Sunday, May 28, 2023

Underserved in Topeka: Is it a Choice?

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There is a unique community in Topeka, Kansas, that is underserved and within a geopolitical community. Topeka has a homeless population of more than 400 people, and half of them are living in the Topeka Rescue Mission (TRM), and around 200 are living unsheltered, outside (Moore, 2019). 

Those living in TRM for a temporary stay are held to rules that will accommodate respect and safety for all, including restrictions on entry and exit during the night. Additionally, they do not allow someone to stay if they are currently using illicit drugs or drinking. Although this community of residents is underserved in relation to the rest of the public, they do not represent the most underserved (Topeka Rescue Mission [TRM], n.d.).

Right outside of the TRM is a collection of homeless individuals living in tents and makeshift shelters using blankets and trash cans. For some, there is only a single tarp covering multiple sleeping bags and individual spaces. This "tent community" is a truly underserved population. They do not have access to medical care, clothing, showering, bathrooms, and their personal safety is compromised. There is no safe place to store their belongings, which can include food or valuables. Although the “tent city” community of people consider themselves a “family,” there is a consistent presence of mental illness and addiction, and the danger is heightened for those who live within this phenomenological community.  

Windshield Survey 

The tent city population would be evident in a windshield survey and this survey would also reveal many risks close by. There is no access to fresh water, plumbing, electricity, or climate control (Moore, 2019). In the harsh, snowy winters, many suffer from frostbite, and on the scorching summer days, many end up in the ER with heatstroke symptoms and dehydration. 

There is visual evidence of trash, clutter, and unsanitary conditions, and the area looks like a harbor for infestations of rodents and insects – ideal vectors of disease. There are feral, stray animals roaming about as well as pets living within this community.

There is a code among the residents of tent city, and “snitches” are swiftly dealt with under the “community rules” and there have been stabbings, beatings, and other violent actions in this little subcommunity culture, that go unreported because of “the code.”  

Although there are protections against homelessness for children, adults are not granted those same protections.  

Partner Framework 

To address the basic needs of this phenomenologic community within a geopolitical community, it is important to establish partnerships in the city. Meeting the simple daily needs for showering, toileting, first aid, clothing, and food, as well as providing basic medical services for first aid and health screening – this is the need.  

Topeka has already developed this coalition of partners. The “Mobile Access Partnership” or MAP services, are offered through a collaboration between the Topeka Police Department, the local hospital, the rescue mission, and the local agency that provides mental health and addiction treatment services and medications. 

This partnership, with the funding support of many Topeka businesses, provides mobile bathrooms, showers, and laundry facilities, as well as a mobile health clinic, and a mobile food pantry and kitchen. The unsheltered can enjoy warm meals, a warm shower, and a fresh set of clothing, and can drop their clothing off to be laundered and returned to them the following week.  

Nurses are available for important health screenings, social workers and licensed counselors are available to assist with referrals and follow up. The goal is to meet the needs where the people are, to show support and acceptance, and to help establish trust for these individuals to rejoin society again when they are ready.  

Family Relationships 

As previously stated, this is a microcosm of interconnected people who all believe that they are a family, however dysfunctional. They share a commonality, in that they have been damaged, hurt, discarded, and treated as burdens, junkies, or menaces to society.  

Many of this population share similar childhoods, where poverty and abuse were the norm, or similar issues in their adult life with addiction or other struggles. They have each experienced a loss of trust, in a society that has abandoned them and treated them as outcasts. In this, they find community, comfort, and unspoken understanding.  

I am personally familiar with this phenomenological community within the geopolitical community, as I have volunteered with the Topeka Rescue Mission at least one day weekly for more than 5 years. I have spent every Tuesday morning in the nurse-run pseudo-clinic/medicine-cabinet for the rescue mission. I have also served in the past year coordinating with the Mobile Access Partnership (MAP) alliance of community partners.

I have seen firsthand the dilapidated tents and canvases meant to provide shelter for these individuals, and have sensed the mistrust this community feels toward society, systems, and civil services. Somehow, though, despite sometimes desperate circumstances, these individuals band together to remain a close-knit community, looking out for each other when it is needed the most.  

A Personal Choice

There are many in this community that have chosen to remove themselves from society, and choose to live this way. For those individuals specifically, it is important that they have access to services as described in the "Mobile Access Partnership" where they can turn in dirty laundry, shower, get a fresh set of clothes, and when they return the following week, their laundry is clean and ready for them. We also have nurses providing screenings and basic first aid, Medical Providers performing physicals and referring people to free assistance and resources. They can have labs drawn, xrays done, and they assist with applying to medicare or medicaid (Kancaid in Kansas). 

But - this community is located less than 200 feet from the railroad tracks, and unfortunately there are many who choose to die on those tracks. It is so sad, and I don't know that the Topeka population of 300,000 know much about it or worse, even care about this. There are many who do care, and want to help, but that percentage is extremely low. 

The police force attempts to "clear out the riff raff" every month or so, but they can not do anything for stabbings, beatings, drugs, theft, or sexual assaults, if these crimes are not reported. That is probably the most difficult for me to absorb - that individuals in this tightknit community do not want to come forward (fear of retaliation violence) or can not come forward, so they live by the "community rules." 

References 

Moore, K. (2019, January 17). Unsheltered in Topeka: Ban on camping would leave some of city's homeless with no options. usatodaynetwork. Retrieved November 30, 2022, from https://stories.usatodaynetwork.com/unsheltered/ Links to an external site. 

Topeka Rescue Mission (TRM). (n.d.). Mobile access partnership. TRM Ministries. Retrieved November 30, 2022, from https://www.trmonline.org/map Links to an external site. 

Friday, May 26, 2023

The Funny Side of Depression?

Who knew you could ever find joy again... I was required to post a final reflective discussion for Adult II Practicum for FNP program. Now I am sharing my submission here, and yes, this really happened!

The Experience 

Background

My preceptor (Randi) and I saw a 63-yo female for an initial visit to establish care because her primary care provider moved out of state. She had just completed an annual physical last month with labs, and we had quite a lot of medical information available to us. We decided that a quick physical assessment to would suffice for this visit as she was on quite a few medications for mental health. We decided to focus more on her mental health, sleep, nutrition, and home stressors during this initial visit. It seems that Randi was using this visit to establish a relationship, and that she would take the medically driven approach during a follow up in 2 weeks. This patient was on more than a handful of psych medications, including antidepressants, stimulants, anxiolytics, sleep aids, nerve pain meds, and meds to address the extrapyramidal symptoms that all of these meds were causing!  

Findings

As she was telling us briefly about her childhood (ACE score was 7), and that she had 4 prior attempts at suicide, and a little about her mom and her daughter - both whom she loves dearly, she had a flat affect. Was it her? or was it the meds? A review of when-she-takes-what for her meds revealed she is taking things that bring her down, in the morning, and some meds that stimulate, she was taking at night! It seemed like her flat affect was a direct result of the many meds she was taking. Randi and I agreed that a strong improvement could be achieved by a shift in timing - when she takes her meds could start the ball rolling on an improved quality of life. This should also help with her current sleep patterns and overall abilities to cope with stressors and to perform daily activities with greater success and maybe even joy. We decided that making med changes would be high priority for this patient.  

The Heart of the matter

After building a rapport, we were able to get into a discussion about her current feelings, any suicidal ideations, and her goals. She said she thinks about killing herself every day. This is just a part of her life, she said. These thoughts are daily - that she should just die, or that she just wants to die. "I won't do it though. I made a solemn promise to my mom and my daughter. I just won't do that to them," she professed.

Again, her affect was flat, and she was not complaining as she was reporting these symptoms. She was very matter of fact about the thoughts and the refusal to act. She was almost accepting of the fact she has these daily thoughts; they are a regular part of her life because “that’s just the way it has always been” or something along those lines.

During this time the anxiety-wrought patient began to relax; her tense, nervous body language slowly loosening. Randi and I both started this patient's visit by sitting in chairs close-by. Really, I think, it was a proximity that you would expect among a caring group of three friends; close enough to reach out and touch a hand or shoulder if needed, but far enough to allow for personal space. 

The Beauty

This part of the interaction is where the beauty lies... deeper into the patient interview...  

Randi asked, “so you think about it every day...tell me what you see? ...how are you doing it?”  

The patient said “pills - ya, I guess pills.” 

(pause)

(pause)

...

She then said, “But I guess the last time, it was the car.”

(pause)

You know how, now, cars have a catalytic converter?”  

Randi and I glanced at each other, and back to the patient. The patient was looking up in the corner of the room as if in thought, remembering the time she is talking about, reliving it...not expecting a response about catalytic converters...  

I said, “Ya, the catalytic converters. Aren’t those for the exhaust or something?” 

She said, “Yep. Ya, that’s right.”

(pause)

(pause)

(silence) 

And then, “Well the last time, I sat in my car for about three hours. I sat, and I waited.”  

...

(pause)

(pause)

(pause)

(another almost an awkward pause length)

“...and after three hours, all I had was a sore throat.” 

It was just so unexpected. She did not say any of this to be funny, she didn’t crack a smile, she was still reliving the moment, almost... but it couldn’t be helped.

A stifled, abrupt chortle flew out of my throat,

before I had any chance to stop it!!

This is the moment when everything 

proceeded in slow motion for me...

Randi looked at me, I looked at her, my hand was covering my mouth to hold back any further assault-by-chortle... and then we both looked at the patient...and the patient looked at me and then looked at Randi.... this - all - in a matter of milliseconds... yet time stood still, and it was an eternity of awkwardness for me...

...and then... the magic.

We all started to giggle. 

Which then turned into unshrinking laughter...

...and grew into hold-your-belly, throw-your-head-back-laughter! 

Some of it was the patient laughing at her own situation, her story; some of it was each of us laughing at how she worded it, and the unexpected visual that went along with it; and some was probably because it felt so inappropriate to be laughing at all... and some of it a tension release...but here we were.  

I couldn't stop picturing how this patient's story had just unfolded...her, sitting in a garage with the car running, for 3 hours...in an effort to die...  but with the new catalytic converters, the exhaust isn't what it used to be so it only gave her a sore throat...

Asisde: Think of the tshirts: "I sat in my car for 3 hours and all I got was a stupid sore throat"

Thoughts and Feelings 

We had taken a journey together, and arrived at a place that broke down the barriers, opening the doors to what ended up being a very meaningful experience for our patient. This shared moment led to trust and hope for the patient, and she openly shared that with us just before leaving. We know it is true, and we have all heard it so many times before, but humor really is the best medicine. Humor, when used in the right way, can be a healing power all on its own.  

Evaluation of Strengths and Challenges 

This experience validated (to me) my strength in connecting with patients, my ability to offer support, encouragement, and even hope, when available. The challenge is that I don’t always get it right. And I won’t always get it right. The challenge is learning to distinguish between the receptive patient and the patient who is a sycophant because of the perceived or inferred power dynamics in the provider-patient relationship. The challenge is discernment, a skill to be honed.

Analysis and Self Reflection 

It was a meaningful experience for me, as well. The patient is not the only one who came away from the meeting with hope and trust. This experience, this interaction with the patient, was my expression of deep caring and compassion for someone who has been utterly rocked by trauma in her life. I quickly grew to care about this patient’s outcome – her quality of life – her future.

I can only say how relieved I am that this interaction had such a positive outcome, despite a terrible mistake. Laughing at something that is not humorous to the patient can destroy the relationship, and the potential for honest interaction. Laughing at the wrong thing, or at the wrong time, or sometimes even laughing at all can result in the complete opposite of “doing no harm.”  

Action Plan 

I have not had any experiences like this before – where my emotions betrayed me in front of a patient. Although this all worked out and turned into the best-ever patient reaction, it could have gone differently. Much differently. I plan to continue just as I had up to this point – managing my emotions when engaging with patients  – to provide them with respectful, supportive, professional care.


Addendum: 

So what I didn’t write in the reflection, was that after all of this laughing, she had made a few other comments and remarks, in her very flat-affect-overmedicated monotone… that were also just kind of hilarious, unintentionally. 

I told her “Wow. You are so funny, you’re such a survivor. You are amazing and you have important, relevant stories to tell, and you HAVE to share them with the world! Can you please do this? You need to write a book!”

…and her comment was “Ya, ‘The Funny Side of Depression’” and I thought, “oh my gosh that’s perfect, I would totally buy that book”  đŸ˜‚

Sunday, May 21, 2023

Championing for Providers in Rural Areas

How can we champion for more providers in rural areas and expand the network of access?

We need to get the word out that Nurse Practitioners (NPs) are trained to practice medicine, and are highly advanced in the practice of nursing. This combination enables the NP to provide a high level of care unmatched by other disciplines. So I believe it first begins with policies that allow nursing at all levels to practice to their full scope, and advanced practice nurses to practice medicine, also to the full scope of their training and capabilities.

The patients needing care in these rural areas, are typically older, in worse health, and have lower incomes than those in urban areas. Many don't understand what NPs are capable of, what they are trained for. They don't understand the "whole iceberg" approach to care that NPs provide versus the "tip of the iceberg" care generally provided by Medical Doctors and Doctors of Osteopathic medicine. Many MD and DO direct their care on or at the illness, not with or for the patient. A response to disease or abnormalities, rather than prevention of the disease and acute management.   

The current AMA campaign (n.d.) #FightingforDocs doesn't really help the matter either. This campaign is spreading the idea that NPs are not equipped, trained, or experienced enough to provide Primary Care or lead a healthcare team. The AMA has been preaching about "preventing scope creep" which fosters further mistrust in these rural areas, effectively grooming the population to feel they are getting less than optimal care when being treated by an NP versus MD or DO. I do believe that not all MD, DO, or NP fit into the “typicals” I am discussing, but generally speaking about these disciplines…well, this is my opinion.

Finally, limited access to programs of study and local, advanced training programs for nurses who are currently practicing in rural areas, may be a result of faculty shortages, community support, or financial limitations that coincide with a current state of economy. Increasing that training access and quality would enable those already living rurally, to continue practicing in their locale, at an advanced level. 

Reference

American Medical Association (AMA). (n.d.). AMA recovery plan for America's physicians: Fighting scope creep. American Medical Association. Retrieved November 11, 2022, from https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-physicians-fighting-scope-creep

Mononucleosis

Surprising Facts

One click to get to the article by Ben-Joseph (2020) and there, in very simple terms, is the astonishing information about this wily disease. Mono is a tricky, sneaky, and sometimes silent contagion. One can be exposed to it, then is immediately contagious, without symptoms or knowledge of exposure. Is this not incredible? 

Someone can be a carrier and never appreciate any symptoms, while the virus lies dormant for the rest of their life. Even if they experience symptoms and recover well, the contagion can still be spread by that host for months. In fact, experts are not sure how long someone remains contagious after symptoms are gone!  

The Awakening

Specifically regarding infectious mono caused by the Epstein-Barr virus (EBV), it is possible for the dormant virus to awaken and find its way once again to the saliva of the host. The host may or may not experience symptoms, but they can still spread this Machiavellian contagion! And by Machiavellian, I do mean this official definition "characterized by subtle or unscrupulous cunning, deception, expediency..." (Dictionary.com, LLC, 2022).

But Wait, There is More 

As if all of this was not shocking enough for those learning about it for the first time, or refreshing after a long time, there are other contagions that can cause mononucleosis (Centers for Disease Control and Prevention [CDC], 2020). I do not fully grasp this, and am not sure that I want to, but there are eight other viruses that can cause infectious mono! Here they are: cytomegalovirus, toxoplasmosis, HIV, rubella, adenovirus, and the sisters - Hepatitis A, B, or C (CDC, 2020). Yes, I do not know how or why, and did more than a fair amount of searching and reading and digging, but each one can cause infectious mononucleosis as well. Go figure.

Conclusion

First of all, I have more questions than answers after following Alice the way I did, way down into that rabbit hole...and boy did I find a crazy tea party.

hole-rabbit-hole.gif

Someone please explain this to me. I am not even sure how to write my biggest question... so is the word "mononucleosis" more of a descriptor of what occurs with the infection? Why do we call it a mononucleosis infection - instead of an EBV infection? ...or a human herpesvirus 4 infection? It is a fact that when someone talks about "mono" or "mononucleosis" they are referring to the EBV viral infection, the most common cause of mono (National Center for Immunization and Respiratory Diseases [NCIRD], 2020). 

I looked into the pathology of infectious mononucleosis and then looked at the virology and genetics, and most resources primarily focus on EBV because that is the causative agent 90% of the time (Smatti, et al., 2018). Also according to Smatti, et al. (2018), "...[EBV] is a DNA lymphotropic herpesvirus and the causative agent of infectious mononucleosis" (para. 1).

Riddle me this, medicine...riddle me this!

References

Ben-Joseph, E. P. (Ed.). (2020, January). How long is mono contagious? KidsHealth For Teens. Retrieved December 13, 2022, from https://kidshealth.org/en/teens/mono-long.htmlLinks to an external site.

Centers for Disease Control and Prevention (CDC). (2020, September 28). About infectious mononucleosis. Epstein-Barr Virus and Infectious Mononucleosis. Retrieved December 13, 2022, from https://www.cdc.gov/epstein-barr/about-mono.htmlLinks to an external site.

Dictionary.com, LLC. (2022). Machiavellian definition & meaning. Dictionary.com Unabridged, Based on The Random House Unabridged Dictionary © Random House, Inc. Retrieved December 13, 2022, from https://www.dictionary.com/browse/machiavellianLinks to an external site.

National Center for Immunization and Respiratory Diseases (NCIRD). (2020, September 28). About infectious mononucleosis. Epstein-Barr Virus and Infectious Mononucleosis. https://www.cdc.gov/epstein-barr/about-mono.html

Smatti, M. K., Al-Sadeq, D. W., Ali, N. H., Pintus, G., Abou-Saleh, H., & Nasrallah, G. K. (2018, May 24). Epstein–Barr virus epidemiology, serology, and genetic variability of LMP-1 oncogene among healthy population: An update. Frontiers in Oncology. Retrieved December 13, 2022, from https://www.frontiersin.org/articles/10.3389/fonc.2018.00211/fullLinks to an external site.

Infectious Disease Highlight: Monkeypox


Monkeypox has resurfaced recently, with outbreaks occurring in non-endemic countries, creating a worldwide public health emergency (Conger, 2022). These outbreaks have brought contemporary public health concerns in the United States, and new fears to a public still recovering from the siege of SARS-CoV2. Awareness and understanding of the monkeypox virus have been limited in the public, as they have grown numb to the threats of infectious disease because of pervasive assaults from the 2020 Covid-19 pandemic. Monkeypox slipped into mainstream public knowledge in May of this year with the first case in the U.S. reported on May 18 in Massachusetts (Assistant Secretary for Public Affairs [ASPA], 2022). 


Because of the associated stigmatism and other negative connotations from online language throughout this year, the World Health Organization (WHO) (2022d) has officially adopted mpox as the preferred term for the disease, a decision made after careful consultation and stakeholder input. For the next year, mpox will be used interchangeably with monkeypox, with the goal of phasing out the term monkeypox completely. The Centers for Disease Control (CDC) (2022a) is currently working to align their website pages with this terminology change, as indicated in an alert box at the top of every page related to the mpox infection. The remainder of this informational review will refer to the disease as mpox.


This work will present an overview of mpox that will cover a brief history of the disease, public health policy, and future projections. Further review will provide insight on the endemic nature of mpox, herd immunity potential, and will indicate the current stance on the disease as an epidemic, a pandemic, or as a well-mitigated viral infection with limited reach and impact. Finally, the chain of infection, vulnerable populations, and current treatment recommendations and options will be presented.


History of Mpox


According to WHO (2022b), mpox was first discovered in humans in 1970, in the Democratic Republic of the Congo, despite the eradication of smallpox taking place in 1968. Since the 1970 case, the mpox virus has been found in 11 African countries, and there was an outbreak in 1996-1997 in the Congo, and in 2017 in Nigeria. The disease traveled outside of Africa in 2003, when an outbreak took place in the United States where 70 cases were reported, said to have originated from imported rodents from Africa. The disease has since spread to Israel and the United Kingdom in 2018, 2019, 2021, and 2022, and to Singapore in 2019. In 2020 and 2021, the disease had returned to the United States, before the most recent outbreak in May 2022 involving multiple nonendemic countries (WHO, 2022b). The WHO declared the mpox outbreak to be an international public health emergency on July 23 (Conger, 2022; Huang, et al., 2022) and the US Department of Health and Human Services (USDHHS) declared mpox in the US to be a public health emergency on August 4, 2022 (Conger, 2022; Philpott, et al., 2022). 


A review of multiple resources informs that the infective agent of mpox is a non-variola Orthopoxvirus, a zoonotic virus with a reservoir of unknown origin (Huang, Mu, & Wang, 2022). Figure 2 reflects the chain of infection using data retrieved from WHO (2022a). According to WHO (2022a) the portal of exit, mode of transmission, and portal of entry include direct or intimate contact with an infected human or animal or through respiratory droplets; close, personal, or skin-to-skin contact with material from skin lesions, scabs, saliva, mucus, or upper respiratory secretions; or by touching the genitals, anus, rectum, or vagina. Additionally, mpox can be transmitted by intimate contact through hugging, massage, kissing, prolonged face-to-face contact, or oral, anal, or vaginal sex, and can be spread to the fetus during pregnancy.


Endemic Countries 


Although all countries are currently on alert for the mpox outbreak, it is endemic to at least 10 countries in Africa (WHO, 2022b). In June, the recent outbreak was found to include 27 non-endemic countries that had confirmed cases of mpox (WHO, 2022b). According to Conger (2022), by late August, 91 countries that previously did not report any cases, reported current cases, and each of the 50 United States had reported at least one case. 


Current Status of Mpox


Currently, mpox is not a pandemic, but concerns are heightened related to the outbreak of mpox in non-endemic countries that began May of this year. According to the CDC (2022a), in mid-September there were nearly 58,000 confirmed cases, in more than 90 countries and territories. 


As reported by Phillpot, et al. (2022), the data collected on the cases in the United States from this year suggest that gay, bisexual, and men that have sex with other men make up most of the infections (99%) and racial and ethnic minority groups this population are disproportionately affected (para.1). Of the 99%, 94% reported recent male-to-male intimate contact. The recent outbreak in the US began in May and was declared an outbreak in the first week of August. Enhanced surveillance then began with detection and reporting of cases. 


Nearly one-fifth of the infections were travel-associated, and three-fourths were acquired locally (Philpot, et al., 2022). Outside of the United States, this virus has been of global importance since 2017 when Nigeria had an outbreak, and it then spread to Israel, the United Kingdom, and Singapore, before coming to the United States (Silenou, et al., 2020). In 2022, several cases of mpox with no epidemiological link to imported animals or travel have been identified in multiple countries.


Public Policy  


After the first known case in May, the USDHHS initiated a response to increase vaccine stock, availability, testing for the virus, treatment options, and public awareness and education (ASPA, 2022). WHO (2022b) supported information sharing early on with this outbreak and the incident response system was activated to collaborate and share case findings, clinical management practices, infection control and prevention measures, and isolation practices. 


The WHO is bound by International Health Regulations, which established criteria that must be met to decide if an outbreak represents an international health emergency (Ghebreyesus, 2022). The criteria include reviewing data provided by countries, 3 components that are required for declaring a public health emergency, the advice from the emergency committee, scientific principles and evidence, and finally the risk to human health, spread of the contagion, and risks for impacting international travel (Ghebreyesus, 2022). The risk was high in European regions, but moderate globally (Ghebreyesus, 2022). 


Future Projections 


Based on the November basic reproduction number calculated on the CDC (2002c) website, it is expected that the incidence of mpox infections in the US will continue to decline, as the R0 number has been less than one since the end of July this year. There could be several reasons that the infection rate is declining, but it is difficult to determine which factors had the greatest impact. It may be that behaviors have changed, vaccinations, or simply that there is an increase in the infection-acquired immunity at this point (CDC, 2002c). 


The future is geared toward development of an mpox vaccine, (WHO, 2022d). Philpott, et al. (2022) suggested that public health direct efforts to prioritize men who have sex with men, whether gay, bisexual, or other, as well as those who are affected disproportionately. This effort should include addressing health equity and offering increased testing and prevention services. Additionally, they wanted to minimize the stigma associated with mpox and the population most effected by the disease, which the WHO (2022d) and CDC (2022a) have started to work on with the name change and upcoming change to the ICD-10 code identifying the disease as mpox. The current assessment by WHO (2022b) places us at a moderate risk globally.


Herd Immunity


Herd immunity does not comprehensibly apply to this disease. Although it is true that anyone can host the virus and be stricken with the infection, there are distinct risk factors that are known to increase an individual’s risk. It can then be presumed that avoiding those risk factors will provide sufficient protection from the disease at this time. There is just not enough of the population immune to the infection, to protect those who are vulnerable. As for those seeking vaccination, there are criteria that must be met to determine eligibility; this will be addressed in greater detail later in this report. If the mpox virus begins to mutate rapidly, increases in virulence, or if transmission modes change or increase, expansion of the eligibility requirements for vaccination may be warranted.  


Chain of Infection


Conger commented in her 2022 article, how the “longest documented chain of infection” was only six people (para. 3). This makes it seem as though transmission of the virus from one person to another is not a common occurrence, which is likely. Transmission rates are higher in men who have sex with men, and highest among those who have close contact through sexual activity, with one or more lesions on the skin or in the mucous membranes of someone with the infection (CDC, 2022b). An overview of the epidemiological triad is represented in Figure 1. 


Figure 1

Epidemiologic Triad for Monkeypox

  If any aspect of the chain of infection is broken, the outcome will improve. For a visual representation of mpox chain of infection, see Figure 2. 

Figure 2   

Chain of Infection for Monkeypox

  The incubation period is the time from infection to the onset of symptoms, and there were variances in the incubation period across multiple references. Sources suggested an incubation period of several days, up to a few weeks. The Maine Center for Disease Control & Prevention (MeCDC) (n.d.) indicated an incubation period of three to 17 days, while Huang, et al., (2022) indicated an incubation period of five to 21 days. 


According to WHO (2022a), the incubation period is “usually from 6 to 13 days but can range from 5 to 21 days” (para. 10). They have also divided the infection into an invasion period, which lasts from zero to five days, and the skin eruption period, which begins within one to three days of fever onset. The symptoms of the infection can last from two to four weeks, but illness can last longer if complications arise including pneumonia or encephalopathy. Ultimately, a person with the virus can spread it to others starting with onset of symptoms, through complete epithelialization or healing of the rash (CDC, 2022a).


Vulnerable Populations


Relating to the causation, there are identifying factors that place some at a higher risk than others, but these factors are unrelated to race, age, gender, religion, marital status, or family background. They are currently associated with occupation as a healthcare worker caring for an infected person, and as a sex worker. Personal choices for intimate activities, number of partners and frequency can also be sources of increased risk (MeCDC, n.d.). 


Vulnerable populations consist primarily of those engaging in riskier sexual behaviors including multi-partner sex, unprotected sex, and/or anonymous sexual partners or sex with someone engaging in sexual relations with someone previously mentioned (MeCDC, n.d.). 


Current Treatment Recommendations and Options 


There is no direct or specific treatment for mpox currently. Symptom management and prevention from spreading the virus seem to be the primary focus for care of an infected individual. Symptoms, symptom management, antiviral treatments, prevention of spread, and vaccination options will be discussed in this section. 


Symptoms


Mpox can present with several symptoms including fever, chills, headaches, muscle aches, backaches, swollen lymph nodes, exhaustion, itching, pain or sores in mouth, sores in the genital or anal regions, nausea, vomiting, or diarrhea (Cleveland Clinic, 2022; Huang, et al., 2022; MeCDC, 2022). Some may have many of the symptoms, while others may have one or none, prior to developing the skin rash. Patients may also present with bacterial infections secondary to the pox, which form a rash of pimple-like, pus-filled lesions that rupture and crust over before healing. Table 1 has been created to provide a summary of recommendations for symptom management.


Table 1

Symptom Management Recommendations

Content SourcesL Cleveland Clinic, 2022; Huang, et al., 2022, Maine Center for Disease Control & Prevention, n.d.  

Antivirals


In some instances, the infected individual may be at considerable risk for complications or already have a compromised immune system and may develop a severe form of the disease, which can include extensive lesions in the mouth or eyes, or the urethra or rectum (Conger, 2022). These individuals would be appropriate candidates for treatment using antivirals. There are some antivirals that can reduce the impact of the disease, but there is no treatment leading to a cure. “Despite the fact that monkeypox has no specific treatment, smallpox antiviral drugs such as brincidofovir, tecovirimat, and cidofovir may have effect against monkeypox because of their similar genetics” (Huang, et al., 2022, pg. 8).


Basic Prevention


The best option for treating mpox, is preventing infection with the mpox virus. As stated in previous sections, there are several ways to spread the disease and there are several ways to prevent the spread of the disease. The CDC (2022d) suggests that prevention can be achieved by avoiding close contact with someone who has the mpox rash, avoiding contact with items that an infected person has used, and thorough and frequent handwashing as a standard. Hand sanitizers containing alcohol work well, but soap and water should be used after using the bathroom. 


Vaccination


A vaccinia virus-based vaccine used for other orthopoxviruses including smallpox, can be effective against mpox for those at increased risk (WHO, 2022d). These vaccines are not designed for protection against the mpox virus but have been shown to reduce the spread of the disease, as initially noted in the epidemiology reports on the 1980-1984 outbreak in what is currently known as the Democratic Republic of the Congo (Huang, et al., 2022). Jynneos is a vaccine that is given in two doses, 28 days apart, with effective protection approximately two weeks after the second dose. The vaccinia virus has been modified in this vaccine so that it cannot replicate in the cells of humans (Conger, 2022). 


Another option, given as a one-time dose that provides peak protection after 28 days, ACAM2000 is a vaccine that contains a vaccinia virus that has not been altered, so the vaccinia virus can spread from the site of injection to other parts of the body or to others (Conger, 2022). It is also thought that a childhood vaccination against smallpox may offer some protection, but the vaccine originally only provided three to five years of immunity, with protection decreasing after immunity timeframe (New York State Department of Health, n.d.).


Additional options include MVA-BN, a “highly attenuated” vaccinia virus vaccine which is approved in Canada and the European union (Timm, et al., 2006) and LC16m8, also an attenuated smallpox vaccine, that is licensed for use in Japan, and is prepared as a “freeze-dried cell culture” vaccine for smallpox and mpox (Precision Vaccinations Staff, 2022, para. 1). 


Conclusion


Mpox is a newer-known contagion that has shown considerable ability to spread, given the right conditions. Mpox does pose a threat to the health of humans, although currently limited to the more vulnerable populations taking part in riskier activities – for now. However, the virus can spread across the globe, as it has, moving from the 11 endemic countries in Africa to over 91 countries since spreading outside of Africa in 2003. The CDC and WHO have stepped in quickly to make plans for future risk of outbreaks, and have established surveillance, monitoring, and reporting systems to stay atop the trends with the mpox infection rates across the world. 


References 


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Centers for Disease Control and Prevention (CDC). (2022a, September 30). 2022 outbreak cases and data. Centers for Disease Control and Prevention. Retrieved December 10, 2022, from https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html 

Centers for Disease Control and Prevention (CDC). (2022b, October 18). Science brief: Detection and transmission of monkeypox virus. Mpox. Retrieved December 19, 2022, from https://www.cdc.gov/poxvirus/monkeypox/about/science-behind-transmission.html 

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