A nurse’s guide to monkeypox
William Kelly, MSN, FNP-C
Author | Nurse Practitioner
Published: September 19, 2022
Unless you’ve buried your head under a rock, you probably have heard about the recent outbreak of Monkeypox.
Just like any infectious disease, nurses are on the front lines and we need to be educated about how to care for these patients, as well as how to minimize the risk of spread to our patients or families.
What is Monkeypox?
Monkeypox is a virus that is similar to smallpox because they are part of the same genus – the orthopoxvirus genus. It is a zoonotic disease, which means its natural hosts are animals – in this case primates and rodents. This virus causes a syndrome of fevers, body aches, malaise, and a pustular rash that is similar to smallpox, although less deadly and less contagious.
This is not a new virus, and normally tends to occur primarily in the tropical forests of West and central Africa. However, this does occasionally cause small outbreaks outside of these areas.
In 2003 there was a brief outbreak in the US, which included only 71 confirmed cases. Out of these, there was no spread to any healthcare staff or other patients within the hospital, and no associated deaths.
Since May 2022, there is another outbreak in the US that is current and continues to spread, this time much more prevalent with over 21,000 cases confirmed in Septemeber, and over 50,000 cases globally.
Check out CDC for updated statistics.
Transmission of Monkeypox
There are multiple ways in which viruses can be transmitted to other people.
Monkeypox has a few different routes of transmission, some more common than others. These routes of transmission include:
Skin-to-skin contact with an infected lesion is the most common route of transmission for monkeypox. This. ismost contagious when the lesions are present on the skin. This is why it is commonly transmitted via sex, even though it is not a sexually transmitted infection.
Is Monkeypox an STI?
Despite what you may have heard on some news outlets, monkeypox is NOT a sexually transmitted infection and you cannot only get it through gay sex.
Most cases that are occurring are currently within the gay community of men who are having sex with men. This is sometimes how viruses work – they will spread in a certain community, and then make their way to other communities.
As with many viruses such as COVID, respiratory droplets can transmit infection. So if you cough sneeze or even speak, this can sometimes infect others depending on how close you are to them. Prolonged face-to-face contact may be required for this to occur with monkeypox.
Fomite transmission is when the virus lives on a surface and another person picks up that object or touches that surface and then infects themselves. This can commonly be bed linens, clothing, or surfaces. This is different for every virus, and monkeypox has been known to be able to live on surfaces for up to 15 days!
Not Contagious Anymore?
A person is considered infectious from the onset of clinical symptoms until all lesions have scabbed over and re-epithelization has occurred.
What to do if Exposed?
The CDC recommends that if a patient is exposed to monkeypox in the community, they should:
- Monitor for symptoms for up to 21 days
- If any symptoms develop, should isolate for at least 5 days to watch for the development of a rash
- If the rash develops, isolate until evaluated by a healthcare professional (likely isolate until lesions resolve)
How dangerous is Monkeypox?
It’s difficult to predict how dangerous monkeypox is for those in the US, as most of our data comes from Africa. In Africa, they have less access to quality healthcare, and the predominant strain (called a “clade”) is more deadly there.
From the data regarding Monkeypox in Africa, up to 3-6% of cases die.
So far. in the US, there have been one confirmed death from Monkeypox in LA.
Remember that most of the current monkeypox infections are circulating among younger, generally healthy men.
We have not yet seen monkeypox in large amounts in older patients with significant comorbidities and immunocompromised patients, and they’re expected to have higher rates of complications and death.
Even if monkeypox does not cause death, it can last for weeks and lead to very painful and sometimes scarring lesions.
Prevention is the most important aspect of infection control. If we can prevent spreading the virus, we can’t control the virus. This leads to better patient outcomes overall.
With monkeypox, there are ways to prevent the spread within and outside of the hospital. Monkeypox prevention includes:
Universal precaution should ALWAYS be used on all patients in every setting, and includes proper hand hygiene, and the use of clean gloves when dealing with or anticipating contact with a patient’s body fluids. This is one of the most important things we can do in healthcare to prevent the spread of infection.
Patients who have suspected or confirmed monkeypox should be placed into isolation as per your facility protocol. As we discussed, monkeypox is spread primarily through physical contact as well as through respiratory droplets. This means that you should be using contact and droplet precautions, so typically that involves the use of a gown, gloves, N95 facemask, and protective eyewear.
The CDC currently recommends N95 masks when entering a patient’s room with Monkeypox.
Smallpox, a similar but more contagious and deadly virus than monkeypox, was essentially eradicated in 1977 thanks to vaccinations. Because of this, routine vaccination was discontinued in 1980.
Because smallpox and monkeypox are so similars and comes from the same family of viruses, the smallpox vaccine is effective against monkeypox. However, it is in short supply and is being given to patients who meet high-risk criteria.
Currently, vaccination is recommended for patients who:
- Have had close contact with Monkeypox for extended periods of time
- A recent sex partner (the last 2 weeks) has been diagnosed with Monkeypox
- A man or transgender/non-binary who has sex with men and in the last 2 weeks has:
- Had multiple sex partners or group sex
- Had sex at a commercial venue (bathhouse, sex club, etc)
- Had sex in an area where monkeypox transmission is occurring
Patience with monkeypox will often present with a Prodromal period of symptoms, followed by the characteristic rash. During the prodrome, these symptoms will usually last up to 5 days and include:
A temperature above 100.4 F
Patients often complain of a severe headache
Back & Body Aches
Myalgias and pain are common with monkeypox, as with many other viruses
Patients are often very fatigued and tired
Patients often have swollen lymph nodes, which can be localized toa specific area, or generalized throughout their body
The Monkeypox Rash
The characteristic rash of monkeypox will typically develop 1-4 days after the prodromal symptoms start.
Monkeypox will cause a characteristic vesicular/pustular rash that progresses through different stages (See more on the stages below). These lesions are often in the same stage as each other, but not always.
Recent travel to an area where Monkeypox is Endmic, such as western Africa or the Congo Basin
Any recent contact with someone who may have had monkeypox
Any recent sexual contact or history that would place them at risk of getting monkeypox?
The physical inspection will primarily involve inspecting the skin for the monkeypox lesions, noting their quality, amount, number, and locations.
- Generalized: May be febrile, sweaty, pale
- HEENT: May have enlarged and tender anterior cervical lymph nodes, throat may be erythematous
- Cardio: May have tachycardia, especially if fever present
- Respiratory: may have increased respiratory rate, sometimes could have cough
- Skin: Monkeypox lesions as described in detail below
- Extremities: Lymphadenopathy may be present in axillae or groin
- Temp: Often have fever >100.4
- BP: Often normal
- HR: May have mild tachycardia d/t fever, dehydration, etc
- RR: May by mildly tachypneic
- SPO2%: Often normal
The characteristic monkeypox rash begins approximately 1-4 days after the start off the other symptoms, although some people get the rash first. This begins as a macule, then slowly develops into vesicles, pustules, and then scabs over.
The rash will typically last 2-3 weeks. Patients are considered infectious until the scabs fall off and a new layer of skin forms.
1. Enanthem Stage
In some cases, lesions will first form in the mouth and/or on the tongue.
2. Macular Stage
Macular lesions will first appear, which are basically just rounded red spots that are flat.
This stage lasts 1-2 days
3. Papular Stage
The macular lesions will then turn into papules, which are raised red bumps.
This stage also lasts 1-2 days
4. Vesicular Stage
The papular lesions will then turn into vesicles, which are raised bumps filled with clear fluid.
This stage also lasts 1-2 days
5. Pustular Stage
The vesicular lesions will then turn into pustules, which are raised bumps that are filled with pus (suppurative fluid).
Initially, these are deep-seated, meaning firm and hard. Eventually, they develop an umbilication in the center.
This stage lasts 5-7 days
6. Scab Stage
Finally the pustules crust over and become scabs. These fall off after about 1 week.
This stage lasts 7-14 days
There are some nursing inventions that you can do right off the bat with these patients he suspected to have a monkeypox:
Patients with suspected monkeypox or even chickenpox should be placed in contact and droplet precautions. The difference with chickenpox is that that tends to be airborne, whereas monkeypox is not, so a negative air pressure room is not required, although may be prudent just in case of chickenpox or other airborne viruses.
Follow proper isolation precautions to minimize the acquisition and spread of the virus. Always refer to your facility’s protocols.
Place the IV
Place at least one IV, preferably 20 gauge or larger, in order to infuse normal saline once it’s ordered. These patients are usually tachycardic and have fevers, and fluids will help rehydrate them, improve their vitals, and help them feel better overall.
Prime your Fluids
Prime at least 1 L of NSS spiked and ready to infuse. Verify a verbal or electronic order being administering (as always 😉).
If these patients are significantly ill and tachycardic, it would be a good idea to hook them up to a cardiac monitor. While doing so, a full set of vitals should be taken if not done already in triage.
Ask for and verify any medication that the patient may need, including antipyretics like Tylenol, an analgesic like morphine or Toradol, and/or an antiemetic like Zofran.
Diagnosis of Monkeypox
Diagnosis of monkeypox is largely clinical – so based on their history and the rash. However, it is recommended to confirm this in a lab due to the current outbreak.
There are a few ways monkeypox can be confirmed in the lab:
A swab of the lesions can be obtained and sent to the lab, they should be obtained with a dry synthetic swab. For more information on how to collect the swab – see here.
2 swabs should be obtained from at least 2 different lesions. Vigorously swabbing back and forth is fine, and you do not need to “unroof” the lesions.
Some facilities can check for IgG and IgM antibodies to monkeypox. IgM is typically detected 5 days after onset of rash, and IgG is detected 8 days after onset of the rash.
Monkeypox can be identified under a microscope as well, where the pathologist visualizes brick-shaped poxvirus virions (indistinguishable from smallpox).
Other Lab abnormalities
There are other lab abnormalities that can present in patients with monkeypox, although these are NOT specific to monkeypox. these include:
- Leukocytosis (increased WBC)
- Transaminitis (Elevated liver enzymes)
- Thrombocytopenia (Low platelets)
- Hypoalbuminemia (low albumin levels)
Prognosis & Treatment
With the current US outbreak, patients who get Monkeypox generally have a good recovery, and most can fully recover at home without hospitalization. So far only one death has been specifically attributed to monkeypox in the US during this current outbreak.
However, patients can present with more severe symptoms and complications, which can lead to worse outcomes and even death. These patients are kept in the hospital and given more extensive treatment.
For most people who get Monkeypox, treatment is going to be symptomatic, just like with most viruses. Symptomatic or supportive care includes:
Antipyretics like Tylenol or Ibuprofen can be used to control fever and symptoms of pain.
Encouraging oral hydration is important with any virus, and will help the body recover quicker, and prevent complications such as acute kidney injury. If the patient is admitted, these fluids can be given IV as well.
Resting while the body recovers from infection is important for any virus, and will help the body heal as quickly as it can.
TPOXX is the abbreviation for Tecovirimat – an antiviral used for severe monkeypox infections. This is reserved for patients who are admitted to the hospital and have severe disease. Although we don’t have much data in humans, this antiviral has been shown to decrease mortality rates in animals with monkeypox when started early in the course of the illness.
- Rx: 600mg IV or PO Q12h x 14 days (depending on weight).
- Side Effects: include headaches, nausea, and abdominal pain.
Mechanism of Action
Potently inhibits the orthopoxvirus protein required for the formation of virus particles
600mg IV/PO Q12H x 14days (for 40-120kg)
Headache, Nausea, abdominal pain
Cidofovir has been shown to be effective in killing monkeypox in animal studies. Brincidofovir is a prodrug of cidofovir and was also approved for the treatment of monkeypox, however, did show some elevated liver enzymes in animal studies.
Complications & Monitoring
As discussed, most patients recover well at home, but there are certain complications and monitoring that you should watch for.
Patients at increased risk of developing more severe complications include:
- Immunocompromised: People with HIV/AIDS, leukemia, chronic steroid use or other immunosuppressants
- Age < 8
- Pregnant or breastfeeding women
- People with active skin diseases like severe eczema, impetigo, burns, etc
Secondary bacterial infections can occur with viral infections, and this is no different than with monkeypox. Bacteria like to strike while the immune system is busy fighting the virus. This can lead to infections like pneumonia or sepsis.
Common secondary infections include:
Bacterial infections in any location can cause sepsis. This often happens from UTIs, lung infections, or skin infections.
Pneumonia should be suspected with productive cough, shortness of breath, adventitious breath sounds, and respiratory distress. This is evaluated with a CXR.
Encephalitis can occur with various infections and cause confusion, migraines, seizures, and overall altered mental status. This may be diagnosed by brain imaging (CT or MRI), EEG, and a lumbar puncture.
And hopefully that gave you a pretty good understanding of Monkeypox and how to care for your patients who may have it!