Speaker 1: [00:00:04] Welcome to Stories of Care, a podcast from the American Medical Association and the CDC's Project Firstline. This is the first part of our episode covering the recent MPV outbreak in the United States. Part one focuses on how the virus is transmitted and the infection control and prevention measures that you can take to protect yourself and other health care professionals. Part two will look at how local health clinics have been impacted by and responded to MPV. We are joined today by Dr Abigail Carlson, an infectious diseases doctor at the Centers for Disease Control and Prevention.
Megan Srinivas, MD: [00:00:41] Thank you so much for being with us, Dr Carlson. There has been so much going on in the world of infectious disease over the last few years that it's been a whirlwind for people in the division, let alone people who have no knowledge of infectious disease. So it's great to have your insights today.
Abigail Carlson, MD: [00:00:57] Well, thank you. It's really wonderful to be here.
Srinivas: [00:01:00] And so I would really love to touch base on monkeypox. We've been talking about COVID for so long. And then monkeypox started, right? Where are we right now. What do we know about it?
Carlson: [00:01:12] So, you know, we know a lot and obviously we're learning a lot as we've gone along in this in this outbreak. We're at a point where cases are coming down and there's, you know, fewer and fewer cases as we go along each week. But certainly it's not gone. And so there's always a fear that as it falls out of public view, that people are going to think, oh, well, there is there's no monkeypox anymore because I'm just not hearing about it. But unfortunately, that's not the case. It's very much still present. It's still primarily with men who have sex with men, gay and bisexual men, and other men who have sex with men. But that doesn't mean, as we all well know, that it's limited to that population. And certainly anyone with close contact with somebody who has monkeypox can get monkeypox. We've had very little transmission in health care. The health care, fortunately, it's been very rare to have health care associated transmission of monkeypox. But that, of course, never means that we don't try to prevent it. And so a lot of what we are doing is working. And for that we're glad and it's just important that we keep doing that. So that's really where the focus is in health care epidemiology and infection control in the health care setting is to keep health care associated monkeypox from ever becoming a problem.
Srinivas: [00:02:49] That makes that makes a lot of sense. Maybe you should take a couple steps back and describe to our audience exactly what is monkeypox and when did this start to become a concern here in the U.S. as of late.
Carlson: [00:03:02] Yeah. So monkeypox is an orthopox virus. There are a lot of viruses within that particular group. The one that most people are familiar with that is a relative is smallpox. But monkeypox is much less severe than smallpox and has actually been present in Africa, in African countries for a very long time. And we're really talking about certain parts of Western and Central Africa. This particular strain came through Europe, so we started seeing cases in Europe and then spread over into the United States. It is one of two clades or sort of groups that we think about with monkeypox. Clade I is a monkeypox that is found more in Central Africa, like the Democratic Republic of Congo. That one is more severe and has a different presentation than the clade that we're seeing in the United States, which is Clade II. And so this really came over. And what was unique about this particular outbreak was that it was clear from early on that sexual contact was one of the biggest risk factors, certainly not the only risk factor, but a lot of people seem to be getting the disease from their sexual partners. And so it presented very differently than how people traditionally thought of monkeypox as we had seen it before. And, of course, it presented in countries that didn't usually have monkeypox cases, so non-endemic countries. So those are the things that made it different from the beginning. And since then it's kind of it's spread. It's fortunately not as contagious as COVID or other respiratory viruses, and so that's been a positive. But of course, for the people who get it, it is very painful often. It has a very long period where people are infectious. And so it has a huge impact on people's lives because they remain infectious for a long period of time. And so that can mean a lot of different things for treatment and work. And, you know, and the length of time that the rash is present, things like that.
Srinivas: [00:05:38] And you mentioned sexual contact as being a really big driver, and that this clearly is not as contagious as COVID. And since it kind of arose during that same time, people were so concerned and it's nice that we had a jump on this disease in the sense that we know about monkeypox. It's not a brand new disease, even if this one behaves a little bit differently than the past. But one of the big concerns, of course, was how exactly is it transmitted when this first popped up? Yeah, maybe you can help our listeners and describe all the different ways in which it's transmitted, but also how people can protect themselves.
Carlson: [00:06:15] Sure. So the simple way to see this is that the most common way monkeypox goes from an infected person to a person who is not infected is by touch. So in our group in Project Firstline, that I'm a part of, we talk about the touch pathway. Right. And people are used to thinking about this in health care as the contact pathway or Contact Precautions. But really, it comes down to touch. It's diseases that travel through movement, through people touching things and people touching skin of patients, of family, of whomever, you know, other human beings. And so this touch pathway is a, is the main pathway that monkeypox really travels through. And even when we're talking about sexual contact, this is really about touch. And it's, people touch each other. And that is what transmits the virus, that's what spreads the virus.
So when you start there, when you say, really the biggest risk on the table is the risk that comes from touch, then it becomes a little simpler to think about, well, how do I protect myself? And that is not to say don't touch your patients. Absolutely not at all. We have to touch our patients. We want to provide comfort in the form of, you know, a hand on the shoulder or even the handshake when you walk into the room. But in health care, we have a very simple way that we protect ourselves from that pathway, and that is gloves and gowns. And so that is the mainstay of protecting health care workers from monkeypox. And the same really that extends to hand hygiene. That if there's, you know, anything that the gloves and gowns didn't quite get, you end up with, you know, virus on your hands. Virus is actually carried away quite well by soap and water and dissolved essentially quite well by alcohol-based hand sanitizer. And so both of those things will prevent that touch pathway from continuing on to cause infection. So the touch, the contact is really your core.
Now, there has always been some concern about the respiratory transmission of monkeypox and whether or not, again, we simplify things over at Project Firstline, we're like “is it breathed in?” Right. That's a breathed in pathway. And the answer is maybe it's sometimes there's a risk, but we really have not seen that in this particular outbreak with this particular clade. We are being cautious. It is still part of the recommendations for protective equipment, for PPE. When you go in to see a patient that might have monkeypox, this we still recommend, that you wear an N95. But a lot of that has to do with, you know, trying to minimize the risk as much as is reasonably possible at this point, not quite being certain about how much that risk actually is. So I think that there's some of this that is still reemerging disease. We're still figuring out just how much there's a risk from this pathway.
And then I think also there's a concern about the lesions themselves. And you see this when you read through the guidance, there's a lot of talk about, oh, don't do anything that's going to suspend the, any debris from the lesions, such as like shaking out linen or dry dusting and dry sweeping. This really applies to your environmental services workers. And the reason that recommendation is there is because the lesions themselves contain virus, like most viral lesions in this family that we think about. Smallpox for sure. And, of course, chickenpox, which is a separate virus, but has many of the similar characteristics in the sense of how we think about transmission specifically. And so these lesions, there's this concern that there is still a live virus in these lesions that could be resuspended and potentially breathed in. And therefore, you don't want that to happen. Now, this is all biologically plausible, but does it actually happen is sort of the second question, and that's the one that hasn't really been solved yet. So based on biological plausibility, the recommendations are still, you know, use the eye protection, use the N95 in order to provide you the most conservative protection while we work on figuring out just exactly what the risk is.
Srinivas: [00:11:24] It really goes back to that whole adage of better safe than sorry.
Carlson: [00:11:28] Right. And that's a very common way you approach pandemics. And I think you saw that in COVID-19. I mean, hopefully we saw that in COVID-19 where that's really where the PPE was about. Now, the supply issues are a separate thing, but the recommendations themselves came out of a “we don't know yet. And therefore, we're going to apply what's called the precautionary principle.” Right, which is very familiar from environmental health, but often applies in situations like this, where you sort of say, I am going to prevent, you know, what could happen as much as I am able to in terms of PPE and health care worker protection. Certainly because, you know, our goal is for health care workers to be safe in their jobs. And, you know, and if I find out that the safety is equal with and without the N95, then without may become okay. But I need to first figure that out. And I'm not going to put you in danger in case the thing I discover is that, in fact, no, that there is a higher risk if you're not wearing an N95.
Srinivas: [00:12:44] A lot of what you're saying comes down to how much can we protect the health care worker to determine the risk of exposure when we're trying to take care of patients. And one of the big shields we've talked about, PPE and the importance of that. Another big shield is prevention in the form of things like vaccination. So can you tell us a little bit about what the guidelines were when we initially started to roll out vaccines and how they've evolved since then to where we are now?
Carlson: [00:13:13] So I can't say much about the history of what happened in the past. I can definitely say now. The current guidance is that only specific health care workers are really in need of what we would say is pre-exposure prophylactic vaccination. So when I say that, really what we're talking about is getting a vaccine to prevent getting monkeypox through your job. Right. And the category of health care workers that really falls, that fall into a group that would get vaccine is the laboratory health care workers and very specifically, those health care workers in the laboratory that are working with the genetic testing, so the diagnostic PCRs. Those health care workers that prep those PCRs and run those PCRs, they are the ones that are considered at sort of the most risk, in part because they're the most likely to see the virus, they're the most likely to encounter it maybe without the right PPE on, etc. And so that is the one group really that is recommended to have this. In research, as well. The same applies if you're a laboratory research technician who runs such PCRs, a vaccine is recommended for you. For all other health care – oh, go ahead.
Srinivas: [00:14:50] I was going to say, I imagine some of that also has to do with the fact that as you're prepping the tissue in the sample, you're probably doing some aerosolizing procedures, too. So there's that risk.
Carlson: [00:15:00] Right, so there is some concern about that. And so, what I would say there is, for the rest of the health care workforce, vaccination is not recommended unless you have other risk factors. You know, personal risk factors that would put you in a group where vaccination is recommended. And that really speaks to just how well PPE is working. Right, and how little transmission is happening when people are using the right gowns and gloves and protective equipment to get their samples, to see their patients, to do their work. And so, and also just the degree of infectiveness of this virus. So right now, that's where the recommendations stand.
Now, certainly that could change if you start seeing more health care associated transmission or if you see more burden of infection in the community. You know, it really it depends on the epidemiology and those are things that just depend on time. And that doesn't mean that you aren't prepared for it. You sort of, you think through the possible scenarios and you say, okay, what are we going to do if it's X, Y or Z? But given the current moment, there does not seem to be a high risk for transmission for health care workers, and therefore it's not a priority group for vaccination. What I will say, however, is there is post-exposure prophylaxis that is vaccination. So if you are exposed to monkeypox in a higher risk exposure in particular, and that really most of the time it involves not wearing PPE in some form. So if you're exposed to monkeypox and you don't have the respirator on and you don't have your gloves and gown on, in particular, then you know, that is a time to go to Oc[cupational] Health right away and say, “Am I eligible for post-exposure vaccination?” And the same goes, you know, if you don't have an occupational health team and many people in these small clinics do not, talk to your public health department. Call your county health department and say, “here's what happened, and do you have vaccine? And how can I get it? And can I get, you know, help with monitoring and management and guidance there.” And in a pinch, if you're not getting answers from them, our door here at CDC is always open. There are a number of lines of communication with us, including CDC-Info, which is available 24/7. There is a phone number if you just Google “CDC info.” We respond to all sorts of questions like this. And if CDC Info isn't the right place, they will track down who the right person is. So, you know, don't hesitate to reach out to the public health structure, which is there. But I always recommend going to the county and the state first just because they're the ones who have the vaccine in hand. They know what's going on in your community. And they're often the people who will get on the ground to where you are and where you need to be.
Srinivas: [00:18:31] That's really great information. And one of the things that you really highlighted there was because the PPE is working that the need for vaccination for PrEP or pre-exposure prophylaxis is really not as much needed. What about in many of these small clinic scenarios? I work a lot in rural health. We're seeing patients who, they don't know they have monkeypox, they're walking in. And so people who are at the front desk, people who are checking patients in and even honestly, CNAs, nursing staff and potentially even the nurse practitioner, the PA or the physician are seeing these patients unaware that they might have monkeypox and then diagnosing it. But because of that, we're not necessarily gowned up and fully protected. How often are you seeing this happening or how concerned are you about these types of scenarios? And what would that change as far as your recommendations with vaccination in clinic sites like these?
Carlson: [00:19:33] Yeah, so, you know, I think the first answer is we're not seeing a lot of transmission in that way. And this really goes back to the risk is from touch and particularly close touch. Right. And so although it's very scary to be like, oh, my gosh, we saw a monkeypox patient and they traveled all through this clinic and nobody knew. The risk that something is going to happen because of that is extremely low. Especially when the rash is covered up. And many of these rashes are just by natural clothing. So that is, that's one part of this. You know, the other part is that I always encourage people if they're concerned, you know, that they're, they have these patients, they're not going to know, to think about how they can structure their screening in a way that might catch people who might be at risk. And this is challenging, right? It's not easy. And you don't want to, in the middle of the waiting room at the check-in desk go, “So have you been in contact with monkeypox lately?” That is not what you want to do. But we've learned a lot about how to screen our patients through COVID. Right? And we've put in place things like text messaging systems and pre-appointment emails and let us know if you've had exposure to X, Y or Z. You know, the simple thing is to ask a person if they have a rash. Right. Are you coming in with a rash? And, you know, if they say yes, that's one way to say, okay, this person's coming in with a rash. It could be infectious. It could be not infectious. It could be monkeypox. It could definitely be something different. And so, but let's dig a little more before they walk into the waiting room.
Another, you know, simple thing is just asking them privately through your messaging portal or by calling them, you know, when you call them with their appointment reminder. Have you had any exposure to monkeypox that you're aware of within the last three weeks? You know and having that that just as a as a clarifying question. You know, one of the other things that we also encourage is for staff to be trained on what a monkeypox lesion could look like. Unfortunately, that means a lot of things that aren't monkeypox, because monkeypox lesions look like many, many things, including herpes, including shingles. And so it's tricky. But even being even being able to spot that, you know, to say to your clerk, if you see somebody and you see they have this kind of lesion, don't hesitate to let us know. And then the nurse can take a look and prioritize that patient to go back.
So there's a lot of options you have, right? And I think that our goal is always to make the risk as low as possible. Right. Knowing that the risk in health care is never going to be zero. We're always afraid of missing someone, and there's always a real possibility that we will. And that's a reality that we live with, kind of in the hospital, in the clinic every day. And we have to figure out how to navigate around that. And there's not an easy answer, but there are a lot of tools. And so I just, I continue to go back to the touch pathway, touch pathway, touch pathway. You know, if it's a concern focusing in on when do you want to be using gloves, when do you want to be using gloves and gowns. It is never wrong to put on gloves to touch your rash. Right. Or to even to say, you know, I see somebody who's got a lesion on their face. I'm going to tell our nurse, hey, this person has at lesion on their face and go from there. And I think, you know, we can do that without discriminating against our patients. Right. We can do that in a way that is consistent with good care and where we're really concerned as much for their own well-being as we are for the well-being of everyone, you know, at our workplace.
Srinivas: [00:24:13] Of course, and with all of these things that we're talking about, we're talking about active care of patients. Then there's a whole, such an important group of health care workers that come in between patients to make sure that our spaces are safe and we want to protect them, too. So our environmental services. How do we ensure, I know we're talking a lot about direct contact is really the risk. Is there a risk with fomites at places that are empty but had been potentially exposed? And how can we protect our environmental service staff when they're cleaning these places?
Carlson: [00:24:54] So you definitely want to make sure that you have a way to tell your environmental services staff if there was a monkeypox patient in the room. You want that not only because they're going to have to come in after that patient and do your cleaning and disinfection, but also because it can be easy to forget, right? People are so caught up in the clinical workflow and the person, the people who know that this has happened are usually the physician and the nurse. Right. It's the people who do the diagnosis and the testing that are like this could be monkeypox. Those team members have to have a clear way to communicate to everyone else, and that includes EVS, that this is this was a risk. And once EVS knows there's a lot that they can do to protect themselves. But knowing is the key part. And many people forget that EVS has this role.
Srinivas: [00:25:54] No, that's so true. Clear communication is the number one step. And once that's been communicated, what would you recommend to our EVS providers? Because we want to make sure that everybody's safe. And oftentimes there's inequities in forgetting to protect those that aren't giving direct service to the patient themselves even though they're such an important part of the team. Would you recommend still having all those same contact precautions?
Carlson: [00:26:22] Yep, yep. Yes. Respirators as well. So we still recommend the full PPE for somebody who's cleaning. And that really is true for almost all infectious diseases. Right, because they're really the person who's going in and disinfecting, they're the person who's going in and getting rid of that infectious burden. And so while they're doing that, the burden is still present and they need to have protection. So still recommend the gown and gloves, still recommend the eye protection and the respirator. And the respirator here really is about, again, that debris from rash that we're worried about. And it might seem like, well, the person had one lesion on the inside of their lip and this is true. But we still recommend that full PPE here, just along the lines of still not knowing what the risk is from this process and the respiratory system as a whole. Right.
So I focus in on the lesions because that's actually particularly relevant to EVS. But the respiratory droplets and the respiratory aerosols and where they land on fomites and all of that is still is still being sorted out. So all of that is something we have to consider. Even though the patient has left the room, their respiratory particles may still be floating in the air, probably are, depending on how long it's been and depending how much air exchange is going on in the room. So lots of complicated variables. Really simple actions, though. Keep the PPE on until you are done with cleaning and take the respirator off once you've left the room and the eye protection as well. The reason the respirator is particularly important for EVS is that is because the activities that they do tend to kick up dirt and dust. Right. So the dust on the floor in sweeping and wiping and mopping. You still can, you can kick that up into the air, and then once it's up in the air, it can be breathed in. All of us who have ever dusted our house in places that the dust bunnies have collected know this. But it's a daily truth for EVS workers. So one of the key recommendations for EVS that your EVS workers will want to know and remember is that they should avoid things like dry dusting and dry mopping and sweeping, and they should really focus on wet techniques. So using wet cloths, wet mops, because obviously the water soaks up some of these particulates and decreases this burden in the air. And so the in again, biological plausibility here, not necessarily research shows that, simply by biological plausibility, it is just better to get that burden out of the air so that if there is any risk, it is now lessened.
Srinivas: [00:29:30] Well, that makes complete sense. I hadn't thought about the dry versus wet techniques, but that's such an important thing to highlight with the potentially aerosolizing procedures. And it's really reassuring to know how effective the PPE precautions are of themselves, knowing what all the exposures are and how people can feel reassured.
Carlson: [00:29:52] Yeah, I think there's this tendency. I think there's this tendency when something big and scary comes along. Right. Like monkeypox, which hopefully it won't feel big and scary after, you know, you've heard this podcast and you and you've gone through the experience of taking care of these patients. But something new. Right. Always feels a little bit like. Shouldn't we be doing something special? Right. Shouldn't there be something more? Isn't there isn't this extra risky, extra problematic? And so it can feel a little bit odd to say, nope, the answer is actually very simple. And it is these things, right? And if you do these things, the protection is very good. But gowns and gloves. Cleaning your hands, respirators and eye protection like those are the core of the things you can do. Now, certainly there are big system things like making sure you have good screening and making sure you have good airflow and things like that that are also incredibly important. And in fact, you know, when we think about how we think about infection control, PPE is the last step you should take when all the other steps have been taken. Right. But it is also just a very good way to protect yourself. So focusing in on that simple aspect is actually still the most important thing you can do.
Srinivas: [00:31:26] No, that makes complete sense. And as you mentioned before, we've seen the numbers now down-trending, thank goodness. Where do we see this going? Do you think that this downtrend will continue or do you worry that we'll have another spike in the future?
Carlson: [00:31:44] You know, we're always worried about another spike. Unfortunately, epidemiology doesn't have very good crystal balls. You never know how a disease is going to progress, if it's going to go away completely. And, you know, it will not become endemic, which I think is a hope. But I think the reality is that we're still unsure where we are. And we're we are preparing for monkeypox to be around for the long term until proven otherwise. However, it looks like the interventions that have been made are working, right. And that includes vaccination, that includes treatment, that includes people being much more aware of what their personal risks are and what they can do to decrease those risks. And I think, you know, we will just you know, you don't mess with a good thing. If the things are going down and it looks like things are improving, then you consider you stay on the same course while also considering, you know, what the steps would be in the future if things take a turn. And I think, you know, I think we're ready if we get there. I will say, I think that there's a lot of infrastructure that's been put in place in the process of responding to the initial wave that makes the prospect of a second upturn much less frightening.
Megan Srinivas, MD: [00:33:21] And this is one of those situations when in order to overcome potential geographic inequities, because we know certain places just aren't equipped with people who are specialized in this disease or to have that knowledge, even if able to provide really great other types of care. And so it's something to remember that if you're in an area that might be like this, it's always good to reach out to a higher level of public health department or to potentially even the CDC. Like you said.
Carlson: [00:33:52] CDC-Info is open even to patients, it is open to everyone. It's not just for clinicians. And so it is not, it is not unreasonable and not wrong at all. We welcome those questions. So if you're running into a place and you don't know who to contact, we're happy to help.
Srinivas: [00:34:19] And that's great because that alone can help with some of the geographic inequities that just may exist with the world that we live in, unfortunately.
Carlson: [00:34:28] Indeed. And I think that also just in the world of telemedicine and other providers, you know, a lot of major centers have started to do tele-medical visits. And so if you don't have a specialist in the area and this, too, goes for people who don't have occupational health teams, right? If you don't have a specialist in the area, you may be able to get consultation from one of your larger medical centers. So a lot, I mean, University of Iowa is a great example. But all around a lot of the academic medical centers recognize the need for specialized expertise in their state and are reaching out. And the same goes actually for infection prevention departments in those centers. We used to field calls all the time from kind of wherever might be saying we don't know what to do, we're the infection control nurse in, you know, a small rural clinic or a small rural hospital, how do I deal with this situation? And your infection control team in your larger center is happy to provide guidance on what they're doing. So, you know, it definitely, I understand the feeling alone part of things, especially when you're in independent practice. But don't hesitate to call and say, can I speak to the infection prevention department? And they, you know, from most centers, I think would be happy to help.
Srinivas: [00:35:58] Yeah, we definitely fielded a lot of those calls when I was at UNC.
Carlson: [00:36:01] I bet.
Srinivas: [00:36:03] And those were always the fun calls to get compared to “come in for another five hour consult at 9 p.m. at night.” So those are the easy questions you can take from home that you love to take and help.
Carlson: [00:36:14] Exactly. And, you know, some of it is again, there are no easy answers. Right. I'm sitting at the CDC and I don't have an easy answer for you. And that's that is because it's a complicated thing. And so sometimes it just helps to have two brains looking at the same problem, saying, how do we deal with this? And so, you know.
Srinivas: [00:36:39] It just helps to talk things through and…
Carlson: [00:36:43] Exactly.
Srinivas: [00:36:44] Where we can come to a justification that makes the most sense for the individual. Well, this has been absolutely wonderful to talk about monkeypox with you and where we are, where we could be going. Before we leave, do you have any parting words for our audience on this?
Carlson: [00:37:03] You know, I think it's the parting words are the ones that I've kind of been saying over and over again that this is really a close contact disease in terms of spread. Right. And that what you really want to avoid is touching rashes and skin with rashes on them. And the very simple answer to that is gown and gloves. And then, you know, an N95 and eye protection are always recommended if you're concerned about monkeypox. And your suspicion does not have to be high. If you're not sure, there's very little negative consequence to using a respirator and eye protection. So, you know, don't feel like you can't if you're concerned. But for now and hopefully for the future, the risks in health care are low. And that is a very good thing.
Srinivas: [00:38:07] Well, thank you so much, Dr Carlson. I know that you have answered a lot of questions that I hear all of the time, both from patients and colleagues. So I know that your information is going to be extremely useful to those that are listening in.
Carlson: [00:38:19] Thanks. Yeah, no, thank you, guys. So thank you.
Srinivas: [00:38:26] Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings, and other infection control resources, visit CDC.gov/projectfirstline and AMAfirstline.org.
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