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Dr. Russell:
Public health officials play a huge role in the control of spread of diseases, including monkeypox. So, what’s been done so far to stop the spread? And what kind of role do primary care physicians play in that?

Welcome to Clinician’s Roundtable on ReachMD. I’m your host, Dr. John Russell. And here to share his insights on monkeypox and the role of public health in stopping the spread is Dr. Randy Young, former Director of the Division of Pulmonary and Critical Care Medicine at the Milton S. Hershey Medical Center, a practicing pulmonary and critical care physician and fellow ReachMD host.

Dr. Young, welcome to the program.

Dr. Young:
Thanks, John. It’s really nice to be here with you.

Dr. Russell:
So let’s begin with some background. So, what can you tell us about monkeypox? And, and how can we identify this disease in our offices?

Dr. Young:
Monkeypox is actually a fascinating illness. As you know, the virus is a member of the orthopoxvirus family, which also includes some serious players like smallpox and the vaccinia strain, which is what’s used for the smallpox vaccine that’s been largely discontinued around the world, and thankfully, compared to the disease that used to be associated with smallpox virus, or variola, the monkeypox clinical syndrome is generally much milder. It, like many viral illnesses, is recognized almost entirely on the basis of the clinical syndrome that people, uh, present with. They have flu-like symptoms that are very nonspecific at first. They have headache, and it’s very prominent, lots of myalgias, fever, and the fatigue that people get is apparently very severe. And then ultimately, they develop this rash that goes through a series of stages. It starts out as little, reddish macules and ultimately becomes vesicles and then pustules and scabs, and it is the fluid, not only bodily fluids but the fluid from these, these skin lesions, that is the mechanism of transmitting the disease from one to the next.

Dr. Russell:
You mentioned vaccines and we’re on the radio, so people can’t tell. You and I sound so young, you know, on the, on the radio, but you and I probably received the smallpox vaccine prior to them going away in 1972.

Dr. Young:
That’s correct. And I tell people, when I introduce myself to patients that the only thing young about me anymore is my name, so I’m way past any sort of physiologic youth. But as you point out nobody’s been vaccinated in the United States in 50 years, so there is now this enormous population of people who don’t have smallpox immunity and therefore not necessarily much monkeypox immunity.

Dr. Russell:
So kind of two kind of follow-ups: For more mature clinicians like you and I, how much protection is that 50-plus-year-old smallpox vaccine giving you and I if we encounter this new virus?

Dr. Young:
It’s honestly hard to say for sure because we have so little experience with it. But it probably provides some. The good news is that in almost all cases monkeypox remains a self-limited illness. It rarely goes on to disseminate or cause serious disease, and the people who find themselves at risk for that are people who either have extensive disease and it continues to progress or people who are immunocompromised, and those are the people who need to be considered for therapy.

Dr. Russell:
So there’s a newer vaccine that’s now available for monkeypox/smallpox. Could you tell us about that?

Dr. Young:
Yeah. I’ll confess that I don’t have any real personal experience with it, but it is held to be safe. It is the WHO and CDC’s recommendation that it not be given to people on a broad basis at this point in time, but that if somebody, is immunocompromised, and is at risk for developing a severe case of monkeypox, then vaccination might be appropriate. As you also know, there is an antiviral drug called TPOXX that has been approved very recently by the FDA for the treatment of monkeypox, but I think, we all may have to come to grips with this, over the next several months.

Dr. Russell:
So it sounds like the vaccination strategy though is going to be a big part of the public health response, correct?

Dr. Young:
I think so. Case identification, quarantine, isolation, and vaccination, I think are going to be the three pillars of the response to this as they for many public health outbreaks.

Dr. Russell:
So as you and I and everyone who’s listening is just emerging from a long period of time taking care of a virus that no one knew a whole lot about, you know, three years ago, you know, do you think this is just something that’s part of the 24-hour news cycle, or do you think that this is something that we’re going to be dealing with for a while?

Dr. Young:
I’m concerned that we’re going to be dealing with it for a while. I, I don’t think it’s going away. Most of the cases that have been identified in the U.S., cannot be tied directly back to a Central or Western-African exposure, so there’s got to be some spread going on outside of completely endemic areas, and I think that, we need to be able to recognize it and put into place the appropriate public health responses. I think people in your situation and mine, you know, actively practicing on the frontlines need to be able to tap into that public health response very quickly and easily. And maybe that’s one of the good things that’s happened in the setting of COVID is that we are now much more aware of the importance of epidemiology and effective public health programs.

Dr. Russell:
So it has a relatively long kind of incubation period, correct?

Dr. Young:
It does, and that makes contact tracing difficult because there—for any one of us who develops a case, there’s a bunch of people to whom we might have been exposed.

Dr. Russell:
My understanding is during this asymptomatic time people aren’t infectious.

Dr. Young:
That’s apparently the case. That’s true. The people who are clearly infectious when they’re having skin-to-skin contact. It doesn’t appear to be sexually transmitted, but the closeness that’s involved in romantic encounters is certainly a risk factor. And then once people develop the blisters, they’re not only shedding virus in that blister fluid but they’re probably shedding virus in other bodily fluids as well.

Dr. Russell:
So, what do you think the consequences are going to be, for the world for our country with regard to this? Is this just something that has scary pictures but not scary outcomes?

Dr. Young:
I think that’s a good description. I think thankfully the vast majority of people who develop monkeypox have self-limited disease. The skin lesions heal. They may scar a little bit, but they don’t propose a, in the vast majority of cases a significant threat to life or limb. There do not appear to be frequent cases of visceral organ disease, lung disease, myocarditis, hepatitis, you know, nephritis, things like that, and the sepsis syndromes that we’ve become familiar with, in the setting of SARS-CoV-2 or some of the other viruses we’ve been dealing with, don’t appear to be a very prominent feature of the disease.

Dr. Russell:
So, for someone like myself who can be on the frontlines of kind of patient encounters, and maybe that first rash or that first fever or that first swollen lymph node might present, you know, to someone like myself, how important is it for, you know, the average primary care clinician in Anytown USA to start developing a little knowledge about this?

Dr. Young:
I think it’s vital. I mean, there have been cases now spread from coast to coast. Here in the U.S. there’s a bunch of cases on the East Coast, a bunch of cases on the West Coast and a few in the Midwest Illinois and places like that, and I think there’s a significant chance that urgent care centers and primary care practices are going to be the initial points of contact for subsequent cases as they accrue.
The important thing is going to be to have a high index of suspicion for anybody who develops a blistering rash, and I think things in the differential will be sort of shingles and some of the other viral illnesses that we encounter. Thankfully, we don’t see as much chickenpox these days, so that should be easy to rule out if people have had the appropriate vaccines. I think not only recognizing it early so we can protect ourselves against transmission from a skin lesion. Many of us examine patients still without gloves on even if there’s a rash, and that’s probably something that should change. Anytime somebody presents with a flu-like illness, we probably need to ask them some relevant historical questions.

Dr. Russell:
Yeah. And you had mentioned that, you know, the largest population has been in the group of men who have sex with men. Not an STI, but I think in that arena, you know, anyone I might see who I think might have genital herpes or a chancre or something like that, I might need to take pause and not, and not jump to, you know, one of our tried and true STIs, but think, you know, could it be one of these viruses.

Dr. Young:
Exactly. I think the main thing that will differentiate the more traditional STIs from this is the relative lack of systemic symptoms in the syphilis, gonorrhea, genital herpes patient. Hopefully the monkeypox patient who happens to have similar lesions will be recognizable based upon the history of headache, fever, swollen lymph nodes, fatigue, myalgias.

Dr. Russell:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. John Russell, and I’m speaking with Dr. Randy Young about monkeypox and the role that public health plays.

So we’re both in Pennsylvania. What do you see the role of kind of Pennsylvania Department of Health or other state departments of health versus the CDC in some of the testing?

Dr. Young:
Well, I think we’re blessed to have a pretty strong department of public health here, especially in some of the cities that have extraordinarily good public health departments. I worry a little bit about exhaustion on the part of our public health departments because they’ve been so under the gun, but I think they’re going to be absolutely vital in helping to coordinate our response.

Dr. Russell:
And I think one of the things kind of testing-wise is—and that’s why these numbers seem to change by the day—is our health departments can identify something as an orthopoxvirus, but really the CDC has to identify it as monkeypox.

Dr. Young:
Yeah. Some of the PCR-based assays aren’t yet widely available, and the more specific assays aren’t widely available in the community departments.

Dr. Russell:
So, you know, you and I have seen kind of a lot over our careers, and we have seen other infectious entities come and stay, and we’ve seen other stuff that kind of came and went more or less. What would be your final tips if you’ve kind of been on the end of the critical care spear, what are some of the reassuring things you could have, and what are some of the wisdom that you could pass on from your career?

Dr. Young:
Well, as you point out, my career, and maybe yours to a very similar extent, has been bracketed by 2 pandemics. I was in training when we first started seeing our cases of HIV before we even knew what it was. The very first scientific paper on—which I worked and published was an HIV paper in the mid-1980s and now the SARS-CoV-2 epidemic of the last 3 years. I think we’ve learned a number of things, some medical, some philosophical. Our pharmaceutical system and our public health system really shows a remarkable ability to rise to challenges, and there’s a lot of controversy about that in the public at large, but I think what was accomplished with COVID and our approaches to it has been nothing short of truly remarkable, so that’s a positive thing.

I think the potential for despair and discouragement about yet another pandemic is very real, especially for people who, as you earlier said, are still kind of on our heels reeling from the traumas of these last couple years, so I think we need to be sure to do a lot of self-care, a lot of care for each other and do our level best to get accurate health information out there about things like this, and that needs to be targeted not only at professional audiences but at lay audiences.

Dr. Russell:
So, with those insights in mind, I want to thank my guest and fellow ReachMD host, Dr. Randy Young, for sharing his perspectives on monkeypox and its potential impacts on public health. Dr. Randy Young, it was great. A pleasure to speak with you today. Thanks for joining me.

Dr. Young:
It was my pleasure entirely. Thanks for having me.

Dr. Russell:
I’m Dr. John Russell. To access this and other episodes in our series, visit reachmd.com/cliniciansroundtable where you can be Part of the Knowledge. Thanks for listening.