Monkeypox (MPX) Information For Health Professionals - Minnesota Dept. of Health

Monkeypox (MPX) Information For Health Professionals

On this page:
Reporting monkeypox
Clinical presentation
Testing and specimen submission
Infection control
Vaccine
Treatment
Health advisories and resources

Reporting monkeypox

  • Reporting Orthopox Virus
    Monkeypox is caused by an Orthopoxvirus. All suspected cases of orthopox virus must be reported to MDH immediately 24 hours a day, seven days a week.
    • Call 651-201-5414 or 877-676-5414 immediately if monkeypox is suspected or to report Orthopoxvirus.
      Infectious Disease Epidemiology, Prevention and Control staff are available for disease consultation 24 hours a day, seven days a week.

Clinical presentation

Clinical disease may start with a prodrome lasting 1-4 days prior to any rash. Prodrome often includes lymphadenopathy, malaise, headache, myalgia, fever, and fatigue. The rash can be deep-seated, vesicular or pustular with lesions that are well circumscribed and umbilicate. The evolution of the rash usually progresses through four stages—macular, papular, vesicular, to pustular—before scabbing over and resolving. Generally the rash progress through the four stages synchronously across the body. Lesions are often described as painful until the healing phase when they become itchy (crusts).

Recent monkeypox cases suggest a less classic symptom presentation, which includes:

  • Absence of the typical prodrome period of fever, tiredness, or swollen lymph nodes.
  • Atypical rash presentation:
    • Few lesions, sometimes small, and present very similar to herpes viruses, syphilis, chickenpox, and other rash differentials.
    • Starts around the anus or genitals and does not always result in a disseminated rash across the body.
    • Stages of rash do not always progress in a synchronous fashion.
  • Symptoms such as anorectal pain, tenesmus, and rectal bleeding caused by ulcerative skin lesions and proctitis have been reported.
  • Dual infection with syphilis, HSV or VZV has been reported in individuals with monkeypox. Testing lesions consistent with monkeypox should be performed even if lesions from other infections are observed or identified.

More information: CDC: Monkeypox: Clinical Recognition

Monkeypox should be suspected in:
  • An individual with a new unexplained acute rash,
    OR
  • An individual who within 21 days of symptoms has had:
    • Contact with a person or people with a similar appearing rash or who received a diagnosis of confirmed or probable monkeypox
      OR
    • Close or intimate in-person contact with individuals in a social network experiencing monkeypox activity, this includes men who have sex with men (MSM) who meet partners through an online website, digital application (“app”), or social event (e.g., a bar or party)
      OR
    • Traveled outside the US to a country with confirmed cases of monkeypox or where Monkeypox virus is endemic
      OR
    • Contact with a dead or live wild animal or exotic pet that is an African endemic species or used a product derived from such animals (e.g., game meat, creams, lotions, powders, etc.)

MDH also encourages evaluating and testing for other common rash illnesses including syphilis, herpes simplex, and chickenpox if indicated.

Testing and specimen submission

Please call MDH at 651-201-5414 or 1-877-676-5414 before sending any specimens to MDH-PHL.
Preliminary screening for Orthopoxvirus will be performed at MDH-PHL using real time PCR.

Turnaround time for testing at MDH-PHL is 1-2 business days. Specimens that test positive will be forwarded to CDC for confirmatory testing for monkeypox.

Dry swabs of lesion fluid, lesion surface and/or lesion crust are acceptable specimen types. Dry swabs are required (do not put swab in viral transport media). Lesion crusts may be submitted with a dry swab specimen.

  • Use only dry nylon, polyester, or Dacron swabs.
  • Vigorously swab the lesion with a sterile dry swab.
  • Submit two swabs per lesion: one for screening at MDH-PHL and one for confirmatory testing. If more than one lesion, sample at least two different sites.
  • Place the paired swabs into a dry sterile vial (not urine) for each site swabbed.
  • Keep specimens cold:
    • Refrigerate within one hour of collection.
    • Ship at refrigeration temperature. Ice packs may be used to maintain refrigeration temperature during shipment.
  • Label each vial with:
    • Two unique patient identifiers (e.g., patient name, date of birth) that match the patient information provided on the specimen submission form.
  • For each specimen (i.e. each vial containing 2 swabs), fill out:
  • If any of the above criteria are not met, the sample(s) will be rejected.
  • Send specimens to arrive Monday-Friday between 8:00 a.m. and 4:30 p.m. to:
    MDH Public Health Laboratory
    Attn: Biological Accessioning
    601 Robert St. N
    St. Paul, MN 55155-2531
  • For help with packaging and shipping, call MDH-PHL Biological Accessioning at 651-201-4953
  • Note: Patient should be sent home and told to isolate until monkeypox is ruled out.

For more information on collecting and submitting specimens: Clinical Laboratory Guide to Services - Monkeypox.

Consider testing for other rash illnesses, such as syphilis, herpes simplex, and varicella, using your standard reference laboratory if indicated.

Infection Control

Health care providers evaluating individuals for suspected monkeypox should use a combination of standard, droplet and contact precautions when patients present with fever and/or vesicular/pustular rash.

Providers should wear gloves, gown, eye protection and an N95 respirator. The patient should be placed in a negative pressure room if any aerosol-generating procedures occur.

Vaccine

Two vaccines are currently authorized or approved in the U.S. to prevent MPX, JYNNEOS and ACAM2000. JYNNEOS is currently being used internationally to address MPX. Vaccine is prioritized for people exposed to known MPX cases for post-exposure prophylaxis (PEP). Ideally vaccination should be received within 4 days of the first day of exposure to prevent disease but can be given up to day 14 to reduce the severity.

Vaccine may also be given to people at high-risk, with a high potential for exposure to a case (expanded PEP). The Advisory Committee on Immunization Practices (ACIP) recommends pre-exposure prophylaxis (PrEP) for certain individuals with a high risk of occupational exposure. However, most clinicians and laboratorians are not advised to receive PrEP at this time.

More information:

Treatment

There is currently no specific treatment that is either FDA approved or has an emergency use authorization (EUA) for monkeypox infection. However, antivirals developed for use in the treatment of smallpox, such as tecovirimat (TPOXX), may prove beneficial for some individuals.

For patients with intact immune systems, supportive care and pain control may be enough. However, in certain individuals, including those that are immunocompromised, have severe disease or lesions in anatomically concerning areas of the body, supportive care and pain control may not be enough. In these cases, treatment should be considered. Treatment should be considered for use in people who have the following clinical manifestations:

  • Severe disease — consider severe disease when a patient has conditions such as hemorrhagic disease; large number of lesions such that they are confluent; sepsis; encephalitis; ocular or periorbital infections; or other conditions requiring hospitalization.
  • Involvement of anatomic areas which might result in serious sequelae that include scarring or strictures — these include lesions directly involving the pharynx causing dysphagia, inability to control secretions, or need for parenteral feeding; penile foreskin, vulva, vagina, urethra, or rectum with the potential for causing strictures or requiring catheterization; anal lesions interfering with bowel movements (for example, severe pain); and severe infections (including secondary bacterial skin infections), especially those that require surgical intervention such as debridement.

Treatment should also be considered for use in people who are at high risk for severe disease:

  • People currently experiencing severe immunocompromise due to conditions such as advanced or poorly controlled human immunodeficiency virus (HIV), leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient of a hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component.
  • Pediatric populations, particularly patients younger than 8 years of age.
  • Pregnant or breastfeeding people.
  • People with a condition affecting skin integrity — conditions such as atopic dermatitis, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease (keratosis follicularis).

More information on the specific conditions described above can be found at CDC: Interim Clinical Guidance for the Treatment of Monkeypox.

For patients at high risk for progression to severe disease, treatment should be administered early in the course of illness along with supportive care and pain control.

The current therapeutics available under expanded access protocols held by CDC are listed below.

Tecovirimat (TPOXX)

Tecovirimat (TPOXX) is an antiviral developed for the treatment of smallpox that is currently available through an Expanded Access – Investigational New Drug (EA-IND) held by CDC. Currently TPOXX is being utilized in the treatment of some patients with monkeypox. TPOXX is still in investigational status but is widely available, and recent evidence suggests it is well tolerated, with few side effects. Refer to MMWR: Clinical Use of Tecorvirimat (Tpoxx) for Treatment of Monkeypox Under an Investigational New Drug Protocol for more information.

Because TPOXX is an investigational drug, it is only available in consultation with MDH, or in those health systems that have completed the necessary regulatory paperwork, including FDA Form 1572. It is not available in outpatient pharmacies, and providers wish to prescribe but are not part of health systems with a current stock of TPOXX will need to work directly with MDH to ensure the necessary investigational requirements are completed prior to obtaining TPOXX.

If you are interested in obtaining TPOXX or would like a consult on use or regulatory affairs, you can email health.tpoxx@state.mn.us.

Clinical guidance and reporting requirements are available at CDC: Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox.

Vaccinia Immune Globulin Intravenous (VIGIV)

VIGIV is licensed by FDA for the treatment of complications due to vaccinia vaccination. CDC holds an expanded access protocol that allows the use of VIGIV for the treatment of orthopoxviruses (including monkeypox) in an outbreak. Refer to the Package Insert – VIGIV for more information.

If there is a patient you think meets clinical criteria for VIGIV treatment, providers should contact the MDH infectious disease line at 651-201-5414 for more information.

Cidofovir (also known as Vistide)

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). Data are not available on the effectiveness of cidofovir in treating human cases of monkeypox. However, it has shown to be effective against orthopoxviruses in in vitro and animal studies. CDC holds an expanded access protocol that allows for the use of stockpiled cidofovir for the treatment of orthopoxviruses (including monkeypox virus) in an outbreak.

If there is a patient you think meets clinical criteria for VIGIV treatment, providers should contact the MDH infectious disease line at 651-201-5414 for more information.

Monkeypox Health Advisories and Resources

Updated Friday, 23-Sep-2022 16:20:00 CDT