Viral Infections Management & Treatment - IT3 PDF

Management & Treatment of Non-HIV Viral Infections Integrated Therapeutics 3 Infectious Diseases Pharmacotherapy Monika N. Daftary, PharmD, BCPS, AAHIVP Professor  Objectives Identify the major types of viral infections – HSV, VZV, CMV, Influenza...

Management & Treatment of Non-HIV Viral Infections Integrated Therapeutics 3 Infectious Diseases Pharmacotherapy Monika N. Daftary, PharmD, BCPS, AAHIVP Professor  Objectives Identify the major types of viral infections – HSV, VZV, CMV, Influenza and others. Identify and describe the pathophysiology and pharmacotherapy of viral infections Specifically name the appropriate pharmacological, non-pharmacological and OTC products (where applicable) used to treat/prevent/suppress viral infections  Objectives Name MOA, brand/generic and dosing for antiviral agents Be able to discuss and name uses of these agents in special populations Be able to discuss emerging viral infections: Hantavirus, West Nile Virus, SARS, COVID-19 and MPox  Epidemiology Common Self-limiting to fatal Many viral diseases have no vaccines Progress with chemotherapy and diagnosis  Viral Infections Common HSV-1, HSV-2, VZV and CMV Following acute infection, these types of viruses share a common feature of latency and reactivation leading to recurrent disease Epidemiology, pathogenesis and clinical features vary  Herpes Simplex Infections DNA virus that infects humans Two types of herpes: -HSV-1 non-genital herpetic infections -HSV-2 genital infections Previous infection with one type of HSV does not provide immunity for the other Genital herpes is a chronic, lifelong viral infection  Herpes Simplex Infections Background HSV-2 is transmitted sexually and perinatally Majority of genital herpes infections are transmitted by persons who are – unaware they are infected with HSV-2 or – asymptomatic when transmission occurs Efficiency of sexual transmission is greater from men to women than from women to men  Herpes Simplex Infections Background Likelihood of transmission declines with increased duration of infection Incubation period after acquisition is 2- 12 days (average is 4 days) Drying and soap and water readily inactivate HSV; fomite transmission unlikely  Herpes Simplex Infections The virus remains latent indefinitely Reactivation is precipitated by multiple known and unknown factors and induces viral replication The re-activated virus may cause a cutaneous outbreak of herpetic lesions or subclinical viral shedding Up to 90% of persons seropositive for HSV-2 antibody have not been diagnosed with genital herpes  Herpes Simplex Infections First Clinical Episode Primary infection – First infection ever with either HSV-1 or HSV-2 – No antibody present when symptoms appear – Disease is more severe than recurrent disease  Herpes Simplex Infections Recurrent symptomatic infection Antibody present when symptoms appear Disease usually mild and short in duration Asymptomatic infection Serum antibody is present No known history of clinical outbreaks  Herpes Simplex Infections Primary Characterized by multiple lesions that are more severe, last longer, and have higher titers of virus than recurrent infections Typical lesion progression: – papules → vesicles → pustules → ulcers → crusts → healed Often associated with systemic symptoms including fever, headache, malaise, and myalgia Illness lasts 2-4 weeks  Herpes Simplex Infections Secondary Numerous, bilateral painful genital lesions; last an average of 11-12 days Local symptoms include pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal adenopathy Median duration of viral shedding detected by culture (from the onset of lesions to the last positive culture) is ~12 days  Herpes Simplex Infections After the primary infection, HSV appears to remain latent in the sensory ganglia Trigger factors Primary infections preceded with 1-2 days of local tenderness  Herpes Simplex Infections Any disorder of T-cell immunity typically associated with severe HSV infections Watch in organ transplantation/AIDS – confusing presentation – can disseminate Diagnosis: skin biopsy, cytologic smear, viral culture, PCR techniques Adequate analgesia very important – both systemic and topical  Herpes Simplex Infections Most HSV-2 is transmitted during asymptomatic shedding Rates of asymptomatic shedding greater in HSV-2 than HSV-1 Rates of asymptomatic shedding are highest in new infections (10 episodes/yr.  Herpes Treatment Infections in HIV+ patients Acyclovir 400 mg po tid x 5-10 days OR Acyclovir 200 mg po 5x/day x 5-10 days OR Famciclovir 500 mg po bid x 5-10 days OR Valacyclovir 1 g po bid x 5-10 days  Herpes Treatment Daily suppressive therapy in HIV+ patients Acyclovir 400-800 mg po bid-tid OR Famciclovir 500 mg po bid OR Valacyclovir 500 mg po bid  Herpes Treatment If resistance suspected: Foscarnet 40 mg/kg IV q8h until clinical resolution OR Topical Cidofovir 1% gel applied to lesions qd x 5 days All acyclovir-resistant strains are resistant to valacyclovir and most are resistant to famciclovir.  Herpes Encephalitis Both HSV 1 and 2 are associated with CNS infections HSV-1 in adults and HSV-2 in newborns Cultures are only for HSV-2 (CSF) PCRs more useful Mortality between 50 – 85%, early dx key Empirical treatment needed DOC: Acyclovir 5-10mg/kg Q8 hours 2-3 weeks Resistance noted!! DOC? Foscarnet 40mg/kg Q8-12 hrs for 2-3 weeks  Neonatal Herpes Neonates exposed during pregnancy Associated with mortality and morbidity Treatment  Herpes Treatment Neonatal herpes Acyclovir 20 – 60 mg/kg IV q8h x 21 days for disseminated/CNS infection x 14 days for infection limited to skin/mucous membrane Some experts recommend acyclovir for infants born to mothers who acquired HSV near term.  Oral-Facial Herpes Herpes labialis (cold sores) Treatment depends on immune status PO vs. topical treatment  Oral-Facial Herpes Drug Dose Docosanol (Abreva) Apply 5 times a day, continue until healed Acyclovir Topical (Zovirax) Apply 5 times a day for 4 days Acyclovir Buccal Tablet (Sitavig) Apply 50mg tablet as single dose to the upper gum region Penciclovir Topical (Denavir) Apply every 2 hours for 4 days  Herpes Keratitis Infection of the eye Any age group (contrary to belief) Most frequent cause of corneal blindness in the United States Is a leading indication for corneal transplantation Treatment: -Trifluridine*** -Idoxuridine -Vidarabine  Varicella-Zoster Infections Varicella (chicken pox) the primary manifestation of VZV infection, usually in childhood Herpes Zoster (shingles) is the secondary form of VZV Risk increases with age  Chicken Pox Common childhood infection Decreased incidence secondary to vaccine availability Highly contagious Infectious from 2 days before before onset until all vesicles crust Certain patients can benefit from tx, esp if extracutaneous manifestations  Chicken Pox The typical case of chickenpox begins 10 to 14 days after exposure and is often associated with fever. The rash is very itchy: there may be 10 to 1500 blisters but the usual child will have about 300 lesions. One of the most common complications of chickenpox is that the blister can become infected with bacteria;  Chicken Pox Supportive care Cool baths Calamine/Topical antipruritic No aspirin  Varivax Indicated for vaccination against in individuals 12 months of age and older Children 12 months to 12 years of age should receive a 0.5-mL dose administered subcutaneously If a second 0.5-mL dose is administered, it should be given a minimum of 3 months later**  Herpes-Zoster Infections Varicella Zoster Virus (VZV) Results from reactivation of latent virus in dorsal root or cranial nerve ganglion cells No seasonal pattern 2/3 of patients > 40 years old Lesions preceded by a mild preeruptive itch, tenderness or pain for several days - erupt and are gone within 2-4 weeks Herpes-Zoster Infections  Herpes-Zoster Infections Presentation: erythematous macules, papules and plaques seen first and grouped vesicles appear within 24 hours Post-herpetic neuralgia (PHN) a problem Treatment: acyclovir, famciclovir, valacyclovir Acyclovir proven effective in both localized and disseminated VZV – decreases pain and time of healing Role of corticosteroids - controversial  Herpes-Zoster Infections Drug Dose Acyclovir (Zovirax) 800mg po 5 times a day for 7 – 10 days Famciclovir (Famvir) 500mg po TID for 7 days Valacyclovir (Valtrex) 1 gram po TID for 7 days  Herpes-Zoster Infections PHN that lasts >30 days after the onset of rash Most common manifestation FDA-approved tx for PHN: -Topical capsaicin -Topical lidocaine patches 5% -Gabapentin -Pregabalin Other agents…..?  Herpes-Zoster Infections As of November 18, 2020 there is one licensed vaccine and recommended to prevent shingles in the U.S. Zoster vaccine live (ZVL, Zostavax) has been in use since 2006 (off market) Recombinant zoster vaccine (RZV, Shingrix), has been in use since 2017 and is recommended by ACIP as the preferred shingles vaccine. Herpes-Zoster Infections  Herpes-Zoster Infections Exposure - Varizig® Use to decrease the incidence or severity of disease in patients without evidence of immunity to varicella zoster who have been exposed to the virus and who are at high risk for severe disease and complications.  Resistance Does not have activity against viral pathogens until it is converted to the active form acyclovir triphosphate Mainly in immunocompromised patients Confers resistance to both valacyclovir and famciclovir May respond to foscarnet or cidofovir  Cytomegalovirus Infections 53% of Americans between 18-25 age CMV+ 81% of Americans >35 are CMV+ >95% of MSM CMV+ 90% of infections asymptomatic Virus remains latent in host until immunosuppression  Cytomegalovirus Infections Acquired by a variety of routes – congenital, sexual and person-to-person CMV is also transmitted via contaminated blood products/organ transplants In the US – acquired/latent 90% of MSM and >70% in IVDA CMV end-organ disease – one of the most common OIs in patients with AIDS  Cytomegalovirus Infections CMV can infected virtually any organ system – but in AIDS patients most common manifestation – chorioretinitis Left untreated, can cause blindness GI infections (esophagitis & colitis) also occur In transplant pts, CMV pneumonia CNS infections – severe M & M  Cytomegalovirus Infections Diagnosis – in the retinitis based on lesions that appear as patches of fluffy white retinal infiltrate with areas of hemorrhage Manifest as floaters, flashes of light, blind spot Peripheral disease mostly asymptomatic Various fluids, tissues, histologic exam  Cytomegalovirus Infections Serology -Detects exposure Isolation -Tissue culture…6 weeks -Shell vial technique…16 hours Cytology -Large cell’s (owl’s eye)  Cytomegalovirus Infections Manifestations: -GI: Colitis, Esophagitis/Gastritis, Hepatitis -Pneumonia -Retinitis  Cytomegalovirus Infections Treatment Agents: Ganciclovir Valganciclovir Foscarnet Cidofovir Letermovir**(Prevymis) **(narrow indication – approved 11/2017) Maribavir (Livtencity)  Cytomegalovirus Infections Ganciclovir (Cytovene IV, Zirgan) Valganciclovir (Valcyte) MOA: Inhibits viral DNA synthesis Must be triphosphorylated – rate-limiting step Valganciclovir is rapidly converted to ganciclovir in the intestinal wall and liver (F = 60%)  Cytomegalovirus Infections AE: Moderate to severe neutropenia Thrombocytopenia Confusion, convulsions N/V/D Abnormal LFTs Reproductive toxicity  Cytomegalovirus Infections Dose: Induction- Valcyte 900mg BID x 14-21 days or Cytovene 5mg/kg IV Q12hrs for 14-21 days Maintenance –Valcyte 900mg daily or Cytovene 5mg/kg IV daily Relapse w/o maintenance IV maintenance means CVC Renal adjustment  Cytomegalovirus Infections Dose: Intraocular implant (ganciclovir) – releases 1 mcg/hr (replace after 6 – 8 months) plus Valcyte 900mg Qdaily Local therapy cannot be done alone increases incidence of AE, contralateral CMV retinitis  Cytomegalovirus Infections Foscarnet Inhibits viral-induced DNA polymerase Foscarnet should be reserved  Cytomegalovirus Infections Foscarnet AE Renal Impairment - **prevent by admin 2.5 L per day of NS Dec H & H Altered serum electrolytes (Ca, Phos, Mg) Penile ulcerations  Cytomegalovirus Infections Foscarnet Prep/Dose Commercial Prep: 500 ml – 24 mg/ml (central), but use 12 mg/ml for peripheral admin 1 gram of Foscarnet has 600mg NaCL  Cytomegalovirus Infections Foscarnet Dose Induction: 60mg/kg Q8hrs or 90mg/kg Q12hours for 14-21 days (admin 1 hr) Maintenance: 90 – 120mg/kg/day (admin 2 hours) Dec dose by 3.5mg/kg for each 0.1 ml/min/kg of CrCl below 1.6 ml/min/kg Need CVC  Cytomegalovirus Infections Cidofovir (Vistide) Inhibits viral DNA polymerase Intracellular activation needed AE: renal impairment (issues with proteinuria, inc Scr); neutropenia, carcinogenic, teratogenic **sulfa allergy** -Dec effects with use of Probenecid (2 g, 3 hours before infusion, 1g, 2 and 8 hours after infusion) and saline hydration  Cytomegalovirus Infections Cidofovir (Vistide) Dose Induction: 5mg/kg/week x 2 weeks Maintenance: 5mg/kg every other week Hazardous  Cytomegalovirus Infections Prophylaxis: Secondary prophylaxis is required for all patients May be d’ced if CD4 >100 for 3-6 months Restart secondary prophylaxis if CD4 falls Primary prophylaxis not recommended  Cytomegalovirus Infections Prevymis™ (letermovir) for Prevention of Cytomegalovirus (CMV) Infection and Disease in Adult Allogeneic Stem Cell Transplant Patients Approved November 2017 IV and oral Class of non-nucleoside CMV inhibitors (3,4 dihydro- quinazolines) MOA: inhibits viral replication by specifically targeting the viral terminase complex Drug interaction issues  Influenza Epidemic nature with significant mortality Epidemics begin abruptly, peak and then resolve Occur almost always in the winter months (Dec to April) Overall rates 10-20% Mortality greatest in those >65 (esp with heart and lung disease)  Influenza vs Common Cold S/Sx Influenza Cold Onset Sudden Gradual Fever Characteristic Rare Cough Dry Hacking Headache Prominent Rare Tiredness Yes Very mild Chest Discomfort Common Mild Stuffy nose Sometimes Common Sneezing Sometimes Usual Sore throat Sometimes Common Myalgias Usual Slight  Influenza Acute infection Virus from the Orthomyxoviridae family Types A and B Transmission by inhalation Incubation 2 days (on average)  Influenza Type A Grouped by variations in hemagglutinin and neuraminidase (eg, H1N1, H1N2) Changes through antigenic drift or shift Pandemic can occur with one shift Causes epidemics every 1-3 years  Influenza Type B Carries one type of hemagglutinin and one form of neuraminidase Changes occur from drifts (mutations), need a bunch of them to cause an epidemic Causes epidemics every 5 years  Influenza Amantadine,Rimantadine - Prevention Prevents 50% of infections and 70-90% of illnesses Dosing: short-term; prophylaxis during presumed outbreak of influenza A in pts who did not receive vaccine NEITHER ONE IS USED BASED ON CURRENT GUIDELINES!!  Influenza Amantadine,Rimantadine Inhibits viral uncoating and release of viral nucleic acid by inhibiting M2 gene Only effective against Influenza A virus Decreases duration of s/sx by one day AE: Dry mouth, N/V, loss of appetite, insomnia, impaired concentration Caution: Use with caution in patients with seizures  Influenza Dosing - Treatment 100mg po BID Elderly should not receive higher doses Adjust for renal disease (CrCl 5 yo) AE: HA, throat pain, cough Warning: Neuropsychiatric events, bronchospasm (do not use in asthma or COPD) www.fda.gov  Influenza Neuraminidase Inhibitors (sx disappear 1- 1.5 days sooner) Prophylaxis vs. Treatment Peramivir (Rapivab) Dosing: 600mg IV once, CrCl 12 years) Baloxavir Marboxil (Xofluza) Dosing: 40kg - 80kg: 80mg po x 1 dose within 48 hours of onset Use with caution in renal or hepatic impairment AE: diarrhea Other caution: Avoid administration with dairy products, calcium, antacids or supplements with polyvalent cations Store in original packaging  Influenza Prevention - chemoprophylaxis can be done for influenza- related complications in high-risk patients - only Neuraminidase Inhibitors (Tamiflu and Relenza) Influenza  Influenza Vaccine (Influenza) Each year’s vaccine contains 2 strains of type A and 1 one strain of type B (at least) Prevents illness in 70-90% of healthy persons 50, nursing home residents, adults/children with chronic issues [pulmonary/cardiac], DM, Renal, HIV, asthma, anemia, etc. -Transmit issues, healthcare workers, homecare or household with high-risk pts Intranasal live-attenuated (FluMist) -2-49 w/o underlying disease  Influenza Vaccine Composition for the 2022–23 Season There are many different flu viruses, and they are constantly changing. The composition of U.S. flu vaccines is reviewed annually and updated as needed. The recommendations for the 2022-2023 season include two updates compared with the recommended composition of last season’s U.S. flu vaccines. Both the influenza A(H3N2) and the influenza B(Victoria lineage) vaccine virus components were updated. The recommendations for egg-based and cell-based and recombinant flu vaccines are listed below: -Egg-based vaccine composition recommendations: an A/Victoria/2570/2019 (H1N1) pdm09-like virus; an A/Darwin/9/2021 (H3N2)-like virus (updated); a B/Austria/1359417/2021-like virus (B/Victoria lineage) (updated) a B/Phuket/3073/2013-like virus (B/Yamagata lineage) - Cell- or recombinant-based vaccine composition recommendations: an A/Wisconsin/588/2019 (H1N1) pdm09-like virus; an A/Darwin/6/2021 (H3N2)-like virus (updated); a B/Austria/1359417/2021-like virus (B/Victoria lineage) (updated); a B/Phuket/3073/2013-like virus (B/Yamagata lineage).  Outbreak of Hantavirus Infection in Yosemite National Park As of September 13, 2012 the National Park Service (NPS) had announced a total of 9 confirmed cases of hantavirus infection in people who recently visited Yosemite National Park.  Hantavirus Infections Rodents are primary hosts Transmission 4 Serotypes: -ARDS/bilateral pulmonary infiltrates -Autopsy of noncardiogenic pulm edema -Hantavirus antigen in tissue -+Hantavirus RNA  Hantavirus Infections Manifests as: -Hemorrhagic fever with renal syndrome -Nephopathia Epidemica -Hantavirus Pulmonary Syndrome (HPS)** Southwestern US Sx: F/myalgia/HA/cough, fast progress to ARDS  Hantavirus Infections Tx is supportive No FDA-approved drugs IV ribavirin in trials No approved protocols: Treatment: Load 30 mg/kg IV (up to 2 g), THEN 16 mg/kg IV (up to 1 g) q6hr x4 d, THEN 8 mg/kg IV (up to 500 mg) q8hr x6 d IV form available from CDC on compassionate basis Prophylaxis: 500-600 mg PO q6hr x7-10 d Orphan indication sponsor Valeant Pharmaceuticals International; 3300 Hyland Avenue; Costa Mesa, CA 92626  West Nile Virus Rapidly grown in US due to migratory and weather patterns Flaviviridae family Vector: mosquito **requires mosquito bite Summer/early fall Ranges from asymptomatic disease to fever to encephalitis  West Nile Virus Low mortality, except in encephalitis CDC Classification S/Sx Treatment -Supportive -**current antivirals not effective, dose- limiting toxicities  West Nile Virus Serious Symptoms in a Few People. Milder Symptoms in Some People. No Symptoms in Most People. Transmission Infected Mosquitoes Transfusions, Transplants, and Mother-to- Child Not through touching  West Nile Virus There is no specific treatment for WNV infection. Mild cases: self-limiting Severe cases: supportive treatment  West Nile Virus Prevention DEET (OFF!, Cutter, etc) -DEET 30% can last about six hours. -DEET 10% can last two to three hours. -A product with up to 30% DEET is safe for kids two months and older. - chemical name N,N-diethyl-m-toluamide or N,N- diethyl-3-methyl-benzamide. Picaridin (Cutter Advanced, Natrapel, etc) Oil of lemon eucalyptus (Citrepel, Cutter Lemon Eucalyptus) Soybean oil (Bite Blocker, etc) Permethrin (Repel Permanone, etc)  SARS (2003) Severe Acute Respiratory Distress Syndrome Identified in China first, tends to be associated with travel to endemic area CDC Classification Possible coronavirus Incubation 2 to 7 days Treatment Options – ABx?  MERS (Middle East Respiratory Syndrome) Viral respiratory illness first reported in Saudi Arabia in 2012. It is caused by a coronavirus called MERS-CoV. Develop severe acute respiratory illness Most cases linked to countries near Arabian Peninsula, no cases in US Spread from ill people to others through close contact. CDC Classification Incubation with 14 days? Treatment Options – a lot of interesting data, but no specific drug available  Ebola Virus  Prototype Viral Hemorrhagic  >20 previous Ebola and Fever Pathogen Marburg virus outbreaks Filovirus: enveloped, non-segmented, negative-  2018 West Africa Ebola stranded RNA virus outbreak caused by Severe disease with high Zaire ebolavirus species case fatality (five known Ebola virus Absence of specific treatment species) or vaccine 100  Ebola Virus  Zoonotic virus – bats the most likely reservoir, although species unknown  Spillover event from infected wild animals (e.g., fruit bats, monkey, duiker) to humans, followed by human-human transmission 101  Clinical Management  Hypovolemia and sepsis physiology Aggressive intravenous fluid resuscitation Hemodynamic support and critical care management if necessary  Electrolyte and acid-base abnormalities Aggressive electrolyte repletion Correction of acid-base derangements  Symptomatic management of fever and gastrointestinal symptoms Avoid NSAIDS  Multisystem organ failure can develop and may require Oxygenation and mechanical ventilation Correction of severe coagulopathy Renal replacement therapy Reference: Fowler RA et al. Am J Respir Crit Care Med. 2014 102  Investigational Therapies for EVD Patients  No approved EVD-specific prophylaxis or treatment Ribavirin has no in-vitro or in-vivo effect on Ebola virus Therapeutics in development with limited human clinical trial data o Convalescent serum o Therapeutic medications o ZMapp – three chimeric human-mouse monoclonal antibodies o Tekmira – lipid nanoparticle small interfering RNA o Favipiravir – oral RNA-dependent RNA polymerase inhibitor  Vaccines – in clinical trials Chimpanzee-derived adenovirus with an Ebola virus gene inserted Attenuated vesicular stomatitis virus with an Ebola virus gene inserted References: 1Huggins, JW et al. Rev Infect Dis 1989; 2Jarhling, P et al. JID 2007; 3Mupapa, K et al. JID 1999 S18; 4Olinger, GG et al. PNAS 2012; 5Dye, JM et al. PNAS 2012; 6Qiu, X et al. Sci Transl Med 2013; 7Qiu, X et al. Nature 2014; 8Geisbert, TW et al. JID 2007; 9Geisbert, TW et al. Lancet 2010; 10Kobinger, GP et al. Virology 2006; 11Wang, D et al. J Virol 2006; 12Geisbert, TW et al. JID 2011; 13Gunther et al. JID 2011; 14Oestereich, L et al. Antiviral Res. 2014. 103  Clinical Management - Antiviral Drugs  There is currently no antiviral drug licensed by the U.S. Food and Drug Administration (FDA) to treat EVD  During the 2018 eastern Democratic Republic of the Congo outbreak, four investigational treatments were initially available to treat patients with confirmed Ebola  For two of those treatments, called Regeneron (REGN- EB3) and mAb114, overall survival was much higher. These two antiviral drugs currently remain in use for patients with confirmed Ebola 104  Prevention of EVD  Ebola Vaccine  The U.S. Food and Drug Administration (FDA) approved the Ebola vaccine rVSV-ZEBOV (tradename “Ervebo”) on December 19, 2019  The rVSV-ZEBOV vaccine is a single dose vaccine regimen that has been found to be safe and protective against only the Zaire ebolavirus species of ebolavirus  This is the first FDA approval of a vaccine for Ebola 105  Zika Virus Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). Zika can be passed from a pregnant woman to her fetus No vaccine exists to prevent Zika Prevent Zika by avoiding mosquito bites Mosquitoes that spread Zika virus bite during the day and night Mosquitoes that spread Zika virus also spread dengue and chikungunya viruses Zika can be passed through sex from a person who has Zika to his or her sex partners. Condoms can reduce the chance of getting Zika from sex Coronavirus Disease 2019 (COVID-19) www.cdc.gov  Coronavirus Disease 2019 (COVID-19)  Outbreak of respiratory disease caused by a novel (new) coronavirus that was first detected in China and which has now been detected in 60 locations internationally, including in the United States.  The virus has been named “SARS-CoV-2” and the disease it causes has been named “coronavirus disease 2019” (abbreviated “COVID-19”).  On January 31, 2020, declared a public health emergency (PHE) for the United States 108  Coronavirus Disease 2019 (COVID-19)  Coronaviruses are a large family of viruses that are common in people and many different species of animals, including camels, cattle, cats, and bats  Rarely, animal coronaviruses can infect people and then spread between people such as with MERS-CoV, SARS-CoV, and now with this new virus (named SARS-CoV-2)  All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir  Early on, many of the patients at the epicenter of the outbreak in Wuhan, Hubei Province, China had some link to a large seafood and live animal market, suggesting animal-to-person spread. Later, a growing number of patients reportedly did not have exposure to animal markets, indicating person-to-person spread  Travel-related exportation of cases reported 109  Coronavirus Disease 2019 (COVID-19)  The primary transmission of COVID-19 is from person to person through respiratory droplets – Droplets are released when someone talks, sneezes, or coughs – Infectious droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs  COVID-19 may also be spread if you touch contaminated objects and surfaces  Recent data suggest transmission by people who are not showing symptoms https://www.covid19treatmentguidelines. nih.gov/whats-new https://www.covid19treatmentguidelines. nih.gov/whats-new  Coronavirus Disease 2019 (COVID-19) Prevention  Vaccines: three approved (Moderna, Pfizer, J&J, Novavax) https://www.covid19treatmentguidelines. nih.gov/whats-new  Monkey Pox Virus  Mpox outbreak in the United States is caused by Clade IIb of the mpox virus  Treatment: -Tecovirimat (also known as TPOXX, ST-246) -Brincidofovir (also known as CMX001 or Tembexa) -Vaccinia Immune Globulin Intravenous (VIGIV) -Cidofovir (also known as Vistide)  Two vaccines may be used for the prevention of mpox disease: JYNNEOS vaccine is approved for the prevention of mpox and smallpox. During the current outbreak, JYNNEOS is the main vaccine being used in the United States. ACAM2000 vaccine is approved for immunization against smallpox and made available for use against mpox under an Expanded Access Investigational New Drug (EA-IND) protocol.  References 1. www.cdc.gov [Accessed February 28, 2022] 2. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season. MMWR Recomm Rep 2020;69(No. RR-8):1–24. DOI: http://dx.doi.org/10.15585/mmwr.rr6908a1