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Posted on: June 2, 2023

Health Advisory: Potential Risk for New Mpox Cases

June 2, 2023

Action Requested 

  • Be aware that spring and summer could lead to a resurgence of mpox (formerly monkeypox) as people gather for festivals and other events. 
    • U.S. cases of mpox have declined since peaking in August 2022, but the outbreak is not over. CDC continues to receive reports of cases that reflect ongoing community transmission, including a cluster earlier this spring in the Chicago area.
  • Healthcare providers should report suspected mpox cases in Snohomish County to the Snohomish County Health Department within 24 hours.
  • Conduct a thorough patient history to assess possible mpox exposures or epidemiologic risk factors. Mpox is usually transmitted through close, sustained physical contact and has been almost exclusively associated with sexual contact in the current global outbreak. It is important to take a detailed sexual history for any patient with suspected mpox.
  • Perform a complete physical examination, including a thorough skin and mucosal (e.g., oral, genital, anal) examination. Doing so can detect lesions of which the patient may be unaware.
  • Consider mpox when determining the cause of a diffuse or localized rash, including in patients who were previously infected with mpox or vaccinated against mpox. Differential diagnoses include herpes simplex virus (HSV) infection, syphilis, herpes zoster (shingles), disseminated varicella-zoster virus infection (chickenpox), molluscum contagiosum, scabies, lymphogranuloma venereum, allergic skin rashes, and drug eruptions. Specimens should be obtained from lesions (including those inside the mouth, anus, or vagina), if accessible, and tested for mpox and other sexually transmitted infections (STI), including HIV, as indicated. The diagnosis of an STI does not exclude mpox, as a concurrent infection may be present.
  • Mpox can cause severe pain and, particularly during the current epidemic, can commonly affect the anus, genitals, and oropharynx, which can lead to other complications. Assess pain in all patients with mpox virus infection and recognize that substantial pain may exist from mucosal lesions not evident on physical exam. Topical and systemic strategies should be used to manage pain. Pain management strategies should be tailored to the needs and context of an individual patient.
  • Tecovirimat is considered first-line among options that have not been approved by the U.S. Food and Drug Administration to treat eligible patients with mpox. If a clinician intends to prescribe oral tecovirimat, consider seeking access through enrollment in the AIDS Clinical Trials Group (ACTG) Study of Tecovirimat for Human Monkeypox Virus (STOMP) so that the trial can determine efficacy of this drug. This trial includes a placebo-controlled, randomized arm, and an open-label option for individuals with severe disease or those who decline randomization. Remote enrollment is available. For patients not eligible for the STOMP trial or who decline to participate, stockpiled oral tecovirimat is available upon request for mpox patients who meet treatment eligibility (e.g., have severe disease or are at increased risk for severe disease) under CDC’s Expanded Access Investigational New Drug (IND) protocol. More information about evaluating and treating patients can be found on the CDC mpox Clinical Guidance web pages.
  • Vaccination continues to be one of the most important prevention measures. 
    • Vaccine-induced immunity is not complete and CDC expects new cases among previously vaccinated people, but those who have completed the two-dose JYNNEOS vaccine series may experience less severe symptoms.
  • JYNNEOS vaccine can be given as post-exposure prophylaxis (PEP) both to people with known or presumed exposure to the mpox virus. Vaccine can also be given to people with certain risk factors and recent experiences that may make them more likely to have been exposed to mpox. As PEP, vaccine should be given as soon as possible, ideally within 4 days of exposure; however, administration 4 to 14 days after exposure may still provide some protection against mpox. People who are vaccinated should continue to avoid close, skin-to-skin contact with someone who has mpox. JYNNEOS involves 2 vaccine doses given 28 days apart; peak immunity is expected 14 days after the second dose.
    • Previous studies have suggested that JYNNEOS vaccination is protective against mpox. When combined with other prevention measures, vaccination prior to exposure and PEP vaccination strategies might help control outbreaks by reducing transmission of the mpox virus, preventing disease, or reducing disease severity and hospitalization. Duration of immunity after one or two doses of JYNNEOS is unknown.
  • Currently, CDC does not recommend routine immunization against mpox for the general public. Mpox vaccination should be offered to people with high potential for exposure to mpox:
    • People who had known or suspected exposure to someone with mpox.
    • People who had a sex partner in the past 2 weeks who was diagnosed with mpox.
    • Gay, bisexual, and other MSM, and transgender or nonbinary people (including adolescents who fall into any of these categories) who, in the past 6 months, have had
      • A new diagnosis of one or more sexually transmitted diseases (e.g., chlamydia, gonorrhea, syphilis).
      • More than one sex partner.
    • People who have had any of the following in the past 6 months
      • Sex at a commercial sex venue.
      • Sex in association with a large public event in a geographic area where mpox transmission is occurring.
      • Sex in exchange for money or other items.
    • People who are sex partners of people with the above risks.
    • People who anticipate experiencing any of the above scenarios.
    • People with HIV infection or other causes of immunosuppression who have had recent or anticipate potential mpox exposure.
    • People who work in settings where they may be exposed to mpox.
      • People who work with orthopoxviruses in a laboratory.
  • Extensive risk assessment should not be conducted in people who request vaccination to avoid the barriers created by the stigma experienced by many who could benefit from vaccination. People in the community at risk (e.g., gay, bisexual, or other MSM; transgender or nonbinary people) asking for vaccination is adequate attestation to individual risk of mpox exposure. People who previously received only one JYNNEOS vaccine dose should receive a second dose as soon as possible.
  • The following 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 attended a bathhouse or public sex venue or participated in group sex (sex including >3 people at the same time) in the last 6 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 6 months.
    • Individuals who are currently or in the past 6 months have been incarcerated.
    • Individuals who are currently taking PrEP to prevent HIV infection.

See full HAN alert for more information


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