Mpox: Information for Health Care Professionals

Wisconsin DHS Health Alert Network (HAN) messages

• Alert #48: Expanded Mpox Vaccine Eligibility Criteria
• Alert #47: Expanded Mpox Testing Capacity
• Alert #46: Mpox Detected in Wisconsin Resident
• Alert #44: Mpox: Recommendations for Detection and Reporting

Wisconsin Immunization Registry (WIR) inventory management guides

• Managing JYNNEOS Vaccine in WIR, P-03321 (PDF)
• Managing JYNNEOS Vaccine in WIR Guide for Data Exchange Providers Who Do Auto Decrement Inventory, P-03321A (PDF)

Webinars

• DHS - COVID-19 Provider Webinar Series
• CDC (Centers for Disease Control and Prevention) - COCA Call: What Clinicians Need to Know about Mpox in the United States and Other Countries (5/24/22)

DHS fact sheets

• Mpox: What Clinicians Need to Know About Testing, P-03279 (PDF)
• JYNNEOS Vaccine Eligibility Screening Tool, P-03285 (PDF)
• JYNNEOS Vaccine Guidance and Best Practices, P-03286 (PDF)

Webpages

CDC - Mpox: Information For Health Care Professionals

Clinicians should suspect mpox in any patient who presents with a compatible rash-associated illness regardless of the patient’s travel or social history, sexual orientation, or the presence of risk factors for mpox virus infection. However, the CDC reports that most cases of mpox in the U.S. have occurred among gay, bisexual, trans, and other men who have sex with men (MSM).

• The rash associated with mpox involves vesicles or pustules that are deep-seated, firm or hard, and well-circumscribed; the lesions may umbilicate or become confluent and progress over time to scabs.
• Presenting symptoms typically include fever, chills, the distinctive rash, or new lymphadenopathy; however, onset of perianal or genital lesions in the absence of subjective fever has been reported.
• People who know that a sexual partner in the past 21 days was diagnosed with mpox or who had multiple sexual partners in the past 21 days in a jurisdiction with known mpox, may be at higher risk of mpox infection

Clinicians should advise any patient being tested for mpox to isolate at home until results are returned.

Several commercial laboratories have brought on fee for service mpox testing which has greatly increased the capacity to conduct mpox testing in Wisconsin. The Wisconsin State Laboratory of Hygiene (WSLH) and also continues to conduct fee exempt mpox testing. DHS is no longer requiring clinicians to obtain approval from DHS for mpox testing. Patients must have lesions and symptoms consistent with mpox to be eligible for testing at any laboratory.

Patients must have lesions and symptoms consistent with mpox and meet one or more of the following criteria to qualify for fee-exempt testing at WSLH:

• Patient is uninsured or underinsured (for whom cost would pose a barrier to getting tested).
• The patient’s clinician is unable to send specimens to one of the commercial or clinical lab conducting mpox testing.
• Patient is a known contact to a mpox case.
• Patient reported skin-to-skin contact with someone in a social network experiencing mpox activity; this includes men who have sex with men.
• Other priority testing (such as patients from areas with confirmed cases of mpox) as authorized by DHS.

As long as the patient meets one of these criteria, pre-approval from DHS is not needed to test at WSLH. Public health mpox testing at WSLH is conducted Monday through Friday.

Testing resources

Refer to list of resources below for specific testing instructions for each commercial lab.

• WSLH
• Aegis
• Labcorp
• Mayo Clinic
• Quest
• Sonic Healthcare USA

Vaccine effectiveness

The smallpox vaccine can protect people from getting mpox because the mpox virus is closely related to the virus that causes smallpox. Data from previous outbreaks suggests that the smallpox vaccine is at least 85% effective at preventing mpox. Vaccination after exposure to mpox may also help prevent the disease or make it less severe.

Receiving vaccine after exposure to mpox virus

The CDC recommends that the vaccine be given within four days from the date of exposure to prevent the onset of disease. If vaccinated between four and 14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent it. People exposed to mpox within the last three years who have not received the smallpox vaccine should consider getting vaccinated.

The majority of people infected with mpox virus have a mild, self-limited course of disease without the use of specific medical countermeasures or treatments. However, each case should be reviewed on an individual basis by the patient’s clinician. Medical countermeasures may be considered in the following cases:

• People with severe disease:
  • Hemorrhagic disease
  • Confluent lesions
  • Encephalitis
  • Sepsis
  • Requiring hospitalization
• People at high risk for severe disease:
  • Patients with immunocompromising conditions
  • Pediatric populations, especially those under 8 years of age
  • People with a history of or active exfoliating skin conditions
  • Pregnant or breastfeeding people
• People with lesions located in a site that could constitute a special hazard (i.e. eyes, mouth, genitals, anus, rectum)

No treatment is specifically approved for the treatment of mpox. However, antiviral therapies developed for the treatment of smallpox may prove effective in the treatment of mpox. The following therapies are currently available from the Strategic National Stockpile (SNS) only at the request of state or territorial health departments:

• Tecovirimat/TPOXX/ST-246
• Vaccinia Immune Globulin Intravenous (VIGIV)
• Cidofovir (Vistide)/Brincidofovir (CMX001/Tembexa)

Pain management

People diagnosed with mpox may experience severe pain from mucosal or genital lesions that are not evident during a physical examination. Clinicians should utilize pain management strategies that are individualized and patient centered when assessing people with mpox. Validating a patient’s experience can help build trust while providing care.

Over-the-counter analgesics (acetaminophen, NSAIDs) are recommended for general pain control while topical steroids and anesthetics may be used for local pain management. Topical therapies should be used with caution on open wounds and should be used in conjunction with gloves and good hand hygiene to reduce the risk of autoinoculation. Prescription pain medication such as gabapentin or opioids can be prescribed for short-term management of severe pain that is not controlled by other treatments. However, opioid therapy should only be used after careful consideration and if benefits outweigh the potential risk to the patient. For more information about prescribing opioids, see the CDC’s Opioid Prescribing Guideline Resources. Stool softeners or laxatives should be utilized with opioid therapy, especially when rectal lesions or proctitis is present.

Patients diagnosed with mpox may also experience site specific pain or secondary complications including, proctitis or rectal lesions, genital lesions, oropharyngeal lesions, and pruritus/itching. Pain management strategies should be tailored to the needs and context of an individual patient in these circumstances. Stool softeners and sitz baths may be used in conjunction with the above general strategies for rectal lesions or proctitis. Antiseptic and analgesic mouthwash may be considered for patients with oropharyngeal lesions. Secondary bacterial infections including local abscess should be considered and have been documented in association with all of the above specific lesion sites.

Additional pain management guidance, including site-specific recommendations, can be found on CDC’s mpox clinical guidance webpage.

Tecovirmat (TPOXX) may help reduce painful symptoms but should not serve as the primary treatment for pain control. It should only be considered in patients where supportive care and pain control are not enough to manage and relieve symptoms who have or at high risk for severe disease, or have lesions in location that may cause scarring or stricture such as the eyes, mouth, genitals, or anorectal area. Further considerations for the use of TPOXX can be found on the CDC website.

Infection prevention and control recommendations for mpox in health care settings are available from the CDC.

Transmission of mpox through respiratory droplets requires prolonged close (i.e., face-to-face) interaction with a symptomatic person. The majority of health care interactions, including brief interactions and those conducted using appropriate PPE in accordance with standard precautions are not high risk and would not generally warrant post-exposure prophylaxis (PEP). Vaccines for PEP in the event of a high- or intermediate-risk exposures in health care settings are available from the Strategic National Stockpile and must be authorized for Wisconsin residents by DHS.

Mpox is a rare but potentially serious viral illness caused by the mpox virus. Since May 14, 2022, the CDC has been monitoring new clusters of mpox in several countries where the virus is usually not found, including the United States. On July 23, 2022, the World Health Organization declared mpox a global emergency.

Mpox is typically characterized by a new, unexplained rash that develops into characteristic hard, round, fluid- or pus-filled skin lesions. Other early symptoms include:

• Swollen lymph nodes
• Fever
• Headache
• Chills
• Rash

The mpox rash develops within one to three days after fever. However, some people may experience a rash or sores first, followed by other symptoms. Some people may also only develop a rash.

Mpox does not spread easily from person to person. However, anyone can get the disease if they have close, sustained contact with someone who is infected. Mpox spreads through:

• Respiratory droplets
• Close physical contact, including intimate contact like hugging, kissing, or having sex
• Touching sores or body fluids
• Touching personal belonging that have had contact with sores

If you are attending a large event or festival, consider how much close, personal, skin to skin contact is likely to occur to help prevent the spread of mpox.

Children eight years and younger, people who are pregnant or immunocompromised, and individuals with history of atopic dermatitis or eczema may be at especially increased risk for severe outcomes from mpox disease.

If a patient was exposed to mpox, they should monitor for symptoms for 21 days after their date of last exposure. It is important they check their temperature two times per day during their monitoring period. If symptoms begin, they should contact a doctor and immediately isolate away from others.

They can continue daily activities, like going to work or school, if they do not develop any new symptoms. If their partner has mpox, they should avoid sex or being intimate until all sores have healed and a fresh layer of skin has formed. Standard household cleaning products and disinfectants should be used to wash any surfaces and materials that have been touched by someone who has mpox, followed by hand washing. Remember to wash any bedding, towels, or clothing that have had contact with the infectious rash or body fluids.

Patients with mpox should isolate until all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed. People should use their own bathroom if possible and limit exposure to others. They should also limit the use of shared items. Standard household cleaning products and disinfectants should be used to wash any surfaces and materials that have been touched by someone who has mpox, followed by hand washing. Remember to wash any bedding, towels, or clothing that have had contact with the infectious rash or body fluids.

Most people who have mpox recover without needing treatment within 2-4 weeks. While there is no specific treatment for mpox, antiviral medications that have been used to treat smallpox can also be used. People who have been exposed to someone with mpox may receive a vaccine depending on their level of exposure to prevent the onset of disease.

Two vaccines are available for preventing mpox infection in the United States: JYNNEOS (Imvamune or Imvanex) and ACAM2000. JYNNEOS is the preferred vaccine for the current outbreak of mpox. 

Wisconsinites who meet any of the following criteria can get vaccinated:

• Known contacts who are identified by public health through case investigation, contact tracing, and risk exposure assessments
• Presumed contacts who may meet the following criteria:
  • People who know that a sexual partner in the past 14 days was diagnosed with mpox.
• People considered to have elevated risk of exposure to mpox in the future:
  • Gay men, bisexual men, trans men and women, any men who have sex with men, and gender non-conforming/non-binary individuals who:
    • Have recently had multiple or anonymous sex partners. This may include people living with HIV and people who take HIV pre-exposure because of increased risk of sexually transmitted infections.
    • Have new diagnosis of one or more nationally reportable sexually transmitted diseases (for example, acute HIV, chancroid, chlamydia, gonorrhea, or syphilis).
  • People who attended or had sex at a commercial sex venue or an event or venue where there was known mpox transmission or exposure.
  • Sexual partners of people with the above risks.
  • People who anticipate experiencing the above risks.
• People in certain occupational exposure risk groups:
  • Clinical laboratory personnel who perform testing to diagnose orthopoxviruses, including those who use polymerase chain reaction (PCR) assays for diagnosis of orthopoxviruses, including mpox virus.
  • Research laboratory workers who directly handle cultures or animals contaminated or infected with orthopoxviruses that infect humans, including mpox virus, replication-competent Vaccinia virus, or recombinant Vaccinia viruses derived from replication-competent Vaccinia virus strains.Laboratory staff working with lesion swabs that may contain orthopoxviruses. This includes staff that handle swabs of lesions from suspect mpox cases or test for things other than orthopoxviruses, including Varicella zoster virus or Herpes virus. This also includes microbiologists that do standard bacterial cultures from these lesion swabs.
  • Certain health care providers working in sexual health clinics or other specialty settings directly caring for patients with sexually transmitted infections.

People 18 years and older can receive JYNNEOS as either an injection between the skin (intradermally) or beneath the skin (subcutaneously). People under the age of 18 can receive JYNNEOS only as an injection beneath the skin (subcutaneously).

Note: As allocations increase, and the outbreak changes, the criteria of eligible individuals for vaccination will be updated.

Under the emergency use authorization, JYNNEOS may be used in children and adolescents <18 years old. No minimum age is specified.

Providers cannot charge a patient a fee for the vaccine itself. However, providers may charge the patient an administration fee or seek appropriate reimbursement from the program or plan that covers administration fee for the mpox vaccine, such as private insurance or Medicare/Medicaid reimbursement. Providers must administer JYNNEOS at no cost to the recipient regardless of the vaccine recipient’s ability to pay administration fees.

DHS is encouraging anyone who had a known mpox exposure to talk with their health care provider to learn if they are eligible to receive a vaccine. At this time, Wisconsin clinicians should work with their local or Tribal health department (LTHD) to procure vaccine for eligible individuals. As allocations increase, and the outbreak changes, the criteria of eligible individuals for vaccination will be updated and the network of mpox vaccinators throughout Wisconsin will expand.

Clinicians should report suspect or confirmed cases directly to their LTHD. Suspect or confirmed cases can be reported to DHS if a LTHD cannot be reached.

Updated case counts by county can be found on the DHS Mpox Data page. All clinicians should be alert for suspected mpox cases even if a case has yet to be reported in their county.

Unlike other viruses, like the herpes virus, orthopoxviruses do not lie dormant in the body after infection occurs.