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New and Noteworthy

  • CDC HAN Severe Manifestations of Monkeypox among People who are Immunocompromised Due to HIV or Other Conditions (9-29-22). People who are immunocompromised due to HIV or other conditions are at high risk for severe monkeypox disease. The CDC recommends that providers determine the HIV status of all sexually active adults and adolescents with suspected or confirmed monkeypox.
  • Reporting severe disease. Clinicians must report hospitalizations due to monkeypox to LAC DPH. In addition, they are asked to call the LAC DPH consultation line if a hospitalized patient is worsening clinically, such as being admitted to the ICU. LAC DPH will provide clinical consultation and access to additional therapeutic options.
  • Use the DPH Public Health Lab to expedite testing for suspect cases who are experiencing homelessness or are pregnant, or for children with known exposure.

Clinical Consultation / Testing Approval Line

Providers who need clinical consultation (including for patients who are clinically worsening or hospitalized), access to treatment, or approval for monkeypox testing at the LAC Public Health Lab can call:

Los Angeles County DPH Acute Communicable Disease Control

  • Weekdays 8:30am-5pm: 213-240-7941.
  • Weekends and holidays 8:00am-5pm or evenings (urgent situations only): 213-974-1234 and ask for the physician on call.

Background

Since the first MPX case in the U.S. in 2022 was diagnosed in May, cases have been identified throughout the country. The monkeypox virus strain circulating in the 2022 multinational outbreak belongs to a clade that causes milder illness (Clade II). Case lesions can be present in sensitive areas, such as genital and perianal areas, and be very painful. Reported complications of monkeypox in the US include severe pain, bacterial superinfection, severe pharyngeal swelling with concern for airway compromise and inability to eat/drink. The severity of illness can depend on the initial health of the individual and the route of exposure.

Close, sustained skin-to-skin contact, including sexual contact, with a person with monkeypox appears to be the most significant risk factor associated with transmission. In this 2022 outbreak, most of the reported cases have been among gay, bisexual, or other men who have sex with men (MSM). However, anyone, regardless of sexual orientation or gender identity, is at risk if they have been in close, personal contact with someone who has monkeypox.

Visit the 2022 Monkeypox Outbreak Data websites for most current information:

Evaluation of a Patient with Suspected Monkeypox

Clinical Presentation

The clinical case presentations during this ongoing outbreak have not been characteristic of classic monkeypox infections.

The classic presentation of monkeypox infection includes a flu-like illness lasting a few days, followed by the appearance of a characteristic rash. Presenting symptoms can include fever, chills, a distinctive rash, and/or new lymphadenopathy; the appearance of the rash typically evolves rapidly and sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid), pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off.

Thus far, in the U.S. outbreak (Epidemiologic and Clinical Characteristics of Monkeypox Cases-US May 17-July 22, 2022), some notable features of infected people have included:

  • All have developed a rash
  • The rash has often begun in mucosal, genital, or perianal areas
  • The lesions have at times been scattered or localized to a body site rather than diffuse
  • Lesions have sometimes been in different stages of progression
  • Many did not have prodromal symptoms

Presenting symptoms have included anorectal pain, tenesmus, and rectal bleeding associated with perianal lesions and proctitis.

Most cases of monkeypox reported to the CDC (and globally) so far during the 2022 outbreak have been among men. See CDC, Monkeypox Cases by Age and Gender, Race/Ethnicity, and Symptoms.

Global surveillance of monkeypox cases indicates a high prevalence of HIV infection. Per the CDC, available summary surveillance data from the European Union, England, and the United States, indicate that among gay, bisexual, and other men who have sex with men (MSM) with monkeypox for whom HIV status is known, 28%–51% have HIV infection.

History

Monkeypox infections in the current outbreak may not be classical in appearance or progression. Therefore, the patient history is particularly important for identifying possible monkeypox cases.

Suggestive history includes:

  • Close contact with a person who has received a diagnosis of confirmed or probable monkeypox; and/or
  • Close or intimate in-person contact with persons in a social network experiencing monkeypox infections; this includes MSM who meet partners through an online website, digital application (“app”), or social event (e.g., a bar, bathhouse, or party)

Physical Exam

  • The rash associated with monkeypox classically involves vesicles or pustules that are deep-seated, firm or hard, and well-circumscribed; the lesions may umbilicate or become confluent and progress over time to scabs. The rash usually starts on the face or in the oral cavity and progresses through several synchronized stages on each affected area and concentrates on the face and extremities, including lesions on the palms and soles.
  • However, presentations in this outbreak have not always been classic. Patients have experienced rashes without prodromal symptoms and rashes that are at different stages within an affected area. The rash is often starting in the genital/perianal area and progresses to face, arms, palms and soles. Or the rash only involves the genital/perianal area.
  • The rash can be extremely painful.
  • Clinicians should perform a thorough skin and mucosal (e.g., anal, vaginal, oral) examination for the characteristic vesicular or pustular rash of monkeypox; this allows for detection of lesions that the patient had not previously been aware of.

See CDC Clinical Recognition

Differential Diagnosis

High prevalences of HIV and other sexually transmitted infections (STIs) have been reported in the current global monkeypox outbreak.

Patients presenting with perianal or genital ulcers, diffuse rash, or proctitis should be evaluated for STIs including HIV and monkeypox. The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis. The rash associated with monkeypox is often found in the genital or peri-anal area.

Related resource: HIV and Sexually Transmitted Infections Among Persons with Monkeypox — Eight U.S. Jurisdictions, May 17–July 22, 2022

Photos of Monkeypox Skin Lesions

A. Early vesicle, 3mm diameter
B. Small pustule, 2mm diameter
C. Umbilicated pustule, 3-4mm diameter
D. Ulcerated lesion, 5mm diameter
E. Crusting of mature lesions
F. Partially removed scab
All of the above images are from GOV.UK, https://www.gov.uk/guidance/monkeypox

Testing

Monkeypox testing should be performed on persons for whom monkeypox is suspected based on risk factors for monkeypox exposure and clinical suspicion.

The CDPH Clinical Assist Tool for Monkeypox (MPX) Evaluation includes a clinical decision guide to help with patient assessment.

Providers should submit specimens through commercial labs if possible (with the exception for priority populations-see below).

When colleting specimens, providers should wear appropriate personal protective equipment (see PPE). In addition, use methods to safely collect monkeypox specimens. Unroofing or aspiration of lesions during specimen collection or using sharp instruments for monkeypox lesion testing is not necessary or recommended due to the risk for sharps injury.

Note: at this time, providers are encouraged to only test children and non-sexually active adolescents when there is a known or likely exposure, or a clinical presentation very consistent with monkeypox disease. See Considerations for Testing Pediatric Patients.

Commercial testing

Commercial testing is available through several commercial labs including Quest Diagnostics, Labcorp, Aegis Sciences, Sonic Healthcare USA, and ARUP Laboratories. Labcorp, Aegis Sciences, Sonic Healthcare USA, and ARUP are using the CDC’s orthopoxvirus test (which detects all non-smallpox related orthopoxviruses, including monkeypox). The Quest assay is real time PCR test developed by Quest that detects DNA of non-variola orthopoxviruses and Monkeypox virus (West African clade)—see Quest FAQs.

Providers should submit specimens through commercial labs if possible (with the exception for priority populations - see below). Follow specimen collection instructions provided by the commercial laboratory as there are differences in specimen requirements across the laboratories. In addition, in order to ensure timely and efficient testing and prompt resulting from commercial laboratories, providers should use electronic test orders and should ensure that the required patient demographics are accurately and completely entered on the order.

Providers using commercial labs must report all LA County residents with orthopoxvirus positive and/or presumptive positive test results (see Reporting).

STI/HIV Testing

The CDC recommends that upon initial presentation of signs and symptoms consistent with monkeypox, that provider screen all sexually active adults and adolescents for HIV (including acute infection) and other sexually transmitted infections (such as syphilis, herpes, gonorrhea, and chlamydia).

Priority Populations for Monkeypox Testing at the Public Health Lab (PHL)

To expedite testing, providers with a suspect monkeypox case in one of the following priority populations are asked to submit specimens to the PHL:

  • Persons experiencing homelessness (PEH)
  • Pregnant persons
  • Children with a history of close, personal contact with someone who has monkeypox

In addition, providers that do not have access to commercial orthopoxvirus testing may submit specimens to PHL.

Please note: Consultation from LAC DPH is required before submitting specimens for testing at the PHL. See LAC PHL Preparation and Collection of Specimens below.

Considerations for Testing Pediatric Patients

False-positive test results have been reported. This is more likely when testing is performed in people who are unlikely to have the infection, such as children and non-sexually active adolescents.

At this time, providers are encouraged to only test children when there is a known or likely exposure, or a clinical presentation very consistent with monkeypox disease. The monkeypox outbreak in California and elsewhere in the U.S. currently remains concentrated in adults who identify as men and transmission has primarily occurred during sexual and intimate contact with other men. As described by the American Academy of Pediatrics (AAP), the risk of children getting infected with monkeypox is low. While pediatric cases have been confirmed in the U.S., including in LA County, they are rare. The AAP recommends testing patients with suspicious lesions if there is a history of close, personal contact with someone who has monkeypox. This may include living with or having intimate or sexual contact with someone who has monkeypox.

Rashes and skin lesions are common among children and adolescents and are caused by a variety of infectious and non-infectious conditions, including varicella, herpes simplex virus, hand, foot, and mouth disease caused by enteroviruses, acne, molluscum, scabies, drug-related rashes, allergic reactions, and insect bites. Coxsackie A-6 (CAV-6), a type of enterovirus, is well known to cause atypical hand, foot and mouth rashes and is circulating in California at this time. Children with eczema are particularly likely to have the atypical rash with CAV-6 and are also at risk for eczema herpeticum. Per CDPH, both of these conditions, as well as varicella, have led to work-ups for monkeypox in recent weeks in California.

While it is important to consider monkeypox in any person with compatible symptoms, a rash alone should not necessarily prompt testing. If a provider decides to test for monkeypox, a plausible risk for exposure should be identified, unless the child or adolescent has one or more lesions that are highly characteristic of monkeypox (i.e. characteristic progression over 2-4 weeks from pustular to deep-seated, umbilicated lesions).

Reporting

Healthcare providers must report all monkeypox or orthopoxvirus infections, hospitalizations, and deaths within 1 working day from identification (Title 17, CCR, §2500). See Reportable Disease List

If hospitalized patients are worsening clinically, such as being admitted to the ICU, providers are asked to please contact the LAC DPH healthcare provider line for clinical consultation and to access additional therapeutic options.



If providers experience technical difficulties with using the on-line report form, reports may be completed using the standard CMR form and submitted via fax to (888) 397-3778 or (213) 482-5508. Provider reporting is not necessary for positive tests conducted by the LAC DPH PHL.

Monkeypox Confidential Morbidity Report

 

Infection Control Considerations for Suspected and Confirmed Cases

Transmission

Monkeypox virus can be transmitted when a person comes into contact with the virus from an infected animal, infected person, or materials contaminated with the virus.

The monkeypox virus is known to spread between people through close, intimate and/or prolonged contact including:

  • Direct skin-to-skin contact with infectious lesions, scabs, or body fluids
  • Contact with contaminated fabrics or objects (e.g., sharing bedding, clothing, towels, sex toys that have not been cleaned)
  • Contact with respiratory secretions, such as saliva during intimate physical contact or prolonged (3 hours or more) face to face contact

Vertical transmission from a pregnant person to their fetus also occurs.

At this time, it is not known if monkeypox can spread through semen or vaginal fluids.

We are still learning about the likelihood of person-to-person transmission of monkeypox virus through each of these routes. However, it is thought that the most common route of transmission during the 2022 global MPX outbreak is direct (i.e., skin-to-skin) contact with MPX lesions, including but not limited to contact that occurs during sexual activity and close contact within households. Per CDPH, investigation of monkeypox cases in California to-date, has not corroborated that prolonged close proximity alone (without direct contact with skin lesions, body fluids, or contaminated materials) poses sufficient independent risk of monkeypox transmission to recommend notification, monitoring, or consideration of PEP.

Infection Control in Healthcare Setting

Reports of occupationally-acquired monkeypox infection in healthcare personnel (HCP) remain rare in this outbreak, with most reports involving HCP sustaining a sharps injury during specimen collection or when insufficient PPE was used.

These recommendations have been adapted from the CDC guidance, Infection Prevention and Control of Monkeypox in Healthcare Settings.

Patient Placement and Transport

A patient with suspected or confirmed monkeypox infection should be placed in a single-person room; special air handling is not required. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Activities that could resuspend dried material from lesions, e.g., use of portable fans should be avoided. Transport and movement of the patient outside of the room should be limited to medically essential purposes. If the patient is transported outside of their room, they should wear well-fitting source control (e.g., medical mask) and any lesions should be covered with a sheet or gown.

Safe Specimen Collection

Use methods to safely collect monkeypox specimens. Unroofing or aspiration of lesions during specimen collection or using sharp instruments for monkeypox lesion testing is not necessary or recommended due to the risk for sharps injury.

Personal Protective Equipment (PPE)

The CDC recommends the following PPE for healthcare personnel caring for patients with suspected or confirmed monkeypox:

  • Gown
  • Gloves
  • NIOSH-approved particulate respiratory equipped with N95 filters or higher.
  • Eye protections (i.e., goggles or a face shield that covers the front and sides of the face)
Environmental Infection Control

Any EPA-registered hospital-grade disinfectant can be used for cleaning and disinfecting environmental surfaces; CDC recommends using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim (EPA’s List Q).

Take care when handling soiled laundry (e.g., bedding, towels, personal clothing) to avoid contact with lesion material. Soiled laundry should be gently and promptly contained in an appropriate laundry bag and never be shaken or handled in manner that may disperse infectious particles. Activities that could resuspend dried material from lesions such as dry dusting, sweeping, or vacuuming should be avoided. Wet cleaning methods are preferred.

Waste (i.e., handling, storage, treatment, and disposal of soiled PPE, patient dressings, etc.) should be managed as medical waste. See CDC Waste Management for details.

Healthcare Worker Exposures and Risk Assessment

Transmission in healthcare settings has been rarely described. Brief interactions and those conducted using appropriate PPE in accordance with Standard Precautions are not considered high risk exposures and generally do not warrant PEP.

Providers should refer the CDC guidance Assessing Risk of HCP with Monkeypox Virus Exposures to Guide Monitoring and Recommendations for Postexposure Prophylaxis.

Related resource: Health Care Personnel Exposures to Subsequently Laboratory-Confirmed Monkeypox Patients — Colorado, 2022

Home Isolation

Patients with suspected monkeypox infection should be instructed to isolate at home pending the results of testing.

Patients with confirmed monkeypox should be instructed to isolate at home until they have met criteria to resume limited activities outside the home. Isolation precautions should be continued until all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed.

The LAC DPH Isolation Instructions for People with Monkeypox Infection include guidance for returning to work, precautions at home and outside the home to protect others, and cleaning, disinfection, and waste disposal. English | Spanish | Other languages.

Related resource:

Community Exposures (Non-healthcare)

Individuals exposed to monkeypox can continue their routine daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with infection.

It is recommended that they:

  • Monitor their health for 21 days after their exposure for signs and symptoms of monkeypox.
  • Get vaccinated if they have not already completed a two dose JYNNEOS vaccine series. Getting a dose of vaccine within 4 days after exposure may help prevent infection. Getting vaccinated 4-14 days after exposure may make their infection less severe.
  • Answer calls from Public Health. If they are named as a contact to someone with monkeypox, Public Health may contact them to see if they have developed symptoms and to offer vaccination, if appropriate.

See LAC DPH Monkeypox Guidance for People Who have been Exposed to Monkeypox: English | Spanish | Other languages.

LAC DPH PHL Preparation and Collection of Specimens

Consultation is required before submitting specimens for testing at the LAC DPH PHL. Please be prepared to share photos of the rash and to provide pertinent medical information (e.g., rash onset date, rash type, symptoms, smallpox vaccination date if relevant, exposure history). Specimens received at the Public Health Laboratory without approval will not be tested.

PHL testing may be requested seven days a week during daytime hours:
  • Weekdays 8:30am-5pm: call 213-240-7941
  • Weekends and holidays daytime 8:00am-5pm: call 213-974-1234 and ask for the physician on call.
During the evening (Monday-Sunday 5pm to 8am), providers should collect, store, and label the specimens as outlined in this section and call Public Health for approval in the morning.

Collection

Specimen collection involves vigorous, firm swabbing of lesions (vesicular, pustular, or crusted) with paired sets of DRY synthetic swabs. Swabbing may rupture lesion to release fluid or pus material.

The swab used may be made of flocked or spun synthetic material but should have a shaft that is sturdy enough to enable the lesion to be rubbed vigorously. Do not use an NP swab as the shaft is too flexible and the tip too small to collect an adequate sample. Do not place swabs in any type of transport media; use a screw cap tube or sterile cup for transport of swab.

Dry swabs are required for poxvirus PCR. Paired sets of swab samples are required for testing because monkeypox specific PCR confirmation and clade differentiation is performed as a send-out test to CDC.

Additionally, scabs or crusts may be removed for collection in a dry, sterile container. Serum collected in gold top serum separator vacutainer tube may be collected for serology in selected cases for poxvirus serology.

Storage

Swab and scab/crust specimens should be stored refrigerated and ideally frozen within 1 hour. Serum specimens should be spun and stored refrigerated.

Labelling

Label all specimens with a minimum of two patient identifiers and completely fill out the Public Health Laboratory test request form.

For swabs and scabs/crusts, write in "Orthopoxvirus PCR" in the "Other" box at the bottom of the form.

For serum, write in "Orthopox serology" in the "Other" box at the bottom of the form.

Each specimen needs a separate test requisition form. The Public Health Laboratory test request form can be found here.

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