Mpox

Screening and Triage

• Screen and triage all persons who present with a rash and fever or lymphadenopathy.

• Tell patient exposed to mpox, who doesn’t have signs and symptoms, to continue their daily activities, but to monitor for signs and symptoms for 21 days.

Screening and Triage

• Determine risk factors and presence of severe disease.
• High risk groups
• Children
• Pregnant persons
• Immunosuppressed, including those with advanced HIV
• Patients with acute or chronic skin conditions
• Signs and symptoms of complications
• Nausea and vomiting
• Painful cervical lymphadenopathy causing dysphagia
• Poor oral intake
• Eye pain or vision abnormalities
• Hepatomegaly
• Sepsis
• Dehydration
• Respiratory distress/pneumonia
• Confusion

Screening and Triage

• Determine risk factors and presence of severe disease.
• Laboratory abnormalities
• Elevated AST and/or ALT
• Low BUN
• Low albumin
• Elevated WBC
• Low platelet count

• Test suspected patients for MPX.

Mild or Uncomplicated Mpox

• Instruct patients with suspected or confirmed mpox with mild, uncomplicated disease and not at high risk for complications to isolate at home for the duration of the infectious period.

• Conduct a home assessment to ensure the home environment is suitable for the isolation and that IPC measures can be maintained.

• Tell the patient to isolate in an area separate from other household members and away from shared areas of the home.

• Tell patient that isolation practices should be followed for five days after the development of any new sign or symptom.

• Tell patient to use caution when handling and cleaning linens, household surfaces and during waste disposal.

Mild or Uncomplicated Mpox

• Inform patient that antipyretics can be used for fever and analgesia for pain.

• Teach the patient to rinse the mouth with salt water at least four times per day to soothe oral lesions; consider using oral antiseptics or local anesthetics.

• Tell patient that warm sitz baths and/or topical lidocaine may be used to relieve genital or anorectal lesions.

• Assess nutritional status and encourage adequate nutrition and appropriate rehydration.

• Counsel patients about signs and symptoms of complications that should prompt urgent care.

Mild or Uncomplicated Mpox

• Administer conservative treatment of rash lesions to relieve discomfort, speed healing and prevent complications, such as secondary infections or exfoliation.

• Tell patient to resist scratching, and to keep lesions clean and dry. The rash should not be covered.

• Do not use antibiotic therapy or prophylaxis in patients with uncomplicated mpox; monitor lesions for secondary bacterial infection and if they occur, treat with antibiotics with activity against normal skin flora, including Streptococcus pyogenes and methicillin-sensitive Staphylococcus aureus (MSSA).

Mental Health Care

• Promptly identify and assess for anxiety and depressive symptoms; institute basic psychosocial support strategies and first-line interventions for the management of new anxiety and depressive symptoms. These include providing nonintrusive, practical care and support; assessing needs and concerns; addressing basic needs such as food, water, and information; provide comfort; and refer as needed.

• Use psychosocial support strategies as first-line interventions for management of sleep problems in the context of acute stress.
• Teach the patient about sleep hygiene – avoiding caffeine, nicotine and alcohol before bedtime; and stress management techniques.

Treatment

• Tecovirimat (TPOXX, ST-246)
• Antiviral approved to treat smallpox

• Non-research expanded access Investigational New Drug (EA-IND) to treat mpox in adults and children
• CDC Guidance: https://www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html

• Obtaining and Using Tecovirimat: https://www.cdc.gov/poxvirus/monkeypox/clinicians/obtaining-tecovirimat.html

• Available as pill or injection; capsule can be opened, and medicine mixed with semisolid food for children less than 28.6 pounds

Treatment

• Vaccinia Immune Globulin Intravenous (VIGIV)
• Indicated to treat vaccinia vaccine complications
• Expanded access protocol to treat orthopoxviruses during outbreak

• Cidofovir (Vistide)
• Antiviral for treatment of cytomegalovirus retinitis in patients with AIDS
• Expanded access for orthopoxviruses during outbreak
• Contraindicated in pregnancy or breastfeeding

• Brincidofovir (CMX001, Tembexa)
• Antiviral for the treatment of smallpox
• Contraindicated in pregnancy or breastfeeding
• CDC is currently developing an EA-IND to help facilitate its use for mpox.

Vaccines

• JYNNEOS
• Approved for the prevention of mpox and smallpox
• CDC Interim Guidance
• https://www.cdc.gov/poxvirus/monkeypox/interim-considerations/jynneos-vaccine.html

• ACAM2000
• Approved for immunization against smallpox; available for use against mpox under EA-IND protocol
• Contraindicated in pregnancy or breastfeeding
• Medication Guide
• https://www.fda.gov/media/75800/download

Infection Prevention and Control at Health Facilities

• Implement contact and droplet precautions for any suspected or confirmed patient with mpox. Implement airborne precautions if varicella zoster virus is suspected and until it is excluded.

• For confirmed mpox infection, use respirators.

• Implement airborne precautions if aerosol-generating procedures are performed.

• Clean and disinfect areas within the health care facility frequently used by the patient or where patient care activities occur; clean and disinfect patient care equipment per guidelines.

Infection Prevention and Control at Health Facilities

• Collect and handle linens, hospital gowns, towels and any other fabric carefully.

• Treat all bodily fluids and solid waste of patients with mpox as infectious waste.

• Limit visitors.
• Visitors should have no direct contact with patient with mpox.
• Institute measures to support patient interaction with family and visitors.

Sexually Active Populations

• Advise patients to abstain from sex until all skin lesions have crusted, the scabs have fallen off and a fresh layer of skin has formed underneath.

• Consider and assess for coinfection with other sexually transmitted infections.

• Encourage consistent condom use during sexual activity for 12 weeks after recovery.

During and After Pregnancy

• Monitor pregnant or recently pregnant persons with mild or uncomplicated mpox; admit those with severe or complicated disease to optimize supportive care or interventions to improve maternal and fetal survival.

• Provide access to respectful, skilled care, as well as mental health and psychosocial support. Screen birth companion; if companion has suspected or confirmed mpox, arrange for alternative, healthy companion.

• Individualize mode of birth based on obstetric indications and the patient’s preferences.

• Encourage those who have recovered from mpox to receive routine care, as appropriate.

Infants and Young Children

• Monitor newborn infants closely for evidence of potential congenital or perinatal exposure or infection, or exposure through close contact.

• Fully vaccinate children exposed to mpox according to the immunization schedule and have their vaccinations up to date.

• Pay particular attention to keeping lesions covered and preventing children from scratching lesions or touching their eyes, which can result in auto-inoculation and more severe illness.

Infant Feeding

• Assess infant feeding practices, including breastfeeding, on a case-by-case basis, considering the general physical status of the parent and severity of disease, which could impact the risk of transmission.
• Direct contact between a patient in isolation for mpox and their newborn is not advised.
• Breastfeeding should be delayed until criteria for discontinuing isolation have been met.

High-Risk Patients and Those with Complications or Severe Mpox

• Admit patients at high risk for complications (i.e., young children, pregnant persons and those who are immunosuppressed) or those with severe or complicated mpox for monitoring and care.

• Manage patients who develop complications or severe disease with optimized supportive care interventions.
• Skin exfoliation
• Necrotizing soft tissue infection
• Pyomyositis
• Cervical adenopathy
• Ocular lesions
• Pneumonia
• Acute respiratory distress syndrome (ARDS)
• Severe dehydration
• Sepsis and septic shock
• Encephalitis
• Nutritional considerations

• Counsel patients about access to follow-up care; tell them to monitor for any persistent, new or changing symptoms and to seek medical care as needed.

After Acute Infection

• Use appropriate IPC measures when handling human remains of deceased individuals with mpox.

Deceased Patients

• Ensure an assessment and management plan for staff with occupational exposure to mpox.

Exposed Health Workers