Monkeypox: Information for Providers


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Epidemiologic and Clinical Information

In the current global outbreak, including in NYC, most people diagnosed with monkeypox have been men who have sex with men who reported having sex or other intimate contact with someone with monkeypox. However, anyone can get monkeypox, so consider this diagnosis in all patients with consistent signs or symptoms.

See the CDC's Clinical Recognition and Clinician FAQs for information on clinical presentation and photos of monkeypox lesions, and CDC’s clinical considerations in specific populations:


Testing and Precautions

Submit specimens for monkeypox testing to a participating commercial laboratory, including LabCorp, Mayo Clinic Laboratories, Aegis Science, Sonic Healthcare or Quest Diagnostics. Refer to the lab's website for specimen collection and submission guidance.

Testing is also available through the NYC Public Health Laboratory if prior approval is obtained by calling the Provider Access Line at 866-692-3641. See Monkeypox Testing at the NYC Public Health Lab (PDF) for specimen collection and handling guidance. Providers are responsible for relaying results of monkeypox tests to patients. The NYC Health Department cannot provide test results to patients, even when testing is done at the Public Health Lab.

Advise patients waiting for test results to isolate at home, avoid contact with others and monitor their symptoms. If the test result is positive, advise them to continue to follow precautions until all the scabs that form on the skin have fallen off and a fresh layer of skin has formed. This can take two to four weeks from when the lesions first appear.


Vaccination

The JYNNEOSTM vaccine is licensed by the FDA for the prevention of monkeypox infection in people ages 18 and older. Two doses, at least four weeks apart, are indicated. Full immunity from the vaccine is expected two weeks after the second dose.

Supply is limited, and in NYC the vaccine is currently available only through the Health Department.

People who are identified by the Health Department as close contacts of a person with monkeypox will get scheduled appointments to receive two doses of the JYNNEOSTM vaccine for postexposure prophylaxis (PEP). Vaccination within four days of an exposure provides the best chance to prevent monkeypox, and vaccination within five to 14 days may reduce symptoms for people who go on to develop monkeypox.

The Health Department is also conducting expanded PEP (also called PEP plus-plus, or PEP++), which offers an initial dose of the JYNNEOSTM vaccine to people who may be at high risk for recent exposure to monkeypox. Once vaccine supply increases, the Health Department will communicate with people who received a first dose about how to schedule a second-dose appointment. Delay of the second dose is not thought to affect the immune response to the second dose. This strategy allows more people to immediately receive some protection against monkeypox. It is consistent with the monkeypox vaccine distribution strategy in the United Kingdom and Canada.

Eligibility is currently limited to people age 18 years or older who:

  • Identify as gay, bisexual, or other men who have sex with men, or transgender, gender non-conforming, or gender non-binary people AND
  • Report having had multiple or anonymous sex partners in the preceding 14 days

Vaccination with JYNNEOSTM is not indicated for people who have been previously diagnosed with monkeypox, or who have active symptoms that may be due to monkeypox.


Treatment

Supportive care

Skin lesions

  • Keep lesions clean and dry when not showering or bathing to prevent bacterial superinfection.
  • Manage pruritus with oral antihistamines, inert anti-irritant topical agents such as calamine lotion or petroleum jelly, and cooling lotions such as menthol and camphor lotions.
  • Take warm oatmeal baths to reduce pruritus and pain.
  • Seek medical care if they observe an increase in pain, redness, swelling or milky/cloudy fluid at the site of the sores.

Oral lesions

  • Rinse mouth with salt water at least four times a day.
  • Keep lesions clean by using alcohol-free oral antiseptics, such as Listerine® Zero Alcohol or chlorhexidine mouthwash.
  • Suck on ice chips or ice pops to reduce pain, or use compounds such as “magic” or “miracle” mouthwashes used to treat mucositis.
  • Use topical treatments (e.g., DenTek® Canker Covers or benzocaine gels) for temporary pain relief and to facilitate eating and drinking.

Painful genital and anorectal lesions

  • Take warm sitz baths lasting at least 10 minutes several times per day.
  • Use topical benzocaine/lidocaine gels or creams.

Proctitis

  • Use stool softeners such as docusate at the first sign of proctitis.
  • Take sitz baths to calm inflammation.
  • Take pain medications such as acetaminophen and ibuprofen.
  • Apply topical anesthetics such as dibucaine ointment (often used for hemorrhoids) or lidocaine gel.

Gastrointestinal symptoms

  • Control nausea and vomiting with antiemetic drugs.
  • Manage diarrhea with appropriate hydration and electrolyte replacement.
  • Generally, avoid anti-motility agents given the potential for ileus.

Use of gabapentin or opioids should be balanced with the possibility of side effects, such as constipation.

Antiviral treatment

Consider antiviral treatment of monkeypox infection for people with:

  • Severe disease, including confluent lesions or lesions in anatomical areas at special risk of scarring or stricture (e.g., near or involving the eye, mouth, rectum or urethra).
  • Illness complications including proctitis (particularly with tenesmus, challenges in pain control or rectal bleeding), urethritis and phimosis.
  • Increased risk for progression to severe disease, including people who are immunocompromised, pregnant or breastfeeding, have atypic dermatitis or other exfoliative skin conditions, and children.

Tecovirimat (TPOXX or ST-246) is an antiviral medicine available in oral and intravenous formulations through an expanded-access Investigational New Drug (EA-IND) protocol for monkeypox treatment. The CDC recently simplified its IND protocol, allowing any provider to prescribe tecovirimat. Providers can use telemedicine for all patient encounters as long as the patient can submit the signed consent form electronically.

To provide tecovirimat, make sure you facility has submitted an FDA Enrollment Form 1572 to the CDC. Email MPXtherapeutics@health.nyc.gov for assistance with IND enrollment.

To prescribe tecovirimat to eligible individual patients:

  1. Have the patient sign an Informed Consent Form (PDF).
  2. Email the NYC Health Department at MPXtherapeutics@health.nyc.gov to have prescriptions delivered to your site or directly to the patient by the NYC pharmacy courier service.
  3. Submit the completed Patient Intake Form (PDF) and Informed Consent Form (PDF) no more than three days after the patient starts treatment.
  4. Conduct follow-up visits while the patient is on treatment (ideally between days seven and fourteen) and after the patient completes treatment.
  5. Submit a Clinical Outcome Form (PDF) no more than three days after post-treatment follow-up.
  6. Report any serious adverse events within three days of awareness by sending a MedWatch Form to regaffairs@cdc.gov.

Currently, providers and patients receive tecovirimat from a dedicated NYC supply managed by the NYC Health Department’s partner pharmacy. In the future, providers will be able to coordinate with the Health Department to request a supply from the strategic national stockpile to have on site or at their health system’s pharmacy. Email MPXtherapeutics@health.nyc.gov if your facility is interested in maintaining a supply of tecovirimat or serving as a referral site to prescribe tecovirimat for patients who do not have a primary care provider.

Tecovirimat is provided at no cost by the federal government. Patients should not be charged for the medicine, but providers may bill for the encounter.

For more information see Health Advisory #16: Accessing Tecovirimat for People with Monkeypox (PDF, August 2).


Infection Prevention and Control in Health Care Settings