June 3, 2022
With monkey pox in the news, I was reminded of an inpatient consult I received right out of residency. In my first real job, I was called to a local Westchester hospital to rule out smallpox. The patient was an immunocompromised young women whose husband was in the military and had received a smallpox vaccine as part of his training in preparedness for biological attack. She wound up having disseminated herpes zoster or shingles. The “pox” headline can really grab your attention though. I took a lot of time putting on my gown, masks and gloves. Years later, I would be doing that same careful routine during the Pandemic and we had a new term: personal protective equipment (PPE).
Smallpox, like monkey pox, is an orthopox virus. The last known case of smallpox was in 1979. Smallpox was eliminated through mass vaccination. Prior to global systematic vaccination, the common variant of smallpox carried a mortality rate of 30% and survivors were left with disfiguring scars, especially prominent on the face.
Another blistering virus current generations are more familiar with is the varicella zoster virus (VZV). That was the diagnosis of my patient consult. As a child, we called it chickenpox. Then as an adult, it lurks as the ominous shingles, re-emerging. While most of my contemporaries had chickenpox, our children’s generation have almost no experience with it, as a vaccine was introduced in 1995. In the United States this has drastically reduced the prevalence by more than 70% annually. VZV is yet another disease that vaccines turned from outbreak to preventable disease.
Let’s talk about the vaccinology history. While modern vaccines are precise and synthetically refined, vaccinology, the development and practice of immunization dates back centuries. Buddhist monks drank snake venom to confer immunity to snake bite. Variolation (smearing of a skin tear with cowpox to confer immunity to smallpox) was practiced in 17th century China. Edward Jenner is considered the founder of vaccinology in the West in 1796, after he inoculated a 13 year-old-boy with vaccinia virus (cowpox), and demonstrated immunity to smallpox. In 1798, the first smallpox vaccine was developed.
Smallpox was a plague on the human race until the vaccine turned it into a preventable disease. .
During dermatology training, we discover that most plagues on the human race come with skin findings. Just as early on, we learn while there are not many emergencies in dermatology, fever and a rash does qualify as a dermatological emergency. Monkeypox falls in the category of dermatological emergency. Patients are febrile and the rash follows. It starts on the inside, mouth and genitals, and spreads to the outside skin, eventually into a blistering rash. Treatment is mostly supportive.
There are two major monkey pox variants, West African and Central African. The current outbreak is of the West African variant which has a lower mortality rate, 1% or less.
Compared to the ever present COVID 19 newsreel, Monkeypox is harder to contract. It is much less contagious than COVID. This is why it has stayed endemic to Africa. But we have much to glean from our colleagues in Africa on how to handle an outbreak. It is spread by large droplet. Whereas COVID 19 is spread in aerosol (microscopic droplets). That means for Monkeypox, you need prolonged close contact, including sexual exposure and the exchange of bodily fluids to contract it. In fact the current outbreak is for now clustered in men who have sex with men (MSM). But take note, In Africa, monkeypox is not a sexually transmitted disease. So let’s avoid that label here as it may falsely represent a “not my problem” disease. Monkey pox is a respiratory transmitted disease. That means you breathe in the infectious particles. So anyone who breathes is at risk if exposed.
While there is pandemic fatigue after two plus years of COVID, we do have good evidence of at least two things to handle a respiratory pandemic: Good masks protect us and vaccines train our immune system so it does not have to go in naïve to battle a virus.
Masks may be controversial but N95s are not. An N95 that satisfies the simple fit test (https://youtu.be/CoSb-HJJ5tk- don n95) protects its wearer from breathing in infectious particles, especially large droplets like monkey pox and even aerosol like the coronavirus.
The second is that vaccination, even when given after exposure can reduce severity of disease. There are a couple vaccines available for orthopox viruses.
If monkeypox virus became more problematic and wide spread then its current endemic nature, I have full confidence that our scientists could redesign and optimize a vaccine for wide distribution. And hopefully that would lead monkeypox to the same area where smallpox now rests and VZV is headed: the realm of historic plagues turned preventable disease.
Saryna Young, MD, FAAD