Clinician alert: Updated hMPXV (Monkeypox) interim guidance July 13, 2022

July 13, 2022

This alert updates prior guidance issued May 27 and June 16

General information about hMPXV (Monkeypox)

Community transmission of hMPXV (aka monkeypox) has been documented in Oregon. Clinicians should be alert to hMPXV in patients with compatible symptoms; cases in Oregon and internationally have largely involved prolonged, skin-to-skin contact with others primarily in social networks in which hMPXV is circulating, including men who have sex with men (MSM). The virus is not a sexually transmitted disease per se and can affect anyone. There are now more commercial laboratory testing options for Orthopoxvirus and prior approval from state public health is no longer required. Clinicians should gather current and emergency contact information for patients and advise self-isolation until lab results are back and negative, or if positive, when the rash is completely healed. In the case of a negative test, the patient may still need to isolate for the actual cause of the rash.

Summary

Oregon is seeing a distinct increase in locally-acquired hMPXV viral infections, with 5 confirmed cases so far and more expected. Cases are increasing in several areas of the United States.

Transmission has been observed through prolonged, skin-to-skin contact with others primarily in social networks in which hMPXV is circulating, including men who have sex with men (MSM). The virus is not a sexually transmitted disease per se and can affect anyone.

hMPXV is a known orthopox virus most commonly seen in Western and Central Africa until recently. Current cases are presenting as a febrile rash illness spread by close skin-to-skin contact with infected individuals or with contaminated materials such as bedding or towels, and less commonly by respiratory spread via large droplets. Sexual contact is a known source of transmission for many of the current cases, and can cause oral, anal, and genital lesions that may lead individuals to present to STD and HIV clinics or other STD testing programs. Most individuals recover in 2-4 weeks without treatment.

We are asking clinicians

Consider monkeypox as a possible diagnosis for anyone with a compatible clinical presentation, especially in the setting of intimate or other skin-to-skin contact with an individual known or suspected to have monkeypox (similar rash). hMPXV testing should also be considered for individuals with atypical rash and epidemiologic risk factors, and can be done concurrently with tests for other conditions.

For possible cases

Take a good history, including:
- Recent domestic or international travel; good sexual history including not only number and timing of partners, but use of apps to meet partners, attendance of bathhouses or sex clubs, any anonymous partners, etc.
- Date of onset of symptoms, which symptoms are present, and for a rash, what parts of the body are affected.
- Relevant comorbidities (immune compromise, pregnancy or HIV)
- Race/ethnicity, gender identity and sexual orientation
- County of residence and other contact information
Advise patient on home isolation precautions and instructions for the individual being tested and for those they live with..
Advise them to make a list of individuals they have spent time with / had contact with since the onset of symptoms. Let them know that if the result is positive, a public health contact tracer will reach out to them and review these details to help determine if anyone is eligible for post-exposure prophylaxis. Local public health will also help ensure they have the support needed to isolate safely.
Take a picture of the rash if possible.

Test for hMPXV

Collect at least 2 separate vigorous swabs of each of at least 2 freshly unroofed skin lesions. Carefully unroof the lesion and rub at the base of the lesion with sterile polyester or Dacron-tipped swabs and place each swab into separate 1.5-2 mL screw-top sterile containers without media, labeling each clearly with the specimen site. Swabbing the top of a lesion is acceptable if there are no vesicles or pustules to unroof. See further specimen collection, storage, and shipping information from the Oregon State Public Health Lab here, and case definitions and further clinical considerations for determining need for testing here. Store specimens refrigerated per OHA guidance.

Test for other diseases as appropriate, including but not limited to syphilis (very common), herpes, shingles, molluscum contagiosum, chancroid, varicella, lymphogranuloma venereum, granuloma inguinale, folliculitis. Keep in mind that orthopox may present concurrently with another diagnosis.
You are no longer required to consult with public health in order to send hMPXV tests. As of today, there are two private labs (LabCorp and Mayo) now doing orthopox testing with more coming on-line in the coming weeks.
If your patient is positive they may receive those results from local public health contact investigators before you are able to provide results. We encourage clinicians to follow-up with positive patients regularly to determine if they need symptom relief and assess for severe or complex infection. We also ask that hMPXV positive individuals be evaluated in-person when the rash has resolved (all scabs have fallen off) to release them from isolation, and that this release from isolation be communicated to local public health at the number provided below.
Consult with the OHA state epidemiologist on-call at 971-673-1111 if you believe treatment is indicated for a patient with confirmed or probable hMPXV infection based on severity of infection, presence of complications, or high-risk factors (immune compromise, pregnancy, age 8 or younger). At this time all treatment must be approved by state public health and coordinated with the CDC. Examples of complicated or severe infections include those with bronchopneumonia, secondary bacterial infections, atypical infection sites such as eyes or anus, hemorrhagic disease, sepsis, encephalitis, or other indication for hospitalization. See current CDC case definitions here.
Current supplies are limited, but post-exposure prophylaxis (PEP) with JYNNEOS vaccine is available for high and intermediate risk contacts to individuals with hMPXV, including occupational exposures, and must be coordinated with local public health. If you identify a close contact to a confirmed or probable case, work with your local public health agency to determine if PEP is needed.

Infection Prevention

In the clinic or hospital setting, implement standard infection control precautions, including but not limited to:

Mask all patients with a febrile or rash illness as source control, preferably with a surgical or KN95 mask.
For patients with visible lesions on the body, provide a gown or dressing to cover lesions
For clinicians and staff: If monkeypox is suspected, all staff interacting directly with the patient should use gloves, gown, NIOSH-approved N95 respirator or higher level of protection, and eye protection. Notify your infection prevention and control personnel immediately. If possible, exclude pregnant and/or immune-compromised staff from interaction with individuals with suspected hMPXV.
Limit time spent in a waiting room or other parts of the clinic and keep the room door closed as much as possible. Handle laundry and PPE carefully including disposal of any PPE or dressings in biohazard containers, routine disinfection of surfaces and careful handling of patient-used laundry. Activities that could resuspend dried material from lesions, e.g., use of portable fans, dry dusting, sweeping, or vacuuming should be avoided.

See further information regarding infection prevention in clinical settings here.

Notify and consult with your organization’s infection preventionist regarding any positive or suspected cases. Ensure that you have a mechanism for tracking which staff have interactions with potentially infectious patients. Consult occupational health for any potential staff exposures.

There are no dedicated orthopox evaluation/testing sites in our area at this time and healthcare providers should plan to evaluate patients on-site.

Patients in need of testing and who have no medical home or other access to testing may be seen at the Multnomah County Health Department STD clinic. Appointment availability is limited, and individuals seeking testing must notify schedulers when calling that they need to be seen for hMPXV (orthopox, monkeypox) testing.

Patient education

Educate patients presenting with symptoms concerning for hMPXV on home isolation precautions.

They should isolate at home and away from other household members until results are back.
They should keep lesions covered, and if this is not possible due to the extent or severity of the rash, should restrict themselves to a single room if possible. A surgical mask or greater respiratory protection should be used at all times by the infected individual when they must share space with others, especially when respiratory symptoms are present.
Family members, housemates, and pets should avoid contact as much as possible, and unexposed individuals should not visit the home.
Contaminated waste (such as wound dressings) must be handled and disposed of carefully. See waste disposal guidance here.
If test is positive, patients must continue isolation until the rash has resolved and all scabs have fallen off (usually 2-4 weeks). Individuals in isolation should only leave the home to seek medical care. The local public health department may be able to provide support to individuals needing to isolate.

For individuals currently suspected of having monkeypox: let patient know that public health may call to provide further guidance, to ensure they are able to isolate, and to get additional information about who they may have had close contact with and where they may have spent time.

For individuals who are not currently suspected of having hMPXV: educate at-risk patients/clients about risk factors, common symptoms, and what to do if they are concerned about possible hMPXV infection or exposure, including:

Encouraging individuals to abstain from sex/close contact with others if they develop a new skin lesions or otherwise suspect they may have hMPXV (such as prodromal symptoms and risk factors for acquiring hMPXV). Condoms will not prevent transmission of hMPXV. Advise them to isolate and consult with a clinician to determine need for testing.
If individuals identify as having had close contact with a known or probable hMPXV case, consult with your local public health agency about whether PEP is indicated.

For individuals exposed to a confirmed or probable monkeypox case:

They do not need to quarantine, but should watch for signs and symptoms of hMPXV infection, and are encouraged to monitor for onset of fever with twice daily temperature measurement until 21 days from the last known exposure. The local public health agency will be in contact with any identified individuals meeting intermediate or high-risk exposure criteria. The CDC provides further guidance for symptom monitoring in exposed individuals here.
Individuals with known exposure should consider avoiding any group event expected to include sexual or other skin-to-skin contact until 21 days from the last known exposure. They should also avoid donating blood, tissue, breast milk, semen or organs until through the 21 day observation period. Individuals with high risk exposure and those in isolation also should not travel by public transportation (plane, train, bus).

More Information

The incubation period (time from exposure to symptoms) for hMPXV is typically 7-14 days, but can range from 5-21 days.

Current cases have presented in a variety of ways including those with and without prodromal symptoms. All cases have a rash, and most have fever. Prodromal symptoms typically start 1-3 days before development of the rash and can include fever, chills, fatigue, malaise, headache, and swollen lymph nodes. The rash may be painful or itchy, and lesions appear in crops which start with macules that progress to papules, then firm, well-circumscribed, fluid-filled vesicles and/or pustules over the course of 2-3 weeks. The lesions may umbilicate or ulcerate and may be deep seated. Skin lesions may involve any part of the body including the mouth, palms and soles, and anogenital lesions, and classically have a centrifugal pattern (predominant on the face and extremities).

The current circulating virus is a known hMPXV virus strain from Western Africa, and is considered to be a milder form. Severe outcomes such as bronchopneumonia, sepsis, encephalitis, and corneal infection with vision loss are possible but uncommon, and the WHO estimates mortality from hMPXV at 3-6%. Severe outcomes are thought to be more common in those with immune compromise, in children, in pregnant people, and in individuals with eczema and other exfoliative dermatologic conditions. There have been few hospitalizations and 3 deaths to date with the current identified cases in this outbreak worldwide.

Unlike COVID-19, individuals with hMPXV are thought to only be infectious while symptomatic, and individuals with confirmed or suspected monkeypox should isolate until the rash has resolved (scabs gone) except to seek testing and/or medical care. Most individuals recover spontaneously in 2-4 weeks without treatment.

The vaccine strategy for addressing this outbreak will continue to evolve as more cases are identified and as more vaccine becomes available from national stockpiles. At present in Oregon, vaccine is only available for those requiring PEP and for individuals needing PrEP (pre-exposure prophylaxis) due to high risk for occupational exposure (very few individuals in this category).

Resources

Communicable disease programs

Clackamas County Public Health: 503-655-8411
Multnomah County Health Department: 503-988-3406 (choose option 3 after hours for urgent needs)
Washington County Public Health Division: 503-846-3594
OHA 24/7 Communicable Diseases phone line 971-673-1111 should be used for consultation regarding suspected hMPXV cases and for treatment determination/requests for all Oregon residents.

References

Thank you for your partnership,

Christina Baumann, MD, MPH, Health Officer, Washington County

Teresa Everson, MD, MPH, Deputy Health Officer, Multnomah County

Ann M Loeffler, MD, Deputy Health Officer, Multnomah County

Sarah Present, MD, MPH, Health Officer, Clackamas County

Jennifer Vines, MD, MPH, Health Officer, Multnomah County

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