected in dry plain tube (without any bacterial culture or VTM).
  • Blood (4-5ml) collected in SSGT (yellow top) for serum preparation.
  • Blood (2-3ml) collected in EDTA vial.
  • Urine in sterile container.
  1. Recovery phase-
  • Blood collected in SSGT tube (4-5ml).
  • Urine in sterile urine container (3-5ml).

Diagnostic modality-

For confirmation of monkeypox on a suspected clinical specimen following test are done-

  1. PCR for orthopoxvirus genus (cowpox, buffalopox, camelpox, monkeypox).
  2. If sample shows positivity for orthopoxvirus, it would be further confirmed for monkeypox by monkeypox specific conventional PCR or a real time PCR for monkeypox DNA.
  3. Virus isolation and next generation sequencing for further characterization of positive samples.

 

 

MANAGEMENT OF MONKEYPOX –

Principles of management –

For mild or uncomplicated disease– Patients with mild disease are ambulatory, have good oral intake, are able to bathe and dress themselves and require little or no assistance.

  • Patient isolation.
  • Protection of compromised skin and mucous membranes.
  • Rehydration and nutritional support.
  • Symptom alleviation.
  • Monitoring and treatment of complications.

 

PATIENT ISOLATION

  • Isolate the patient in a separate room with separate ventilation.
  • Patient should wear a triple layer mask.
  • Hand hygiene with soap and water or alcohol based rub.
  • Skin lesions should be covered (e.g. long sleeves, long pants) to minimize the risk of contact to others.
  • Isolation should be continued until all lesions have resolved and scabs have fallen off.
  • Care giver should maintain a distance of 1metre or else wear a well-fitting medical mask and gloves.
  • Linens and bedding should be carefully lifted without shaking to avoid dispersal of lesion material, and either disposed or washed with soap and warm water.
  • Sharing of utensils to be avoided, and used utensils must be washed with warm water and dishwashing soap.
  • Contaminated surface should be disinfected with standard household cleaning agents.
  • Waste generated from patient care, should be placed in strong bags, tightly secured, collected by municipal waste service.

 

PROTECTION OF COMPROMISED SKIN AND MUCOUS MEMBRANES-

  1. Skin rash – Clean with simple antiseptic.
    • Mupironic acid/ Fucidin can be applied.
    • Cover with light dressing.
    • Do not touch/scratch.
    • Systemic antibiotics for secondary infection.

 

  1. Genital ulcers- Sitz bath (warm water with baking soda or Epsom salt).
  2. Oral ulcers- warm saline gargles/ oral topical anti-inflammatory gel.
  3. Conjunctivitis – usually self-limiting.

REHYDRATION THERAPY AND NUTRITIONAL SUPPORT-

  1. Encourage the patient to take plenty of oral fluids and oral rehydration solutions.
  2. Encourage them to consume nutritious food.

SYMPTOM ALLEVIATION

  1. Fever- Tepid sponging, Paracetamol as required.
  2. Itching- Topical calamine lotion, anti-histamines.
  3. Nausea and vomiting- Anti-emetics.
  4. Headache – Paracetamol, hydration.

MONITOR FOR COMPLICATIONS-

Closely monitor for appearance of any of the following during the period of isolation-

  1. Pain in eye or blurring of vision.
  2. Shortness of breath, chest pain, difficulty in breathing.
  3. Altered consciousness, seizure.
  4. Decrease urine output.
  5. Poor oral intake.
  6.  

 Appearance of any these symptoms, patient require immediate transfer to nearby healthcare facility. So patients and their caregivers must be educated about this.

Management of high risk patient and patient with severe disease.

High risk population– Children, pregnant females, immunosuppressed are at a high risk for severe disease so they should always be monitored at healthcare facility

Assessment for severity-

  1. General condition– poor oral intake, non-ambulatory patients, patients with weight loss are at risk.
  2. Vital signs– PR, BP, RR, Temp, SpO2. Any deviation from normal may be suggestive of severe disease and thus such patients should be carefully monitored and treated in healthcare facility.
  3. Characterization of rash-
  4. Stage of rash – macule, papule, vesical, pustule, crusted, exfoliation.
  5. Location- face, arms, torso, genitalia, legs, mucosa.
  6. Number of lesions- mild (<25), moderate (25-99), severe (100-250), very severe (>250 skin lesions).

  Patients with higher number of lesions and exfoliation involving >10% body surface area will require admission.

  1. Secondary infection – Cellulitis, abscess, pyomyositis, soft tissue infection.
  2. Neurological status – altered sensorium, seizures are suggestive of severe disease.
  3. Assessment of Volume status-

Patient with volume depletion will require Intravenous rehydration.

 

CLINICAL MANAGEMENT-

  1. Skin exfoliation– this may develop in patients with heavy rash burdens. Cases are similar to those with partial thickness burns. As a result of widespread exfoliation patient loses significant amounts of fluids and proteins. % Estimation of exfoliation should be done as in burns patients. Management includes intravenous fluids, nutrition (enteral or parenteral), bedside debridement, antibiotics for secondary infections, skin grafting for severe cases.
  2. Necrotizing soft tissue infection– This affects deeper tissue and fascia. It is characterized by edema, crepitus, malodorous discharge and pain at the affected site. Treatment includes systemic antibiotics covering staphylococcus and streptococcus species, surgical debridement.
  3. Pyomyositis – It is due to development of pus within the muscle and presents with muscle pain and tenderness. Treatment requires antibiotics, incision and drainage.
  4. Cervical lymphadenopathy– If large can cause respiratory compromise. If it is secondary to retropharyngeal abscess then it can cause throat pain, fever, sepsis and respiratory compromise. Treatment is with antibiotics, I&D, appropriate surgical, anaesthetic and ENT consultation, steroids can be given in severe cases.
  5. Ocular lesions– Can cause corneal scarring and loss of vision. May present with non-specific symptoms like conjunctivitis. Examination should be done by ophthalmologist. Proper eye care with lubrication, saline-soaked protective eye pads, Ophthalmic antibiotics/antivirals to treat suspected coinfections, vitamin-A supplementation should be given. Avoid steroid ointments as they can delay the viral clearance. Trifluridine eyedrops may hasten symptom resolution and prevent long term scarring. 
  6. Pneumonia- pneumonia complicating monkeypox will require antibiotics for superimposed infection and supportive care.
  7. ARDS – Ventilatory support (Oxygen ,NIV, IMV).
  8. Sepsis and septic shock– Antibiotics, fluids, vasopressors.
  9. Encephalitis- Supportive treatment, antibiotics/ antivirals for suspected coinfections.

 

THERAPEUTICS-

Cidofovir and brincidofovir (CMX001) –

They act by inhibiting DNA polymerase enzyme. Both agents have shown activity against pox viruses in vitro and animal studies. However, data for effectiveness in human cases is not available. These agents may be considered in severe cases. Brincidofovir is preferred due to improved safety profile. Cidofovir is associated with significant renal toxicity and electrolyte abnormalities.

Tecovirimat (TPOXX, ST-246)-

It inhibits viral envelope formation by targeting the viral protein p37.

Formulation – oral capsules (immediate release)

Duration of treatment- twice daily for 14 days.

Effective in animal species but efficacy data in human cases not available. It is licensed by European medical Agency (EMA) for monkeypox in 2022. However, the drug is not widely available yet.

SIDE-EFFECTS- headache , nausea, pain abdomen, weak inducer of cytochrome p450.

NIOCH-14- It is a chemically synthesized compound and is an analogue of Tecovirimat. However, its clinical efficacy in monkey pox is not certain.

       Vaccinia immune globulin (VIG) –It is a hyperimmune globulin (antibodies from individuals   inoculated with smallpox vaccine) prepared for treatment of complications of vaccinia vaccination. Data of its efficacy is not available. However, its use may be considered in severe cases. It has a prophylactic use in exposed person with severe immunodeficiency in T-cell function.

Vaccination-

Smallpox vaccine is at least 85% effective in preventing monkeypox. So previously vaccinated people may have milder illness. At present original first generation smallpox vaccine are no longer available. Following vaccination are in consideration for monkey-pox-

  • Imvamune or Imnavex (JYNNEOSᵀᴹ)- licensed in US to prevent monkeypox and smallpox.
  • ACAM2000 – contains live vaccinia virus. Licensed for people who are at least 18yrs of age and at and high risk for smallpox infection. Can be used in people exposed to monkeypox under expanded access investigational new drug protocol.

Prevention

At health care center-

  1. Hand hygiene (both patient and care givers).
  2. Isolate patient in a single room with dedicated bathroom.
  3. If single rooms are not available, cohort confirmed cases with 1m distance between patients.
  4. Healthcare worker must don full PPE- gloves, gown, respirator and eye protection.
  5. Triple layer surgical mask for patients.
  6. Aerosol generating procedure should be performed in AII (airborne infection isolation) rooms. If such rooms are not available these procedures can be performed in well ventilated, single patient rooms with doors closed. Full PPE to be worn by HCW during the procedure.
  7. Dedicated footwear.
  8. Dedicated patient equipment.
  9. Surface disinfection.
  10. Biomedical waste disposal (in accordance with local regulations). Avoid dumping and landfills.

 

 

 

Caring for sexually active transmission–

  1. Abstinence until all lesions have crusted and fallen off.
  2. Thorough history and physical examination for people with suspected MPX.
  3. PLHIV- continue ART. If diagnosed for the first time start ART as soon as possible and within 7 days.
  4. Use of condoms for 12 weeks after recovery from monkeypox to prevent potential transmission.

Caring for woman during and after pregnancy

  1. Mild / uncomplicated disease- monitoring in health care facility preferred.
  2. Severe or complicated disease- admit to health care facility for management.
  3. Data suggests possibility of vertical transmission that may lead to spontaneous abortion, still-birth.
  4. Ensure and educate regarding healthy diet, mobility, exercise, hydration.
  5. Proper access to antenatal care.
  6. Delivery to be individualized based on obstetric indications.
  7. Post-partum care.

 

References –

  1. Guidelines for management of monkeypox disease. Ministry of health and family welfare. https://main.mohfw.gov.in/sites/default/files/Guidelines for Management of Monkeypox Disease.pdf
  2. Clinical management and infection prevention and control for monkey pox. Interim rapid response guidance. 10 June 2022. https://www.who.int/publications-detail-redirect/WHO-MPX-Clinical-and-IPC-2022.1