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Q&A with Dr. Josh Hill on Monkeypox

In science and medicine, information is constantly changing and may become out-of-date as new data emerge. All articles and interviews are informational only, should never be considered medical advice, and should never be acted on without review with your health care team.

You’ve most likely heard that there is a worldwide monkeypox outbreak. Patients with chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are immunocompromised, meaning their immune system does not work as well as in healthy people. So naturally, patients have many concerns about infectious diseases, such as this monkeypox outbreak. In this interview, Dr. Brian Koffman spoke with Dr. Joshua Hill, an infectious disease specialist at the Fred Hutchinson Cancer Center in Seattle, Washington about monkeypox and the current outbreak. Dr. Hill specializes in the infectious disease care of cancer and other immunocompromised patients.

What is monkeypox?

Monkeypox is a pox virus. It is related to viruses such as smallpox and chickenpox, although historically, it has not been nearly as prevalent. It is endemic to central and west African countries, where its natural host is most likely rodents (not monkeys). In the past, there have been contained local monkeypox outbreaks. But with the current outbreak, monkeypox has spread rapidly worldwide.

How is monkeypox spread?

Monkeypox is most commonly spread through direct contact with an infected person or animal with active skin lesions. Direct contact includes touching an infected individual, kissing, sexual contact, contact with oral secretions, or contact with body lesions. It can also be spread through prolonged contact with the bedding, towels, or clothing of someone with an active infection. In some cases, it can be spread through close, prolonged, face-to-face contact through large respiratory droplets. A pregnant woman can also spread the virus to their fetus through the placenta. Please visit the CDC website here for more information regarding how it is spread. 

Thus far, there is no evidence that monkeypox is spread through aerosol transmission or brief contact with objects that an infected individual has touched. Therefore, normal day-to-day activities such as touching a doorknob or sitting in a seat in a public area are very unlikely to result in becoming infected.

What are the symptoms of monkeypox?

After exposure to monkeypox, symptoms typically start in 1-2 weeks. Monkeypox typically begins with flu-like symptoms, which include fever, headache, muscle aches, swollen lymph nodes, chills, and exhaustion. This is typically followed within 3-4 days by a painful red rash that can look like pimples or blisters, and usually first appears on the face or inside the mouth and then progresses downwards to other parts of the body (like the hands, legs, feet, chest, genitals, or anus). In severe cases, the infection can cause pneumonia, infect the brain (encephalitis), or infect the gastrointestinal tract, but this is not common. 

How can I prevent monkeypox infection?

Basic good hygiene practices still apply here. Wash your hands or use hand sanitizer when going about your day-to-day activities. Avoid contact with anyone who is ill. It is important to keep in mind that monkeypox is not a sexually transmitted disease. However, that is one of the ways that the virus can be transmitted. If you have sexual contact with someone, (especially if it is not a monogamous relationship) ask them how they feel and if they’re experiencing any of the symptoms described above. Avoid intimate contact with individuals with skin rashes or lesions, especially in their genital area. Condoms are unlikely to provide adequate protection.

Are CLL / SLL patients at higher risk?

Yes. Since CLL / SLL patients are immunocompromised, they are at higher risk of having a severe version of the disease. This means they might have a more severe rash or be at risk for the infection spreading to other organs such as the lungs, brain, or gastrointestinal tract.

Are treatments available for monkeypox?

Yes. Because monkeypox is closely related to smallpox, a handful of therapeutics were already developed for smallpox which also works against monkeypox. However, none of them are approved explicitly for monkeypox, which makes obtaining them a bit more challenging. In addition, they would likely only be used for severe cases, such as if an immunocompromised patient were hospitalized. Sometimes when lesions form in the mouth, hands, feet, genitals, or anus they can be extremely painful. So some may occasionally need hospitalization for pain control. 

Are vaccinations available for monkeypox?

Unlike COVID-19, vaccinations are available for use pre-exposure and post-exposure (which can reduce the potential for severe infection). However, because the current prevalence of monkeypox is not extremely high, pre-exposure vaccination is only to be given to individuals with a high exposure risk. Right now pre-exposure vaccinations are only being offered in a few states to men who have sex with men (which is where we are currently seeing the majority of cases in the US). However, if cases continue to rise, this may be extended to healthcare professionals or people that work with monkeypox samples in a lab.

Post-exposure vaccination is recommended for immunocompromised CLL / SLL patients who have had a known exposure to someone with monkeypox to reduce the chances of developing severe disease. There are also antibody infusions that are available for post-exposure prevention for those who are high-risk.

Are the monkeypox vaccines safe for immunocompromised patients?

There are currently three monkeypox vaccines available, two of which are licensed by the FDA. ACAM2000 is a live vaccine, which is not appropriate for CLL / SLL patients because there is a chance that the live injected virus might replicate.

JYNNEOS (a.k.a. Imvamune or Imvanex) is an attenuated vaccine, meaning the virus in the vaccine was weakened and is not able to replicate. So the JYNNEOS vaccine would be safe for CLL / SLL patients. However, it is in very short supply at this time.

Please enjoy this brief interview with Dr. Hill.

Since this interview, the World Health Organization (WHO) declared monkeypox a “global health emergency,” its highest alert level on 7/23/2022. In addition, New York and San Francisco had declared monkeypox a state of emergency as of 8/1/2022.

While the situation is rapidly changing, monkeypox does at this time seem easily avoidable for most with CLL / SLL with basic risk-averse behaviors and good hygiene that we should all be practicing to prevent COVID-19. While monkeypox is concerning, demands our vigilance, and is dangerous to some in our community based on their increased risk of potential exposure because they work in a lab or medical setting, or their demographic, at this time monkeypox seems to pose a less significant risk to those with CLL / SLL compared to the present COVID-19 pandemic. That is what the CDC and Dr. Hill are saying, and CLL Society concurs with the experts. However, there are some who disagree with this more optimistic outlook as we don’t fully understand how or why monkeypox has suddenly spread so quickly.

As always, CLL Society will continue to keep you informed with the latest credible information as it emerges.

Take care of yourself first.

Ann Liu, PhD