Monkey Pox
Clarissa Chan, PharmD
For years, a monkeypox pandemic has been waiting to happen. For starters, the number of cases in central Africa has grown from only a few cases in the 1980s and 1990s to thousands in the past couple of years.
“Urbanization and increased transportation have surely contributed, as may have changes in the virus itself,” said Yaneer Bar-Yam, PhD, president of the New England Complex Systems Institute and cofounder of the World Health Network in Cambridge, MA. “In recent years, several travelers with monkeypox unknowingly spread it from Africa to other countries including the United Kingdom, Israel, and Singapore.”
Bar-Yam helped Pharmacy Today answer some questions about monkeypox in an effort to inform pharmacists and other health care providers.
What are the symptoms of monkeypox?
The hallmark symptom of monkeypox is a painful or itchy rash that initially looks like a pimple or blister that can occur on many areas of the body, like the genitals or mouth, from exposure to the virus. The rash goes through several stages, including scabbing, until healing occurs.
Other symptoms people may or may not experience include fever; chills; swollen lymph nodes; exhaustion; muscle aches and backache; headaches; and respiratory symptoms like sore throat, nasal congestion, or cough.
After exposure to monkeypox, symptoms typically begin within 3 weeks and usually last between 2 and 4 weeks. If flu-like symptoms occur, a rash usually develops within one to four days. Monkeypox can be spread as long as symptoms are present.
What is the most common reason for patients to seek treatment?
The monkeypox rash can be highly painful, so pain treatments are often needed. A wider set of treatments can be found within the guidelines (apha.us/MonkeypoxTreatments).
Who is most severely affected by monkeypox?
Children, immunocompromised patients, and pregnant people experience the most severe cases. Historically, children have a high proportion of deaths.
“Since recent cases have mostly been in young healthy [males], we have yet to see the severity of this disease at its extreme,” said Bar-Yam.
What is tecovirimat?
Tecovirimat (also known as TPOXX [Siga Technologies] or ST-246) is the only treatment that is approved for monkeypox. Even though it is not FDA-approved, it is available through CDC’s expanded access mechanism. Informed consent is required for its use.
On May 19, 2022, FDA approved the I.V. tecovirimat formulation for smallpox for treatment of monkeypox. The oral tecovirimat formulation was approved by FDA for the treatment of smallpox in 2018. Tecovirimat is approved for monkeypox only under an expanded access investigational new drug application protocol. The oral formulation should be taken with a full and fatty meal to ensure optimal absorption. I.V. tecovirimat should not be administered in patients with severe renal impairment (creatine clearance [CrCl] < 30 mL/min). Oral tecovirimat is an option in this case. For patients with mild (CrCl 50–80 mL/min) or moderate (CrCl 30–49 mL/min) renal impairment and children younger than 2 years old with expected immature renal function, tecovirimat should be used with caution.
What are the possible adverse reactions from tecovirimat?
For the oral formulation, people may experience headaches, nausea, abdominal pain, and vomiting. One study subject experienced neutropenia.
For the I.V. formulation, patients may experience infusion site pain, swelling, erythema, extravasation, and headache.
How do we obtain tecovirimat?
To obtain tecovirimat for patient use, CDC recommends contacting the local state/territorial health department. For after-hours urgent clinical questions, contact the CDC Emergency Operations Center at 770-488-7100 to speak with a clinician.
More information on how to access tecovirimat for treatment is available at apha.us/ObtainingTecovirimat.
When is it appropriate to prescribe tecovirimat?
The accepted conditions for use are severe disease, high risk for severe disease, and lesions in high-risk locations (e.g., in the eyes, mouth, genitals). See apha.us/TecovirimatGuidance for more information.
As noted by CDC on September 15, 2022, clinicians will use tecovirimat to treat monkeypox only in cases likely to progress to severe disease. CDC has limited the intervention to immunocompromised populations such as people with uncontrolled HIV, certain cancers, solid organ transplant recipients, pregnant or breastfeeding women, and young children.
What is important to know about the vaccines?
There are currently 2 available vaccines approved for monkeypox prevention: ACAM2000 and JYNNEOS. The vaccines are also effective as a treatment if given early in the course of the disease, especially within 4 days after exposure. Vaccination may prevent symptoms, and until 14 days after infection it can reduce the severity of the disease, said Bar-Yam.
Which vaccine is safer: ACAM2000 or JYNNEOS?
The smallpox vaccines (ACAM2000 and JYNNEOS) are estimated to be 85% effective against monkeypox, though there isn’t much historical data on JYNNEOS, said Bar-Yam. While it was key to smallpox eradication, ACAM2000 is a live virus vaccine that has significant adverse effects and should not be used in patients with immune system or heart problems or who have some skin conditions like eczema, dermatitis, or psoriasis.
“JYNNEOS is based upon the same virus but has undergone selection to be replication incompetent to reduce the risk of side effects,” said Bar-Yam. “JYNNEOS is therefore much safer than ACAM2000.”
Is the vaccine effective?
The JYNNEOS vaccine has not yet been produced at the scale of need.“Recent policy decisions have been made to use one-fifth the dose in order to provide 5 times as many people with vaccinations,” said Bar-Yam. “The effectiveness of the new dosage has yet to be fully evaluated. This is in addition to the current practice of only providing a single dose of a two-dose regimen, with a 4-week period between doses. There have already been reported breakthrough infections.”
What myths should pharmacists be aware of when educating others about monkeypox?
The main myth is the claim that only men who have sex with men (MSM) are being infected and that monkeypox has become an STD. While it can be transmitted through sexual contact, it can also be transmitted by other physical contact through rash, scabs, or bodily fluids and by contact with contaminated clothing, bedding, and other surfaces. It can also be transmitted through airborne respiratory secretions.
“It is essential that testing be available to anybody with either an acute rash that has lesions that are deep-seated, painful, and well-circumscribed, or new rash symptoms and any of the other early symptoms of monkeypox (e.g., fever, headache, weakness, swollen lymph nodes),” said Bar-Yam. “Many people with these symptoms have been confirmed to have monkeypox after being denied testing because they are not MSM.”
Why has monkeypox become a public health emergency? Who is most at risk?
While spread of the disease in the U.S. was first seen among MSM, the disease can also be transmitted to and through people who are not active members of the LGBTQ+ community, including children. With the return to schools and daycares, there may be a significant new level of transmission, said Bar-Yam.
How are monkeypox and smallpox different?
Smallpox and monkeypox are from the orthopox virus genus. Vaccina virus is the virus used for the smallpox vaccine.
Since monkeypox virus has not had widespread transmission until the past few years in Africa—and now across the world—there is limited data available on the effectiveness of vaccines or treatment for monkeypox that have been developed for and tested on smallpox.
Is the current monkeypox outbreak related to the COVID-19 pandemic?
“COVID-19 is now known to damage the immune and other physiological systems, which can cause increased vulnerability to other infectious diseases and medical conditions,” said Bar-Yam. “We don’t yet know if this is an important contributor to the monkeypox outbreak, but it might be.” ■
For the most up-to-date information about monkeypox for pharmacists, please visit www.pharmacist.com/Practice/Monkeypox.