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Signs and Symptoms: Classically, monkeypox occurs in three stages. After an incubation period of approximately 1–2 weeks, a prodrome, characterized by fever and lymphadenopathy occurs, which is followed by the onset of a deep-seated vesicular or pustular rash that often begins centrally and spreads to the limbs (11). Transmission of monkeypox can occur through direct contact with the infectious rash, scabs, or body fluids, through respiratory secretions during prolonged face-to-face contact or intimate physical contact, or through touching items, such as clothing or linens, that previously touched a patient’s infectious rash or body fluids.§ Patients are considered contagious until the scabs have crusted over and fallen off and a fresh layer of intact skin has formed underneath.
Reports from the current outbreak suggest transmission patterns and clinical manifestations might not follow the classic presentation of monkeypox (5–10). Although any person can acquire monkeypox, epidemiologic data indicate that transmission is currently most intense among interconnected networks of sexually active MSM, with transmission occurring primarily through intimate skin-to-skin contact during sex (6). Prodrome or systemic symptoms do not always occur or precede the rash. Mucosal involvement occurs in approximately 40% of cases, including genital, perianal, and oropharyngeal lesions (5). Genital and perianal lesions can be associated with severe and painful proctitis, urethritis, phimosis, and balanitis. Oropharyngeal symptoms, including symptoms resulting from tonsillitis and epiglottitis, can be associated with pain or difficulty swallowing.
Treatment: There are no Food and Drug Administration (FDA)–approved treatments for monkeypox. However, drugs that are approved for treatment of smallpox and cytomegalovirus might have activity against Monkeypox virus. Tecovirimat is an antiviral medication available in oral and intravenous formulations. Animal studies have shown that tecovirimat is effective in treating orthopoxvirus-induced disease (12). Data are not available on the effectiveness of tecovirimat in treating monkeypox in humans; however, a case report from the United Kingdom suggested that tecovirimat might shorten the duration of illness and of viral shedding (13). Human clinical trials indicate that the drug is safe and tolerable with only minor side effects (14). Randomized controlled trials in humans are underway to further assess safety as well as efficacy in treating monkeypox. Tecovirimat is available from the Strategic National Stockpile (SNS) and is administered under an expanded access (i.e., compassionate use) Investigational New Drug (EA-IND) protocol held by CDC.¶
Other treatments that can be considered in severe cases include vaccinia immune globulin intravenous (VIGIV), cidofovir, and brincidofovir. Cidofovir and brincidofovir have proven activity against poxviruses in in vitro and animal studies, but only cidofovir is currently available either commercially or from the SNS. VIGIV is available from the SNS and is administered under an EA-IND protocol for monkeypox. At this time, it is unknown whether a person with severe monkeypox will benefit from treatment with VIGIV, cidofovir, or brincidofovir because effectiveness data are not available.
Pre- and Postexposure Prophylaxis: The only form of pre-exposure prophylaxis available or authorized for monkeypox is vaccination, which currently is recommended for persons at risk for occupational exposure to orthopoxviruses, such as laboratory personnel performing diagnostic testing for Monkeypox virus and members of health care worker response teams designated by appropriate public health and antiterror authorities (15). Routine immunization of all health care workers against smallpox or monkeypox is not currently recommended.**
Postexposure prophylaxis can be considered after exposure to monkeypox.†† Although the use of smallpox vaccines for postexposure prophylaxis has not been studied in the context of monkeypox outbreaks, early administration of vaccines (≤4 days after exposure) might prevent monkeypox, and later use (5–14 days after exposure) might decrease the severity of monkeypox if infection occurs (16,17). Vaccination given after the onset of signs or symptoms of monkeypox is not expected to provide benefit.§§
Two vaccines are licensed by FDA for the prevention of orthopoxvirus infections. JYNNEOS is a live virus vaccine that uses nonreplicating modified vaccinia Ankara (MVA) which is licensed for prevention of smallpox and monkeypox in adults aged ≥18 years (18). Because JYNNEOS contains replication-deficient MVA, it does not present a risk for disseminated infection, autoinoculation, or transmission to others (15). JYNNEOS vaccine is administered as a series of two doses given 28 days apart (18). ACAM2000 is a replication-competent live vaccinia virus vaccine licensed for prevention of smallpox that is administered as a single dose (19). ACAM2000 was derived from Dryvax, the vaccine used in the eradication of smallpox (19).
Source of original article: Centers for Disease Control and Prevention (CDC) / Morbidity and Mortality Weekly Report (MMWR) (tools.cdc.gov).
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