Monkeypox for the OB/GYN
/Reading/sources:
What is monkeypox and how is it transmitted?
Name and type of virus
WHO is planning to rename the virus to reduce stigma and racist overtones - but this hasn’t happened yet!
Orthopoxvirus (genus of Poxviridae family) and has features similar to smallpox or variola
DNA genome
There are two different strains: the Congo basin clade and the west African clade
Congo basin clade has historically caused more severe disease and is thought to be more transmissible
The West African clade seems to be the dominant circulating strain → case fatality ratio of 3% to 6%
Cases and outbreak
First case was in 1970 in the Democratic Republic of Congo
First case in the US in this outbreak was on 5/17/2022
Most recent reports from the CDC states (as of 8/31/2022) - there have been 18,989 total confirmed monkeypox cases in the US
Demographics
There is not complete demographics data for everyone
Most recent data from mid August from the CDC shows that only 1.5% of all cases were in women and transgender men
No deaths have been reported in this population
Transmission
Human to human transmission can occur from
Direct contact with infected rash, scab, or body fluid
Respiratory secretions during prolonged or intimate physical contact
Contact with contaminated items, such as clothing or bedding
A person with monkeypox infection is considered contagious from initial viral prodrome and development of rash until lesions have full healed and new skin has formed over the scabs
Unclear if transmission can also occur through vaginal or seminal fluids
Perinatal infection can occur through transplacental transmission or during close contact during and after birth
Zoonotic transmission can also occur following direct contact with blood, bodily fluids, or cutaneous/mucosal lesion of infected animals
Clinical Presentation
Current outbreak
Many of the initial patients in this outbreak have shown painful genital and perianal lesions, oral lesions, and proctitis in the setting of mild or no prodromal symptoms
Clinical course
Average time between contact with monkeypox and symptoms is 5-13 days, with range of 4-17 days
Classic features of infection:
Fever, lymphadenopathy, malaise, headache, muscleaches
Can have lymphadenopathy
Rash develops approximately 1-4 days after prodromal symptoms → deep-seated vesicular or pustular, often beginning centrally and spreading to the limbs
Rash can last 2-4 weeks, progressing through stages includes macules, papules, vesicles, pustules, and even scabs and crusts
Rash can leave scars
From the Green Journal article (not sure we can use?)
Pregnancy Implications of Monkeypox
Not very much is known:
We reviewed that the monkeypox virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth
There has been an increased risk of maternal mortality and morbidity documented with other poxviruses, but it’s unknown if pregnant people are more susceptible to monkeypox or if disease is more severe in pregnancy
One publication looked at 5 cases of documented perinatal outcomes
2 = SAB
1 = stillbirth
1 = preterm birth
Evaluation for individual with suspected monkeypox
Routine screening is not recommended for asymptomatic patients
If suspicion of monkeypox virus infection:
Collect recent travel history, ask specifically about countries where monkeypox has been reported
If rash or anogenital lesions, ask about close contact or sexual exposure to someone with monkeypox
Full body skin exam, including oral mucosa, genital, and rectal areas, + evaluate lymph nodes
Isolation from others
Consultation with infectious disease
Diagnosis
Two-step process requiring initial identification of an orthopoxvirus
If orthopoxvirus is confirmed, specimens are sent for monkeypox virus-specific testing
Multiple samples should be collected, ideally from different lesions (2-3 from different areas of the body with diff appearance) for PCR testing
Please follow your own hospital’s guidelines on how to obtain these samples!
As there aren’t really any other orthopox viruses in the US, we shouldn’t wait for the confirmatory testing before initiating infection-control procedures and preventative strategies + treatment
Healthcare provider precautions
Standard precautions and wear PPE: gown, gloves, eye protection, and N95 mask
Any procedure where there is aerosolization (ie. intubation/extubation), should be done in airborne infection-isolation room
Treatment
Disease is usually self-limited, but disease can progress to severe, so certain populations at risk of severe disease
This includes pregnant patients, people who are breastfeeding, and those with oral, ocular, genital, or anal lesions
No specific treatment for monkeypox virus infection
However, there are 2 antivirals +immune globulin available
Tecovirimat (Tpoxx) - antiviral (limited to health department/CDC Expanded access protocol)
Approved by FDA for treatment of smallpox virus infection and may prove beneficial for monkeypox
Available in oral and IV formulations
Works by blocking cellular transmission of the virus
Both forms have been used to treat patients during the current outbreak in the US
No human data is available during pregnancy, but no fetal toxic effects were observed in mice studies using oral medication
Not known if present in breastmilk
Cidofovir - antiviral (Off-label use, available for use in outbreak setting)
Approved by the FDA for treatment of CMV retinitis in patients with AIDS
Can be used for orthopoxviruses in an outbreak setting
In animal studies, cidofovir has been associated with embryotoxicity and teratogenicity, but no adequate or well-controlled studies in humans
Brincidofovir - antiviral (availability limited to Strategic National Stockpile distribution)
Approved by FDA to treat smallpox
Unfortunately, in animal studies, there have been embryo-fetal toxicity demonstrated + structural malformations
Therefore, alternative therapy is recommended in pregnancy
IVIG - also available in outbreak setting
Also no human data or animal data in pregnancy
Prevention
Primary prevention is from isolating from individuals with infection
Avoid close contact and sexual activity with people with infection
Postexposure prophylaxis
CDC has tools to assess the risk of monkeypox virus infection and recommends post-exposure vaccination for specific risk exposures or risk factors
Criteria
Within 4 days of known exposure to reduce likelihood of infection or between 4-14 days to reduce severity symptoms
Known contacts of monkeypox cases ID’ed by public health via case investigation
Presumed contacts who meet criteria:
Know that sexual partner in the past 14 days was diagnosed with monkeypox or
Had multiple sexual partners in past 14 days in a jurisdiction with known monkeypox
If given within 4 days of exposure, vaccine is likely to prevent monkey pox virus infection
Of note, there are two types of vaccines
JYNNEOS = live-non-replicated viral vaccine - There are no studies in pregnant patients
Pregnancy, however, is not a contraindication to post exposure prophylaxis with vaccination if the individual is otherwise eligible
ACAM2000 - repliating viral vaccine licensed for prevention of smallpox
Contraindicated in pregnant or breastfeeding people due to risk of pregnancy loss, congenital defects, and vaccinia virus infection
Preexposure prophylaxis
Attenuated live-virus vaccine and replication-competent vaccine are available
Routine immunization of all healthcare workers is not currently recommended
Only recommended for those whose jobs may expose them to monkeypox (ie. lab personnel and healthcare workers who administer a replication-competent vaccinia virus vaccine or anticipate caring for many patients with monkeypox)