September 2, 2022
As cases rise, and some start showing up in kids, it’s time we all learn what we need to know to counsel, prevent and prepare for monkeypox. We are joined by Kid Expert infection preventionist, Joe Kurland, to learn how to counsel and care for our pediatric and adolescent patients. Join us as we discuss common symptoms, how to test, how to treat, pediatric vaccination options and, also dispel some common myths about how the disease is spread.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. Well, just when we thought we might finally be getting a handle on how to manage the COVID pandemic, another virus has crept onto the scene, monkeypox. As of this past week, close to 15,000 cases have been reported in the United States. And on August 4th, it was declared a public health emergency. So here to talk to us all about all things monkeypox today is our very own kid expert and infection preventionist, Joe Kurland. Joe, thanks for joining me today.
Joe Kurland: Hey, thanks for inviting me.
Dr. Angela Kade Goepferd: All right. Well, let’s start out with what is monkeypox?
Joe Kurland: So monkeypox is an infectious virus that causes onset of fever and chills and body aches, but progresses to a rash that develops as like little red bumps. It develops into blisters which scab over and remain infectious actually until the scabs fall off and you have healthy skin underneath. It’s a virus that we’ve known about, or it’s been in the medical records since at least the 1970s, if not before. So it’s something that we are familiar with. We have treatments for. We have a vaccine that works against it, and we better understand how it’s transmitted among people. And it’s not coming as a surprise, or it’s not a new virus like COVID was.
Dr. Angela Kade Goepferd: So why are we hearing more about monkeypox now if we’ve known about this virus since the 70s? What’s different and why is it in the news?
Joe Kurland: Yeah, so there’s two strains of the virus that typically circulate. One is the west African clade, and then there’s the Congo clade. And what we’re seeing is the west African clade which isn’t as fatal. It’s not always as severe a strain, but we still don’t maybe understand exactly why or how this has gotten as widespread as it is. I think in the coming months and years, we’ll learn more about it as public health goes back and does their reviews. But this is basically a virus that originated in Africa and was circulated in communities of individuals that were having skin to skin contact or coming in close contact with each other. And for whatever reason, it wasn’t recognized maybe as monkeypox initially, because it appeared with more limited pox reaction.
When we think of pox viruses, we think of chickenpox or we think of small pox with these body wide rashes and blisters and bumps that are horribly itchy and are really severe. It sounds like the initial cases that were identified of monkeypox really had more of a limited appearance that they were localized to the genital areas or in areas that maybe are more usually covered. They weren’t as widespread a blister presentation early on and were mistaken for other viruses or other illnesses at the time.
Dr. Angela Kade Goepferd: So let’s talk a little bit more about how monkeypox is spread, and I think there’s a mistaken or idea or myth out there that because these lesions are showing up in more of the genital area, that this is a sexually transmitted infection, which we know not to be the case. It’s spread in other ways. So what can you tell us about how someone, including kids, could get monkeypox or how it is spread from one person to another?
Joe Kurland: So there’s two primary routes of spread for this virus. One is, and the predominant one is, skin to skin contact. It’s making direct physical contact with the lesion itself. And when you think about it, the lesion or the rash or the blister, however you want to call it, it’s basically pure virus. And this is going to be just teaming with virus that if you get it onto your skin, it’s going to find a way into you and make you sick.
Also, if direct contact with the virus or with items or products that are contaminated with virus. So thinking about if you’re sharing clothing with somebody that hasn’t been laundered, if you’re using bedding or towels that haven’t been laundered by somebody that was sick, these can all be what we call fomites or inanimate objects that can transfer the virus to other people.
The other route that is a possibility for spread that isn’t all that significant we think because of the really high efficiency of skin to skin transmission, the other route is through respiratory droplets. And the fact that when you have the early symptoms, when you have a cough or a fever, or you have the body aches, you may have more of the virus presenting in your throat or your pharynx, and you may be breathing it out or speaking it out. So it may have a small component where you could spread it through droplets, but from what the CDC originally said and what the WHO had indicated is that let’s compare it against COVID. When you have COVID, we’re looking at 15 minutes of exposure to somebody or being within six feet of a sick person to get exposed and possibly be sick. With monkeypox, the original guidelines are you had to be there for more than three hours. So it is really not a highly effective respiratory transmission, but that doesn’t mean that it can’t happen. And we might see that more in closed environments where you’re there for a long time, such as people sharing households together.
Dr. Angela Kade Goepferd: Sure.
Joe Kurland: People that might be in automobiles during the winter when windows are all closed. I think about that. But really the predominant method we’re seeing for spread is physical skin to skin contact or contact with objects that are contaminated. And the reason around this being confused with a sexually transmitted disease is it’s not truly transmitted in sexual fluids or body fluids in the sense, but it’s more the mechanics of having physical contact with someone during the practice of having sexual intercourse or having kind of sexual contact that can lead to the transmission.
And I think this has been so sensitive or this has been so confusing that the CDC has been very blatant and very clear in what qualifies as possible transmission. And this can be including as much as cuddling. It can be including kissing or hugging someone if you’re having bare skin to skin contact.
Dr. Angela Kade Goepferd: Let’s talk about kids. Can you tell us a little bit more about, can kids get monkeypox? Are kids getting monkeypox and what do we know about the spread to kids?
Joe Kurland: So this is an endemic virus in several regions of Africa, and I think the highest proportion or the highest severe outcomes we see in children are kids under eight. And this is for African communities and other areas that have this occurring, unfortunately on a regular basis. And I think we need to take a moment to actually reflect on that. That this is something that has been endemic and circulating, and really been unaddressed overseas. And it’s really a kind of an equity issue and a global health disparity issue that we’re only paying attention to because it’s now impacting us directly. And if we’re going to talk about efforts and the mindset about diseases, the West and developed countries really need to start paying more attention at preventing illnesses before they come to our shores and helping other communities that don’t have the resources we do.
That being said, yes, kids can get this. And they see it in Africa. We’ve seen several cases occur here in the United States. They’re not occurring at the rate that we’ve seen in adults, but I think that’s because kids are out of school, kids aren’t engaged in some of those skin to skin activities as frequently as we see some of the adults are. We’re not seeing the international travel occurring in children as frequently. But in areas where you have more activities, we are seeing these break out. And I’ve noted that just today, there was a report that in Brazil they’ve already identified at least, I think it was more than 70 cases occurring in children under 17 years of age. And 20 of those were in kids under four. So this can be a disease that infects children.
And it’s just going to be a matter of time till we start seeing parents being infected with this, potentially spreading it to their children just through general caretaking of their kids, caring for them, hugging them, tucking them into bed and cuddling with them at night. If they’re not aware of what the rash is on their body, if they have a rash on their arm, they could spread it to their child. And it’s really going to be important for parents to be mindful, to be aware, and to be on the lookout for fevers, unexplained rashes, and illnesses, and make sure that they’re doing their part to contain this and prevent further spread.
Dr. Angela Kade Goepferd: So speaking of kids in their environments, we all know that we’re about to head back to school. So kids are now going to be in close quarters with each other again. They’re going to be doing sports and having more physical contact with each other than they’ve had over the summer. And kids in daycare have physical contact with each other constantly, including with their secretions and drool and things like that. So what should we be telling parents in terms of preventing transmission with kids? And is there any particular precautions we should have kids take based on the environment they’re in?
Joe Kurland: We don’t know enough yet about how this is presenting to actually put out big red flag warnings. I don’t think we have widespread transmission occurring in our communities to make this a panic situation. But I think being aware of the virus, being aware of how it presents and talking to your daycare provider, talking to your school nurse, talking to your school administrators and finding out what their policies or procedures are to interrupt this, to be on the lookout for this and other transmissions, other viruses, would be important.
There are reports of individuals that have claimed asymptomatic illness leading to the spread. I don’t know how valid all those are because there seem to be some confounding factors in there, but it’s important for us to keep in mind that historically speaking, this virus presents first with fever, malaise, lethargy. You’re going to be tired. You’re going to have body aches. And those are kind of the prodromal syndromes before the rash develops. So it’s going to be contingent on parents to be aware of their kids, who they’ve been in contact with, if anything is circulating in their school or the daycares, and really to do their part to keep their kids out of activities and out of daycares if they don’t feel well until they’ve been tested and cleared.
I don’t ever want a kid that’s sick to be going into a daycare or a school if we can avoid it. But I think more so I’d have a better feeling about a kid returning to activities if they have a rash, if we know that it’s not COVID, if we know that it’s not measles, if we know it’s not chickenpox, and we know that it’s now not monkey box. There’s a lot of variety of rashes and illnesses that present as rash. So not every rash that appears, as you said with your calls, is going to be monkeypox. I think there’s the talk about zebras and horses. Monkeypox has always been a zebra, although it sounds like more zebras may be appearing around the world these days.
But it’s going to be important to be on the lookout for it. Take preventative measures. And some of those interventions that we had several years ago when MRSA or MRSA was new on the block, thinking about wrestlers. I’m thinking about basketball and football players that come into close physical contact and have frequent physical contact with a number of people. Those are probably some of the sporting events that are going to be at greatest risk.
I like the idea that daycares may be at risk as well. We see outbreaks of hand foot and mouth disease. We see GI illnesses circulating daycares. This could be very similar that we’ll see the illness experience there.
And this is not often a fatal illness. I think it’s important to say that this is rarely fatal. And especially the clade that’s circulating right now has a very low fatality rate, but it’s painful. Everyone that’s described this rash has talked about it being like shards of glass in your skin. They’ve talked about extreme discomfort, burning sensations. I wouldn’t wish this upon anybody. And then following that, there’s the possibility that the pox themselves may leave scars. So this may be a somewhat disfiguring illness depending on where the pox present, and that may be lifelong. So really anything we can do to avoid this is a good thing.
Dr. Angela Kade Goepferd: Yeah and you mentioned the pox and the rash, and probably the number one complaint that we get other than colds and flu symptoms in pediatrics is rashes. Smallpox, luckily is not a rash that any of us practicing now have seen, but chickenpox is. And so in terms of the pox themselves, can you help describe for us, this is a podcast, so we can’t put up a slide. How will we differentiate a chickenpox rash from a monkeypox rash if we have a kid coming in with the kind of prodromal symptoms and a new rash?
Joe Kurland: Yeah and I’m not a clinician, so I can’t always speak well to the presentation and the clinical appearance of these illnesses. But I think what’s been described to me in the past is chickenpox presents as dew drops on rose petals. So you have small little pustules or you have small little liquid-filled blisters on a red rash or on a red presentation. These may initially present as… I think I’ve heard about the rash starts as a diffused red rash that may develop into some pustules and into some localized blisters. But it then goes on to develop into a very tight, concentric, firm or hard embedded blister that’s deep. And it’s very firm and it’s in the skin, not on top of the skin.
And I think that’s a critical identification. Eventually like chickenpox, it does crust over, or like a herpes zoster rash, it does crust over. Even that crust, that still remains infectious. And making sure that individuals aren’t picking at that. And then it remains infectious again until that crusted layer falls off and you have new skin that’s healthy and intact underneath. So I think what we’re looking for is chickenpox where you can have the blisters all progress in the same way at the same time.
Dr. Angela Kade Goepferd: There are chickenpox is different stages. So there are different stages of lesions.
Joe Kurland: And I’ve heard monkeypox can do the same thing.
Dr. Angela Kade Goepferd: Okay.
Joe Kurland: You can have monkeypox progressing at different times, or you can have the rash in different stages of development on an individual at the same time. Whereas I think smallpox was uniform and I think it was all progressing at the same time.
I want to mention one additional symptom that’s supposed to be unique to monkeypox and that’s lymphadenopathy. And you’re actually seeing inguino or cervical lymphadenopathy with this. And it’s a little different. You don’t see that with smallpox apparently, and I don’t think you see that with chickenpox either. That has been claimed in the past at least as a distinguishing factor of monkeypox from other pox illnesses.
Dr. Angela Kade Goepferd: Sure.
Joe Kurland: However, I’ve also heard reports now that not everybody presents with lymphadenopathy. So take it with a grain of salt, perhaps when you’re looking at your patients in this outbreak.
Dr. Angela Kade Goepferd: The other rash that’s out there, unfortunately still is measles. I always think about our former colleague, Patsy Stinchfield would talk about getting bucket of measles dumped on your head. And so I always think about that. But one thing I was going to ask you, Joe, relative to the rash, because none of us probably have seen the monkeypox rash. I mean, you’re not a clinician, but I am. I still haven’t seen the monkeypox rash and even chicken pox is something we don’t see very often.
And most patients, thankfully, are vaccinated to chickenpox, so when we do see it, it’s not the chickenpox that I got when I was a kid. It’s not the widespread lesions. It’s a little bit different. So a lot of times what we end up relying on is testing. So if we think something’s measles or if we think something’s chickenpox, we’ll go ahead and test for it. What can you tell us about testing for monkey monkeypox? And is that something that would be readily available to us if a child were to walk in our office with a rash and we were having a hard time distinguishing chickenpox versus monkeypox?
Joe Kurland: Minnesota Department of Health is really helping coordinate testing with Minnesota patients. And the first recommendation is if you suspect monkeypox in the patient would be to contact the Minnesota Department of Health. Their main line for that is 651-201-5414. I used to work there. That’s the infectious disease line. I’m very familiar with it.
But the recommendation is to test for monkeypox, you’re going to take a non-cotton swab, so synthetic swab and vigorously scrub the surface of the lesion. And then place that in a dry, sterile container in either a refrigerator or keep it frozen until it gets to the lab. So that’s that. However, at the same time, they may advise you to consider other differential diagnoses. So collecting your samples for a varicella swab. Consider syphilis or gonorrhea test, perhaps. And also maybe even consider looking at a MRSA test if you have a patient that has a history of any type of MRSA illness or has it in the community. So it’s not just going to be a monolithic thing.
And it’s also important to recognize that one patient could have multiple illnesses. So the Minnesota Department of Health is also advising individuals or clinicians to test multiple swabs or multiple sites. So you would be swabbing one swab and putting that in a sterile container. And then you would be swabbing another swab and putting it in a different sterile container. So the Minnesota Department of Health, please don’t be surprised if they ask you to test multiple sites because they want to actually get multiple coverage. Especially if you have blisters and different stages of progression to identify whether or not we have multiple illnesses, or if it’s really monkeypox in different phases.
Dr. Angela Kade Goepferd: So early in our conversation, you mentioned a monkeypox vaccine, and I know that there are limited numbers of monkeypox vaccines available. But I think there’s also a treatment, an antiviral for monkeypox. And so I wonder if you could talk to us about, relative to kids, are kids eligible A, for treatment of monkeypox, the treatment that’s available? And are they eligible for a vaccination?
Joe Kurland: The EUA that just came out actually helped clarify this a little bit more for us. So recently to help expand the number of doses available, the recommendation for the JYNNEOS vaccine, that is a non replicating vaccine that’s given in two doses 28 days apart, was recently updated from giving all eligible patients a half mL dose sub-q to being for individuals 18 years of age and older, a 0.1 mL dose given intradermally. It’s a different administration route, but it has high efficacy, actually encouraging and causing immunity.
The EUA also said that individuals under 18 years of age should be getting still the half mL sub-q because they don’t have data about intradermal administration in young kids. So they do open that option. In other countries, there is data looking at JYNNEOS vaccine administration in kids as young as six months. I can’t recall off the top of my head if the EUA permits that age range. JYNNEOS is an option for kids.
I think that the outset here in Minnesota Department of Health is really going to limit administration of that to high risk exposed individuals such as kids that have confirmed monkeypox in their households. Or God forbid, we had a situation where we had a daycare environment where a caregiver was diagnosed with monkeypox and was at high risk of spreading it to people in that kind of a situation. Outside of that, I think it would be more limited and more restricted as far as who’s going to be eligible to get the vaccine.
There’s another vaccine. That’s the ACAM2000, which is a smallpox vaccine. This is an attenuated replicating vaccine that was more widely used following the 911 emergencies and fears of bioterrorism given to many healthcare professionals and military personnel. And this is the one that leaves the traditional scab-scar on the shoulder. This is not officially been licensed against monkeypox. It was focused on smallpox prevention, but it is possible that that may be utilized if we truly don’t have enough JYNNEOS or if this becomes a much more widespread illness, but there are risks associated with getting a smallpox vaccine as well.
Going to treatment, there’s a medication, an oral product called TPOXX. This is a medication that does have indication for use in children. And I would need to defer to my pharmacy colleagues and my clinical infectious disease pharmacologist to really outline how that’s best used, but we do have options for treatment. And I believe there’s also discussion about an antiviral eye drop because one of the complications is that if you get the virus on your hands from itching or scratching and then rub your eyes, you can get actually a corneal infection that can result in corneal damage and potentially blindness. The eyedrops are available for adults. I do not know off the top of my head if they are available for children though. Yeah.
Dr. Angela Kade Goepferd: Yeah. I think it’s just important for us to understand that they’re one, how we approach the testing and then two, what treatment options are available. One of the stories that I’ve heard is that because monkeypox is not something we’ve seen a lot of, adults at least, who have presented with it, there’s been a leg between their presentation, their diagnosis, and getting access to vaccine and or antiviral treatment.
And as you mentioned, it’s not a pleasant illness to suffer through. And so thinking about kids and potential exposure to monkeypox, I wouldn’t want kids unnecessarily experiencing that pain of those lesions, if we can accurately diagnose and interrupt the disease progression.
So in wrapping up today, Joe, thanks so much for talking to us about the details of monkeypox. It’s been really helpful. From your perspective as an infection preventionist and coming up on two plus years of a COVID pandemic, what have we learned about how to respond to new infections on the scene that we can apply from COVID to monkeypox and or to the next virus that’s coming? I think we all sort of expect that in this sort of global infectious pool that we’re in there are going to be other viruses that are going to come onto the scene. So are you seeing a different response to the increased spread of monkeypox because we just went through COVID? Or what sort of lessons have we learned that we can take forward?
Joe Kurland: Public health has been more quick this time around, especially with monkeypox at recognizing and admitting their failures and their shortfalls. Dr. Lewinsky from the CDC just came on in the last week and said that she has plans to revamp or restructure the CDC because of some of the deficiencies that they identified in their response to COVID and monkeypox. And one of the most important things we can do with monkeypox that we truly failed to do with COVID was share the information we can as widely as we can as quickly as we can, but also be forthright in what we know and what we don’t know.
And I think not trying to make things up, not talking about drinking bleach or shining UV lights under the skin, things that really have no medical evidence, really practice and promote practices that are evidence based. Be very clear about the treatments that we have that are effective. And it’s different than COVID. And again, in the sense that we have therapies and products that we can use to act against this virus. With COVID, everybody was scrambling to find whatever they could, and there wasn’t a whole lot of coordination from the top and there wasn’t a whole lot of value in what’s true and what wasn’t. And I think we’ve slowly started to come around to recognizing the harms that were incurred because truth wasn’t told early on. We didn’t take it as seriously as we needed to.
And my hope is that with this monkeypox epidemic that we start looking at this seriously, we respond more quickly, and we don’t wait to have it totally out of control before we actually start trying to make people aware of it.
Dr. Angela Kade Goepferd: That’s what I hope that we see. I hope that we see consolidated and accurate reporting of information, good scientific basis in our recommendations, and some improved public health measures. I think our country and our infrastructure has a long way to go from a public health and infection prevention standpoint, but luckily we’ve got experts like you helping us get there. So thanks again for joining us today. I really appreciate you sharing your expertise with us.
Joe Kurland: Thank you very much.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.