In today’s COVID-19 Update, monkeypox questions on transmission, testing, treatment, prevention, personal protective equipment (PPE) and more answered by Sandra Fryhofer, MD, chair, American Medical Association Board of Trustees and AMA liaison to the Advisory Committee on Immunization Practices. AMA Chief Experience Officer Todd Unger hosts.
Learn more at the AMA COVID-19 resource center.
- Sandra Fryhofer, MD, chair, Board of Trustees, AMA; AMA liaison, Advisory Committee on Immunization Practices
Unger: Hello, this is the American Medical Association's COVID-19 Update video and podcast. Today's topic—what you need to know about monkeypox with Dr. Sandra Fryhofer, the chair of the AMA Board of Trustees and AMA's liaison to ACIP, the CDC's Advisory Committee on Immunization Practices in Atlanta. This interview with Dr. Fryhofer was filmed the day before monkeypox was declared a public health emergency in the United States on Thursday, August 4, so this information is more important than ever.
I'm Todd Unger, AMA's chief experience officer in Chicago. Hi, Dr. Fryhofer, welcome back.
Dr. Fryhofer: Hello, Todd, and thanks for having me.
Unger: Well, we've seen so many recent reports about monkeypox. Let's just start off with ... tell us how serious this is.
Dr. Fryhofer: The AMA is focused like a laser beam on improving the lives of physicians and our patients. And we're very concerned, deeply concerned about the public health crisis monkeypox will cause our nation unless we act decisively and act now.
We have to learn from our experiences with COVID and not make the same mistakes. It's not, quote, "over there." It's rare but it's here and we have to deal with it. And, yes, this can happen to a patient in our practice. We need to think about it if we see a patient with a new rash or blister.
Physicians sometimes refer to unusual diseases and conditions as zebras. Well, be on the lookout. This zebra could be in your backyard.
Unger: Now, people are very used to case numbers, of course, coming out of COVID. What numbers are we talking about and why are they so meaningful at this point?
Dr. Fryhofer: The World Health Organization has declared monkeypox a global health emergency. Right now the United States has more than 5,800 cases. The first case in the U.S. and the current outbreak was confirmed on May 18. And with community spread, those numbers are increasing every day and every hour. CDC has an online map with total confirmed monkeypox case counts by state that updates Monday through Friday. And some of the states with the highest case counts include New York, California, Illinois, Florida, my home state of Georgia and also Texas. Governors in New York, California and Illinois have now declared a state of emergency over monkeypox.
Unger: Who's most at risk from monkeypox right now?
Dr. Fryhofer: Many cases are in males. So—and so far the vast majority of cases are in MSM and the LGBTQ community. But we're also seeing cases in women and now in children. Anyone and everyone, regardless of gender identity or sexual orientation, is at risk if they've had close skin-to-skin contact with someone who has it or if they've been exposed to contaminated materials, including towels, sheets and other personal items.
It can also be passed, though not as easily, in respiratory secretions, which means you can get it from prolonged face-to-face contact with an infected person. And this does include kissing.
Before this current outbreak, cases were linked to travel to endemic areas or exposure to infected animals. But we're now seeing person-to-person community spread here in the U.S. and across the world. People at highest risk of severe infection include those with immunocompromised conditions, pregnant people, patients with eczema or atopic dermatitis and children under eight years old.
Unger: So when we've talked about community spread and the importance of really trying to stop that right now, what is the biggest barrier to stopping the outbreak?
Unger: Unfortunately, there's a lack of understanding among the public in general about the disease. And let's face it, many of us doctors haven't had much experience dealing with monkeypox and we've got to change that. We need to spare no expense in educating doctors and the public about the symptoms of the disease and what to do if the patient presents with blisters or a rash and some possible risk of exposure.
Dr. Fryhofer: Understand, monkeypox can be a masquerader. It can be confused with other infections, such as herpes and chickenpox or even syphilis. It can co-exist with other infections. Patients can be concurrently infected with monkeypox along with something else.
Unger: So with easily confused symptoms sometimes, when you're talking to our physician audience out there, what symptoms should they be looking for?
Dr. Fryhofer: The incubation period is roughly one to two weeks and patients can have flu-like symptoms, fever, headache, muscle aches, fatigue, swollen lymph nodes before the rash begins but not always. Some patients complain of isolated rectal pain. The rash can be flat or raised and may seem just like an ingrown hair or a pimple.
The rash can be painful, painless or itchy. It can look like spots, blisters, pustules or scabs. The skin lesions are often described as looking deep seated, firm, rubbery and umbilicated, meaning they often have a little dent in the middle.
You're infectious once any symptoms begin and remain infectious until the scabs fall off and a fresh layer of skin forms. Illness typically lasts about two to four weeks.
Unger: Well, let's talk about testing and treatment. There is a confusion out there. What is the appropriate protocol?
Dr. Fryhofer: Unlike COVID, when we had to invent vaccines and antivirals, we already have two FDA-approved vaccines that can be used for monkeypox—ACAM2000 and Jynneos. These can be given to those exposed to reduce symptoms as well as those at increased risk of exposure for prevention.
We also have FDA-approved antiviral medicines to reduce the course of the disease—TPOXX, a.k.a. Tecovirimat, and cidofovir, brand name Vistide. These antiviral drugs and vaccines were originally developed to treat or protect against smallpox or other infections. There's also FDA-approved vaccine immunoglobulin available for treating severe cases.
If you see a patient, who's been exposed to monkeypox or has unexplained rash or blisters, think "Could this be monkeypox?" and test for it. If there's any suspicion, first, isolate the patient. Put them in a private room. And before collecting the specimen, health care personnel should put on full PPE—gloves, gown, N95 mask and eye protection.
To test, vigorously swap the lesion or punctuate it with a tiny 25-gauge needle. Soak up any fluid on a swab and send it to the health department or a commercial lab. At least five large commercial labs, including Labcorp and Quest, are now able to do monkeypox testing. Also, be sure to disinfect the room after the patient leaves.
If the test comes back positive, contact your local health department for vaccines and antivirals. AMA CPT code update now includes codes for diagnostic testing for monkeypox as well as the vaccines.
Unger: So this can be somewhat complicated. It's certainly urgent. Any final thoughts on how we can address this situation?
Dr. Fryhofer: We need to educate our patients and the public on how to prevent the spread of the disease. Patients need to avoid skin-to-skin contact with anyone who could be at risk. If someone has monkeypox, they need to isolate from friends and family to avoid spread by contact with them or with contaminated towels, sheets, et cetera.
If we educate physicians and the public on how to avoid monkeypox, how to recognize the symptoms and ensure access to testing and FDA-approved treatments and vaccines, we can stop the spread. We need to get the vaccine doses we have to the people that need them most now. We have to get vaccine out of storage and into arms.
The president has now appointed a monkeypox response team to coordinate these efforts. The federal government also needs to increase funding to get more patients vaccinated and treated to stop this spread. If we act quickly, we can contain this disease and improve the health of the nation.
If we don't move quickly, this outbreak will evolve into another pandemic. We could then be dealing with monkeypox spreading among young children at schools and daycare and then bringing it home to parents and grandparents. Nobody wants that. That would be a disaster for patients and physicians, which is why it must be avoided.
Unger: Absolutely. And Dr. Fryhofer, thanks for being here and bringing us that perspective, that information for physicians, residents, medical students and the public looking for more information on monkeypox. The AMA has built a monkeypox resource center that can be reached through the AMA site. And I encourage everyone out there to take a look at that. That includes videos like the one we're doing right now and others with information that you need.
That concludes today's episode. We'll be back with you with more information as the situation progresses. In the meantime, you can check out all our videos at ama-assn.org/podcasts. Thanks for joining us, everyone. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.