Health Advisory: Updated Monkeypox Guidance for Testing, Reporting, Treatment and Vaccination in Snohomish County  

September 16, 2022

Action Requested 

• Be aware of the ongoing global outbreak of monkeypox with local transmission in Snohomish County.

• Consider monkeypox in all individuals with compatible clinical presentation or epidemiologic link to known cases. 

1. Symptoms of monkeypox may include prodromal symptoms (e.g. fever, headache, lymphadenopathy, fatigue, chills, sore throat) and a characteristic rash. Most cases of monkeypox will have a rash which can be located in the mouth or the body including the anorectal mucosa. Rashes typically evolve over time beginning as a maculopapular lesion which then progresses to become vesicles and/or pustules (some with umbilication), before scabbing over and falling off. 
2. Lesions can be mild at first and may be limited to a single relatively small area (particularly the anogenital region). In cases where patients have multiple risk factors (see below criteria for Pre-Exposure Vaccination below for potential risk factor considerations), lower thresholds for testing should be considered.
3. Individuals remain infectious from onset of first symptoms (including prodromal symptoms) until the scabs have fallen off and an intact layer of fresh skin is present for all lesions; typically 2-4 weeks. In some patients who commonly have skin lesions due to other conditions, determining when to end isolation can be difficult.
4. Patients should be counseled by their provider to isolate from time of suspicion of monkeypox until negative test or complete resolution of symptoms. 

• Report all cases of monkeypox immediately to Snohomish Health District at the time of suspicion and/or testing (425-339-3503).

Testing

• Be aware that testing for monkeypox can now be initiated through several commercial laboratories. 

1. Commercial testing is available for providers to use through multiple commercial laboratories including the following partners and does not require Public Health approval of testing: 
   • University of Washington
   • Labcorp
   • Quest Diagnostics
   • Aegis Science Corporation
   • Sonic Reference Laboratory
2. Washington State Public Health Laboratory (WA PHL) may still be used as an alternative to commercial testing with prior approval from Public Health; without prior approval, specimens may not be tested and results may be delayed. Vaccination and Post-Exposure Prophylaxis Guidance  

• Consider post-exposure prophylaxis (PEP) for people with sexual or close intimate contact with an individual with confirmed monkeypox virus infection. 
  1. To date, Snohomish County has been allocated 760 doses of JYNNEOS vaccine for use, an amount much smaller than demand and need. 
  2. Public Health is prioritizing giving the first dose of vaccine to as many people at high risk of recent exposure as possible with the expectation that we will deliver the second dose as close to the 28 day mark as possible, but second doses may be delayed based on demand and availability. 
  3. Vaccination as PEP is being prioritized for high-risk exposures to a person with diagnosed monkeypox virus infection. 
  4. The Centers for Disease Control and Prevention (CDC) recommends that the vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease.
  5. If given between 4 and 14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease.
• Vaccination is also prioritized for people who meet any of the following criteria as part of a strategy known as Pre-Exposure Vaccination [previously PEP++ (PEP plus plus)]: 
  1. Gay, bisexual, or other men or transgender people who have sex with men and who have had multiple or anonymous gay, male bisexual, or transgender sex partners in the last 3 months: 
  2. Methamphetamine use in the last 3 months
  3. People who have exchanged sex for money, drugs, or other purposes in the past 3 months
  4. People who have been sexually assaulted, regardless of gender or sexual orientation.
  5. People who have had sexual contact or prolonged skin-to-skin exposure with people who were exposed to MPV. 
  6. The following minority populations (among those who meet the above criteria) should be prioritized for outreach and for vaccination: 
     • Black, Hispanic/Latinx, Native Hawaiian and other Pacific Islanders, Asian, Indigenous, or American Indian/Alaska Native who are GBMSM.
     • Individuals who have been diagnosed with early syphilis or gonorrhea in the prior year. 
     • Individuals who have attended a bathhouse or public sex venue, or participated in group sex (sex including >3 people at the same time) in the last 3 months.
     • Individuals who have experienced homelessness/unstable housing (including living in a shelter, car, or congregate setting; living with friends or relatives; couch surfing; agricultural workers and seafood workers) in the last 3 months. 
     • Individuals who are currently or in the past three months have been incarcerated. 
     • Individuals who are currently taking PrEP to prevent HIV infection. 
  7. If there is a surplus of vaccine, the following populations should be included: 
     • All individuals who have had multiple or anonymous sex partners in the last 3 months. 
     • Healthcare and public health workers who provide direct care to individuals with syphilis or other STIs.
  8. If your practice does not have JYNNEOS vaccine available, please refer patient to Snohomish Health District at (425) 339-3503 to speak with a public health nurse. Eligible individuals will be referred to a provider who can administer the vaccine.
     • Patients who quality under the Pre-Exposure Vaccination criteria also may fill out the online form linked at www.snohd.org/monkeypox to be connected with a vaccine provider. 

Treatment 

• Consider treatment for confirmed, probable, and high suspicion monkeypox cases with the antiviral tecovirimat (TPOXX) if patients are experiencing severe disease, or are at high-risk of severe disease
  1. Tecovirimat, an FDA-approved antiviral treatment for human smallpox disease caused by Variola virus in adults and children, may be considered for treatment in people with monkeypox virus infection. Its use for monkeypox virus infections is not approved by the FDA but is available for use under a non-research expanded access Investigational New Drug (EA-IND) protocol. 
  2. Severe disease includes those experiencing severe pain, widespread infection, or infection of the eyes.  
  3. Populations at high-risk for severe disease include people with weakened immune systems, children especially those under 8 years of age, people with a history of eczema, and people who are pregnant or breastfeeding. 
  4. The CDC has provided Clinical Guidance | Monkeypox | Poxvirus | CDC  which providers may consider using for determining which patient requires treatment
  5. For the most up-to-date information about the EA-IND process, see CDC's website https://www.cdc.gov/poxvirus/monkeypox/clinicians/obtaining-tecovirimat.html.   
     • A physician with a physician license must be listed as the clinical investigator on the FDA 1572.  Sub-investigators listed on the EA-IND can include physicians or advanced practice providers (APPs).
     • TPOXX in Snohomish County is currently available outpatient through Credena Health Pharmacy Everett.  EA-IND clinical investigators can arrange for TPOXX to be provided to their patients by sending a prescription order to Credena Health Pharmacy Everett   for patient pick up
       • For clinicians who do not have an EA-IND they would need to refer patients to a EA-IND clinical investigator for treatment. For assistance with this please call (425) 339-3503 to speak with a public health nurse.
       • If you are an inpatient facility that would like to pre-position a course of TPOXX at your facility please call (425) 339-3503 to discuss availability.

Infection Prevention and Control  

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  Ensure infection control measures are in place when evaluating patients for monkeypox in your facilities 
  1. Notify infection prevention immediately when a patient seeking assessment for monkeypox is identified.
  2. Patients with suspected monkeypox should be placed in single-person room and no special air-handling is required; intubation and extubation, and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room. 
  3. All personnel entering the patient room are recommended to wear gown, gloves, eye protection, and a NIOSH-approved respirator with N95 or higher filter
  4. Standard cleaning and disinfection procedures should be carried out using EPA registered hospital-grade disinfectant with an emerging viral pathogen claim. Laundry should be handled with standard practices, and promptly contained in a bag and never shaken, avoiding dispersal of infectious lesion materials
  5. Complete infection prevention guidance may be found at the CDC Infection Prevention page 

Background 

Monkeypox virus is a DNA virus in the Orthopox genus and is acquired through close contact with an infected person or animal. In the 2022 global outbreak of monkeypox, contact with infected animals has not been established as a means of transmission. After infection, there can be an incubation period of roughly 1-2 weeks. The virus may be transmitted through direct contact or close contact with an infected person, through contact with objects contaminated with the monkeypox virus, and may be transmitted by a pregnant person to their fetus transplacentally. Although in this current outbreak men who have sex with men are overrepresented, anyone who is in close contact with an infected person or objects contaminated with monkeypox is at risk of developing monkeypox. Most infections in this outbreak resolve within 2-4 weeks of onset, even without treatment but severe outcomes are possible. Immunocompromised persons, persons who are pregnant or breastfeeding, and children and adolescents may be at higher risk of severe disease. 

Local Case Counts 

As of September 16, a total of 29 cases of monkeypox have been identified in Snohomish County.

National and Global Case Counts 

On July 23, 2022, the World Health Organization (WHO) declared monkeypox a global health emergency. As of September 14, 2022, a total of 59,147 laboratory confirmed cases and 489 probable cases in more than 100 countries, including 22 deaths, have been reported to WHO. A total of 22,774 cases have been reported in the U.S., according to the CDC.

Resources 

• Snohomish Health District Monkeypox Information page: www.snohd.org/monkeypox 
• Case Definitions† for Use in the 2022 Monkeypox Response | Monkeypox | Poxvirus | CDC
• Information For Healthcare Professionals | Monkeypox | Poxvirus | CDC 
• Clinical Recognition | Monkeypox | Poxvirus | CDC 
• Clinical Considerations for Monkeypox in Children and Adolescents | Monkeypox | Poxvirus | CDC
• Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding | Monkeypox | Poxvirus | CDC
• 2022 U.S. Monkeypox Outbreak | Monkeypox | Poxvirus | CDC
• Monkeypox | Washington State Department of Health
• Guidelines for JYNNEOS Vaccine Use | Washington State Department of Health