What’s new since our May 27 interim guidance:
- Updated outbreak numbers, including one probable case in Oregon
- Link to images of rash from current outbreak cases
- Clarification of incubation period and clinical features
- Additional details for specimen collection
- Updated guidance for home isolation
- Updated guidance for those with known exposure or seeking to limit exposure
- Additional resource for messaging to the public about navigating social situations when Monkeypox is a concern; link to CDC clinician guidance for Tecovirimat
Clinicians should be alert to monkeypox in patients with compatible symptoms and especially in those risk factors (recent travel, skin-to-skin contact with a known or likely case). Globally, many cases so far have identified as men who have sex with men, but the virus is not a sexually transmitted disease per se and can affect anyone. Evaluation, testing, and proper infection control can be achieved in any clinical setting.
Europe and North America are experiencing clusters of monkeypox viral infections, with 84 confirmed or presumed cases in the United States as of 6/15/22 and several more under investigation. There is one probable case in Oregon at this time.
On interview, many individuals have identified as men who have sex with men, making education and support of this community and the clinicians and organizations who care for them essential.
Monkeypox is a known orthopox virus most commonly seen in Western and Central Africa. 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 travel outside the US in the past 21 days, or intimate or other skin-to-skin contact with an individual known or suspected to have monkeypox (similar rash and/or travel to an area with transmission in the past 21 days). Monkeypox testing should also be considered for individuals with epidemiologic risk factors who fail to improve as expected from alternative diagnoses with similar clinical presentation.
For possible cases:
- Take a good travel and sexual history, including:
- Date of onset of symptoms, which symptoms are present, and for a rash, what parts of the body are affected.
- Any risk factors as above (travel, sexual or other contact with at risk individual)?
- County of residence and other contact information
- Advise patient on home isolation precautions as detailed below.
- Advise them to make a list of individuals they have spent time with / had contact with since the onset of symptoms. A public health contact tracer will reach out to them and ask for these details.
- Take a picture of the rash if possible.
- For Multnomah County residents, call the Multnomah County Health Department at 503-988-3406 for consultation and to determine appropriateness of testing. For all other Oregon residents, call the Oregon Health Authority (OHA) at 971-673-1111.
- If approved for testing, 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 information from OHA 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.
- Consult the Multnomah County Health Department at 503-988-3406 (for Oregon residents outside of Multnomah County call the OHA at 971-673-1111) if you believe treatment is indicated for a patient with confirmed or probable monkeypox 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 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.
- Post-exposure prophylaxis may be available for this disease. If a confirmed or probable case is identified, work with your local public health agency to identify those who may need it.
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 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 monkeypox.
- 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 avoidance of unnecessary shaking / 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 interaction 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 be prepared to evaluate and test patients on-site.
Educate patients presenting with symptoms concerning for monkeypox on home isolation precautions.
- They should isolate at home and away from other household members until results are back
- 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.
- 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) cannot be sent to landfills with regular garbage pick-up and should be collected and contained. Proper waste disposal in our area is still under consideration.
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 monkeypox: educate at-risk patients/clients about risk factors, common symptoms, and what to do if they are concerned about possible monkeypox 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 monkeypox (such as prodromal symptoms and risk factors for acquiring monkeypox). Condoms will not prevent transmission of monkeypox. Advise them to isolate and consult with a clinician to determine need for testing.
For individuals exposed to a confirmed or probable monkeypox case:
- They do not need to quarantine, but should watch for signs and symptoms of monkeypox 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 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).
The current cluster of cases includes more than 1000 cases worldwide, and is currently thought to have been spread at large events in western Europe in early May, with sexual contact thought to be a primary method of transmission.
The incubation period (time from exposure to symptoms) for monkeypox 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 monkeypox 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 monkeypox 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 no deaths to date with the current identified cases.
Unlike COVID-19, individuals with monkeypox 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. There is no specific treatment for monkeypox, and most individuals recover spontaneously in 2-4 weeks without treatment.
Information about indications for vaccination, treatment, and post-exposure prophylaxis will be evolving as more cases are identified in the US.
More information can be found at: https://www.who.int/news-room/fact-sheets/detail/monkeypox and https://www.cdc.gov/poxvirus/monkeypox/index.html
Watch for further communications from the Multnomah, Clackamas and Washington County Health Departments, the Oregon Health Authority, and the CDC regarding prevention and management of Monkeypox virus infections as the current situation evolves. In the meantime contact your local health department with questions about this guidance. Health department staff will investigate all cases of probable or confirmed monkeypox infection and will notify identified close contacts.
Communicable disease program contact information
- 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 to discuss suspected monkeypox cases / testing determination for Oregon residents outside Multnomah County.
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