Table of Contents
What is monkeypox?
Monkeypox is a viral disease endemic in some parts of Africa which has now made its way to the US and many other countries. It’s in the same family of viruses as smallpox, but it is far less deadly. The most prominent symptom is a rash of painful, pox-like lesions. Other symptoms include fever, chills, and swollen lymph nodes. These symptoms are primarily self-limiting, resolving around 2-4 weeks. It spreads via close, prolonged contact with infected cases or through their scabs, which may be present in clothes, sheets, etc.
What do we know about the current outbreak?
While monkeypox is not a new disease, this is the first time that it’s being seen in so many non-endemic countries across the globe. As of the end of August, the World Health Organization (WHO) has reported over 44,000 confirmed cases1 worldwide, with the majority of cases coming from the US, Spain, Brazil, Germany, the UK, and France. The US alone has over 16,000 reported cases.2 Additionally, in previous outbreaks, the spread was limited primarily to travel to endemic regions or exposure to infected animals. In this current outbreak, we’re seeing a lot more local spread with transmission due to sexual encounters.
Who is the most vulnerable?
What’s particularly interesting about this outbreak is that, although it has since been identified in other populations, the majority of cases are in gay, bisexual, and other men who have sex with men (gbMSMs). This puts gbMSMs at higher risk. Since monkeypox spreads through close contact, those who live in communal settings such as homeless shelters, prisons, and college dorms are also at risk. This is potentially worrisome given that students will soon be gathering and living back on university campuses again.
Are there vaccines for monkeypox?
Yes, we do have vaccines, two of them actually – ACAM2000 and JYNNEOS. These vaccines were originally designed for smallpox but are also effective and have been granted expanded access to be used for monkeypox. While we have more than enough ACAM2000 in our national stockpile, it’s an attenuated, live virus vaccine associated with more adverse side effects and is not recommended for persons with compromised immune systems. Instead, the CDC is recommending JYNNEOS. However, our stockpile of the vaccine is still too low, at 400,000 doses, to provide for the approximately 1.6 to 1.7 million at-risk individuals who will need to be vaccinated.3
Some good news, however, is that recent studies have demonstrated that giving 1/5 of the normal dose of JYNNEOS intradermally, or right under the skin, is effective against monkeypox. The Biden Administration just this month4 recommended using this dose, which would extend the amount of people who can be vaccinated to 2 million. To further prioritize individuals for vaccination, the CDC is recommending a post-exposure prophylaxis (PEP) strategy. This targets individuals that have already been exposed or are at high-risk for exposure. This is the way that smallpox was eradicated and works when the disease is relatively confined and has no asymptomatic spread. This is different from pre-exposure prophylaxis (PrEP), which is how we handled the COVID-19 vaccination campaign.
What should clinicians know about this latest outbreak?
Clinicians need guidance on screening, treatments and vaccination. As mentioned above, while earlier outbreaks were due primarily to travel or exposure to infected animals, transmission this time is centering around sexual behavior and living conditions. Furthermore, clinicians should be aware that the symptomology is slightly different. Monkeypox is classically associated with a prodromal period – characterized by fever, intense headache, lymphadenopathy, back pain, myalgia, fatigue – which precedes the skin rash. However, today many cases are presenting with the rash right away, with little to no prodromal symptoms.5 Many patients are showing up to outpatient treatment centers mistaking a rash on their genitals for a sexually transmitted infection. This means that providers now must consider monkeypox while doing routine STI screening.
How can the health IT community help?
First and foremost, with this new outbreak comes new documentation needs. Social Determinants of Health (SDOH), which were so important for the COVID-19 response, are critically important once again. We also need to be able to differentiate “suspected monkeypox” from “confirmed monkeypox” as well as exposure to cases or people suspected of having monkeypox. There are different tests for monkeypox, and these results need to be documented correctly to ensure accurate counts of suspected and confirmed monkeypox cases. Finally, administration of the vaccine needs to be appropriately documented with specific details such as route of administration, dose, and vaccine type. With the recent changes in vaccine administration guidance mentioned above, it is important to keep accurate records of who got which vaccine and how.
With a highly granular clinical interface terminology (CIT), this information can be captured at the right level of specificity to inform patient care and notify public health agencies. Clinicians can leverage CIT to perform a variety of tasks in the EHR, from identifying patients who may benefit from treatment or vaccination to driving up-to-date clinical decision support engines. By providing these tools, we can help clinicians with the extra documentation burden that comes with tracking a new, quickly-spreading disease. In doing so, clinicians can focus on delivering the right care to their patients while providing critical information to public health agencies.