Monkeypox cases have risen to over 15,900 in the United States. Case rates are highest in New York and California followed by Florida, Texas, and Georgia (at press time) and have been confirmed in most parts of the country. Misinformation is also on the rise and we turned to the presidents of the American Association of Nurse Practitioners (AANP) and American Academy of PAs (AAPA) to get the facts. April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, discussed what signs and symptoms to look for, where to direct patients for testing, who is eligible for pre-exposure prophylaxis or post-exposure vaccines, and how intradermal administration can stretch the vaccine supply. Jennifer M. Orozco, DMSc, PA-C, DFAAPA, discussed how PAs and NPs can best be used to help manage Monkeypox in the US and how the COVID-19 pandemic shaped clinician response to the Monkeypox virus.
Q: Do we have enough doses of Monkeypox vaccine at this point for everyone who needs it?
Dr Kapu: “For everyone who needs it” is an important clarifier. Understanding the mechanism of transmission of Monkeypox is essential so that we can better focus on prevention strategies targeted to those individuals who are at high risk or have been exposed to Monkeypox; these people should be prioritized for vaccination. The vaccine can be administered within 4 days of exposure as a prevention strategy.
Of the 2 vaccines approved for use in the US — ACAM2000 (smallpox [vaccinia] vaccine, live) and Jynneos (smallpox and monkeypox vaccine, live, nonreplicating) — the US has a large supply of Jynneos. Historically, Jynneos has been delivered subcutaneously but studies show that the vaccine can also be effective if it is delivered intradermally (just under the top layer of skin) at one-fifth of the usual dose. The FDA has authorized administration of 0.1 mL of Jynneos intradermally compared with the 0.5-mL dose required for subcutaneous injection; this extends our supply of the vaccine.
Focusing on individuals who need the vaccine and extending the supply is a very effective strategy for mitigating the supply that we have.
|The CDC currently recommends vaccination for people who have been exposed to Monkeypox and people who may be more likely to get the virus including: |
• People identified as a contact of someone with Monkeypox
• People who know one of their sexual partners in the past 2 weeks has been diagnosed with Monkeypox
• People who had multiple sexual partners in the past 2 weeks in an area with known Monkeypox
• People whose jobs may expose them to orthopoxviruses such as:
– Laboratory workers who perform testing for orthopoxviruses, including Monkeypox
– Laboratory workers who handle cultures or animals with orthopoxviruses
– Certain health care and public health response team members designated by public health authorities to be vaccinated for preparedness purposes
At this time, most clinicians in the US and laboratorians not performing the orthopoxvirus generic test to diagnose orthopoxviruses are not advised to receive orthopoxvirus pre-exposure prophylaxis
Q: How can NPs and PAs identify patients who qualify for the vaccine and encourage them to get vaccinated?
Dr Orozco: The best thing that they can do is contact their department of public health and find out who qualifies for the Monkeypox vaccine and how they can order and get those vaccines readily available in their community. Similar to what we did at the beginning of the COVID-19 pandemic, we have to prioritize who is going to get vaccinated. How do I identify my high-risk groups? That all comes from the Centers for Disease Control and Prevention (CDC) guidelines, World Health Organization (WHO) guidelines as well as from local departments of public health. Some states aren’t in quite endemic situations yet, but clinicians can be proactive in identifying when they are.
A lot of organizations are screening for COVID-19 and Monkeypox at the same time by screening for symptoms of the viruses and identifying high-risk groups. I work in vascular surgery and I can still screen patients for Monkeypox and refer them to the appropriate resources.
Q: What are the characteristic signs and symptoms of Monkeypox and what should NPs and PAs do if they think a patient has the disease?
Dr Kapu: When an individual has a rash, they should pick up the phone and call their NP or health care provider. We can see patients virtually, in their home, or in a clinic. Characteristic symptoms of Monkeypox include fever, headache, body aches, chills, and lymph node swelling. In many patients, the rash becomes diffuse across the body and has a blistering effect (Figure). Typically, a lot of blisters are found and the fluid contained in those blisters is highly contagious.
As an NP, if a patient has a rash that is concerning for Monkeypox, I sample that rash and send it to the lab to be tested. If the test comes back positive, then I am going to talk more about treatment from that point on. While we’re waiting for those test results, we advise individuals to isolate themselves from family members, friends, and colleagues; they need to understand the mechanism of transmission and that they may pass the virus through contact with fluid in the blisters.
That also includes anything that the contagious fluid might come in contact with. Friends and family members should wear barrier protection (eg, disposable gloves) not only when caring for people infected with Monkeypox, but also when cleaning their clothing, towels, bedding, and dishes.
Progress has been made on testing. Several months ago we sent samples to our local health department. Now, more and more laboratories are equipped to test the sample and results come back quickly. We want all health care providers to be able to assess for Monkeypox.
Q: How are Monkeypox and COVID-19 different?
Dr Kapu: A lot of people think that the Monkeypox virus is similar to the SARS-CoV-2 virus. The Monkeypox virus was first discovered in the 1950s in an animal and then later we had our first human case. We have had many years to study the characteristics of this virus, which is very different from our experiences with the COVID-19 pandemic. We better understand the signs and symptoms of Monkeypox, we know how to prevent it, and we have effective vaccines available.
Other misinformation on Monkeypox is that it is limited to a certain patient population; it doesn’t discriminate and can be passed on to anyone. If I had Monkeypox on my arm and touched your arm on a spot where you had a cut, you would be at high risk for acquiring Monkeypox. The virus can last anywhere from 7 to 21 days, and patients are contagious as long as they have a rash. The rash needs to have time to heal, scab over, and form new skin. Once the rash is gone, patients are not contagious anymore and can stop isolating.
Q: How has the COVID-19 pandemic shaped clinician response to the Monkeypox virus?
Dr Orzoco: I am in Illinois, which is one of the hot spots for Monkeypox right now. Based on lessons learned from the COVID-19 pandemic, our approach is to first learn about the virus as clinicians and then inform our patients. As a profession, PAs have learned how to be proactive, not only in preparation at your organization and your facility, but also in how to improve, share, and communicate information. At Rush, we have taken a proactive approach to make sure patients have access to Monkeypox vaccines, communicate with those who qualify for the vaccine, and be overly cautious with personal protective equipment (PPE) for clinicians.
We also are taking a much more proactive approach to screening at-risk patients than we did at the start of the COVID-19 pandemic. Even in Chicago, several Monkeypox screening clinics are available for clinicians to refer patients to if they do not have access to screening at their facility.
Q: How can PAs and NPs best be used to help manage Monkeypox in the US?
Dr Orozco: PAs and NPs have the education, training, and skills to educate patients with accurate information about Monkeypox. One of the lessons learned from COVID that we applied as soon as Monkeypox became evident is to aggressively screen earlier. We are proactively educating patients on this virus so they don’t get misinformation from social media or other potentially inaccurate sources. PAs and NPs recognize how critically important it is to proactively educate patients, and you don’t have to be an infectious disease expert to answer basic questions.
Q: What message should PAs and NPs have for parents and students as they go back to school?
Dr Kapu: This is a great time to get information out to communities on the signs and symptoms of Monkeypox. As students are going back to school, it is important to tell parents to keep their children home if they have a fever or are not feeling well. If someone in the child’s home has Monkeypox, avoiding direct skin-to-skin contact is important. If children develop a rash, that is when they need to reach out to their NP or PA provider.
Students are not considered at high risk for Monkeypox. For college students, it is comforting to know that they are most contagious when they have the rash. If they have a fever or are not feeling well, they should not go to parties or class. If they develop a rash, they should reach out to their health care provider or student health center to talk about getting tested.
While isolating for up to 3 weeks following Monkeypox infection can be difficult, we are also comfortable in the virtual world and many classes are available virtually.
Dr Kapu is AANP President, an acute care NP at Vanderbilt University Medical Center, Associate Dean for Clinical and Community Partnerships at Vanderbilt University School of Nursing, and professor of nursing at Vanderbilt University School of Nursing in Nashville, Tennessee. Dr Orozco is AAPA President and Chair of the Board as well as director of Advanced Practice Providers at Rush University Medical Center in Chicago and an assistant professor in the Department of PA Studies at Rush University College of Health Sciences.
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