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)