Epidemiologist Tara Palmore, MD

Monkeypox, newly declared a health emergency in the United States, is not considered a sizable threat to residents of long-term care facilities. But that doesn’t mean that eldercare clinicians are off the hook when it comes to educating themselves and staying vigilant about the disease, an expert tells McKnight’s Clinical Daily.

“In my opinion, [LTC] clinicians should be aware, informed and prepared — but not alarmed — about the possibility of monkeypox infections,” said Tara Palmore, MD, an epidemiologist with the George Washington University Hospital in Washington, DC.

“As this epidemic spreads, the infection will likely spread beyond the demographic in which it is currently most concentrated, and facilities need to be prepared to handle exposed or even infected patients,” said Palmore, an expert in infectious diseases with the Society for Healthcare Epidemiology of America. “Hopefully these will be infrequent events.”

The following is an edited version of Palmore’s responses in an email exchange.

Q: What are the key risk factors for older adults in long-term care settings?

A: For individuals of any age, close skin-to-skin or mucosal contact with a person who is symptomatic with monkeypox, or close contact with oral secretions of a person who is symptomatic with monkeypox, can lead to transmission. Contact with contaminated fabrics such as linens can also result in transmission of the virus.

Q: Where are we now as far as spread of the disease and risk level in LTC? 

A: The most highly affected group thus far has been men who have sex with men, but there is nothing about the virus that limits it to one demographic group. Patients from all walks of life are admitted to long-term care facilities and may have been exposed to monkeypox in a variety of ways before their admission to a LTCF. They may have had a sexual exposure, a household or visitor exposure, or been the roommate of a patient with unrecognized monkeypox in an acute care hospital, then discharged to a LTCF. 

Q: What should eldercare clinicians be on the lookout for?

A: The illness can begin with fevers but does not start that way in every patient. Clinicians should look for any combination of vesicular, papular or pustular lesions that appear in a non-dermatomal [skin area] distribution. They can appear anywhere — including the head, trunk, limbs, palms, soles, genital area and rectal area. Patients may have mucosal involvement, such as oral ulcers, pharyngitis and proctitis. 

If a rash that does not appear clearly dermatomal, like shingles, and there is not another known cause of the rash, it may be prudent to isolate the patient and test for monkeypox.

Q: How should clinicians protect themselves from the virus in the healthcare setting?

A: Surgical masks, gloves and hand hygiene greatly reduce the risk of occupational monkeypox exposure for healthcare professionals. This is an added reason to encourage mask wearing in addition to preventing COVID-19 transmission.

Q: What is a good source of information on this disease?

A: The CDC website is an excellent source of information on the clinical presentation, transmission and infection control considerations.  

Facility infectious disease policy

Meanwhile, although LTC-specific guidance would be premature at this point, facility operators should ensure that their general infectious disease policy is updated so that it can serve as a resource if needed, attorney Patrick Dennison, a partner at law firm Fisher Phillips, has told the McKnight’s Business Daily.

“The Occupational Safety and Health Administration has not provided specific guidance regarding monkeypox, but long-term care employers are being urged by the Centers for Disease Control and Prevention to follow its Infection Prevention and Control of Monkeypox in Healthcare Settings,” he added.

Currently, the United States is experiencing the largest outbreak of monkeypox in the world, and health officials have recommended that those at greatest risk be vaccinated. This has led to concerns about shortage of Jynneos, the vaccine used to prevent infection. 

The Food and Drug Administration has attempted to stretch out supplies by authorizing  delivery of one-fifth of a full dose via intradermal (under-the-skin) injection vs. subcutaneous injection. This method has been shown effective in clinical trials by the drugmaker. The Department of Health and Human Services is also paving the way for emergency use approvals for potential future vaccines to combat the disease.

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Infection Prevention and Control of Monkeypox in Healthcare Settings

CDC Clinician FAQs