Mpox Update ISTM TMRU Course 02-04-2023 PDF

Mpox Update ISTM TMRU Course 02-04-2023 Recorded 01/13/2023 David O. Freedman, MD, FISTM, FASTMH Professor Emeritus of Infectious Diseases University of Alabama at Birmingham Past Secretary-Treasurer, ISTM Associate Editor, EID Journal Section Editor, JTM Outline for Today ⚫Clinical aspects and som...

Mpox Update ISTM TMRU Course 02-04-2023 Recorded 01/13/2023 David O. Freedman, MD, FISTM, FASTMH Professor Emeritus of Infectious Diseases University of Alabama at Birmingham Past Secretary-Treasurer, ISTM Associate Editor, EID Journal Section Editor, JTM Outline for Today ⚫Clinical aspects and some cases ⚫Mpox origins and emergence ⚫Diagnosis ⚫Vaccines – Dosing, admin, efficacy, single dose Jynneos (MVA-BN), indications ⚫Antivirals 2022 Clinical symptoms Rash or enanthem Mucosal lesions new from 2022 Lesions in different phases of development seen side-by-side Rash either scattered or diffuse; sometimes limited to one body site and mucosal area (e.g., anogenital region or lips/face) Anogenital location reflective of sexual practices in non-cis males Presenting complaint sometimes anorectal pain or tenesmus Some co-infections with sexually transmitted infections Isolated proctitis not uncommon; 1 case reported with acute Mpox, HIV, syphilis simultaneously Prodromal symptoms may be mild or not occurring Fever, lymphadenopathy not occurring in all patients Early Mpox lesions, United States 2022 Shared with permissions from patients, CDC From Basgoz N, Brow n CM, Smole SC, et al. Case 24-2022: A 31-Year-Old Man w ith Perianal and Penile Ulcers, Rectal Pain, and Rash. Epub ahead of print. Copyright © Jun 15 2022. Massachusetts Medical Society. Reprinted w ith permission from Massachusetts Medical Society Clinical Presentation in Females-similar to men Ulcerations with raised white borders extending from the labia minora into the vaginal walls Emerg Infect Dis. 2023;29(1):222-223. Pustules in gluteal area (A), genital area (B, C), intravaginal area (D), arm and hand (E), and finger (F) in young woman with mpox virus infection after sexual intercourse, France, September 2022. Emerg Infect Dis. 2023;29(1):219-222. Father to Mother then to 2 young children by presumed skin to skin Contact Mpox virus lesions for the 4-year old daughter in a family (father, mother, 2 children) infected with mpox, August 2022. A) Umbilical pustule on pulp of the finger; B) papulopustule on the ankle; C, D), faint erythematous rash on the thighs. Emerg Infect Dis. 2023 Feb doi.org/10.3201/eid2902.221674 Non-needlestick Occuptional Exposure Timeline of occupational mpox in LA county. Patient B was treated by the HCW 4d prior to HCW symptom onset. Gloves+mask only for 5 min; full PPE during swabbing. Total 10 lesions diffusely. Lesion evolution over 30 days Emerg Infect Dis. 2023 Feb doi.org/10.3201/eid2902.221750 Transmission by contaminated needles Tattoo parlor Spain: Over 2 wks, 21/58 clients with no risk factors infected. Median 7d incubation. 15/16 tattooing implements or supplies +ve for MPXV DNA DOI: 10.1056/NEJMc2210823 Circular Facial Pattern from Massage Table Face Cradle No sex/intimate contact in previous 3 mos Spas (2) had good hygiene protocols, no other cases Few papules eventually on limbs Emerg Infect Dis (in press). Detailed epi investigation by both Mass and NYC DOH Mpox Origins in Africa ⚫ Mpox identified in humans in 1970 in the DRC. – ⚫ Since 2000 endemic with 1-5000 cases/yr with CFR 2% Since 2016 human cases of mpox have also been reported in Cameroon, Central African Republic, Liberia, Nigeria, Republic of the Congo, and Sierra Leone, mostly in forested rural areas. – Nigeria now epicenter Waning herd immunity from previous smallpox vaccination (>97% cases born after 1979 (no smallpox vaccination ⚫ 2018-2021 10 cases were exported from Nigeria to US, Israel, Singapore, and the UK ⚫ 2022 division of virus into Clade 1, 2a, 2b(=outbreak clade) ⚫ 84,000 Mpox Cases as of January 3, 2023 United States Brazil Spain France Colombia United Kingdom Germany Peru Mexico Canada Chile Netherlands Argentina 75 deaths 29792 10498 7500 4114 4021 3730 3677 3643 3637 1460 1377 1259 1018 California New York Texas Florida Georgia Illinois Pennsylvania 5640 4200 2859 2852 1984 1419 864 Diagnosis In many places PCR testing (from lesions) is difficult to obtain and confirmation of cases takes time. In the US, testing is coordinated through state health departments and also done at Laboratory Response Network laboratories or at 5 large commercial labs. Positive test results technically require confirmatory testing by US CDC to specify Mpox and not just ”orthopoxvirus”. Specimen taken by rubbing lesion, even if crusted Even scabbed lesions contain high viral loads Medical Countermeasures Stockpiled for Orthopoxviruses Vaccines ▪ JYNNEOS ▪ ACAM2000 Treatment ▪ Tecovirimat ▪ Vaccinia Immune Globulin Intravenous (VIGIV) ▪ Brincidofvir (hepatotoxicity) Vaccine Dosing Jynneos Administration ⚫ ⚫ No history or screening is required because because of safety in immunocompromised and HIV Compared to ACAM2000 (a replication-competent vaccine), Jynneos (a replication-deficient vaccine), has fewer contraindications – ⚫ Administration is via the standard subcutaneous (SC) route – ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Only allergic reaction to vaccine or components precludes use ACAM2000 needs one drop into deltoid using 15 punctures with a special bifurcated needle by specially trained vaccinators Cardiac (myocarditis or pericarditis) or other toxicities much lower risk No replicating virus-containing scab is formed (no care needed) US experience, first 1M doses: 14 SAE (0 if