I find myself waking up and reminding myself to take deep breaths as often as I can remember to. I hope this finds you as well as you can be and that you are taking the time to care for yourself in addition to caring for the well-being of others, as so many of you are.
I write to share what I have learned about recent monkeypox cases and where things stand in Massachusetts. This information is gathered from conversations I have had with infectious disease doctors who work in MA and in other states, DPH staff, the WHO fact sheet, and the CDC’s guidance. I hope that this will be useful.
Some infectious disease experts I have spoken with believe that while monkeypox is not a novel or new virus, its rapid global spread suggests we may not yet know enough about this strain of monkeypox. What we do know is that the number of current cases exceeds previous case numbers outside of Africa, and most of these do not have the traditional travel or animal-associated exposure risk. We also know that monkeypox is not a novel virus, and its similarities to smallpox have given the public health world a head start in combating it.
The World Health Organization estimates there are thousands of monkeypox cases spanning a dozen countries in Africa each year, with the highest concentration in the Congo (approximately 6,000 cases annually) and Nigeria (approximately 3,000 cases annually). While it’s not unusual to have a case randomly occur outside of West and Central Africa, the recent, seemingly rapid spread of the virus across 12 countries without established travel links to endemic areas indicates that we are not dealing with the typical monkeypox strains.
Cases of monkeypox have occurred in the U.S. on occasion. Historically, cases of monkeypox in non-endemic areas have been linked to travel or contact with animals imported from certain countries in Africa. In 2003, 47 confirmed and probable cases were reported across 6 states and were linked to close contact with animals imported from Ghana. Additionally, in 2021, Texas and Maryland each reported a case among travelers from Nigeria. Since 1970, we’ve seen a major increase in monkeypox cases overall. It is theorized that we will continue to see this trend due to the eradication of smallpox, which has led to ending smallpox vaccinations and waning immunity.
Monkeypox is a zoonotic disease, meaning that an outbreak must begin with the virus jumping from an animal reservoir to a human. After a human is infected, they can infect other humans through several avenues:
- Respiratory droplets and aerosols from prolonged face-to-face contact;
- Contact with bodily fluids or monkeypox lesions;
- Indirect contact with items that have been contaminated with fluids or sores, such as clothing or bedding
Monkeypox has a long incubation period, meaning the interval from infection to the onset of symptoms ranges from 5-21 days. Traditionally poxviruses (i.e. monkeypox and smallpox) rarely transmit prior to disease onset; however, it’s still unknown at this time if that is true in regards to the current spread of monkeypox.
In terms of the infection period, once someone is infected, they can be sick for 2-4 weeks. The infection period is categorized into two periods:
- Invasion period (0-5 days): people typically present flu-like symptoms (fever and body aches) and swollen lymph nodes.
- Rash period (1-3 days of fever): a distinctive rash typically starts in the face, which then moves to the extremities. A distinct sign of monkeypox is the vesicles that can form.
Since much is still unknown about the virus, a person should be tested if they exhibit any of the symptoms above.
Vaccination and containment strategy
The vaccination and containment strategy will likely look very different from what we saw with COVID due to several factors. Monkeypox spreads much differently than COVID, primarily relying on contact with bodily fluids and long periods of being in the same room. Britain’s health officials are using the “ring vaccination strategy.” This strategy focuses on inhibiting the spread of disease by vaccinating the contacts of confirmed cases, instead of relying on population-level mass vaccination. This strategy was used to successfully eradicate smallpox in the late 20th century.
Another mitigation technique is a post-exposure prophylaxis strategy. This would include giving smallpox vaccines to a person who is infected with monkeypox within 4 days of exposure, with the intent of limiting and preventing disease onset. If given between 4-14 days after the date of exposure, vaccination may reduce the symptoms of the disease, but it may not prevent the disease altogether. One challenge with this strategy is the long, 3-week incubation period of monkeypox.
There are no proven treatments specifically for monkeypox. Instead, cases of monkeypox can be treated with medical countermeasures designed for the closely related smallpox virus. There are 3 “pox” vaccines that could potentially be used for monkeypox in the U.S: JYNNEOS, ACAM2000, and Aventis Pasteur Smallpox Vaccine. Both JYNNEOS and ACAM2000 can currently be used as post-exposure prophylaxis for monkeypox. The third pox vaccine is the Aventis Pasteur Smallpox Vaccine, an investigational vaccine that would require an Emergency Use Authorization or Investigational New Drug application before being made available to the public. This vaccine would likely only be used if the licensed vaccines are unavailable or contraindicated. It's unclear at this time if this vaccine could be used for monkeypox.
You may have heard that the federal government recently purchased $119 million worth of the freeze-dried version of the Jynneos smallpox vaccine, which can help prevent both smallpox and monkeypox disease. This purchase was not made in response to the new monkeypox outbreak. Instead, it was part of the standard and ongoing preparedness efforts. The order will convert existing smallpox vaccines into a more shelf-stable freeze-dried version and will be manufactured in 2023 and 2024. Additionally, the Strategic National Stockpile (SNS) has stored enough smallpox vaccines to vaccinate every person in the United States. These vaccines can be disseminated in a smallpox emergency in coordination with state health departments.
We know that doctors at Mass General Hospital have been in close consultation with the CDC and the Department of Public Health to determine the best course forward in terms of surveillance and containment strategies. We are fortunate that, unlike other states, our state lab has the ability to test for monkeypox although the test results must be confirmed by the CDC. The Department of Public Health has been in close contact with the Massachusetts resident who contracted monkeypox and conducted contact tracing in an effort to mitigate the spread of the virus. A CDC official reported that 200 people have been identified as coming into contact with the patient and that the vast majority were healthcare workers.
We recently received the following update from the Department of Public Health:
Anyone who is identified as a close contact, including healthcare workers, is allowed to continue to be in public and go to work.
- Close contacts are monitored for 21 days for the development of symptoms; in the case of healthcare workers that monitoring is often conducted by the healthcare facility where the individual came into contact with the virus.
- Massachusetts is basing their categorization of close contacts on the CDC guidance for the identification and tiering of close contacts and which can be found here: https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html
- All identified close contacts, including those outside of healthcare settings, have been advised to contact the Department of Public Health right away if they develop symptoms.
Post-exposure prophylaxis through vaccination is recommended for contacts with high
risk exposures (same CDC link as above)
- As the case investigation was ongoing, DPH ordered and received 200 doses and distributed enough for the staff identified as high risk by the hospital that cared for the patient
- The vaccine is supplied by the federal government through the Strategic National Stockpile
Other key issues to be aware of:
While it is being reported that this virus is disproportionately affecting men who have sex with men (MSM), what we know from infectious disease doctors is that this is not contained to the MSM community, including gay men, bisexual men, and other men who have sex with men. This is an important fact to highlight in order to 1) reduce and eliminate stigma, and 2) recognize that the MSM community has a history of being hyper-vigilant in surveillance and testing, particularly for STIs and infections spread by close physical contact, and tends to self-advocate and seek more routine testing for infections spread via close physical contact than other populations do. Monkeypox is not a sexually transmitted infection, but it can spread through intimate contact during sex when someone has an active rash.
I continue to have scheduled meetings with the Department of Public Health and other infectious disease doctors. I’m also working with Health and Human Services Secretary Sudders and Commissioner Cooke, in coordination with Speaker Mariano, on briefing the Legislature on monkeypox information as it becomes available. I will continue to provide you with updates as well.