Friday, June 3, 2022

The Monkeypox: What We Now Know

Episode 71


Announcer (00:04):

Coming to you from Beaumont, this is your HouseCall.

Dr. Nick Gilpin (00:14):

As you listen to this right now, it's highly likely that you have heard of the multi-country outbreak of monkeypox that's currently occurring. Well, over 500 cases have been confirmed and dozens of additional cases are suspected. Fortunately, illnesses are relatively mild and there have been no deaths so far. But the emergence of this unusual viral illness in countries where it normally doesn't exist has certainly been caused for heightened concern. Keep it here, the HouseCall podcast has the latest on the current monkeypox outbreak.

Dr. Nick Gilpin (00:50):

Hello, and welcome to the Beaumont HouseCall podcast. I'm Dr. Nick Gilpin, and my goal is to help you and your family live a smarter, healthier life. Today we're taking a little break from COVID to talk about another viral illness that's making the rounds, this time, it's monkeypox. The current outbreak has involved more than 30 countries that usually never see a single case of monkeypox. As I mentioned in the intro, more than 500 confirmed cases so far around 15 or so confirmed cases in the United States.

Dr. Nick Gilpin (01:18):

Generally, this is mild illness, as I said, there have been no deaths, but there are some unusual epidemiological characteristics of this outbreak that my guest and I will get into. Our guest today is a podcast veteran, Dr. Matthew Sims, infectious disease, physician, and director of infectious disease research at Beaumont. Matt has also become one of our defacto monkeypox experts, having discussed the current situation in the local media, and we previously discussed Lyme disease together among other things on the podcast. Matt, good to have you back.

Dr. Matthew Sims (01:47):

Thanks, Nick. It's good to be here.

Dr. Nick Gilpin (01:49):

So, I guess let's just do this. The first thing I like to do, Matt, in situations like this is, I like to timestamp things, and we've done this certainly with COVID because the information can change pretty quickly. It's early June 22, we've done our best to try to get in front of this subject, but things can change quickly. Hopefully this information won't date itself too fast, and as always will, we'll try to do everything we can to keep the information current and keep you the listener up to date. So Matt, let's get into the basics of monkeypox with a little quick Q&A. First off, tell us what monkeypox is. Give us a background.

Dr. Matthew Sims (02:25):

Sure. Well, monkeypox is a virus that's been out there many, many years, it's usually seen in Africa, and it is a distant cousin to the smallpox virus, which has fortunately been wiped off the face of the earth.

Dr. Nick Gilpin (02:40):

Would you say ... Let me pause there for just a second, would you say monkeypox in terms of other diseases that it most closely resembles clinically, would you say that's smallpox?

Dr. Matthew Sims (02:49):

Yeah, probably smallpox it's not nearly as contagious as smallpox, and it's not nearly as dangerous as smallpox.

Dr. Nick Gilpin (02:55):

Definitely. Okay.

Dr. Matthew Sims (02:56):

But it does spread similarly. It's a disease that's characterized by this rash that appears, looks like boils or blisters. It can be all over the body. You get swollen lymph nodes, aches pains, fever, and it generally spreads by close contact. So, contact with the fluid that comes out of those lesions, but those lesions can also be in the mouth so that the virus can get into your respiratory secretions and spread by coughing. It doesn't spread super far because it stays in those heavy particles that fall out of the air within five feet or so, but it can spread that way, and it can spread that way before you see the lesions on the skin.

Dr. Nick Gilpin (03:38):

Yeah. Fair point. I'm glad you got into some of the clinical characteristics of monkeypox. Generally, when someone becomes infected with monkeypox, there is an incubation period. Right? If I contact someone with monkeypox today, it could be anywhere between say five days and 21 days.

Dr. Matthew Sims (03:58):

That's right.

Dr. Nick Gilpin (03:59):

That my illness will begin. And then the typical, I guess, textbook monkeypox case, if there is such a thing.

Dr. Matthew Sims (04:05):

It's a small textbook.

Dr. Nick Gilpin (04:08):

Well said. Would be this viral prodrome that we call it like a flu-like illness for a couple of days, and then the rash comes.

Dr. Matthew Sims (04:15):

That's correct. And before you get that prodrome, it's thought that you're not contagious, but we can't be a 100% sure of that.

Dr. Nick Gilpin (04:25):

Yeah. We're still digging into that. Right?

Dr. Matthew Sims (04:26):

Yeah. Once you get that prodrome, that achy fluish feeling, there is a small chance of being contagious, especially if you might have lesions in your mouth that you don't realize are there. And once the rash shows up, that's when people really, really get contagious.

Dr. Nick Gilpin (04:42):

Right. And that rash lasts what, two weeks, three weeks, four weeks usually?

Dr. Matthew Sims (04:47):

It takes a while, weeks before it starts to heal and scab over, and you're contagious until every last lesion is scabbed over.

Dr. Nick Gilpin (04:56):

And so, I think therein lies the problem. Right? We've got a disease that lasts a long time and it's contagious for a long time. And it has a very long, or somewhat long incubation period. So when you put those two things together, that makes things hard to control from an outbreak control investigation perspective. Right?

Dr. Matthew Sims (05:18):

Right. Somebody could be exposed to it and you won't know it for weeks. And it's really hard to contact trace everybody.

Dr. Nick Gilpin (05:27):

It is. We've had this problem before in other conditions, one that comes to mind is hepatitis A, long incubation period. Right? So when a new case pops up, you find yourself asking people questions about things that they ate or came into contact with a month or two ago.

Dr. Matthew Sims (05:42):

And it's hard to remember.

Dr. Nick Gilpin (05:43):


Dr. Matthew Sims (05:44):

Until you get enough people to put the picture together.

Dr. Nick Gilpin (05:47):

Yep. I guess I would also say here that, thankfully this is a relatively rare disease. Right? It is endemic or it does exist naturally in a handful of countries, mostly west and central Africa. Right?

Dr. Matthew Sims (06:01):


Dr. Nick Gilpin (06:02):

I was reading before the pod here that prior to this current outbreak, only eight confirmed cases outside of Africa in the last two years.

Dr. Matthew Sims (06:13):

Yeah. It's very rare, and almost all of those cases were associated with travel to Africa. If you remember back, we had an outbreak of this before in the US.

Dr. Nick Gilpin (06:22):

Yeah, talk about that.

Dr. Matthew Sims (06:23):


Dr. Nick Gilpin (06:24):


Dr. Matthew Sims (06:24):

And it was associated with Prairie dogs of all things. So the natural host of this virus is not the monkey, it was named monkeypox because it was first described in monkeys in a research center. But the natural host are actually small rodents in Africa, and one of them is called the Gambian rat, and there was a pet store that imported some Gambian rats that turned out to be infected. And it jumped from that to Prairie dogs, which was apparently a popular pet at the time. So it got into kids who had that pet and then to some of their families. I think they were 40 something cases before they got it under control, if I remember.

Dr. Nick Gilpin (07:09):

Yeah, that was back in 2003. That was one of the things I was reading about prior to this, just to get myself buffed up on monkeypox. Interesting. And that outbreak squashed itself. Right?

Dr. Matthew Sims (07:22):

Yeah. Well, again, it's interesting because normally the way this spreads is person to person by contact with the rash or animals to people, from contact with an animal that's infected, and that's how it's spread in that particular outbreak. This outbreak is different though, this actually seems to be most commonly spreading in men who have sex with men.

Dr. Nick Gilpin (07:47):

That's right. That's a perfect segue into what I want to talk about next, which is what makes this particular outbreak somewhat more unique. First of all, one feature that's a little bit puzzling about this current outbreak is that, some of the initial cases early on seemed to lack a clear epidemiological link. Right? Is like whether that was through contact with a known person who was infected or traveled to an endemic region. Historically, that's how you got monkeypox. Right?

Dr. Nick Gilpin (08:15):

So, absent any of those clear established links, people were scratching their heads and trying to figure out where the heck this was coming from. Then as cases started to pile up, as you said, Matt, there was an association with close intimate contact, specifically communities of men who have sex with other men, and a significant proportion of the cases in that current outbreak have been reported in parts of Western Europe, specifically in that population. I want to draw a distinction here that I think is important. This is not being considered a sexually transmitted disease.

Dr. Matthew Sims (08:45):

Absolutely correct.

Dr. Nick Gilpin (08:46):


Dr. Matthew Sims (08:47):

Right. It's not. Sexually transmitted disease generally spreads through vaginal secretions or semen, specifically. This is not spreading that way.

Dr. Nick Gilpin (08:55):

At least as far as we know.

Dr. Matthew Sims (08:56):

As far as we know. This is more like HPV. Right? Which can be spread through intimate contact, but it's because you actually contact the lesions themselves.

Dr. Nick Gilpin (09:06):

Right. And so given this widespread transmission that we've seen, one current investigation that is ongoing is trying to determine whether there is enhanced transmission. Right? Looking at the virus itself, and has it changed in some substantive way that has given it an advantage and allowed it to transmit more readily.

Dr. Matthew Sims (09:26):

Right. It's a great question. And it's an important question because it will speak to our ability to control it ultimately, but so far there's no evidence of that. It just seems that one of the things in this particular outbreak is because of the form of contact, the rash is often appearing first on the genitals or around the anus. That might just be that it's a concentrated area and there's friction involved when you have the exposure and it just more likely to spread the virus. It's a simple handshake.

Dr. Nick Gilpin (10:00):

Yeah. Let's talk about that for just a second because, again, let's go back to that small monkeypox textbook that we referenced earlier. Usually, the textbook question is, usually starts on the face, spreads to the rest of the body, and last two to four weeks scabs up and everybody goes home happy. And generally this is like I said, a mild disease. There are a couple of strains of monkeypox, there's a west African strain and then there's like a Congo strain.

Dr. Matthew Sims (10:27):


Dr. Nick Gilpin (10:28):

The west African strain is a little bit milder than the Congo strain, but still, people generally don't die of monkeypox.

Dr. Matthew Sims (10:34):

Right. So, the Congo strain is a little more deadly, as you said, up to 10%, the west African strain, they usually quote it closer to 1%. But again, remember the area of the world that it tends to spread in, there's not a lot of healthcare, it's not so easy to control and it's not so easy to treat the patients. So, it could be that the mortality estimates are a little elevated because of where we tend to see it.

Dr. Nick Gilpin (11:03):

Yeah. So this is behaving in some ways like a novel pathogen, I mean, it's monkeypox, but the rashes is not characteristic for what we know of monkeypox, it's occurring primarily in genital regions, and it's not causing any real significant, well, zero mortality to this point [inaudible 00:11:22]

Dr. Matthew Sims (11:21):

So far.

Dr. Nick Gilpin (11:22):

So, what other features, are there anything else that you want to say about the current outbreak that is a little bit unusual or has got your attention?

Dr. Matthew Sims (11:29):

Well, again, in the epidemiologic investigation, they are finding that there may be association with some events. So there may have been spreader events.

Dr. Nick Gilpin (11:39):

Oh yeah.

Dr. Matthew Sims (11:39):

I wouldn't say super spreader because it's not large, large numbers still, but-

Dr. Nick Gilpin (11:44):

I think I saw reference to a big party, a rave or something like that.

Dr. Matthew Sims (11:48):

Yeah. They were raves. I think it was in Spain.

Dr. Nick Gilpin (11:51):

I think that sounds right.

Dr. Matthew Sims (11:53):

And there's some association maybe with saunas and things like that again, and as we've already said, it's being spread through sexual contact though, not as a sexually transmitted infection. And that's very unusual for this pathogen.

Dr. Nick Gilpin (12:08):

I've read a little bit, Matt, that experts are cautiously optimistic about the direction of this. Right? I think the WHO has come out and said that they do not expect that this will become a pandemic.

Dr. Matthew Sims (12:18):

No, no, it just doesn't spread that way. I mean, obviously we're still in the middle of the COVID pandemic, so everybody is very leery. Right?

Dr. Nick Gilpin (12:29):


Dr. Matthew Sims (12:29):

And suspicious and worried. Are we going to get another pandemic on top of the current pandemic? But the spread of this, it doesn't seem to have that potential.

Dr. Nick Gilpin (12:41):

One thing I think we can slot in here, we've talked about contact with the lesions themselves can be a mode of transmission. We've talked about respiratory transmission. We should talk about fomite transmission, or contact with inanimate objects, sheets, clothes, surfaces. This virus is pretty robust. Right?

Dr. Matthew Sims (13:04):

Yeah. It can stay on surfaces. There hasn't, as far as I've been able to find, been yet specific research into how long monkeypox itself will stay on the surfaces. But there has been research over the years on various pox viruses, such as smallpox that says it does survive for significant time on surfaces. And everybody remembers learning in elementary school, high school, somewhere about when the new world was settled that the-

Dr. Nick Gilpin (13:36):

Oh, the blankets.

Dr. Matthew Sims (13:36):

The blankets that gave the native American smallpox. That's something we all learn as a kid. And it was a significant outbreak because that started it. We are concerned about that. Now, one of the fortunate things is this is what we call an enveloped virus, which means it has a membrane around it. So if you can disrupt that membrane, it usually prevents the virus from being infective. So, hot water and laundry and bleach soap-

Dr. Nick Gilpin (14:07):

Bleach. Yep.

Dr. Matthew Sims (14:08):

Those all break open envelopes. So, proper laundering of sheets and blankets and pillowcase and all of those things, towels is going to be very important.

Dr. Nick Gilpin (14:18):

Yeah. Good segue. I think as we start to pivot towards treatment and prevention, first things first, prevention. If you have monkeypox, the best way to prevent it from spreading to others is really to isolate yourself. Right? Keep things covered if you have lesions, ideally not allowing those parts of your body to come into contact with others, keeping things clean and covered, making sure you're washing your sheets, your clothes, anything on your body that may have come into contact with those lesions. I would even say probably wearing a mask.

Dr. Matthew Sims (14:53):

Yeah. And the masks should actually work even better than it does for COVID because remember COVID actually can spread further through the small particles.

Dr. Nick Gilpin (15:02):


Dr. Matthew Sims (15:02):

Whereas these only spread the large particles, and the surgical masks, that's what they're really designed to stop. These large particles. So they should work even better to prevent respiratory spread. Now, something to remember is, if somebody coughs and it lands on your skin, that's a potential point of entry for monkeypox, whereas for COVID that wasn't the same point of entry.

Dr. Nick Gilpin (15:24):

Yeah. Good point. So, just thinking about my physician friends out there, if you're working in the emergency room and a patient comes in and you suspect that they have monkeypox, you're going to wear PPE. Right?

Dr. Matthew Sims (15:36):

Yeah, absolutely. You're going to gown glove.

Dr. Nick Gilpin (15:38):

Yep. Wash your hands.

Dr. Matthew Sims (15:39):

Face protection, wash your hands.

Dr. Nick Gilpin (15:41):

And hopefully you're going to tell that person to go home. I think that's probably the best place for most people with monkeypox to be.

Dr. Matthew Sims (15:48):

As long as they're not actually sick enough to be in the hospital, which could happen. One of the things, and it's not as associated with this outbreak, but classically monkeypox can cause lymphadenopathy, swollen lymph nodes. And one of the presentations is, can be what they call a bull neck because the lymph nodes in the neck swell so much. And in children, back in 2003, I remember there were some cases where it was affecting their breathing, because it was so swollen. But that was, again, unusual.

Dr. Nick Gilpin (16:19):

Yeah. There are conditions of course, maybe in an elderly person or an immune compromised person where the disease could be more severe, in that situation, hospitalization is probably warranted. Right.

Dr. Matthew Sims (16:30):

Right. But for the most people, probably not.

Dr. Nick Gilpin (16:33):

And your expectation, I think of that person would be that they're going to stay home. Right?

Dr. Matthew Sims (16:37):


Dr. Nick Gilpin (16:37):

They're going to isolate or quarantine or whatever language you want to use. And they're going to hopefully keep this from spreading to other people.

Dr. Matthew Sims (16:44):

Absolutely. I mean, one of the advantages, if you can call it that, that we have now is, there's a lot of potential for many people, not everybody, of course, to work from home, because that developed during the COVID outbreak. So that may work in our advantage to allow people to isolate more easily without disrupting their life completely.

Dr. Nick Gilpin (17:07):

So in addition to going home, taking two or four weeks to cool your heels, what other tools do we have in our toolkit for prevention and for treatment?

Dr. Matthew Sims (17:18):

Yeah. There are vaccines. The original smallpox vaccine, which, if you're over 50, you may have been vaccinated with. I was one of the last couple of years that got vaccinated for a smallpox, my younger sister didn't.

Dr. Nick Gilpin (17:33):


Dr. Matthew Sims (17:34):

You may have some protection still. Now remember, protection from vaccines waned over years, and it's been 50 plus years since people got vaccinated for smallpox. But those memory cells tend to persist. So, if you did get vaccinated for smallpox and you're exposed to monkeypox, that will hopefully start you making antibodies faster. And so you may have a mild case, or you may have protection. But there are current vaccines. So there is a newer smallpox vaccine, it's called ACAM200, I think. And then there's another vaccine called the JYNNEOS vaccine, which is actually indicated for both smallpox and monkeypox.

Dr. Matthew Sims (18:17):

And we have those vaccines in the national storehouse basically, and we can release it as needed. Right now the recommendation for using them is potentially for post exposure prophylaxis. So if you've been exposed to a confirmed case and potentially if you're just displaying it, you could still vaccinate to, again, give you that boost getting ahead of it a little bit.

Dr. Nick Gilpin (18:40):

Yeah. The idea here, being that you've got that long incubation period. So, even if you've been exposed, it may not be too late.

Dr. Matthew Sims (18:47):

Right. Or it may not completely prevent it, but it may make it milder.

Dr. Nick Gilpin (18:52):


Dr. Matthew Sims (18:53):

But so far, I get the question all the time. It's like, "Should I go out and get that vaccine?" Well, you can't just go out and get that vaccine. It's got to be released from the national storage. And again, it is being released for post exposure, things like that. But so far, the only other thing I've heard them talking about is, for people who are going to be working directly with these patients, that they might vaccinate.

Dr. Matthew Sims (19:18):

Aside from the vaccine, there is actually a treatment now that was developed for smallpox. It's called tecovirimat. Again, I think we have millions of doses of it in the national storehouse. And it does have activity against monkeypox, though there's not a lot of clinical data on how it's used. And I want to caution people because we've had lots of drugs that were developed that older drugs in petri dishes have activity against COVID. But when we use them in people, it really didn't do very much.

Dr. Matthew Sims (19:50):

So, this is a drug that is approved, but it was approved based on viral studies, animal studies, not really based on the type of clinical trial that you normally do, where you give it to people who have the disease and see that it makes it better. So, we have it, but we still don't really know exactly how much benefit it's going to give.

Dr. Nick Gilpin (20:13):

And I would argue, Matt, when you talk about whether it's tecovirimat, the smallpox medication, or whether you talk about cidofovir which is another treatment that could be used in select cases, or immune globulin against vaccinia. I mean, those are really your big three in terms of available treatments. I would argue that the vast, vast, vast majority of people are never going to even come close to these medications.

Dr. Matthew Sims (20:37):

Yeah. Most people aren't going to need it, because as we've said, it tends to be a mild disease. But if you're immunosuppressed, if you're older, there may be a select group of people who we are worried enough about the progression of the disease that they may need some form of treatment.

Dr. Nick Gilpin (20:54):

Yep. That makes a lot of sense. All right, Matt, this is one of those topics that people have been asking me about a lot, this and COVID. Right?

Dr. Matthew Sims (21:03):


Dr. Nick Gilpin (21:04):

When I run into somebody on the street or a friend that I know, it's, "How are the COVID numbers doing, and what's up with monkeypox?" So people are interested in this. What else can we say about this that hasn't been said already? Or what other information do we have for the public about monkeypox?

Dr. Matthew Sims (21:19):

I think I we've covered the majority of it. The big thing is, nobody expects this to become the next COVID. And to be honest, most people are never going to see a case. 550 cases, worldwide sounds like a lot, but when you really think about it, it's a drop in the bucket. Now we don't know how many cases are still out there that haven't declared themselves yet. And we're hoping that we can get ahead of this and really stop it, knock it out, like they did in 2003. But because it's in 30 countries and spread here and there, it's harder to do. Right? Because it's not just in one area of one country where you can really go in and monitor the exposure so closely that you can prevent new cases. Or just go in and vaccinate the whole area, for example. Right?

Dr. Matthew Sims (22:12):

Some of the tools in our toolbox, we can't use for this particular, but if it does start to get larger, to see more cases and spread into the general population, then they'll start to look at whether or not a vaccination campaign is in order. Those are the kind of things that ... Remember, smallpox doesn't exist right now, except in a couple of labs. I think there's one lab here and one lab in Russia that has smallpox, and only for the purposes of creating defenses against it should something like it come back. We wiped it from the face of the earth with a vaccination campaign. Right? It is one of the greatest success stories of modern medicine. Right? The vaccination against pox viruses work really well.

Dr. Nick Gilpin (23:03):

Yeah. That's a really good point. I guess the thing I would punctuate here is that a, this is a real disease.

Dr. Matthew Sims (23:10):


Dr. Nick Gilpin (23:11):

And it's good to have situational awareness about what's going on around you, around the world. I expect, we will definitely see more cases. I think that long incubation period that we talked about means that numbers will continue to grow, and we just need to keep our eye on the ball here, and we'll do our best to keep the community updated on if anything changes vis-a-vis recommendations for vaccines, like you said.

Dr. Matthew Sims (23:35):


Dr. Nick Gilpin (23:37):

I think the other thing that's important to say here is, it's really important not to stigmatize and not to put this disease in a class that this only happens in a community of men who have sex with men, because I worry that stigma will prevent people from wanting to come forward if they have cases, or if they're concerned. And I think that's important. One of the important things about a disease like this is early timely recognition-

Dr. Matthew Sims (24:06):


Dr. Nick Gilpin (24:07):

And isolation to prevent it spreading to other communities.

Dr. Matthew Sims (24:11):

Very true. I mean, think back to the beginning of the days of HIV, how stigmatizing it was. HIV spread into the general population faster than most people realize. And nowadays, I mean, while it still has that association of men who have sex with men, I mean, you and I both treat HIV, we see it in anybody. Right?

Dr. Nick Gilpin (24:34):


Dr. Matthew Sims (24:35):

And it spreads through heterosexual contact, it spread, remember back then, blood transfusions was a big way it spread originally. So, while the initial outbreak seems to have occurred in men who have sex with men, it can jump to other people. All it takes is contact. We shouldn't think of this as a big stigmatizing thing. And though, people are people and people get scared. So I understand it.

Dr. Matthew Sims (25:01):

One other point I just thought about that I want to make, and it's minor, but it's probably important is, this virus is not related to chickenpox. I have gotten that question once or twice. Everybody hears monkeypox, chicken pox, but chickenpox is actually a herpes virus, just like cold sores. The two are not related at all. Chickenpox was misnamed back in the day.

Dr. Nick Gilpin (25:27):

Okay, Matt, I'm going to bring final thought here, for me, that is, I want to just punctuate something that we touched on earlier about confirmed monkeypox cases. So, if anyone's listening out there, if you are a case of monkeypox, if you contract this disease, I think it's fair to say the best treatment for you is going to be home, away from other people, to the extent that that's feasible, and really isolate yourself. And you just got to ride the storm out. Right? 2, 3, 4 weeks, that rash is going to last a while, keep it clean, keep it covered, keep those spots from getting infected to the best of your ability.

Dr. Nick Gilpin (26:06):

If you're going to be around other people, you should make sure that you're covering those spots as best you can, and wearing a mask to prevent that respiratory transmission that we know can happen. And there's really not any other specific treatment, unless of course, you get to the point where you're so sick.

Dr. Matthew Sims (26:21):

That you need to be in the hospital.

Dr. Nick Gilpin (26:24):

That you've got to go to the hospital. And then at that point, we've got a buffet of options that we could select from, if it gets to that point.

Dr. Matthew Sims (26:30):

And if you are one of those people who just for whatever reason, absolutely can't isolate, just remember that you are going to be contagious. So, if you have to be around people, cover up, as you said, but don't touch anybody, don't shake hands, be aware of what you're touching. Right? Because if you have the lesions on your hands and you touch a surface, the virus is going to get on that surface.

Dr. Nick Gilpin (26:51):

Good point, keep those surfaces clean, wash those linens and clothes and all that stuff, I guess, I'll call it common sense general household maintenance.

Dr. Matthew Sims (27:03):

That's exactly it.

Dr. Nick Gilpin (27:04):

And for my doctor friends out there, if you are confronted with a patient that you feel may have monkeypox, there are protocols, state and local county health departments can help you with this. At this point, my best advice to you would be, get in touch with your local health department, and find out exactly how they want those specimens to be collected and where they should be sent to for confirmatory testing.

Dr. Matthew Sims (27:27):

Right. It's incredibly important because you can't just go to the local lab and get tested for monkeypox. Right? It's not a common test. It's all going to be handled through probably state health departments and CDC. It's not something like even at a big hospital like Beaumont, our local lab is not going to run that test, we're going to send it off to the state who then going to send it to the CDC for confirmation.

Dr. Nick Gilpin (27:51):

Perfect. I think we'll leave it there. That's all the information we have time for today. I want to thank Matt. Matt, thank you.

Dr. Matthew Sims (27:57):

You're welcome, happy to be here.

Dr. Nick Gilpin (27:59):

And I also want to remind the listeners to send along any questions or suggestions to our email which is And I will leave you with this healthy thought. It's good to have situational awareness during an outbreak, as with any contagious disease, the best way to avoid getting sick is to avoid contact with people or animals who are infected. And if contact does occur, be sure to practice good hand hygiene afterwards. Knowing the ways that monkeypox can spread and the signs and symptoms of the disease can help us identify and isolate existing cases more quickly, and that will help us limit the spread of new cases. Thank you.

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