Does monkeypox pose much of a risk in Central New York?

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Central New Yorkers may have heard about an outbreak of monkeypox with cases in Europe, Canada, the U.S., and elsewhere. And while we're not in imminent danger, this does spark some curiosity about a disease most of us have probably never heard of. With me to tell us about monkeypox is Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate University Hospital. Welcome back to The Informed Patient, Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you very much for having me.

Host Amber Smith: Now first of all, if I understand correctly, this has nothing to do with monkeys?

Elizabeth Asiago-Reddy, MD: Not completely nothing. The virus was originally identified after an outbreak associated with laboratory monkeys. So monkeys are one of the reservoirs for this infection, but they're actually thought not to be the main reservoir. So it looks like within the natural world, this virus lives more frequently in rodents, such as wild mice, rats and squirrels.

Host Amber Smith: Well, how similar is it to smallpox?

Elizabeth Asiago-Reddy, MD: It's in the same genus. So that's one of the ways that we subdivide viruses. So it's almost like it's in the same family, and it's even closer than just being in the same family, but clinically it's much milder than smallpox is. So smallpox is associated with a high risk of death and severe complications. And monkeypox, as we'll learn, is definitely no fun, but it is definitely less severe overall than smallpox.

Host Amber Smith: Would the smallpox vaccine, if someone's already been vaccinated against smallpox, would that protect them against monkeypox?

Elizabeth Asiago-Reddy, MD: As far as we can tell that would offer a decent degree of protection. There's some evidence of that from an outbreak that occurred in the U.S. several years ago, which was related to prairie dogs imported from Africa. So in that case series, there were individuals who had been previously vaccinated against smallpox, and they appeared to have much milder disease or to avoid disease altogether, despite exposure. So we think that yes, the smallpox vaccinations stopped in the U S in 1972, but individuals would have received it prior to then, and in all likelihood they would have some degree of protection, if not complete.

Host Amber Smith: Well, what can you tell us about this monkeypox disease? What are the symptoms that would tell someone that maybe they're infected?

Elizabeth Asiago-Reddy, MD: So the most classic is the pox themselves. So this is a very unique rash to the particular group of viruses. So the pox viruses have a rash that becomes raised. But when the infection first starts out, it starts out as so many infections do with just more of the fever and malaise. So feeling poorly for a few days before the rash actually starts. The rash tends to focus itself on the face and then spreading to the arms and legs. It can be present on the palms and soles, and importantly, it is frequently present in the genital area and also can be present on the oral mucus membrane, so within the mouth and along the lips. That's kind of the general feature of how the illness goes. It's also important to know that symptoms don't usually develop for almost a week after someone's exposed. So it takes between five days to even up to a couple of weeks after exposure before someone actually gets sick.

The rash, as I mentioned, goes through phases, and it starts out as a flatter rash. Then the lesions become bumpy. So they get raised. And they often become pustular, meaning that if you look at them, it looks like there's pus inside of them. They often have a very well circumscribed, circular appearance to them. And sometimes they have an indentation in the middle, which is called an umbilication.

Host Amber Smith: So how does this disease spread from person to person?

Elizabeth Asiago-Reddy, MD: The main way that it spreads is through direct contact with the rash lesion. So the rash lesions themselves have a lot of virus in them. And, in addition, as the rash matures and people are obviously lying down in bed, sleeping on covers, the lesions can open up, and so exposure from bedclothes or other clothes also can be a form of transmission. So, close contact is by far and away the most important means of spread. Droplet spread from respiratory secretions is also likely because if you test the respiratory secretions of individuals who are infected, there are high levels of virus there. So even though this is not a classic respiratory illness, in the sense that it doesn't usually make you cough or sneeze, if there was kissing, for example, or someone did cough or sneeze and you were in close proximity, that would be considered a way that it could be transmitted.

It is very, very unlikely that it could be transmitted at a distance from anybody. So that's obviously quite different from COVID.

Host Amber Smith: What about sexual transmission?

Elizabeth Asiago-Reddy, MD: At this point it seems like the vast majority of the cases have had sexual transmission, and that's because of the lesions in the genital area. But that's something that we actually knew about before. If you look at case series, having lesions in the genital area is something that was previously described. It's not a new phenomenon. It's probably more just that it occurred in a circumstance where a number of people, there was an ongoing chain of transmission through sexual contact that was unique compared to past circumstances.

Host Amber Smith: So I'm wondering how infectious monkeypox is and whether someone with monkeypox needs to be isolated.

Elizabeth Asiago-Reddy, MD: Yeah. Isolation is definitely recommended, and the reason for that is because of the close contact. So you wouldn't want to come into close contact with, as I said, clothes, bedclothes, direct contact with the rash lesions, etc. But when you talk about the degree to which it's contagious, It is a lot easier to contain than again, for example, COVID, because the illness is much more obvious. So one of the most difficult features of COVID is how different people's symptoms are, ranging from absolutely none to very mild -- like, oh, I'm maybe I have an allergy or something -- whilst the person is highly infectious.

That is not the case for monkeypox. So, as far as we know, there is no asymptomatic illness with monkeypox. Now, there might be some exceptions to that for people who have been vaccinated. They may have a very mild illness because of vaccination, to the point where it could potentially go unnoticed, but for natural disease, this is not something that you're going to be sick with without knowing that you have it. And the other thing is that also as far as we're aware, it cannot be transmitted until after the symptoms develop. So if somebody is sick with it, they should know that they're not feeling well. And naturally that would result in them being more likely to isolate themselves even before they realized what they had. And then once they get to the most contagious stage with the rash that is quite obvious and a lot easier to isolate because of how obvious it is.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Elizabeth Asiago Reddy. She's the chief of infectious disease at Upstate, and we're talking about monkeypox.

So, I wonder how easily it is diagnosed and whether monkeypox could be confused for smallpox?

Elizabeth Asiago-Reddy, MD: Well, it actually is because of a longstanding preparation related to concerns about smallpox being used as a biological weapon that has allowed us to be a bit better prepared for monkeypox. There have been efforts going on ever since the eradication of smallpox to make sure that in case that were ever re-introduced, that we would be prepared for it. And because of similarities between the two, as you're alluding to, there is crossover in terms of vaccines and treatments and what's effective for both viruses. So diagnosis is, there are tests that might make it initially difficult to distinguish between the two, but what's being recommended from us at this point is to do PCR based testing or molecular-based testing. And in that case, the specific target for monkeypox would be investigated, and it would be able to be distinguished from smallpox. And, again, we're in a different place than we were with COVID because COVID was, although we had coronaviruses, this was a completely novel coronavirus. So it was one that we literally had not dealt with before at all. Monkeypox, what's unique in this circumstance, is the degree of spread, maybe I shouldn't even say the degree of spread, but the number of cases that have emerged in various different areas, that's what's unique with what we're dealing with right now. But the disease itself is not unique. So we know about it. We have the capacity to diagnose it. Tests have already been created. Treatments have already been considered. So that puts us at an advantage. So New York state was able to very quickly send out information on what to do if we saw a patient who we were concerned about, how to swab the rash lesions, how to send it, where to send it, and that we would anticipate the results might come back more quickly than something that we were dealing with that was brand new.

Host Amber Smith: Is the testing for diagnosis, you mentioned a swab. Is that of the rash, or is it ... ?

Elizabeth Asiago-Reddy, MD: It's actually the rash lesions. They've done nasopharyngeal swabs, and that's where I said that it is likely that this would be transmitted by droplets because those nasopharyngeal swabs are pretty much universally positive. But typically it's the rash lesions, and mainly that's because that's when people are really going to come to medical attention, right? If you just have a fever, at this point, you still have COVID until proven otherwise. But once you get that rash, it's like, OK, what is this? Now we need to move.

Host Amber Smith: So how do doctors typically treat monkeypox?

Elizabeth Asiago-Reddy, MD: In many cases, it's observation alone. There have been efforts to create an antiviral, and because the disease is relatively rare, we don't have large studies giving us information about exactly how well this antiviral works. There are a couple of case series that go over a likelihood that it reduces the level of virus, and it is recommended in cases where individuals appear to be particularly ill. So that's an antiviral called tecovirimat. But actually, because of the incubation period that I mentioned, the main, quote unquote, treatment is actually prevention, which is to vaccinate as soon as possible after an exposure. So people who have had a high-risk exposure at this point are being recommended for vaccination. And to a large degree -- you'd have to evaluate, are they appropriate candidates for vaccination based on any of the risks and benefits associated with the vaccine and the age groups that it's approved for -- but basically that is the scenario right now is to consider a true high-risk exposure as an individual that might benefit from vaccination as soon as possible. Because if it can be given in that period before illness actually develops, which like I said, can be up to two weeks, then you have the opportunity to nip it in the bud. So you would actually want to get that vaccine in within five days of an exposure.

Host Amber Smith: So do most people recover from monkeypox if they're infected?

Elizabeth Asiago-Reddy, MD: Yes. Most people do recover. There have been case fatalities associated with monkeypox, and the percentage is still, I would say, of concern. There's some variability when you look through case series, potentially up to 3% of cases could result in death. Again, that varies when you look at different reports, and some of those individuals are being treated in resource-limited settings. So overall it's considered to be a milder illness, and people who recover will recover fully. The disease can last a while. So it is definitely, like I said, it's not fun. It looks like it takes three to four weeks for most people to get better, for those lesions to go away. You know, the lesions themselves can become painful, and you feel pretty miserable with a lot of malaise and fatigue throughout a lot of the course of the illness. But yes, the available data show that people recover fully once all those lesions have crusted over.

Host Amber Smith: Does the rash, the monkeypox rash, does that leave scars like, was it ... ?

Elizabeth Asiago-Reddy, MD: Typically it does not. That's something that's interesting and that surprised me because the rash lesions look pretty terrible, but in most cases they resolve completely. Chickenpox, I mean, is a bit similar. So many of us have at least a few little spots here and there leftover from chickenpox, but the vast majority of those will resolve completely. And it appears that that's the case, as well, with monkeypox.

Host Amber Smith: Well, how concerned are you, as an infectious disease doctor in Central New York, about monkeypox? I mean, how concerned should we be?

Elizabeth Asiago-Reddy, MD: I think right now we're in a decent place, which is that the WHO (World Health Organization) and the CDC (Centers for Disease Control and Prevention) are very carefully tracking cases. And we have so many more tools available to us right now to try and mitigate the spread of the illness than we did with COVID. That relates, as I said, to the nature of the illness itself, not having an asymptomatic spread, and then also to the ability to isolate people and then hopefully give them this post-exposure prophylaxis to prevent ongoing disease. So, yes, of course I'm concerned because it looks like, in this case, there were a series of exposures that probably happened very early on. This is looking at as something that maybe started to spread at a location where a number of people got together all at the same time and were traveling internationally, and then as they went back home, their symptoms emerged. So, that would help to explain the number of different countries that we're seeing with cases. So I think that it's just a matter of clear communication and making sure to identify people based on that clear communication. And then we will be able to get a handle on this.

So, I think to say I'm not concerned would belie my ... of course, I'm an infectious disease doctor, so I see an infection cropping up, and I become concerned, but is it something where I've changed anything that I do in my personal life or that I think the vast majority of us need to think about changing anything that we're doing in our personal life? No. It's a matter of being alert to that kind of classic presentation, and then seeking assistance if we were to ever see anything like that.

Host Amber Smith: Well, that's good to know. Thank you so much for making time for this interview, Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you for having me.

Host Amber Smith: My guest has been Upstate's chief of infectious disease, Dr. Elizabeth Asiago -Reddy. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.