Sign Up
For the best experience, choose your profession & state.
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Monkeypox

1 Contact Hour including 1 Advanced Pharmacology Hour
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Tuesday, June 25, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to identify and respond to Monkeypox cases.

Objectives

Upon completion of this course, the learner will be able to:

  1. Define Monkeypox.
  2. Describe the process of Monkeypox transmission.
  3. Differentiate between Monkeypox and other differential diagnoses.
  4. Identify complications of Monkeypox.
  5. Explain recommended treatment for Monkeypox.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Alyssa King (Nurse Planner, DNP, APRN, CPNP-PC, CLC) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Introduction

Monkeypox (MPX) is an endemic Orthopox virus in West and Central Africa. MPX is now occurring in other countries, causing major healthcare concerns. Most human MPX infections are reported from the Congo Basin of the Democratic Republic of Congo (Hughes et al., 2021). MPX is most commonly found in rural, forested communities with poor sanitation and chronic malnutrition (Beer & Rao, 2019). However, as of August 30th, 2022, there were 18,417 total confirmed MPX/Orthopoxvirus cases in the United States (Centers for Disease Control and Prevention [CDC], 2022b).

MPX cases are being reported sporadically around the world. It is believed to have spread worldwide due to the lack of immunization after the smallpox vaccine was stopped (Grant et al., 2020). Therefore, people who did not receive a smallpox vaccine (those younger than 40-50 years of age) may be susceptible.

MPX is categorized into 2 genetic clades. These include the genetic clades of West Africa and Central Africa (also called Congo Basin). These clades have epidemiological and clinical differences. The mortality rate of the West African clade is less than 1%, and there is no human-to-human transmission. The Central African clade is more frequent, can have a mortality of up to 11%, and has human-to-human transmission (Singh et al., 2021). Beer and Rao (2019) conducted a systematic review of the research published in English before August 15, 2018. They found an often-quoted 10% mortality rate. This rate came from early 1981-1986 data: 33 deaths out of 338. Data from the Democratic Republic of Congo (2001-2013) consistently reported mortality of <5%. Case fatality rate (CFR) from countries with the West African MPX were mostly 0%. The mortality for the Nigeria outbreak was 2.8%. Six deaths, 4 of whom were immunocompromised, out of 228 suspect cases. The mortality for 47 cases in United States outbreaks was 0%. No deaths have been reported from the April 2018 outbreak in Cameroon or the recent outbreak in the Central African Republic. In reports documenting the cause of death, people in high-risk groups comprised most of the deaths (Beer & Rao, 2019).

Because of inconsistencies in healthcare and surveillance systems in rural African settings, MPX data is incomplete and unreliable (Beer & Rao, 2019). This unreliable data is insufficient for statistical analysis (Beer & Rao, 2019). Due to the clinical overlap and insufficient laboratory availability, varicella-zoster virus (VZV) is often misdiagnosed as MPX, and the conditions may be co-infected in the same patient (Beer & Rao, 2019; Hughes et al., 2021). There is some suggestion that MPX is increasing in incidence. Data in more developed countries is more reliable.

Below is the Monkeypox Outbreak Global Map with data as of August 26th, 2022, directly from the CDC:

Image 1:

Monkeypox Outbreak Global Map

Centers for Disease Control and Prevention (August 26th, 2022)

global map of monkeypox outbreak

As included in the legend, the orange circles indicate areas of reported cases of MPX that historically had not had cases in prior outbreaks. The blue circles indicate areas that had. For more information and specific numbers, feel free to visit the CDC here.

Transmission

Monkeypox spreads from person to person through direct contact (CDC, 2022c). The transmission mechanisms are respiratory droplets with close and prolonged contact, contact with body fluids, contaminated patient's environment or items, and the rash or scabs of the skin lesion of an infected person. As mentioned above, MPX can spread from the time symptoms start until the rash has become fully healed with new skin formed over it (CDC, 2022c). MPX can also be spread through sexual contact. While it is not, by definition, a sexually transmitted infection (STI), it can be more accurately described as a “sexually transmissible” infection, meaning the contact does not have to be exclusively intimate or sexual to be transmitted, as close personal contact can spread the virus (CDC, 2022c).

Animal-to-human transmission (zoonotic) occurs due to direct contact with the consumption of infected animals or direct contact with the blood, body fluids, and/or lesions of infected animals (The Lancet, 2018). Animals found to transmit MPX are rodents, rabbits, squirrels, monkeys, porcupines, and gazelles (Singh et al., 2021).

According to the United States case data as of July 25th, 2022, the median age of patients with confirmed MPX cases is 35 years. The male sex is being the most highly impacted by this outbreak. Of the male patients who provided information on their own sexual activity, 99% reported male to male sexual contact (CDC, 2022h). According to the Morbidity and Mortality Weekly Report (MMWR) by the CDC, because the report cases seem to be primarily affecting gay, bisexual, and other men who have sex with men, it is essential that public health programs continue to deliver respectful, harm-reducing, tailored educational and informative messages of strategies of generalized protection that do not create or perpetuate stigma to diverse communities of men who have sex with men (CDC, 2022i). It is important to emphasize that anyone can contract MPX as it is a public health concern for all.

Signs & Symptoms

MPX is usually a self-limiting disease lasting 2 to 4 weeks (World Health Organization [WHO], 2022). The incubation period of MPX is usually 3 to 17 days (CDC, 2022c). The invasion stage lasts up to 5 days. In this stage, symptoms are fever, intense headache, lymphadenopathy, back pain, myalgia, and intense asthenia (lack of energy).

The rash evolves in a set sequence from (WHO, 2022):
Flat macules → Slightly raised papules → Clear fluid-filled vesicles → Yellow fluid pustules → Crusted wounds

Directly from the CDC’s Monkeypox clinical recognition site, the following collection of pictures include various characteristics of the MPX rash that are being seen (CDC, 2022d):

Image 2: Monkeypox Rash

Centers for Disease Control and Prevention (August 23, 2022)

images of monkeypox rash characteristics

For additional photos of the MPX rash, visit the CDC’s clinical recognition site here.

See below in the following chart for a breakdown of what is being seen with the rash, from enanthem to scabbing (CDC, 2022d):

Table 1: Monkeypox Rash: From Enanthem to Scab Stages Centers for Disease Control and Prevention (August 23rd, 2022)
StageStage DurationCharacteristics
Enanthem
  • Sometimes, lesions first form on the tounge and in the mouth.
Macules1-2 days
  • Macular lesions appear.
Papules1-2 days
  • Lesions typically progress from macular (flat) to papular (raised).
Vesicles1-2 days
  • Lesions then typically become vesicular (raised and filled with clear fluid).
Pustules5-7 days
  • Lesions then typically become pustular (filled with opaque fluid)- sharply raised, usually round, and firm to the touch (deep seated).
  • Finally, lesions typically develop and depressions in the center (umbilication).
  • The pustules will remain for approximately 5 to 7 days before beginning to crust.
Scabs7-14 days
  • By the end of the second week, pustules have crusted and scabbed over.
  • Scabs will remain for about a week before beginning to fall off.

It is common that areas of lighter or darker skin and/or pitted scars can remain after the rash scabs have healed and fallen off (CDC, 2022d). Once all of the scabs are gone and new skin has covered those spots, the person is no longer contagious (CDC, 2022d).

The number of lesions varies from a few to several thousand (WHO, 2022). The rash is more concentrated on the face and extremities than on the trunk. The rash affects the (WHO, 2022):

  • Face (95% of cases)
  • Palms of hands and soles of feet (75% of cases)
  • Oral mucous membranes (70% of cases)
  • Genitalia (30% of cases)
  • Conjunctivae (20% of cases)

Additional characteristics to note when identifying MPX (CDC, 2022d):

  • The lesions are often being described as painful until the scabs become itchy when they crust over in the healing process.
  • The rash could be confined to only a few or a single lesion.
  • They are typically scattered or localized to a body site rather than diffuse all over the body.
  • The lesions are typically firm or almost rubbery as well as well-circumscribed.
  • The lesions are often deep-seated with umbilication (a dot on the top of the lesion).
  • Rectal symptoms are being reported (bloody or purulent stools, pain in the rectum, rectal bleeding).

Differential Diagnoses

Lymphadenopathy is a distinctive feature of MPX compared to other rash-presenting differential diagnoses that may initially appear similar (Grant et al., 2020; WHO, 2022):

  • Chickenpox
  • Measles
  • Smallpox
  • Bacterial skin infections
  • Scabies
  • Syphilis
  • Medication-associated allergies

VZV skin eruptions usually evolve over 24 hours instead of days, as seen with MPX, and are seen on the trunk more frequently than MPX (Singh et al., 2021). MPX has lesser eruptions than VZV or smallpox. Smallpox is five times more transmissible, has more nausea and vomiting, a less febrile stage before eruptions, more lesions, and a more profound systemic illness (Beer & Rao, 2019).

Diagnostics

At this time (August 2022), testing is only recommended if the patient has a rash that is consistent with MPX (CDC, 2022e).

The polymerase chain reaction (PCR) laboratory test is recommended for accuracy and sensitivity. PCR can be used alone or in combination with sequencing. The recommended specimen type is skin lesion material, including swabs of lesion surface or exudate, roofs from more than one lesion, or lesion crusts. A biopsy is an option, but samples must be stored in a dry, sterile tube with no viral transport media and kept cold. PCR blood tests are usually inconclusive because of the short duration of viremia relative to the timing of specimen collection after symptoms begin and should not be routinely collected from patients (WHO, 2022).

Complications

Complications of MPX can include (WHO, 2022):

  • Secondary infections
  • Bronchopneumonia
  • Sepsis
  • Encephalitis
  • Infection of the cornea with possible loss of vision

Bronchopneumonia occurrence is poorly understood, thought to be a secondary infection, and uncommon (Reynolds et al., 2017). MPX lesions on the cornea can lead to conjunctivitis, keratitis (inflammation of the cornea), or ulceration affecting vision. However, it is thought to be uncommon (Reynolds et al., 2017).

Hypoalbuminemia and low hematocrit, suggesting malnutrition, were found in patients hospitalized with MPX during the 2003 outbreak in the United States (Reynolds et al., 2017). This finding may be due to oral lesions and cervical lymphadenopathy. Malnutrition is a common problem that contributes to the severity of MPX patients in rural Africa (Reynolds et al., 2017).

Treatment

There are no standard guidelines for the treatment of MPX at this time. Reynolds et al. (2017) recommend symptomatic support, fever, and pain management, measures to prevent secondary skin infection, adequate hydration and nutrition, protecting vulnerable anatomical locations such as the eyes, and managing complications. The skin and mucosal lesions require care. A serious rash can lead to dehydration, protein loss, and secondary infection. Focal inflammation of the lymphatic system and lung congestion can affect oxygenation and decrease food and fluid ingestion.

The following drugs are currently stockpiled for use from the Strategic National Stockpile (SNS) as options for treatment (CDC, 2022f; WHO, 2022):

  • Cidofovir (Vistide) is an antiviral that has been proposed as a treatment in serious, dangerous cases. Cidofovir is a nucleotide analog that inhibits the production of herpes viruses.
  • Tecovirimat (TPOXX or ST-246) is an antiviral approved by the United States Food and Drug Administration (FDA) for the treatment of smallpox in adults and in children as well. Clinical trials have found it to be safe with minor side effects. It is available in pill or injection forms.
  • Brincidofovir (CMX001 or Tembexa) is an antiviral approved the FDA for the treatment of human smallpox in adults and children, including neonates. This drug is currently not available from the SNS.

Smallpox vaccination has been shown to be about 85% effective in preventing MPX or resulting in a milder illness if it is not prevented (WHO, 2022). The Centers for Disease Control and Prevention (CDC) suggests a smallpox vaccine to be administered within fourteen days of exposure, though preferably within 4 days, for healthcare workers and others exposed to MPX cases. Vaccinia immune globulin (VIG) has not shown adequacy in treatment or prophylaxis.

ACAM2000 and JYNNEOS (Imvamune or Imvanex) are the two currently available and licensed vaccines in the United States to prevent smallpox infection (CDC, 2022g). ACAM2000 is a live virus that is inoculated into the skin by pricking the skin surface (CDC, 2022g). After it has been inoculated, a lesion is meant to develop at that site. Because the virus is growing and can spread from that site, individuals who receive this vaccine must take precautions to prevent spread of the vaccine virus until they are considered fully vaccinated in 28 days (CDC, 2022g). JYNNEOS is a live virus that is non-replicating that is administered via two subcutaneous injections four weeks apart (CDC, 2022g). This vaccine bears no concern for possible spread. Individuals who receive this vaccination are not considered vaccinated until 2 weeks after the second dose of the vaccine (CDC, 2022g).

Prevention of Spread

The WHO recommends contact and droplet precautions for MPX. The CDC's (2007) most recent recommendations for MPX are contact and airborne precautions. To serve as a reminder (CDC, 2007):

  1. Contact Precautions are used for patients with known or suspected infections or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. The patient should be in a private room.
  2. Standard Precautions should be used, and a gown and gloves should be worn if there is likely to be contact with the patient or environmental surfaces.
  3. Airborne Precautions are implemented for diseases transmitted by microorganisms carried by airborne droplet nuclei. Possibly infectious patients should be separated from others and asked to wear a surgical mask before airborne precautions can be provided. A surgical N95 respirator is recommended for Airborne Precautions. The N95 is a single-use, disposable item that must be fit-tested to be effective. Airborne Precautions also require the use of an airborne infection isolation room (AIIR) that has specially engineered airflow and ventilation systems. The door to the room must be kept closed, and the negative air pressure should be monitored. When the patient in airborne precautions has to be moved or transported, they should wear a surgical mask from when they leave the isolation room until they return.

Regarding environmental infection control in inpatient hospital settings, the following recommendations have been made by the CDC (CDC, 2022j):

  • Soiled patient laundry should be removed from patient rooms while avoiding contact with any lesion material left on them
  • Soiled laundry should be promptly contained in a laundry bag and never be shaken (so as to not disperse infectious material)
  • Cleaning activities such as dry dusting, sweeping, or vacuuming should be avoided and wet cleaning methods used instead (so as not to disperse infectious material in the air)
  • No portable fans should be allowed in patient rooms

Anyone who has been diagnosed with MPX, or suspects that they might have it, should avoid any close contact with other people. Once the rash sores scab over completely and fall off, the infected person is considered to be no longer contagious (CDC, 2022a). Due to the fact that many cases have included sores in the genital and rectal areas among men who have sex with men, abstinence from sex when MPX is suspected is encouraged.

Case Study

Scenario/Situation/Patient Description

A 35-year-old female presents with a five-day history of fever, intense headache, lymphadenopathy, and lack of energy. She has clear fluid-filled vesicles on her face, palms, and soles. Vital signs are within normal limits except for a pulse of 110. She reports that her significant other has been sick for about two weeks and has sores on his face. She does not know if she had chicken pox as a child and has not started any new medications. She has been taking Tylenol. She reports not eating for days and that she has also not been drinking very much. She is pale and her skin turgor is poor. Her physical examination is otherwise normal.

Intervention/Strategies

The patient is given a surgical mask and put in an ER room with the door closed. A CBC, metabolic profile, urinalysis, and swab of her lesions are sent for PCR. The patient is hospitalized on contact and airborne precautions for hydration and symptom management.

Discussion of Outcomes

The patient's symptoms are significantly better the next day. Her PCR was positive for MPX. These results are reported to the Health Department, which has initiated contact tracing. She is discharged with symptom management instructions and contact management education to be followed until her lesions heal.

Strengths & Weaknesses

Hopefully, the ER staff is conscious of the potential for MPX and notices the lymphadenopathy. Given the differential diagnoses and the sanitation and nutrition status of the average American, MPX may not be considered. Contact isolation and blood and urine tests would have been done with open lesions. Swabbing for a PCR would not be a normal test. Worst case scenario, she is treated for her symptoms and discharged.

Conclusion

MPX has been raising concern worldwide. Symptom management is the best treatment at this point. Smallpox vaccination is recommended for exposure to MPX. Healthcare professionals need to be aware of the potential for MPX and how to identify it from differential diagnoses.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  • Beer, E. & Rao, V. (2019). A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLOS Neglected Tropical Diseases, 13(10), e0007791. Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022a). Monkeypox clinical recognition. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022b). 2022 U.S. map & case count. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022c). Frequently asked questions. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022d). Clinical recognition. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022e). Monkeypox testing basics. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022f). Treatment information for healthcare professionals. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022g). Monkeypox and smallpox vaccine guidance. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022h). Technical report: Multi-national monkeypox outbreak, United States, 2022. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022i). Morbidity and mortality weekly report (MMWR). Strategies adopted by gay, bisexual, and other men who have sex with men to prevent monkeypox virus transmission—United States, August 2022. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022j). Infection prevention and control of monkeypox in healthcare settings. Centers for Disease Control and Prevention (CDC). Visit Source.
  • Grant, R., Nguygen, L., & Breban, R. (2020). Modeling human-to-human transmission of monkeypox. Bulletin of the World Health Organization, 98(9), 638-640. Visit Source.
  • Hughes, C., Liu, L., Davidson, W., Radford, K., Wilkins, K., Monroe, B., Metcalfe, M., Likafi, T., Lushima, R., Kabamba, J., Nguete, B., Malekani, J., Pukuta, E., Karhemere, S., Muyembe Tamfum, J., Okitolonda Wemakoy, E., Reynolds, M., Schmid, D., & McCollum, A. (2021). A tale of two viruses: Monkeypox and varicella zoster virus coinfections in the Democratic Republic of Congo. The American Journal of Tropical Medicine and Hygiene, 104(2), 604-611. Visit Source.
  • The Lancet. (2018). Monkeypox contacts: A puzzling problem. The Lancet, 392(10152), 986. Visit Source.
  • Reynolds, M., McCollum, A., Nguete, B., Shongo Lushima, R., & Petersen, B. (2017). Improving the care and treatment of monkeypox patients in low-resource settings: Applying evidence from contemporary biomedical and smallpox biodefense research. Viruses, 9(12), 380. Visit Source.
  • Singh, N., Sharma, S., Ghai, G., & Singh, A. (2021). A systematic review on epidemiology of human monkeypox virus. Annals of the Romanian Society for Cell Biology, 25(7), 602-610. Visit Source.
  • World Health Organization. (WHO). (2022). Monkeypox. World Health Organization (WHO). Visit Source.