Explaining monkeypox, its origin and its threat

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. Monkeypox is a public health emergency, and today we'll go over what you need to know and the ways you can protect yourself and your loved ones with 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 for having me, Amber.

Host Amber Smith: Let's start with some background. This is not a new disease, right?

Elizabeth Asiago-Reddy, MD: Correct. Yes. This was actually originally identified many years ago as a virus that was circulating in west and central Africa. And the name monkeypox, in fact, comes from an outbreak that occurred in a lab that was studying monkeys. So the natural hosts of this virus are not monkeys or people, but they're rodents that live in west and central Africa.

Host Amber Smith: So how did it get to the point where this has become a public health emergency in New York? And do you have any predictions for how things are going?

Elizabeth Asiago-Reddy, MD: Yes. So the first indications that things were different than what we've been used to with monkeypox occurred around April of 2022. And that was when doctors in Portugal started to notice a cluster of cases that occurred there. And very shortly thereafter, multiple cases started to be identified around the world. So the fact that these cases were identified in close proximity to each other timewise suggests that there was some kind of sentinel event that resulted in a lot of spread across the globe.

Host Amber Smith: So this was when we said something is definitely very different in this circumstance compared to what has happened in the past. So in the past, this virus has circulated on and off in west and central Africa. There are two different versions of the virus. The west African version is the one that has been spreading recently. And because of the fact that these cases typically were easily recognized by the rash, they've been able to get public health involved and stop the spread pretty quickly locally when it occurs. So this was a surprise to see so many cases coming up internationally. There have been international cases before, and they typically have been traced to exotic pets.

So it seems like it kind of popped up suddenly. Could it go away just as quickly?

Elizabeth Asiago-Reddy, MD: The good news is that the data suggests that our trajectory right now is favorable. So it looks like the numbers of cases have started to decline in most places, including the ones that had been experiencing a very large number of cases like New York City, San Francisco, Montreal. And largely this is being attributed to uptake in vaccines in those areas, as well as, probably too, changes in people's behavior because of concern about the disease spread.

Host Amber Smith: So I know that it doesn't have anything to do with monkeys. But what about pox? Does it have anything to do with smallpox? Do they share any similarities?

Elizabeth Asiago-Reddy, MD: Yes. This is part of the same family of viruses that causes smallpox. And for that reason, we were a little bit better prepared for this outbreak compared to, I would say, cOVID for example, where it was more of a de novo virus. We had dealt with a few similar viruses to COVID, but when it comes to monkeypox we had been preparing for the possibility that smallpox could be used as a biological weapon. And so vaccines and medications had been prepared on that basis. And because these viruses are in the same family, we were able to quickly pivot and try to use those same vaccines and treatments to help with monkeypox.

Host Amber Smith: So, people who've been vaccinated against smallpox, does that offer any sort of protection against monkeypox?

Elizabeth Asiago-Reddy, MD: That's not 100 % clear. The data would suggest that at least three to four years of good, solid protection exists after receiving a vaccine. There's some evidence that it might be quite a bit longer than that, but because individuals are not typically challenged in that setting to find out how long the smallpox vaccine lasts, we're not 100% sure. So people who have been vaccinated in childhood and are wondering whether or not their vaccine is protective, if they're at risk, they would be encouraged to be revaccinated in this setting.

Host Amber Smith: Now, in caring for patients with monkeypox, what have you and your infectious disease colleagues learned about this disease?

Elizabeth Asiago-Reddy, MD: The surprising feature of the current outbreak is the diversity of presentations that we're seeing. So, previously this was considered to have a very standard and classic presentation where after an incubation period -- which was variable, that could range anywhere from five days to three weeks -- but once people got sick, there was kind of a classic series of events that were thought to occur, which included a few days of fevers and feeling run down, followed by swelling of the lymph nodes, and then followed by this very classic rash that has what we call umbilicated lesions. They're bumps that you can actually feel when you're running your hand across someone's skin. And those bumps often have a depression in the middle of them. That's called the umbilication. And so crops of these would appear and then would disappear, and they were thought to have really always be present in every case and visible in various parts of the body.

So what's unique about what we're seeing now is that there are many individuals who appear to have no obvious spots. Or they have very few, maybe one or two. So that's a surprise that we weren't expecting, but that also is very likely the reason why this was allowed to spread more easily than we expected it would be able to. Because whether it's a change in the virus or it was kind of a just "wrong place, wrong time" situation that allowed more spread to occur, it definitely seems that the fact that some people don't know they're sick is a reason why this is more likely to be spreading now. So their illness is not severe enough to keep them at home. And because of that, they're able to spread this to other people.

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

We've heard that this spreads sexually, but does that make it a sexually transmitted disease?

Elizabeth Asiago-Reddy, MD: You are correct. It does spread sexually, and that appears to have been the primary mode of transmission for this particular outbreak. But we're not classifying it right now as a sexually transmitted disease because of the fact that it could be spread fairly easily outside of a sexual contact, just depending on where the lesions are that the person is experiencing. So if somebody has a rash on their hands, their arms, their face, anything that could come in close contact with someone else, that is the main way that this disease is spread, is the close skin-to-skin contact. It looks like a lot of the early cases involved people who had these rashes in their genital area. And so that's why sexual contact was occurring.

Something that we actually didn't really realize about monkeypox, we've discovered in this outbreak, which is that it seems like wherever the contact occurred the first time is the likely place where the monkeypox rash lesions are going to show up on that individual. So if someone experienced a sexual contact, that's probably where they're going to get sick. So, yes, indeed, it very much has been a sexually transmitted disease, but people can get these rash lesions outside of the area where they were initially infected as well. And so that's where, like I said, any kind of close skin-to-skin contact could result in an infection through somebody even without sexual contact.

Host Amber Smith: So that would explain why we've heard about children that have been infected, right?

Elizabeth Asiago-Reddy, MD: Correct. If somebody had this, regardless of how they originally got it, obviously caring for children typically involves skin-to-skin contact. So for sure that would place kids at risk in a situation where this was circulating in their household.

Host Amber Smith: Now, how soon after exposure did you say that someone might start developing symptoms?

Elizabeth Asiago-Reddy, MD: It can range anywhere from five days to three weeks after exposure. We're typically seeing something like closer to five to seven days.

Host Amber Smith: And is there a test that tells a doctor for sure that the person is infected with monkeypox? Or how do you determine that that's what it is?

Elizabeth Asiago-Reddy, MD: The test is done by taking swabs from the areas where the rash is. There have been a couple of studies now, which has also looked at genital swabs in high risk individuals who do not have rash lesions, and that's where we've discovered that people in fact can have basically no symptoms and still have this. Again, that relates specifically to genital swabs. So we're not aware of other forms of transmission, where somebody might have this without symptoms. But, if somebody does have rash, then those would be swabbed and sent to a lab for a PCR test. So that's a molecular test looking at the genetic material involved in the virus. And that is why it takes a couple days for that kind of test to come back. And that's where we would make the diagnosis. There have been a couple of reports of the possibility of false negative tests, so we're just still learning more about this and how common it might be. It appears to be rare, but as a clinician, I'm keeping my radar up for cases that look classic, regardless of the test results.

Host Amber Smith: How are doctors typically treating this disease?

Elizabeth Asiago-Reddy, MD: If it's a mild case, then it's really treated only with rest, symptomatic treatment and isolation. So the individual who's sick should be isolated until any rash lesions that they have are completely dried up and they're feeling better. So no more fevers. Primarily, it would be fevers that we'd be looking at as resolving indicating that somebody was getting better. But if someone is severely ill, then there is a pill or IV (intravenous) medication that can be given either in the hospital or as an outpatient. And Upstate has worked together with a team here of individuals across a number of different areas in the hospital and outpatient to gain access to that medication and make it available to patients if needed. The reason why it was a bit more complex than usual is because it's a medication that was originally approved for treatment of smallpox. So currently the use is, it needs to be monitored by the Food and Drug Administration carefully to assure safety and efficacy for monkeypox, since that's not what it was originally studied for

Host Amber Smith: If a family member has monkeypox and they're isolating, can they safely do that at home with family members around? Or is there any danger that this would spread through the air or from a towel or washcloth?

Elizabeth Asiago-Reddy, MD: Those are great questions. So as I mentioned before, skin-to-skin contact is really the primary mode of transmission, but there are other things that family members would want to be alert to if they were staying in the same household. The first one is bedding, because of the fact that individuals who have a rash might have some of their skin come off on their bedding, anyone who would be cleaning that bedding -- so accessing that, taking it to a washing machine, etcetera, -- that individual could potentially be at risk from that type of an exposure. And, additionally, it's possible that very early on when somebody is first becoming sick, that there could be maybe some respiratory spread in a close contact situation. So if somebody's really sitting, talking with somebody for a very long time, that type of thing, even without touching them, it's possible.

That's really more theoretical. And all of the evidence that we have so far is that skin-to-skin contact is required. Again, in the past, there have been some circumstances where health care workers have become sick from changing the bedding of patients who have monkeypox without using appropriate protective gear. So that is the other known mode of transmission. We would review this kind of thing with family members to make sure that they understand what would and would not be dangerous.

Host Amber Smith: Would the sheets and towels and clothing for this person need to be sterilized, or can just normal washing take care of getting rid of any of the virus that is shed?

Elizabeth Asiago-Reddy, MD: Yeah, just normal washing would be fine. The virus does not survive well on surfaces for any length of time. So there was a long, detailed study looking at a household where two members of the household were sick, and multiple surfaces were swabbed. And despite the fact that genetic material was uncovered on most of those surfaces, none of the samples grew virus. So it was thought that by touching those surfaces, that would not be a viable way of transmitting the virus.

Host Amber Smith: So, what is the typical prognosis for someone who tests positive for monkeypox?

Elizabeth Asiago-Reddy, MD: The prognosis is very good, and the vast majority of people will recover from this just fine. There have been five deaths reported internationally in the context of the current outbreak. Not a lot of details have been made available about the individuals who have died except to say that they were all severely immune compromised. So, exactly what that means, we just don't have the information to be able to say more about that. But compared to other illnesses that we've been experiencing recently, for example, obviously COVID, this is much, much less likely to be a fatal illness. There have been no deaths in the US, of the cases that have occurred here.

Host Amber Smith: If someone is infected with monkeypox, do they have immunity or would you still recommend that they get vaccinated?

Elizabeth Asiago-Reddy, MD: The current illness is thought to provide immunity at least for several years, if not, again, even longer. So similar to what you would expect from a vaccine.

Host Amber Smith: At this point, who should consider being vaccinated?

Elizabeth Asiago-Reddy, MD: Right now, each state has their own guidelines that they're using to help identify people who are at highest risk. And in most circumstances, that involves men who have sex with men who are outside of a monogamous relationship. So those are the individuals who we've been trying to help access vaccines in Onondaga County and including at our practice, Inclusive Health Services, if such patients are in need of a vaccine.

Host Amber Smith: Well, Dr. Asiago-Reddy, thank you for making time to tell us about monkeypox.

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

Host Amber Smith: My guest has been the chief of infectious disease at Upstate, 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.