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Monkeypox · The SHEA Podcast

• 0:08
  SPEAKER_00: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_00: I'm Dr.
• 0:24
  SPEAKER_00: Christopher Cernich, Chief of Medicine and Hospital Epidemiologist at the Madison VA Hospital and Associate Professor of Medicine at the University of Wisconsin School of Medicine and Public Health, and I will serve as today's podcast moderator.
• 0:38
  SPEAKER_00: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:47
  SPEAKER_00: Shea is excited to launch this episode of the podcast, COVID-19 Updates, What We Know Now.
• 0:53
  SPEAKER_00: Today's discussion, while not COVID-specific, is still important as we navigate the pandemic and will be focused on monkeypox.
• 1:00
  SPEAKER_00: Our speaker today is Dr.
• 1:01
  SPEAKER_00: Erica Shinoi, Associate Chief of the Infection Control Unit and Medical Director of the Region 1 Emerging Special Pathogens Treatment Center at Massachusetts General Hospital.
• 1:11
  SPEAKER_00: Thank you for joining us today, Erica.
• 1:13
  SPEAKER_01: Great to be here.
• 1:15
  SPEAKER_00: So I'd like to kind of jump into a number of basic questions.
• 1:19
  SPEAKER_00: I know that there's going to be a number of additional informational sessions coming out from Shay and Itchy on this topic, but I think our listeners would really benefit from a general overview and getting their minds primed for how to approach this if they were to kind of encounter a case.
• 1:36
  SPEAKER_00: So what are the basics of monkeypox?
• 1:38
  SPEAKER_00: What should healthcare providers know about its origins, how it spreads, symptoms, effects, and et cetera?
• 1:45
  SPEAKER_01: Sure.
• 1:45
  SPEAKER_01: So I think the point you mentioned at the beginning is that there's going to be a lot of information coming out.
• 1:50
  SPEAKER_01: And even the Shea, the Shea Town Hall that just happened had a great overview by Dr.
• 1:55
  SPEAKER_01: Palmore.
• 1:55
  SPEAKER_01: So I would definitely encourage those who hear this podcast and want to learn more to take a look at that, as well as the other content that'll be coming from Shea and Anitchy.
• 2:04
  SPEAKER_01: So I think one part about this, and we've learned a lot about monkeypox at our institution, just having had the experience of having a case patient there.
• 2:12
  SPEAKER_01: And the first part is that it's not new.
• 2:15
  SPEAKER_01: So monkeypox was first identified in 1958 among monkeys.
• 2:20
  SPEAKER_01: These were laboratory monkeys, I think in Copenhagen.
• 2:23
  SPEAKER_01: And that's where the monkeypox name comes from.
• 2:25
  SPEAKER_01: And then the first human case was in the 1970s.
• 2:29
  SPEAKER_01: And the cases from that point on really were in endemic countries in West and Central Africa, where the animals, the rodents, for the most part, and non-human primates that are thought to be reservoirs, live.
• 2:43
  SPEAKER_01: And periodically there would be cases that would come out of those areas of the world being travel-related.
• 2:50
  SPEAKER_01: And so most notably in the United States was the 2003 prairie dog outbreak.
• 2:56
  SPEAKER_01: And then between 2018 and 2021, there were a series of travel-related cases.
• 3:02
  SPEAKER_01: So a few in the UK, there was one in Singapore, one in Israel.
• 3:06
  SPEAKER_01: And then in 2021, there were two in the United States, one in Dallas in July of 2021, and in November in Maryland, there was a case.
• 3:15
  SPEAKER_01: And so those were all travel related.
• 3:18
  SPEAKER_01: There was a travel-related case on May 7th in the UK.
• 3:23
  SPEAKER_01: But then after that, we started hearing in the following week about cases that were not travel related that indicated community spread.
• 3:30
  SPEAKER_01: So that's kind of the history up until this point.
• 3:33
  SPEAKER_01: And obviously by the time this podcast is out, it will be old history because there will be new information about the over 1,000 cases so far that have been identified as part of this outbreak.
• 3:43
  SPEAKER_01: In terms of how it spreads, well, the initial, you know, the reservoir that we think about is those rodents, and they can then get into humans through close scratches, bites, or other sorts of interactions with the animals.
• 3:57
  SPEAKER_01: Once it's in humans, it can be spread human to human.
• 4:00
  SPEAKER_01: And it's thought that it's really about true close contact with infected individuals and specifically having contact with the lesions that develop as part of the rash and the infectious material in those lesions.
• 4:12
  SPEAKER_01: And while there is the possibility of spread via respiratory secretions, at this point it's thought that that's really in the context of truly close face-to-face prolonged sorts of interactions that could result in a transmission.
• 4:27
  SPEAKER_01: But I think for the most part, we're thinking about this as a very close contact spread infection.
• 4:33
  SPEAKER_00: So you've already kind of touched on the fact that this is primarily an animal-to-human transmission and that human-to-human transmission can occur.
• 4:43
  SPEAKER_00: And you've very nicely kind of articulated that this is predominantly transmitted through close physical contact or through large respiratory droplets.
• 4:54
  SPEAKER_00: I think there's a lot of concern, obviously, in the setting of COVID-19 about modes of transmission.
• 5:00
  SPEAKER_00: And already on social media, I think we're hearing a lot of debates back and forth about aerosol transmission, et cetera.
• 5:07
  SPEAKER_00: And even the CDC guidelines kind of say we should have people in aerosol transmission.
• 5:13
  SPEAKER_00: But can you kind of speak to what our level of concern should be for distant aerosols with this organism for our listeners?
• 5:21
  SPEAKER_01: I'm not a monkey pox expert in the sense that I have been studying it for years and years and years.
• 5:26
  SPEAKER_01: But I think I look at the literature of what we know about exposures and transmission to date.
• 5:31
  SPEAKER_01: So in endemic countries, very clear, like household transmission, I think secondary attack rates around 9% have been reported.
• 5:39
  SPEAKER_01: There have been cases of transmission in healthcare settings in endemic areas.
• 5:45
  SPEAKER_01: But outside of those areas, if we look at, for example, the two cases last year in the United States was hundreds of contacts identified, no transmission events reported.
• 5:55
  SPEAKER_01: Now, this isn't a context specifically like on the airplanes where people would have been masked because it's COVID.
• 6:00
  SPEAKER_01: But if you go back even prior to that, in the cases of 2018, prior to the pandemic, where individuals traveled back from areas, they were infected, they were in seen in healthcare facilities, had community contacts, there were not any transmissions reported during that time except in a single transmission.
• 6:19
  SPEAKER_01: And that was in one of the UK cases where there was what appeared to be an intermediate risk exposure to a healthcare worker, and that resulted in a transmission event.
• 6:30
  SPEAKER_01: But outside of that one single transmission event in healthcare facilities, there hasn't been another transmission event.
• 6:38
  SPEAKER_01: And even in the case in healthcare settings.
• 6:41
  SPEAKER_01: So I guess what that's saying to me is that even with many, many contacts in community and healthcare settings, contacts that were, you know, for the most part not the close physical contacts that you might expect a transmission event to occur, that there haven't been transmission.
• 6:57
  SPEAKER_01: So I think it does lend itself to the concept that what we're talking about is very close transmission.
• 7:04
  SPEAKER_01: Now we're learning, right?
• 7:06
  SPEAKER_01: So we're going to learn a lot from the thousand plus cases that are occurring, but I do think it's quite different from COVID.
• 7:14
  SPEAKER_01: And that is just means that we have to have a different approach and different emphasis on various ways to break chains of transmission.
• 7:22
  SPEAKER_00: Thank you.
• 7:22
  SPEAKER_00: I think that's really important for people to hear that this is different.
• 7:26
  SPEAKER_00: And again, circling back to kind of approaching this from the healthcare system, what is your kind of advice, recommendation for how facilities should be preparing for monkeypox?
• 7:38
  SPEAKER_00: Any thoughts there?
• 7:39
  SPEAKER_01: So I bucket this into how we think about identifying isolated form for pretty much anything in healthcare or communicable diseases.
• 7:47
  SPEAKER_01: So I think if you're in a facility, you're probably already doing this where you're educating frontline clinicians about individuals who might present with a rash, talking about how there may or may not be a prodrome prior to that.
• 8:00
  SPEAKER_01: Because I think part of what we're learning is what may have been typical or what we thought was typical presentations of monkeypox may not be as typical in the sense that the classic prodrome followed by the rash, it may not present that way.
• 8:14
  SPEAKER_01: But certainly in anyone presenting with a rash, you need to identify could they possibly be a person under investigation, look at the most relevant epidemiological criteria at the time, because that's changing.
• 8:25
  SPEAKER_01: Isolate those individuals if you think that they could be a person under investigation, and then let the right people know in your facility.
• 8:32
  SPEAKER_01: And that turns out to be the infection prevention control folks for the most part.
• 8:37
  SPEAKER_01: You know, there was some discussion as to whether or not people should adjust their travel screens.
• 8:42
  SPEAKER_01: A lot of us do travel screens in our electronic health record or other sorts of decision support that can help frontline clinicians who have a lot to remember.
• 8:50
  SPEAKER_01: And this is just one more thing to remember, to think about.
• 8:53
  SPEAKER_01: I would say for our facilities, we, and we're part of a large 14 facility system.
• 8:58
  SPEAKER_01: We didn't touch the travel screen.
• 9:00
  SPEAKER_01: Very quickly, it was clear that you know travel wasn't going to be as helpful an epi risk factor, and we didn't think it made sense to do that.
• 9:08
  SPEAKER_01: What we have done is we've developed a smart phrase that a clinician can use, dot monkeypox in the record, and it pulls up the most current, it asks about the rash and if it's unexplained, and then it asks about the current epi risk factors, and then it gives them right then and there in the note, these are the next steps you need to do.
• 9:28
  SPEAKER_01: So we're trying that out.
• 9:29
  SPEAKER_01: It's early days to see if that has worked.
• 9:32
  SPEAKER_01: We use similar things with COVID, and we're trying that out.
• 9:35
  SPEAKER_01: I think the part to remember is that the epidemiological risk factors may evolve.
• 9:39
  SPEAKER_01: They've already have evolved over the last few weeks.
• 9:42
  SPEAKER_01: And so keeping people up to date, it's going to be hard to do that if we're keeping on pushing information in emails or pieces of paper.
• 9:50
  SPEAKER_01: So to the extent that we can try to minimize the kind of memory that people have to have and just have information at their fingertips, I think it'll be easier for people.
• 10:00
  SPEAKER_01: Now, one question that comes up is what isolation?
• 10:03
  SPEAKER_01: And initially the CDC had said, and this was what was in the 2007 guidelines about monkey pox is put the patient in an airborne infection isolation room.
• 10:14
  SPEAKER_01: And that was removed from the recommendations, with the exception of if an aerosol generating procedure is going to be performed.
• 10:21
  SPEAKER_01: Now, the PPE doesn't change, it's the gown, gloves, and 95 respiratory or equivalent and eye protection.
• 10:27
  SPEAKER_01: But I think we're still thinking about initially placing the patient in an airborne infection isolation room if available, just because often people are undifferentiated when they show up in a facility and they may need an AGP or they may have varicella.
• 10:43
  SPEAKER_01: So I think initially it might be appropriate to stick with the airborne infection isolation room.
• 10:48
  SPEAKER_01: Of course, not every place has it, we know that.
• 10:50
  SPEAKER_01: And when you don't, you just make sure the patients mask, put them in a standard room, close the door, and you work with what you have.
• 10:57
  SPEAKER_01: But at least for now, I think just in that undifferentiated part and thinking through how you might might there might be other things on the differential that for which an airborne infection isolation room might be appropriate.
• 11:09
  SPEAKER_01: We're at least starting with that framework for now.
• 11:12
  SPEAKER_00: Great, very practical information.
• 11:14
  SPEAKER_00: So monkeypox is similar to the eradicated smallpox.
• 11:18
  SPEAKER_00: Is there any data to suggest that those who are vaccinated against smallpox would have enhanced protection against monkeypox?
• 11:25
  SPEAKER_01: So I think we think that's the case.
• 11:27
  SPEAKER_01: And in fact, there's some really interesting epidemiology that I'm learning more about.
• 11:32
  SPEAKER_01: There was a great WHO conference last week, a couple days, where they had experts from endemic areas and across the world who've been thinking about monkeypox for a lot longer than I have or many of us have.
• 11:44
  SPEAKER_01: And one of the interesting things they have been talking about is how as smallpox vaccination campaigns basically were turned off, that there has been an increase, and they they were concerned that this would happen.
• 11:57
  SPEAKER_01: And in fact, it seems to have happened that monkeypox has increased now that immunity from vaccination has waned since nobody's being vaccinated anymore for smallpox.
• 12:06
  SPEAKER_01: So I think that that's we don't know how long it would last, right?
• 12:09
  SPEAKER_01: So if you were vaccinated for smallpox as a child prior to in the US, prior to I think 1972, are you protected at this point?
• 12:17
  SPEAKER_01: You know, immunity wanes over time.
• 12:19
  SPEAKER_01: So I think the expectation would be that you may not have the protection that additional boosting or re-vaccination would be required to have levels of protection.
• 12:28
  SPEAKER_01: Again, if that protection is indicated for monkeypox.
• 12:32
  SPEAKER_01: And that's a whole nother question about who it makes sense to either to do pre-exposure prophylaxis in with the available vaccines.
• 12:41
  SPEAKER_00: Great.
• 12:41
  SPEAKER_00: What recommendations do you have for research and surveillance around monkeypox?
• 12:46
  SPEAKER_00: You alluded to the fact that investigators in endemic areas are doing a lot of research, but for kind of a developed country like the United States, what do we need to be doing from research and surveillance perspective to be better prepared for monkeypox?
• 13:02
  SPEAKER_00: And I guess are there any kind of lessons to other emerging zoonotic pathogens that may generalize for a country like ours?
• 13:09
  SPEAKER_01: Well, I think I have an immediate interest in learning more about the cases that are in Spain and Portugal and you know, many, many countries now to learn more about the transmission risk and exposure.
• 13:22
  SPEAKER_01: I mean, we now have all of these cases where they were likely community and healthcare contacts.
• 13:29
  SPEAKER_01: It would be very helpful.
• 13:30
  SPEAKER_01: I mentioned the literature is limited, what outside of endemic areas in terms of exposure or specifically in healthcare facilities and risk of transmission, but now we have many, many cases out there where people are doing the contact tracing.
• 13:44
  SPEAKER_01: It's very difficult to do the contact tracing in community settings as well as healthcare facilities.
• 13:49
  SPEAKER_01: It takes a lot of resources to do that, but I think it will help us understand more about what are the highest risk exposures, how often do those exposures lead to transmission.
• 14:01
  SPEAKER_01: That could really inform how we think about post-exposure prophylaxis, of course, but also pre-exposure prophylaxis.
• 14:08
  SPEAKER_01: So that's a kind of top on my agenda.
• 14:10
  SPEAKER_01: And that may just be from a you know practical I want to know because I would like to have protocols in place that were based on as much data as we have as possible.
• 14:21
  SPEAKER_01: I think in a bigger research agenda, this does raise the issue of for decades and more recently since 2017, there have been increases in monkeypox in endemic countries that, while people have been aware of, the WHO has clearly been tracking, and CDC has been tracking as well, really wasn't on our radar as much.
• 14:43
  SPEAKER_01: And that's something I think we need to think about.
• 14:46
  SPEAKER_01: What else isn't on our radar as much and to be more prepared?
• 14:50
  SPEAKER_01: But I do think that the public health response to this has been incredibly robust.
• 14:55
  SPEAKER_01: The sort of scientific, the sharing in real time of the data from UK as it was, as they were identifying cases from Spain, from Portugal, all sharing that information is absolutely essential.
• 15:08
  SPEAKER_01: And for us, particularly, and I know we won't talk about the case we had so much here, but it it really changed the course of our ability to identify the patient that the UK had published those cases.
• 15:18
  SPEAKER_01: Because I don't think had they published it, what we would have diagnosed or tried to diagnose in this patient because it was a real puzzler.
• 15:26
  SPEAKER_01: And I know that for the clinician that did put monkeypox on the differential, it was key to have seen those reports come out the day before when she was thinking this all through.
• 15:37
  SPEAKER_01: So that piece, I think, understanding what pathogens are we, do we need to have a closer eye on, learning more from this current outbreak and getting really granular about exposure risk and transmission risk.
• 15:49
  SPEAKER_01: And then lastly, just sharing as much as we can across the world so that we can all learn together and progress together with monkeypox but other viruses that are definitely, I think we can say we should not be surprised if we see more emerging pathogens, just the way things are going in the world.
• 16:07
  SPEAKER_00: Great advice.
• 16:08
  SPEAKER_00: Do you have any final thoughts for our listeners?
• 16:10
  SPEAKER_01: I would just say, I mean, I touched a little bit upon it related to the sharing of information, but that has been a theme through COVID with Shay, with these podcasts, with the town halls.
• 16:21
  SPEAKER_01: And I would just encourage those who maybe like the podcast but haven't been to town halls to join us because I really learn so much from the panel each week.
• 16:30
  SPEAKER_01: And I think that that's a great resource for all of us.
• 16:34
  SPEAKER_00: Dr.
• 16:34
  SPEAKER_00: Chinoy, I want to thank you for such a great conversation and for joining us today.
• 16:38
  SPEAKER_01: Thank you.
• 16:39
  SPEAKER_01: It was fun.
• 16:40
  SPEAKER_00: Thank you again to our speaker for sharing her perspective and experience.
• 16:44
  SPEAKER_00: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program, where you will also find resources such as the COVID-19 town halls.
• 16:55
  SPEAKER_00: Interested in becoming a SHA member?
• 16:57
  SPEAKER_00: Take$20 off any membership type using the coupon code LearningCE22 at checkout.
• 17:03
  SPEAKER_00: This concludes today's episode of the Rapid Response Podcast.
• 17:07
  SPEAKER_00: Thank you for tuning in.