Mpox resources for health care providers

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The Colorado Department of Public Health and Environment monitors cases of mpox (monkeypox) statewide. Anyone who has been in close contact with someone who has mpox can get the illness. At this time, cases are predominantly occurring in gay, bisexual, and other men who have sex with men.

    Before the patient visits, learn how to recognize mpox lesions. Consult CDC’s Clinical Recognition webpage for photographs of what lesions can look like. 

    Patients with mpox may have a new, maculo-papular rash that develops into vesicles and then pustules. Lesions may be deep-seated, firm, well-circumscribed, and umbilicated. 

    The rash may be: 

    • Anywhere on the body, including palms, soles, and anogenital region. 
    • Localized to a specific body site or diffuse. 
    • The only symptom patients experience. 
    • Painful, painless, or itchy. 

    Patients may also have: 

    • Fever, headache, malaise, chills, and lymphadenopathy. 
    • Anorectal pain, rectal bleeding, or tenesmus in association with visible perianal skin lesions and proctitis.

    Infection control precautions can lower the risk of mpox transmission. These include:

    • Isolation of suspected mpox patients in a single room with the door closed. No special air handling is necessary, including during sample collection.
    • Disinfection following standard cleaning procedures, using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim. See EPA List Q.
    • Hand hygiene. Wash hands frequently with soap and water or use hand sanitizer with at least 60% alcohol. 
    • Proper PPE use. Follow Standard Precautions PPE recommendations for all patients. with suspected or confirmed mpox patients. PPE should include gown, gloves, eye protection, and NIOSH-approved respirator with N95 or higher filters. 

    Consult CDPHE’s Mpox Infection Control Guidance for Outpatient Settings and CDC’s Infection Prevention and Control of Mpox in Healthcare Settings for more detailed guidance on how to manage occupational exposures as well as protecting health care workers from transmission in the workplace.

      Use the following tools to determine risk and monitor symptoms after exposure to mpox in health care settings:

      Workers with high or intermediate risk exposures should monitor themselves daily for symptoms and contact a health care provider to discuss prophylactic vaccination with the Jynneos vaccine.

        Although most cases in the current outbreak to date have occurred among gay, bisexual, and other men who have sex with men, any patient, regardless of sexual or gender identity, with rash consistent with mpox should be considered for testing.

        False positive test results are possible, so pre-test probability should be considered when determining whether to pursue mpox testing. In some populations, like children and adolescents, the overall risk of exposure to mpox in the current outbreak is low. In otherwise low-risk individuals, identification of a possible exposure by taking a thorough history and/or a very suspicious clinical presentation are important factors that increase pre-test probability.

        Ask the patient - In the last 21 days, have you:

        • Had close or intimate contact with someone with a similar rash or confirmed mpox infection? 
        • Had close or intimate contact with someone in a social network experiencing mpox transmission?
          • Most U.S. cases have been among gay, bisexual, and other men who have sex with men, many of whom had anonymous sex with someone they met on dating apps or sex with multiple partners at venues or events where anonymous sex is common.

        Answering “yes” to either of the questions above should increase clinical suspicion for, and the pre-test probability of, mpox.

          No special training or materials are necessary for mpox testing. Most providers should be able to safely collect specimens using appropriate PPE. Specimens can be tested at one of six commercial laboratories: Labcorp, Mayo Clinic Laboratories, Quest Diagnostics, Aegis Sciences, Sonic Healthcare USA, and ARUP Laboratories. 

          Commercial testing is strongly encouraged when covered by insurance. Follow specimen collection instructions for the specific commercial laboratory and/or CDC’s Preparation and Collection of Specimens for information on how to collect and ship mpox specimens.

          Testing is also available at CDPHE and requires prior approval. The CDPHE lab can be used to test specimens for people who are uninsured or underinsured. Order testing via Lab Online or call (303) 692-2700. Consult CDPHE’s Guidance for mpox specimen collection

            Before a patient with suspected mpox leaves the appointment, share resources on how to prevent transmission at home effectively. Consider printing and/or sharing links to CDPHE’s home isolation guidance and household disinfection guide. CDC’s Isolation and Infection Control At Home page also has information about preventing transmission at home.

            In some highly suspicious cases, empiric mpox treatment may be initiated prior to a positive test result. Consider whether your patient has an indication for treatment with tecovirimat (TPOXX) or other medications including pain management. Email tpoxx@state.co.us to learn more or to request TPOXX. Additional information on treatment is below.

              Inform the patient of their test results. If the test is positive, counsel the patient to expect a call from public health for a confidential interview about recent close contacts. It is important to answer calls from public health with the knowledge that no personally identifying details from these conversations will be released. Patients can learn more about how to notify contacts, including the use of anonymous notification systems, at CDC’s Notifying Close Contacts webpage.

              Consider whether your patient has an indication for treatment with tecovirimat (TPOXX) or other medications including pain management. Email tpoxx@state.co.us to learn more or to request TPOXX. Additional information on treatment is below.

                Medical countermeasures are available for use in the treatment of mpox when indicated. The most commonly used treatment is tecovirimat, or TPOXX, which is available in oral and IV formulations under an Investigational New Drug (IND) protocol. The IND protocol has been simplified to ease the administrative burden. However, a treating health care provider must still complete some IND paperwork when administering TPOXX to patients.

                Indications
                People who may be eligible for treatment may include, but is not limited to:

                • Immunocompromised people.
                • Children, especially those younger than aged 8 years.
                • Pregnant or chest/breastfeeding people.
                • People with certain skin conditions, such as atopic dermatitis, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper rash, psoriasis, or Darier disease (keratosis follicularis).
                • People with one or more complications, such as secondary bacterial skin infection; severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; or another underlying health condition.

                Some people may also be eligible for TPOXX for pain management or preventive reasons, such as having a lesion near their eye. Ocular lesions, including mpox keratitis or conjunctivitis, are considered emergent given the risk of vision loss and hospitalization may be required to promptly initiate treatment and coordinate ophthalmology care. 

                In some highly suspicious cases, empiric treatment may be initiated prior to a positive test result.

                Role of public health
                CDPHE does not administer or dispense medication directly to patients. Public health officials at CDPHE are available to discuss treatment with providers and consult CDC clinical experts as appropriate. Consultation with CDC is recommended in severe cases, pediatric cases, pregnant cases, cases with ocular involvement, or other complicated cases. Call 303-692-2700 or 303-370-9395 (after hours for urgent and/or time-sensitive needs only), or email tpoxx@state.co.us to request clinical consultation.

                CDPHE currently has medication on-hand to facilitate timely administration and can courier TPOXX as needed seven days a week during business hours. If your facility or health system does not have TPOXX on hand, providers must contact public health to request TPOXX. Call 303-692-2700 or 303-370-9395 (after hours for urgent and/or time-sensitive needs only), or email tpoxx@state.co.us to request this treatment. 

                  Some people who have been recently exposed to mpox, or are at high risk for exposure, should receive the Jynneos vaccine. Colorado currently has a limited supply of the vaccine from the federal government.

                  Those who currently qualify for vaccination are:

                  • Anyone (any sexual orientation or gender identity) who has had close physical contact with someone who has mpox in the last 14 days.
                  • Anyone (any sexual orientation or gender identity) who: 
                    • Has multiple or anonymous sexual partners, or
                    • Has close physical contact with other people in a venue where anonymous or group sex may occur, or
                    • Was diagnosed with gonorrhea or syphilis in the past six months, or
                    • Is living with HIV, or
                    • Already uses or is eligible for HIV PrEP (medication to prevent HIV, e.g. Truvada or Descovy or Apretude), or
                    • Engages in commercial and/or transactional sex (e.g. sex in exchange for money, shelter, food, and other goods or needs).
                  • Anyone (any sexual orientation or gender identity) identified by public health as a known high-risk contact of someone who has mpox.
                  • Anyone whose sexual partner identifies with any of the above scenarios.

                  Anyone who meets these criteria should talk with a health care provider to determine whether vaccination is right for them. 
                   
                  Due to limited data on the safety and effectiveness of the Jynneos vaccine in children, Coloradans should consult with their child’s primary care provider and/or local public health agency before seeking vaccination for their child, especially for younger children. Shared decision-making between the family, child’s health care provider, and/or local public health agency should take into account the level of risk from the child’s exposure to mpox and risk of severe disease. 

                  Some children may benefit from alternative options for post-exposure prophylaxis. Data shows that the Jynneos vaccine may not work well to protect infants aged 6 months and younger from mpox illness. In these cases, public health will consult with Centers for Disease Control and Prevention and the child’s primary care provider to discuss available options.

                  CDPHE-hosted clinics can vaccinate eligible people aged 15 years and older. Parents and guardians of children younger than 15 years who may need to be vaccinated should contact their health care provider or local public health agency. Parental/guardian consent is required to administer the Jynneos vaccine to anyone under the age of 18 years. In addition to parental/guardian consent, minors aged 15 to 17 must also sign a formal agreement to receive the vaccine. 

                  For a list of vaccine providers in Colorado, consult CDPHE’s Where to get vaccinated for mpox webpage. For additional information, consult CDC’s Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines during the 2022 U.S. Mpox Outbreak

                    Sign up for Colorado HANs at https://conotification.state.co.us/ to receive continued updates on mpox and other public health issues.