How is monkeypox treated?

As the monkeypox outbreak continues to grow around the world, many people who have become ill with the virus have had mild symptoms and were able to recover without any specific treatment for monkeypox.

As the monkeypox outbreak continues to grow around the world, many people who have become ill with the virus have had mild symptoms and were able to recover without any specific treatment for monkeypox.

“For the most part, these illnesses are relatively mild. They can be disfiguring and gross, but they will heal on their own, although it may take some time,” said Dr. William Schaffner, a professor of medicine at Vanderbilt University School of Medicine.

The US Food and Drug Administration has not approved any specific therapies for the treatment of monkeypox. But the US Centers for Disease Control and Prevention is making the antiviral drug tecovirimat available during the outbreak and says it may be considered for monkeypox patients who have or are at high risk of severe disease.

Data on the number of monkeypox patients who fall into this category remain limited. But Dr. Mary Foote, medical director of the New York City Department of Health and Hygiene’s Office of Preparedness and Response, said last week that the city’s proportion of severe monkeypox cases has been higher than the expected.

Foote said providers there began tecovirimat treatment for “close to 70 patients,” with the number of confirmed cases in the city at the time reaching 336.

Vaccination can prevent or reduce the disease

According to the CDC, monkeypox can spread from person to person in a number of ways, including direct physical contact with the rash caused by monkeypox infection, “respiratory secretions” that can be spread during face-to-face contact face or intimate physical contact, such as sex. and touching items such as clothing that have come into contact with an infectious rash or body fluids.

Dr. Anthony Fauci, the nation’s top infectious disease expert, said Monday that the outbreak has “great weight” in affecting men who have sex with men.

“When you look at that, does that mean it’s just a gay men’s disease? No, that is not the case,” she said. “But under the circumstances of certain types of behavior, that can spread, which is why, while you don’t want to stigmatize under any circumstances people who are affected by a particular infectious disease, you need to let the community know of the danger. , and the doctors who treat these people must be made aware of this so that they do not overlook the diagnosis”.

The Jynneos vaccine is the only one approved specifically in the US for monkeypox. A smallpox vaccine called ACAM2000 has also been approved and can be used during this outbreak.

The CDC says a vaccine may be recommended for people who are close contacts of someone with monkeypox, those who may have been exposed to the virus, and those who are at high risk of exposure, such as some health professionals and construction workers. laboratory. The US Department of Health and Human Services announced in June that it will provide vaccines to people with known or suspected exposure to monkeypox, including men with more than one recent sexual partner.

The CDC recommends vaccination within four days of exposure to monkeypox and says that if a person receives the vaccine four to 14 days after exposure, it may still have benefits, such as relieving symptoms.

“The advantages of vaccination are that people who may have been exposed to monkeypox, prior to the onset of the rash, may benefit from vaccination either to prevent the full spectrum of the disease or to reduce the severity of the disease. disease,” said Dr. Jay Varma, a professor of population health sciences at Weill Cornell Medical College.

The Jynneos vaccine is given in two doses, four weeks apart. The FDA approved it for monkeypox based on studies measuring antibody levels in vaccinated humans, as well as efficacy studies in animals.

“How effective they are, what proportion of infections would be prevented, hasn’t been determined yet,” Schaffner said, “but I think they do have some benefit, it’s pretty clear.”

What to do if you are diagnosed with monkeypox

Signs of monkeypox infection usually begin within three weeks of exposure and include flu-like symptoms such as fever, headache, muscle aches, sore throat, cough, chills, and exhaustion. according to the CDC.

Characteristic features of monkeypox include swollen lymph nodes and a rash. The CDC says the rash can look like pimples or blisters, and can appear on various parts of the face and body, including the genital area.

“In most cases, we are encouraging people who are at risk, if they develop a rash, to see a medical provider to make the diagnosis and rule out other common things like a herpes infection or bacterial infection. skin infection,” said Dr. Roy Gulick, chief of the Division of Infectious Diseases at Weill Cornell Medicine.

People diagnosed with monkeypox should self-isolate at home, the CDC says. If you have a rash or other symptoms, you should be “in a separate room or area from other family members and pets when possible.” The World Health Organization recommends that people with monkeypox try not to touch the rash, as this could contribute to the spread of the disease.

Most cases of monkeypox go away on their own.

“The vast majority of these people will get better on their own, and that’s very fortunate,” Schaffner said. “People may want some symptomatic relief, like Tylenol or this or that, but they won’t need any direct antiviral treatment.”

The WHO guidance for health workers says that paracetamol can be used to control fever and minor pain.

“If there is mild pain at the site of injuries, a topical pain reliever might be helpful,” added Dr. Timothy Wilkin, a professor of medicine at Weill Cornell Medical College.

“Sometimes people are itchy, so we can offer an over-the-counter antihistamine, like Benadryl or Claritin,” Gulick said.

Treatment of serious illness

The CDC has made certain antiviral drugs available during the outbreak through a pathway called Expanded Access.

The agency says an antiviral drug called tecovirimat may be considered for people with severe monkeypox disease, such as sepsis, brain swelling or other conditions that require hospitalization. It may also be considered for people who are at high risk of serious illness, including those with weakened immune systems due to conditions such as HIV/AIDS, skin conditions such as eczema, children, pregnant women, and people with other complications such as bacterial infection of the skin.

People who have symptoms in particularly dangerous areas such as the eyes, mouth, genitals, or anus may also be considered for treatment.

Tecovirimat, sold under the brand name TPOXX, was approved by the FDA for the treatment of smallpox in 2018. It can be given as an oral pill or given into a vein.

The benefits of the drug were evaluated through trials in animals infected with viruses related to smallpox, including monkeypox. The drug was tested in 359 healthy human volunteers to confirm its safety. The CDC says that “no data are available on the efficacy of tecovirimat in treating monkeypox infections in people.”

“Most importantly, we found that the drug has been well tolerated so far,” Foote said of the New York City experience, “with an occasional report of headaches, maybe a nausea, but there hasn’t been reports of serious adverse events. ”

The CDC also says that three other treatments — cidofovir, brincidofovir, and vaccinia intravenous immunoglobulin — may be considered for treating monkeypox during the outbreak. But experts say these treatments have been less relevant because of uncertainty about whether they have benefits that outweigh the risks. Gulick said, for example, that cidofovir treatment can have negative effects on the kidneys.

Challenges with tecovirimat

Given the limited data on how well tecovirimat works, Gulick said, “you have to weigh risks and balances, and that’s often a conversation you have with patients.”

Dr. Lilian Abbo, associate medical director for infectious diseases at Jackson Health System in Miami, said most of the requests for tecovirimat she’s seen have been for people who had malignancies or immunocompromised conditions who have more severe disease.

Wilkin, who has treated monkeypox patients in New York, said he sees it being used primarily for “very painful anal injuries” as well as people who have injuries to the face, which “can be potentially disfiguring with unnecessary complications.” .

He added that he has seen the drug used in several people who have weakened immune systems at risk of progression to more serious disease.

A medical provider can request access to tecovirimat by contacting their state health department or the CDC. Doctors have outlined a series of steps, such as lab tests and consent forms, that are needed to access the drug. The CDC website, as of Friday, indicates that photos and samples of lesions are optional and not required steps to obtain tecovirimat.

“Just to put it in perspective, in my discussions with some of our treatment providers, between all the forms and administrative requirements, a patient visit to start treatment can take anywhere from 1 1/2 to 3 hours,” Foote said.

Fauci said the FDA and CDC are among those working to reduce the required paperwork.

Another problem facing clinicians is the lack of available data to help guide treatment decisions.

Wilkin compared the experience of treating monkeypox patients to the early days of the Covid-19 pandemic, when there were no robust studies to guide treatment decisions.

“We’re under pressure to use what we have, but my other hat as a researcher says we need to show that this really works and that it’s also safe,” Gulick said. “The best way to do it is a clinical trial that has to be randomized against a placebo.”

He added that discussions about such clinical trials are ongoing.

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