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Hot Topic: Mpox

Information for Healthcare Providers

Reporting Cases of Mpox

All cases of mpox (suspected, probable, and confirmed) must be immediately reported within 24 hours. * Health care providers must report cases of mpox to the local public health authority where the office/facility of the health care provider is located. To report a case and find out where you should be reporting, click here.

*Mpox: Mandatory Reporting of Extraordinary Occurrence of Illness | Technical Bulletin | Nevada Department of Health and Human Services

About Mpox

Mpox is caused by the Mpox virus, in the genus Orthopoxvirus. This is the same genus of viruses as variola virus, which causes smallpox. Symptoms of mpox are similar to those of smallpox, but less severe. Like smallpox, mpox often causes a characteristic rash. However, mpox is rarely fatal. Mpox is not related to chickenpox.

Infection Prevention in Healthcare Settings

Transmission in health care settings has been rarely described. As with all infectious diseases, use of adequate PPE, approved disinfectants, and other infection prevention and control measures promotes safety for healthcare providers, staff, patients, and visitors. Healthcare providers who might encounter patients with mpox or patients exposed to mpox should familiarize themselves with CDC’s recommendations for Infection Prevention and Control of Mpox in Healthcare Settings.

Additional Resources

Recognizing Mpox

While many of the cases reported during the current outbreak have been among gay, bisexual, or other men who have sex with men, it is important to remember that anyone can get mpox, including children.

For information on the course of illness including the incubation period and signs and symptoms, click here.

Pictures and more information are available at the following links:

Although mpox is not considered a sexually transmitted infection (STI), it can spread during intimate physical contact between individuals. Patients with mpox may present to sexual health clinics for care.  A healthcare visit for evaluation of a rash that might be mpox should be an opportunity to connect a patient with other important health services such as evaluating a patients interest in receiving HIV pre-exposure prophylaxis (PrEP), COVID-19 vaccination, or other services should be assessed. Evaluation and treatment of STIs should be performed in accordance with CDC’s 2021 STI Treatment Guidelines. Mpox infection does not preclude coinfection with STIs, varicella, or other pathogens. A patient that has been diagnosed with or is suspected to have mpox may be at risk for sexually transmitted infections.

Take a Thorough History to Determine Level of Suspicion for Mpox – Epidemiologic criteria can help inform evaluation of a rash that might be mpox. A complete sexual and travel history during the past 21 days should be obtained for all patients presenting with symptoms concerning for mpox. Be sure to conduct a thorough physical examination to determine any internal or external lesions.

As soon as mpox is suspected, clinicians should isolate the patient in a single person room and immediately notify the facility’s Infection Prevention staff and the local public health authority.

Testing and Specimen Collection

Patients with a new characteristic rash or who meet one or more of the epidemiologic criteria and in which there is a high suspicion should be tested for mpox.

Partnerships with commercial laboratories have increased testing capacity and access. Commercial labs offering Orthopoxvirus tests include:

Coordination with local public health authorities is not required when ordering a mpox test from a commercial laboratory. However, all suspected cases, including anyone for whom a test is ordered, must be reported to public health authorities. Coordination with public health authorities is required when sending a specimen to the Nevada State Public Health Laboratory or the Southern Nevada Public Health Laboratory.

Note that specimen collection must occur at a healthcare facility and is not offered at commercial laboratory collection centers. Staff performing specimen collection should wear PPE and are strongly encouraged to thoroughly review guidance from CDC and the laboratory performing the test prior to collection. Local public health authorities can provide additional guidance if needed.

Additional Resources

 

Considerations for Clinical Management

Though mpox is rarely fatal, symptoms are often severe and may present a risk of long-term sequelae. Pain and pruritis may be disproportionate to rash appearance. Supportive care and symptom management should be initiated for all patients with mpox infection. Referral to, or consultation with, specialists (e.g., ENT, urology, etc.) should be considered for patients with lesions in areas presenting with special concerns. Patients with severe illness, complications, or risk factors for severe disease might benefit from treatment with medical countermeasures (See Smallpox Treatments for Patients with Mpox, below).

Visit CDC’s websites for the most up-to-date information regarding clinical care of patients with mpox infection:

If a patient who has been exposed to mpox or may have been exposed to mpox presents for care, notify local public health authorities immediately. Refer to CDC’s Monitoring People Who Have Been Exposed for more information.

Additional Resources

Patient Education

Educate patients with mpox:

  • About the expected course of illness (up to 4 weeks) and possible complications.
  • To keep lesions clean, dry and covered after bathing.
  • To isolate and avoid contact with other people and animals, including pets until the rash has healed and a new layer of skin has formed.
  • To wear a well-fitting mask and cover any areas of the skin where lesions are present if the patient must be around others who do not have mpox.
  • To take steps to prevent spread to household members.
  • Discourage patients from using contact lenses to prevent inadvertent ocular infection.

Consider providing informational fliers to patients (i.e. stocking them in exam rooms) and using the CDC provider toolkit for more resources.

Treatment Guidance

The STOMP Trial is recruiting patients to learn if tecovirimat (TPOXX) is a safe and effective treatment for human mpox virus. Click here for more information.

There is currently no treatment approved specifically for mpox virus infections. However, antivirals developed for use in patients with smallpox may prove beneficial against mpox. CDC provides Mpox Treatment Information for Healthcare Professionals and Interim Clinical Treatment Considerations for Severe Manifestations of Mpox.

Individuals with immunocompromising conditions may require early and prolonged treatment. See CDC’s Clinical Considerations for Treatment and Prophylaxis of Mpox Infection in People Who are Immunocompromised.

Supportive Care and Pain Control 

Supportive care for mpox includes pain management, skin and wound care, maintenance of fluid balance, and treatment of bacterial superinfections or co-occurring sexually transmitted infections.

Important aspects of pain management include the following:

  • Use of over-the-counter medications for general pain management
  • Prescription pain medications for short-term management of severe pain
  • Topical steroids and anesthetics for local pain relief (use with caution on open skin or draining wounds)

Please see the CDC’s Clinical Considerations for Pain Management of Mpox for specific treatment steps and tools, including detailed information on pain management for lesions in various locations.

Skin and Wound Care is critical for individuals with mpox. This should include prevention and treatment of secondary bacterial infections (and other complications), ensuring hydration and nutrition, and protecting vulnerable anatomical locations such as the eyes and genitals.

Please see the American Academy of Dermatology Association’s Mpox: Caring for skin and Mpox: Treating severe lesions for more information.

Provider Resources

Coexisting Immunocompromising Conditions

Moderate and severe immunocompromising conditions and treatments may increase the risk of severe, prolonged mpox. These include:

  • HIV infection, particularly in the presence of a low CD4 count (<350 cells/mm3) or in the absence of viral suppression
  • Moderate or severe primary immunodeficiency (e.g., phagocyte disorders, agammaglobulinemia, common variable immunodeficiency disease, severe combined immunodeficiency, DiGeorge syndrome, Wiskott-Aldrich syndrome, ataxia telangiectasia, or any other immunodeficiency with immune dysregulation)
  • Active treatment for a solid tumor or hematologic malignancy
  • Immunosuppressive therapy for solid-organ or islet transplant
  • Active treatment with high-dose corticosteroids (i.e., 20 or more mg of prednisone or equivalent per day when administered for 2 or more weeks), an alkylating agent, antimetabolite, transplant-related immunosuppressive drug, cancer chemotherapeutic agent classified as severely immunosuppressive, tumor necrosis factor (TNF) blocker, or other biologic agent that is immunosuppressive or immunomodulatory
  • Receipt of chimeric antigen receptor (CAR)-T-cell therapy or hematopoietic cell transplant (within 2 years of transplantation or taking immunosuppressive therapy)

Tecovirimat (TPOXX)

  • Should be considered as first line treatment of mpox in people who have advanced or poorly controlled HIV or are otherwise immunocompromised, as they may be at high risk for severe disease. It is important to begin tecovirimat as early as possible in such patients.
  • Should be given IV if there is concern for inadequate or altered oral drug absorption or if the patient is unable to take oral therapy.
  • Consider extending tecovirimat beyond the standard 14-day course on a day-by-day basis.
  • Consider the addition of other therapies (e.g., cidofovir, brincidofovir, and VIGIV).

For further information on TPOXX, cidofovir (commercially available), brincidofovir, and VIGIV for the treatment of individuals with moderate or severe immunocompromise, please see CDC’s Clinical Considerations for Treatment and Prophylaxis of Mpox Infection in People Who are Immunocompromised.

Provider Resources

Tecovirimat (TPOXX)

For most individuals with intact immune systems, supportive care and pain control will be sufficient for mpox management. However, in some patients, supportive care and pain control may not be adequate and treatment should be considered. Tecovirimat (TPOXX) is recommended as first-line therapy for eligible patients with mpox. Please see CDC’s Information for Healthcare Providers: TPOXX for Treatment of Mpox, for additional information.

Oral TPOXX has been prepositioned at various facilities throughout the state, please contact your hospital pharmacy or local health department to find the location nearest you.

Provider Resources

TPOXX- Ordering

STOMP Trial

If you are a provider prescribing tecovirimat (TPOXX) , consider first seeking access through enrollment in the Study of Tecovirimat for Human Mpox Virus (STOMP) trial, which is evaluating the efficacy of this medication for the treatment of mpox. In this study, all adults with severe mpox, severe immunodeficiency, or other noted criteria will be enrolled in the open-label arm to receive oral tecovirimat. Patients should be informed about the clinical trial for tecovirimat (STOMP clinical trial) and encouraged to consider enrollment.

Expanded Access IND Protocol

Tecovirimat (TPOXX) can also be provided under an expanded access protocol. TPOXX is available at prepositioned locations throughout the state; please contact your hospital pharmacy or local health department to find the location nearest you.

An online registry is available for providers and affiliated medical facilities providing tecovirimat (TPOXX) under the CDC-held expanded access Investigational New Drug (IND) protocol to register. All providers must register with the TPOXX IND Online Registry. Please speak with your hospital pharmacy as your facility may already be registered. For additional information, please visit Tecovirimat (TPOXX) IND Registry for Providers and Facilities and Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Mpox.

TPOXX Prescribing Requirements

TPOXX is available for the treatment of mpox under an expanded access investigational new drug (EA-IND) protocol through the CDC. A condensed version of the protocol for providers may be found here. The tecovirimat EA-IND protocol is intended to be used in concert with CDC’s Guidance for Tecovirimat Use.

TPOXX IND Online Registry for Providers and Facilities

New providers and affiliated facilities can register online as participating providers/sites under the CDC-held EA-IND for tecovirimat through the Tecovirimat (TPOXX) IND Online Registry for Providers and Facilities. Detailed information about this registry can be found here.

  • New providers and affiliated medical facilities providing tecovirimat under the EA-IND protocol must register with the tecovirimat IND online registry starting October 28, 2022.
  • Through the registry, providers can submit the following forms electronically:
    • Form FDA 1572
    • Patient Intake Form
    • Clinical Outcome Form
  • The tecovirimat IND Online Registry allows for convenient, time-efficient, and secure completion and return of EA-IND forms to CDC. View this  Fact Sheet for an overview of the tecovirimat IND online registry process. (Please check with your hospital pharmacy first to see if your facility is already registered).
  • Providers who have returned required IND forms prior to the online registry transition are grandfathered in as participating providers under the EA-IND. Any providers with valid email addresses on record should have received emails providing them access to the electronic Patient Intake and Clinical Outcome forms on October 25, 2022.
  • Any questions about the registry and transition to electronic tecovirimat IND Patient Intake and Clinical Outcome forms can be directed to regaffairs@cdc.gov.

Required Documentation:

  1. Informed Consent Form: English [238 KB, 6 pages] Obtain prior to treatment.
    1. Other languages: Spanish [263 KB, 7 pages]
    2. Alternative Consent Forms that can be used to obtain informed consent: 
  2. Patient Intake Form: Baseline assessment. Access the electronic form through the Tecovirimat IND Online Registry.
  3. FDA Form 1572: One signed 1572 and treating clinician’s CV per facility suffices for all tecovirimat treatments administered under the EA-IND at the same facility. Access the electronic form through the Tecovirimat IND Online Registry.
  4. Serious Adverse Events: Per FDA requirement, report life-threatening or serious adverse events associated with tecovirimat by completing a  PDF MedWatch Form [956 KB, 5 pages] and returning it to CDC via email (regaffairs@cdc.gov) within 72 hours of awareness or sooner, if possible. The PDF MedWatch Form can also be downloaded from the FDA website. Note: The MedWatch Form can only be viewed on the Adobe desktop app. Please save or download the form for viewing.

Optional Documentation: 

  • Clinical Outcome Form: Progress and outcome information post treatment. Access the electronic form through the Tecovirimat IND Online Registry.
  • Lesion samples for resistance testing: Lesion samples may be sent to CDC for tecovirimat-treated patient with persistent lesions and/or any new lesions that develop during and/or after tecovirimat treatment to assess for development of antiviral resistance mutations. See Optional Lesion Samples to CDC for Resistance Testing [147 KB, 2 pages] for instructions on collection, storage, and submission of samples.
  • Pharmacokinetic samples for testing: During tecovirimat treatment, plasma samples may be collected to monitor tecovirimat levels for adequate drug exposure in patients. Optional Pharmacokinetic Samples for Testing [375 KB, 4 pages] has instructions on collection, storage, and submission of samples.

For more information about the requirements for obtaining TPOXX, please see CDC’s Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Mpox.

Other Treatment Options (Brincidofovir, VIGIV, Cidofovir)

Brincidofovir

Brincidofovir is a prodrug of cidofovir that isapproved by the FDAfor the treatment of human smallpox disease in adult and pediatric patients, including neonates. Data are not available on the effectiveness of brincidofovir in treating mpox virus infection in people.  However, it has shown to be effective against orthopoxviruses in in vitro and animal studies. Brincidofovir should not be used simultaneously with cidofovir.

For information on treatment of mpox with Brincidofivir, please visit CDC’s Treatment Information for Health Care Professionals.

Vaccinia Immune Globulin Intravenous (VIGIV)

VIGIV is  licensed by FDA  for the treatment of complications due to vaccinia vaccination. However, it is not approved for treatment of mpox. Therefore, CDC holds an expanded access IND protocol that allows the use of stockpiled VIGIV for the treatment of orthopoxviruses (including mpox) in an outbreak.

For information on treatment of mpox with VIGIV, please visit CDC’s Treatment Information for Health Care Professionals.

Cidofovir

Cidofovir is an antiviral medication that is  approved by the FDA  for the treatment of cytomegalovirus (CMV) retinitis in patients with Acquired Immunodeficiency Syndrome (AIDS), and is commercially available as an injection. Data are not available on the effectiveness of cidofovir in treatment of mpox virus infection in people. However, it has shown to be effective against orthopoxviruses in in vitro and animal studies. It is unknown whether a person with severe mpox infection will benefit from treatment with cidofovir, although its use may be considered in such instances. Brincidofovir (a prodrug of cidofovir) may have an improved safety profile over cidofovir.  Serious renal toxicity or other adverse events have not been observed during treatment of cytomegalovirus infections with brincidofovir as compared to treatment using cidofovir. Cidofovir should not be used simultaneously with brincidofovir.

For information on treatment of mpox with VIGIV, please visit CDC’s Treatment Information for Health Care Professionals

Provider Resources

Vaccination Information

Two vaccines may be used for the prevention of mpox disease:

  • JYNNEOSTM vaccine is approved for the prevention of mpox and smallpox and is a series of two doses administered 28 days (4 weeks) apart. During the current outbreak, JYNNEOS is the main vaccine being used in the United. States.
  • ACAM2000 vaccine is approved for immunization against smallpox and made available for use against mpox under an Expanded Access Investigational New Drug (EA-IND) protocol. However, ACAM2000 carries a higher potential for more serious side effects and adverse events than JYNNEOS and may not be an appropriate option for all patients.

People may be vaccinated after exposure to mpox virus to help prevent mpox disease (i.e., post-exposure prophylaxis).

People who are at higher potential for exposure to mpox virus may be offered vaccination to help prevent mpox disease (i.e., pre-exposure prophylaxis).

Because there are limitations in our knowledge about the effectiveness of these vaccines in the current outbreak, people who are vaccinated should be advised to continue to take steps to protect themselves from infection by avoiding close, skin-to-skin contact, including intimate contact, with someone who has mpox.

Jynneos Vaccination 

JYNNEOS Vaccine is available at various public health and other clinics within Nevada. The find the nearest mpox vaccination clinic by zip code, please access the Mpox Vaccine Locator (Breanna please put the link to the page on the OSE website you have that on).

  • The standard regimen for JYNNEOS involves a subcutaneous route of administration with an injection volume of 0.5mL.
  • An alternative regimen involving intradermal administration with an injection volume of 0.1mL was recommended in August 2022 under an Emergency Use Authorization (EUA) to allow more persons to be vaccinated with the vaccine supply available. This option can be used for individuals 18 years of age and older.
  • Either regimen (the standard 0.5 mL subcutaneously or the alternative 0.1mL intradermally) may be used.
  • The Centers for Disease Control and Prevention (CDC) encourages providers to discuss with patients to determine which route of administration each patient prefers (intradermally or subcutaneously).

Who Should be Offered the Mpox Vaccine?

Currently, CDC does not recommend routine immunization against mpox for the general public.

Post-Exposure Prophylaxis (PEP)

  • Mpox vaccine can be given as post-exposure prophylaxis (PEP) both to people with known or presumed exposure to mpox virus.
  • As PEP, vaccine should be given as soon as possible, ideally within four days of exposure; administration 4 to 14 days after exposure may still provide some protection against mpox.
  • Healthcare workers who have been exposed to mpox may benefit from post-exposure prophylaxis (PEP) with the JYNNEOS vaccine, which would ideally be administered within 4 days of the exposure.

Pre-Exposure Prophylaxis (PrEP)

  • Vaccine can also be given to people with certain risk factors and recent experiences that might make them more likely to have been exposed to mpox.
  • Mpox vaccine should be offered to:
    • 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 men who have sex with men, 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); or
      • More than one sex partner.
    • People who have had any of the following in the past 6 months:
      • Sex at a commercial sex venue; or,
      • 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 sexual 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

Mpox Vaccination for Healthcare Providers

The risk of mpox for most front-line healthcare workers is currently low. Mpox virus primarily spreads through close contact and does not spread as easily as respiratory viruses (e.g., influenza and SARS-CoV-2 viruses). Proper use of personal protective equipment and infection control practices are likely to be effective at reducing the risk of transmission of the mpox virus when examining a patient or handling contaminated materials. Reference CDC’s guidance on Infection Prevention and Control of Mpox in Healthcare Settings for the most up-to-date information regarding PPE and other infection prevention strategies.

Mpox Infections after Vaccination

Cases of mpox have been reported in people who have been previously vaccinated. Getting vaccinated is still very important. No vaccine is 100% effective, and infections after vaccination are possible, but they may be milder and less likely to result in hospitalization. For additional information, please visit Mpox Infections after Vaccination | Mpox | Poxvirus | CDC.

CPT Coding Guidance

The Editorial Panel approved the addition of code 87593 to report Orthopoxvirus detection by nucleic acid using amplified probe technique, and two new vaccine product codes (90611, 90622) for the JYNNEOS and ACAM2000 vaccines, respectively. For additional information please see the CPT Assistant Guide.

Additional Resources