Clinician Alert Updated Mpox Guidance June 12, 2023

June 12, 2023

What’s new since the September 2022 mpox Clinician Alert?

There has been a change in nomenclature from hMPXV to mpox.
Most at-risk individuals in Oregon have not yet started their JYNNEOS 2-dose series.
We may see increased transmission in our area during the summer months.
The default vaccination administration route is subcutaneous (previously intradermal)
Mpox vaccination, testing, and treatment should primarily occur in community health settings (primary care, HIV and STD specialty clinics). Order JYNNEOS vaccine from OHA using this link.
Breakthrough infections have been observed in those who are vaccinated, but are preliminarily looking less severe and may present differently.
Mpox remains notifiable in Oregon (notifiable condition reporting by county)
The Multnomah County Health Department STD Clinic is faced with downsizing services this summer and will no longer be able to provide certain kinds of routine sexual health services. Primary care clinics, urgent care, emergency rooms, and other clinical settings should be ready to provide routine, patient-centric sexual health services, and healthcare providers should (re)familiarize themselves with current best practices for STI screening and provision of PrEP (references below).
Mpox vaccine (JYNNEOS) should be considered part of routine preventive care for patients at higher risk to prevent individual morbidity/mortality as well as to prevent outbreaks.

Additional key points:

An increase in cases is expected in many parts of the US over the summer months
The majority of individuals at risk for acquiring mpox in our area have not yet started their 2-dose vaccine series with JYNNEOS. Current estimates are that only 48% of at-risk Oregonians have received at least a single dose, and just 27% have received both doses.
Vaccine is readily available for post-exposure prophylaxis (PEP- ideally provided within 4 days of exposure) and for all at-risk individuals.. We encourage all primary and specialty care providers who offer vaccines to add JYNNEOSs to your preventive care and standard vaccination provision for those at risk. Individuals without access to vaccine through their healthcare provider can call the Multnomah County Health Department call center at 503-988-8939 for help identifying options for vaccination.
Health care providers should have a low threshold for testing patients with risk factors and/or consistent rash illnesses for mpox. (See Testing information from September 2023 Clinician Alert). Billing and coding details for OHP patients.
Testing is available via routine lab channels without approval from local or state public health. Every clinical site can and should swab lesions and submit specimens as they would for many other infections. Please follow testing protocols outlined by your lab service provider. Turnaround times for results are typically 2-3 business days.
For possible, presumptive or confirmed cases, providers should offer supportive care and basic education about isolation practices: staying home whenever possible. Masking and keeping lesions covered when leaving home if necessary. (further resources below)
Treatment with mpox-specific medications may be indicated for high risk individuals and those with severe or very painful infection. (further resources below). The STOMP trial to assess effectiveness of Tecovirimat (TPOXX) in humans is ongoing and clinicians are encouraged to enroll patients.

Summary

Community transmission of mpox (monkeypox or hMPXV) is sporadic but ongoing in Oregon, with over 180 cases in the Portland metro area to date. Cases have been identified in every US state with 280 confirmed cases across Oregon, and over 30,000 cases across the US to date. Mpox infections disproportionately impact individuals who are Black and/or LatinX in Oregon and across the US.

Transmission primarily involves intimate, skin-to-skin contact with the rash of an ill person, mostly within social networks of men who have sex with men (MSM). Having multiple sexual partners increases risk. The infection is not thought to be a sexually transmitted disease per se and can affect anyone.

Risk to the broader public is low, but we continue to watch transmission trends for changes. Clinicians should remain alert to mpox in any patient with compatible symptoms, and should test for both mpox and any other suspected conditions, as co-occurring STI’s are common.

Transmission

Sexual and other intimate contact is a known source of transmission for the majority of current cases, and can cause oral, anal, and genital lesions that may lead individuals to primarily present to STD and HIV clinics or other STD testing programs. Cases have also been identified in primary care, urgent care, and ER settings as well.

While transmission via contaminated materials such as bedding or towels and by respiratory spread via large droplets is possible, these routes of infection have generally not been observed in the current outbreak.

Symptoms and incubation period

Current cases have presented in a variety of ways both with and without prodromal symptoms. Nearly all cases have a rash or mucosal lesions, and most have fever. Surveillance studies have shown some individuals with essentially asymptomatic rectal or oral infection. Prodromal symptoms, if present, typically start 1-3 days before development of the rash and can include fever, chills, fatigue, malaise, headache, and swollen lymph nodes. Current evidence supports possible presymptomatic spread, but at this time there is no evidence for spread from individuals who never develop symptoms (asymptomatic spread).

The rash may be painful or itchy. Lesions can start with macules that progress to papules, then firm, well-circumscribed, fluid-filled vesicles and/or pustules over the course of 2-3 weeks. Some patients initially present with a papular rash. The lesions may umbilicate or ulcerate and may be deep seated. Skin and mucus membrane lesions may involve any part of the body including the mouth, palms and soles, and anogenital areas.

The incubation period (time from exposure to symptoms) for mpox is typically 3-17 days, but case series suggest that the incubation period in the current outbreak is 5-7 days on average.

While skin lesions can be painful and subject to secondary infection, most individuals recover in 2-4 weeks without treatment beyond supportive care (resources below).

Treatment options and which patients may need treatment (CDC)

Testing

We continue to ask clinicians to:

Consider mpox 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 mpox (similar rash) or with other risk markers.
Entertain the possibility of mpox even with an atypical rash (especially in the context of epidemiologic risk factors).
Testing can be done concurrently with tests for other conditions.
Test for/consider other diseases as appropriate, including but not limited to syphilis (very common), herpes, shingles, molluscum contagiosum, chancroid, varicella, lymphogranuloma venereum, granuloma inguinale, folliculitis. In children, hand foot and mouth disease can look similar.
Take advantage of the interaction (if appropriate for the context) by doing full STI screening (GC/CT, syphilis, HIV, hepatitis B and C) and discussing HIV PrEP.
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. Please share this one-page document outlining home isolation with patients being tested for mpox.
If test results are positive for a patient with atypical clinical presentation and no epidemiologic risk factors, consider requesting that the lab re-test the specimen. False positives can rarely occur, especially when population prevalence is low. See 08/23/2022: Lab Advisory: Mpox Virus Testing Considerations to Prevent False Positive Test Results
Patients should continue to isolate until subsequent results are back, but can discontinue isolation and should be considered mpox negative if the second test result is negative.

Case definitions and further clinical considerations for determining need for testing (CDC)

Evaluate and test patients on site

There are no dedicated orthopox evaluation/testing sites in our area; healthcare providers should evaluate patients on-site. Testing supplies and PPE required for mpox testing are widely available, and essentially all healthcare settings can provide this care to patients. There are multiple commercial laboratory testing options for orthopoxvirus and approval from state or local public health is not required.

Turnaround times for results is typically 2-3 days, but may be longer with high volumes and depending on transit time. Patients who test positive might receive their results from local public health contact investigators before you are able to provide results and follow-up guidance.

Sample collection

Collection logistics vary slightly by laboratory, but for all laboratories:

Collect vigorous swabs of skin lesions with a sterile polyester or Dacron-tipped swab. If a pustular or vesicular lesion is unroofed, be sure to collect fluid from the lesion, but unroofing a lesion is not necessary and using a sharp implement to unroof lesions is strongly discouraged due to case reports of transmission in healthcare settings due to this practice.
Place each swab (if more than 1) into separate 1.5-2 mL screw-top sterile containers. Commercial labs request universal or viral transport media; OSPHL requests dry swabs without media.
Label each container clearly with the specimen site.
See further specimen collection, storage, and shipping information for:
- Oregon State Public Health Lab (available if other labs are not an option)
- QUEST
- Labcorp
- Mayo (see CDC collection information)
- Sonic (see CDC collection information)
- Aegis
- ARUP
Store specimens refrigerated per OHA guidance

Patient history

If you suspect mpox, ask for:

A brief sexual history. If the person tests positive, public health will inquire about number and timing of partners, 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 conditions (immune compromise, pregnancy or HIV)
Verify:
- race/ethnicity, gender identity and sexual orientation
- county of residence and other contact information

Advise patients on isolation and contact tracing

Advise patient to isolate at home until results are back, typically in 3-6 days, and provide instructions for the individual being tested and for those they live with (both available in additional languages).
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.

Treatment

Follow-up with positive patients regularly to determine if they need symptom relief and to assess for severe or complex infection that may need further treatment.

If you believe treatment is indicated for a patient with mpox infection based on severity of infection, presence of complications, or high-risk factors (immune compromise, pregnancy, age 8 or younger, or those with active, exfoliative skin conditions such as atopic dermatitis) and you do not have access through your health system pharmacy, you may consult with the OHA state epidemiologist on-call at 971-673-1111. 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, severe pain, or other indication for hospitalization. Current CDC indications for tecomirivat use.

Clinical consultation regarding treatment for mpox is available both through the OHA at the above number, as well as through the CDC at (770) 488-7100.

Guidance for supportive care and information about obtaining and providing mpox-specific treatments are available (see resources below). Several treatment options are available for high risk or severely affected patients. The most common is Tecovirimat.

Tecovirimat

Tecovirimat (brand name TPOXX) is an oral antiviral therapy with activity against smallpox and mpox. It is FDA approved for smallpox and now available for mpox patients with severe or very painful infection or those at high risk for unfavorable outcome.

Effectiveness of tecovirimat has been established for smallpox in humans, and for a variety of orthopox viruses in animals. Safety of tecovirimat has been studied and established for human use.

At present Tecovirimat is available through CDC’s Investigational and New Drug protocol. There is an ongoing trial (STOMP) to further assess effectiveness against mpox in humans.

Vaccine

At present in Oregon, vaccine is available for those requiring PEP (post-exposure prophylaxis) and as PreP (pre-exposure prophylaxis) for anyone who wants it. Criteria for individuals at highest risk and greatest need (OHA).

PEP with JYNNEOS vaccine is available in every county for high and intermediate risk contacts to individuals with mpox, including occupational exposures, if the exposure happened less than 14 days prior. The sooner PEP is administered (ideally within 4 days of exposure) the more effective it is at preventing infection/severe infection. Screening, authorization, and scheduling for PEP can be done directly by the health department for the county of residence of the exposed individual (see contact information for each health department below).

Individuals needing vaccine after exposure (PEP) should call / email the communicable disease team for their county of residence ASAP.

Individuals wanting to schedule an appointment for a PrEP vaccine (other than post exposure prophylaxis) should contact their healthcare provider, as JYNNEOS is carried in many clinical settings. Those in the tri-county area without access to health care can call the Multnomah County Health Department call center at 503-988-8939 to identify options in their area. Vaccines are currently scheduled within a week and there are vaccine sites all over the tri county region. Vaccine is available from OHA to provide as PrEP to your high risk patients.

Infection prevention in clinic or hospital settings

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 meeting high or intermediate risk.

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 procedural mask or KN95 mask.
For patients with visible lesions on the body, provide a gown or dressing to cover lesions.
For clinicians and staff: If mpox 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 mpox.
Limit time spent by suspect mpox patients 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. Negative pressure rooms are not required for evaluation of individuals with suspected mpox.
See further information regarding infection prevention in clinical settings (CDC).

Patient education

With symptoms

Educate patients presenting with symptoms concerning for mpox on home isolation precautions (available in other languages on OHA site).

They should isolate at home and away from other household members until results are back.
They should keep lesions covered. If this is not possible due to the extent or severity of the rash, they should restrict themselves to a single room if possible. A surgical mask or greater respiratory protection should be used at all times by infected individuals 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 home infection prevention guidance.
If test is positive, patients should continue isolation until the rash has resolved and all scabs have fallen off (usually 2-4 weeks). The local public health department may be able to provide support to individuals needing to isolate.
If some of these precautions cannot be fully implemented (e.g. the patient cannot completely isolate for the entire duration of rash), CDC does include some guidance to mitigate risk of spread to others.

Exposed

For individuals exposed to a confirmed or probable mpox case and who have not yet developed mpox symptoms:

Direct them to their local public health department to discuss post-exposure prophylaxis (PEP, see above. Contacts for individual health departments may be found below). Vaccination is most effective in the four days after exposure, but may have some benefit for up to 14 days and before rash or lesion eruption.
They are not required to quarantine, but should watch for signs and symptoms of mpox 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.
Individuals with known exposure should strongly consider avoiding any group event or anonymous interaction expected to include sexual or other skin-to-skin contact until 21 days from the last known exposure. In general, limiting the number of intimate contacts / condom use during the current outbreak will help lower risk of disease transmission. As a precaution, they should also avoid donating blood, tissue, breast milk, or semen or through the 21 day observation period. Organ donation from exposed individuals may be considered with thorough risk-benefit discussion, given the severe need for organ donors and high mortality for those waiting for organ transplants. Individuals exposed to mpox are no longer discouraged from travel by public transportation.

Not currently suspected of having mpox

For individuals who are not currently suspected of having mpox: educate at-risk patients/clients about risk factors, common symptoms, and strategies to reduce risk of mpox infection or exposure, including:

Encouraging individuals to be vaccinated
- Vaccine specifics (number of doses, age restrictions, administration route, contraindications/precautions, where folks should call to be screened/scheduled if no access through clinic/health system- see above)
Encouraging individuals to abstain from sex/close contact with others if they develop new skin lesions or otherwise suspect they may have mpox (such as prodromal symptoms and risk factors for acquiring mpox). They should isolate and consult with a clinician to determine need for testing if they develop symptoms.
If individuals identify as having had close contact with a known or probable mpox case, direct them to their local public health department at the below contacts. See below for further guidance.
Condoms may reduce risk if mpox sores are limited to penis/rectum/vagina, but should not be relied on to prevent transmission of mpox as there may be rash elsewhere on the body. Condom use may have increasing value if reports of asymptomatic rectal mpox infection are born out by further study.
Limiting number of intimate contacts will decrease the risk of acquiring infection during the current outbreak.

More Information

The current circulating virus is a known mpox 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 mpox at 1.3 per 1000 cases in the US. Severe outcomes are 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 42 mpox-related deaths in the US to date, with the majority of these deaths in individuals with advanced HIV.

Unlike COVID-19, individuals with mpox are thought to only be infectious while symptomatic or presymptomatic. Data suggests that individuals may transmit virus from presymptomatic oral and/or rectal lesions. There is no evidence of asymptomatic spread. 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.

Communicable disease program contact information

Clackamas County Public Health: 503-655-8411 (PEP requests may be emailed to PH-IDCP@clackamas.us
Multnomah County Health Department: 503-988-3406 (choose option 3 after hours for urgent needs)
Washington County Public Health Division: 503-846-3594 (PEP requests may be emailed to HHS_PublicHealth_DCAP@co.washington.or.us)

References

Thank you for your partnership,

Christina Baumann, MD, MPH
Health Officer, Washington County

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

Sarah Present, MD, MPH
Health Officer, Clackamas County

Paul Lewis, MD, MPH
On-call Health Officer, Multnomah County

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