LAC | DPH | Mpox Evaluation

Transmission Modes

Touching
- Direct skin-to-skin contact with sores or scabs for people who may or may not have active symptoms of Mpox
- Direct contact with body fluids of people who may or may not have active symptoms of Mpox (saliva, drainage from skin sores)
Close Interaction
- Talking, coughing, and breathing near someone for a long period of time mainly when living or caring for someone with Mpox
- Contact with respiratory secretions of people who may or may not have active symptoms of Mpox (saliva, face-to-face contact such as kissing, cuddling, sex)
Sharing Items
- Sharing items (clothing, bedding, towels) that previously touched the sores or body fluids of people with Mpox

Disease Course

Disease Stage	Time Window	Transmissibility	Symptom Monitoring or Isolation?
Incubation Period	~3 days – 3 weeks	May be contagious*	Monitor for symptoms and avoid sexual contact**
Prodrome	1 – 4 days	Contagious	Isolate
Rash Stage	2 – 4 weeks	Contagious	Isolate
Recovery	4 weeks or longer	***	***

*Current evidence indicates all persons are infectious with the onset of illness (i.e., rash or other related symptoms), however, some people can also transmit the virus to others up to four days before they develop signs or symptoms (i.e., while presymptomatic). At this time, there is no evidence that persons who are infected but eventually clear the infection without developing illness (i.e., asymptomatically infected) have transmitted the mpox virus to others. Knowledge regarding the means by which mpox virus spreads is evolving and is subject to change.

**Contacts of probable and confirmed cases should be monitored, or should self-monitor daily, for any sign or symptom during a period of 21 days from last contact. Quarantine or exclusion from work are not necessary while no symptoms are evident but known contacts should avoid sexual contact with others during the 21-day monitoring period, regardless of any symptoms.

***A person is contagious until after all the scabs on the skin have fallen off and a fresh layer of skin has formed. The infectious and recovery period may be longer in severe cases.

Reference: CDPH: Clinical Assist Mpox Evaluation Tool: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Mpox/Clinical-Assist-Tool-for-Mpox-Evaluation.aspx

Symptoms

Stage	Stage Duration	Characteristics
Enanthem		Sometimes, lesions first form on the tongue and in the mouth.
Macules	1-2 days	Macular lesions appear.
Papules	1-2 days	Lesions typically progress from macular (flat) to papular (raised).
Vesicles	1-2 days	Lesions then typically become vesicular (raised and filled with clear fluid).
Pustules	5-7 days	Lesions then typically become pustular (filled with opaque fluid) – sharply raised, usually round, and firm to the touch (deep seated). Finally, lesions typically develop a depression in the center (umbilication). The pustules will remain for approximately 5 to 7 days before beginning to crust.
Scabs	7-14 days	By the end of the second week, pustules have crusted and scabbed over. Scabs will remain for about a week before beginning to fall off.

Examples of Mpox Lesions*

Figure 1: Examples of mpox lesions, from CDC Health Alert Network 6/14/22

Other generalized symptoms (can occur prior to rash)
- Fever/Chills
- Exhaustion
- Body Aches
- Headache
- Swollen lymph nodes
- Respiratory symptoms (sore throat, nasal congestion, cough)
People with Mpox may have all or only a few of these symptoms
- Some might develop a rash before or without generalized symptoms
CDPH Clinical Decision Guide: This document provides 10 clinical questions to consider when evaluating your patient to determine Mpox diagnosis o

Link: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Mpox/Clinical-Assist-Tool-for-Mpox-Evaluation.aspx
Table below

Clinical Decision Guide

Mpox Clinical Decision Guide

Clinical Questions	More supportive of Mpox*	Less supportive of Mpox
1. Did the patient have a prodrome?	Yes: Recent cases have presented without an obvious prodrome. However, a patient with a strong epidemiologic link PLUS prodromal symptoms might increase suspicion of mpox. Notably lymphadenopathy is a distinguishing feature of mpox.	No: Recent cases have presented without an obvious prodrome. A patient with an epidemiologic link without prodromal symptoms might decrease suspicion of mpox. Close monitoring should occur for development of a rash or other symptoms.
2. Did the patient develop a rash?	Yes: Most cases to date in California have developed a rash at some point in their course.	No: Some cases have developed anorectal pain, tenesmus or bleeding, but these were from non-visible perianal lesions.
3. Where is the rash?	Uncertain: Classically, mpox rashes have started in the face and extremities then spread to rest of body. In recent cases, rash has often begun in mucosal areas (e.g., genital, perianal, oral mucosa) and in some patients, the lesions have been scattered or localized to a specific body site rather than diffuse and have not involved the face or extremities.	Uncertain: Classically, mpox rashes have started in the face and extremities then spread to rest of body. In recent cases, rash has often begun in mucosal areas (e.g., genital, perianal, oral mucosa) and in some patients, the lesions have been scattered or localized to a specific body site rather than diffuse and have not involved the face or extremities.
4. What is the rash appearance?	Deep-seated and well-circumscribed lesions, often with central umbilication. Lesions progress through specific sequential stages, sometimes rapidly—macules, papules, vesicles, pustules, and scabs. CDC page.	Other presentations of rashes and rashes that do not progress. Remember, rashes in certain stages can be mistaken for other common rash etiologies, including sexually transmitted infections (STIs) such as syphilis, herpes, etc.
5. Is the stage of rash consistent within each body part?	Uncertain: Classically, lesions on each part of the body evolved at the same stage; however, recent cases have had rashes at different stages of progression in the same part of the body.	Uncertain: Classically, lesions on each part of the body are at the same stage; however, recent cases have had rashes at different stages of progression in the same part of the body.
6. Is the rash painful?	Yes: Mpox rash is sometimes very painful (or pruritic) and is often a reason people seek evaluation and/or treatment.	No: Rashes such as those associated with HSV can be painful however other STIs such as syphilis are not typically painful.
7. Did the patient test positive for other rash etiology?	No: Negative test for other etiologies that cause rashes that appear similar to mpox (e.g., VZV, HSV, syphilis) does not rule out mpox entirely. Coinfections with other STIs have been seen with mpox.	Yes: Positive test for other rash etiology, especially one that cause rashes that appear similar to mpox. Coinfections with STIs, particularly syphilis, have occurred in recent cases, so a positive test does not rule out mpox.
8. Was there contact with a known or suspect mpox case?	Contact with lesions or bodily fluids Sexual contacts Household contacts Prolonged (3+ hours) unmasked contact within six feet	Masked contact within six feet Contact with lesions/bodily fluids while wearing PPE Shared airspace contact while at least six feet apart
9. Did the patient recently participate in parties or gatherings involving sex, especially with multiple sex partners? Or did the patient participate in intimate contact at venues where there is sex on premises such as bathhouses or saunas?	Yes: There have been a number of cases and contacts that were associated with sex or extended physical contact in sex-related events, in bathhouses/saunas, and/or with multiple sex partners.	No: No participation or contact with someone who has participated in these activities or attended these venues/events is less suggestive of mpox.
10. Is the patient part of a social group known to have high mpox incidence or vulnerability?	Yes: The majority of cases seen in this outbreak have been in men or transgender persons who have sex with men, however anyone can get mpox.	No: No known linkage to a more vulnerable group or any reported high-risk social or sexual behaviors would be less suggestive of mpox.

^{*While some of the listed factors more strongly suggest an underlying mpox etiology, no one answer is absolute in determining whether to suspect mpox; instead, the collective responses and overall clinical picture should be considered.}

Clinical Considerations for Mpox in Specific Patient Populations

People with HIV

General information
- Low CD4 counts (<200 per mm3 ) can lead to prolonged and a severe form of illness.
- Inadequately treated HIV can lead to higher rates of secondary bacterial infection and prolonged illness
- Co-infections with Mpox and STIs have been reported, and therefore a broad approach to testing is necessary
Next Steps
- Order HIV viral load, CD4 counts, and STI panel
- Start and ensure patient is on anti-retroviral treatment (ART) for HIV. Treat STIs per CDC guidelines.
- Prompt initiation of TPOXX should be considered in patients with Mpox who have advanced or poorly controlled HIV as they might be at high risk for severe disease
- New HIV diagnoses or out of care patients may be referred to the Los Angeles County Rapid and Ready Program by calling 833-351-2298 during weekdays 8am to 5pm or by emailing rapid@ph.lacounty.gov
CDC Guidance for patients with HIV and other immunocompromising conditions who have been exposed to Mpox: https://www.cdc.gov/poxvirus/mpox/clinicians/people-with-HIV.html

People who are pregnant or breast/chestfeeding

General Information
- Pregnant, recently pregnant, and breast/chestfeeding people should be prioritized for medical treatment if needed.
- Treatment for mpox virus should be offered, when indicated, to people who are pregnant, recently pregnant, or breast/chestfeeding.
Next Steps
- Following consultation with CDC, if treatment is indicated, tecovirimat (TPOXX) should be considered the first-line antiviral for people who are pregnant, recently pregnant, or breastfeeding.
  - Impact of TPOXX on reproductive development is limited to animal studies with no specific fetal effects observed in the studies when oral TPOXX was given at levels approximately 23 times higher than the recommended human dosage
  - It is not known if TPOXX treatment during pregnancy can prevent congenital Mpox
  - TPOXX was present in breast milk in animal studies where oral TPOXX was given at levels approximately 23 times higher than the recommended and present in breast milk.
    - It is not known if TPOXX levels in breastmilk are sufficient to treatment a breastfeeding child with Mpox
    - If indicated, then children with Mpox who are breastfeeding should be treated independently.
  - Close monitoring for pregnancy complications is important, and the decision to monitor and/or treat a pregnant person as an outpatient or in the inpatient setting should be on a case-by-case basis.
- CDC Guidance for patients that are pregnant or breast/chestfeeding: https://www.cdc.gov/poxvirus/mpox/clinicians/pregnancy.html

Children and Adolescents

General Information
- Mpox should be considered when children or adolescents present with a rash consistent with Mpox especially if there is an epidemiologic risk factor
- The predominant route of Mpox infection for children is exposure to a household contact with Mpox.
- The predominant route of Mpox infection for adolescents is a sexual contact
Next Steps
- Treatment should be considered on a case-by-case basis for children or adolescents with concern for Mpox and at risk for severe disease or develop complications.
- TPOXX is the first-line medication to treat Mpox in children and adolescents
- Children and adolescents with close contact to people with suspected, probably, or confirmed Mpox may be eligible for post-exposure prophylaxis (PEP)
CDC guidance for children and adolescents that are 18 years of age or younger: https://www.cdc.gov/poxvirus/mpox/clinicians/pediatric.html

Ocular Involvement

General Information
- Involvement of the eyes can be a vision-threatening condition and should be treated urgently.
- Patients should be instructed to avoid touching their eyes and practice hand hygiene while infected.
Next Steps
- Ophthalmology should be involved early in care and systemic antiviral therapy should be considered for all patients with severe mpox, which includes ocular manifestations.
  - Systemic Treatment Options:
    - TPOXX
    - Vaccinia immune globulin intravenous (case-by-case)
  - Topical Treatment Options:
    - Trifluridine (Prolonged use can result in corneal epithelial toxicity)
    - Topical steroids should be avoided to prevent corneal damage and viral persistence
    - Consider topical lubricant and/or antibiotics to prevent bacterial superinfections in patients with corneal disease or corneal ulcer
  - Preventive Measures
    - Frequent handwashing and avoidance of eye rubbing to reduce risk of autoinoculation in patients
- CDC guidance for patients with Mpox ocular infection: https://www.cdc.gov/poxvirus/mpox/clinicians/ocular-infection.html

Severe Mpox Manifestations

Please see the CDC’s MMWR on Severe Manifestations of Mpox for interim treatment considerations in severe cases

Next Steps if you suspect Mpox?

Test the rash of any patient with suspected Mpox
- Instructions for testing
Isolate the patient immediately pending test results
- Stay in private room and ideally have a separate bathroom
- Avoid sharing bedding, towels, or any household items with others
- Instructions for isolation: http://publichealth.lacounty.gov/acd/Monkeypox/docs/MonkeypoxIsolation.pdf
Notify contacts of exposure
Tell patient that a public health nurse will reach out to them within a few days to check on them
- Identify any high-risk close contacts, so they can receive vaccine PEP
Patient can resume limited outdoor activities if:
- Completely cover their lesions AND have been fever-free without use of fever-reducing medications for at least 48 hours
- If not, then patient wait for rash to resolve
  - Shedding of crust on rash AND observation of healthy pink tissue at ALL lesion sites