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Clinical Assist Tool for Monkeypox Evaluation

August 3, 2022

Related Materials: Latest CDC Monkeypox Health Alert (cdc.gov) | Latest California Monkeypox Health Alert | CDC Health Alert Network (HAN) | California Health Alert Network (CAHAN) | Monkeypox Q&A

 

Background and Summary:

The California Department of Public Health (CDPH) continues to work with local health departments (LHDs) and California healthcare providers on the ongoing monkeypox outbreak impacting the United States and other countries not usually endemic for monkeypox. Reports from investigations in several countries and the U.S., including in California, suggest that person-to-person transmission through close contact is fueling spread, and that clinical case presentations have not always been characteristic of classic monkeypox infections.

Evaluation for Suspected Monkeypox Cases:

Monkeypox spreads between people primarily through direct contact with infectious sores, scabs, or body fluids. It also can be spread by respiratory secretions during prolonged face-to-face contact. Monkeypox can spread during intimate contact between people, including during sex, as well as activities like kissing, cuddling, or touching parts of the body with monkeypox sores. At this time, it is not known if monkeypox can spread through semen or vaginal fluids. A persons should be considered a suspect case if they have  a new characteristic rash OR if they have risk factors for monkeypox exposure and  clinical suspicion for monkeypox. Features of the typical disease course are shown below:

Disease Stage 

Time window

Transmissibility

Symptom Monitoring or Isolation?

Incubation Period

1 – 2 weeks

Not contagious

Monitor for symptoms

Prodrome

1 – 4 days

Possibly contagious

Isolate

Rash Stage

2 – 4 weeks

Contagious

Isolate

Recovery

4 weeks or longer

*

*

* A person is contagious until after all the scabs on the skin have fallen off and a fresh layer of skin has formed

In addition, while it is still unknown if monkeypox can be transmitted via genital secretions, individuals should consider use of condoms during sexual activities for 12 weeks after infection as a precautionary measure.

Physical Exam:

  • The rash associated with monkeypox classically 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. However, presentations in this outbreak have not always been classic. Patients have experienced rashes without prodromal symptoms, rashes that are at different stages within an affected area, or rashes that do not involve the face or extremities but only the genital and/or perianal areas.

  • Clinicians should perform a thorough skin and mucosal (e.g., anal, vaginal, oral) examination for the characteristic vesicular or pustular rash of monkeypox; this allows for detection of lesions of which the patient may not have previously been aware.

Figure 1: Examples of monkeypox lesions, from CDC Health Alert Network 6/14/2022

MonkeypoxImages

Figure 2: Photo credit – General Hospital University of Malaga  

monkeypox lesions

Clinical Decision Guide:

Clinical QuestionsMore supportive of MonkeypoxLess supportive of Monkeypox
1.       Did the patient have a prodrome (fevers, chills, headache, lymphadenopathy, flu-like symptoms)?Yes: recent cases have presented without an obvious prodrome. However, a patient with a strong epidemiologic link PLUS prodromal symptoms might increase suspicion of monkeypox. Notably lymphadenopathy is a distinguishing feature of monkeypox.No: recent cases have presented without an obvious prodrome. A patient with an epidemiologic link without prodromal symptoms might decrease suspicion of monkeypox – close monitoring should occur for development of a rash or other symptoms.
2.       Did the patient develop a rash?Yes: all cases to date in California have developed a rash at some point in their course.No: some cases have developed anorectal pain, tenesmus or bleeding, but these were from non-visible perianal lesions.
3.       Where is the rash?Uncertain: Classically, monkeypox rashes have started in the face and extremities then spread to rest of body. In recent cases, rash has often begun in mucosal areas (e.g., genital, perianal, oral mucosa) and in some patients, the lesions have been scattered or localized to a specific body site rather than diffuse and have not involved the face or extremities.Uncertain: Classically, monkeypox rashes have started in the face and extremities then spread to rest of body. In recent cases, rash has often begun in mucosal areas (e.g., genital, perianal, oral mucosa) and in some patients, the lesions have been scattered or localized to a specific body site rather than diffuse and have not involved the face or extremities.
4.       What is the rash appearance?Deep-seated and well-circumscribed lesions, often with central umbilication. Lesions progress through specific sequential stages, sometimes rapidly—macules, papules, vesicles, pustules, and scabs.Other presentations of rashes and rashes that do not progress. Remember, rashes in certain stages can be mistaken for other common rash etiologies, including sexually transmitted diseases (STDs) such as syphilis, herpes, etc.
5.       Is the stage of rash consistent within each body part?Uncertain: Although lesions on each part of body classically are at the same stage, recent cases have had rashes at different stages of progression in the same part of the body.Uncertain: Although lesions on each part of body classically are at the same stage, recent cases have had rashes at different stages of progression in the same part of the body.
6.       Is the rash painful?Yes: Monkeypox rash is sometimes very painful and is often a reason people seek treatment.No: Rashes such as those associated with HSV can be painful however other STDs such as syphilis are not typically painful.
7.       Did the patient test positive for other rash etiology?No: negative test for other etiologies that cause rashes that appear similar to monkeypox (e.g., VZV, HSV, syphilis). Coinfections have been seen with STDs, particularly syphilis, so positive test for an STI may not completely rule out monkeypox.Yes: positive test for other rash etiology, especially one that cause rashes that appear similar to monkeypox. Coinfections with STDs, particularly syphilis, have occurred in recent cases, so a positive test does not rule out monkeypox.
8.       Was there contact with a known or suspect monkeypox case?Contact with lesions or bodily fluids
Sexual Contacts
Household Contacts
Prolonged (3 hours+) unmasked contact within six feet
Masked contact within 6 feet
Contact with lesions/bodily fluids while wearing PPE.
Shared airspace contact >6 feet
9.       Did the patient recently participate in parties or gatherings involving sex, especially with multiple sex partners? Or did the patient attend venues where there is sex on premises such as bathhouses or saunas?Yes: there have been a number of cases and contacts associated with sex or extended physical contact in sex related events, or bathhouses/saunas, with multiple sex partners.No: no participation or contact with someone who has participated in these activities or attended these venues/events is less suggestive of monkeypox.
10.    Is the patient part of a social group known to have high monkeypox incidence or risk?Yes: the majority of cases seen so far in non-endemic countries have been in men or transgender persons who have sex with men.No: no known linkage to a high-risk group or reported high-risk social or sexual behaviors would be less suggestive of monkeypox.

*While some of the listed factors more strongly suggest an underlying monkeypox etiology, no one answer is absolute in determining whether to suspect monkeypox; instead, the collective responses and overall clinical picture should be considered.

Next Steps:

Vaccination for Monkeypox

The JYNNEOS vaccine is approved by the U.S. Food and Drug Administration (FDA) to prevent both monkeypox and smallpox.  At this time, the federal government has allocated a limited number of JYNNEOS vaccine doses to Californians. CDPH is working with local health departments to make these doses available to protect against monkeypox. JYNNEOS is licensed for adults 18 years and over.  JYNNEOS may be given to children who have been exposed under a research protocol. Contact your local health department for more information about vaccination of children. It is administered as a two dose injection series in the upper arm at least four weeks apart. Most people who receive the JYNNEOS vaccine have only minor reactions such as pain, redness, swelling and itching at the injection site. Less commonly, people also may experience muscle pain, headache, fatigue (tiredness), nausea, chills, and fever.

The  CDC advises  that  people who have been exposed to monkeypox be given the vaccine to prevent them from developing the disease.

These vaccines may be administered as soon as possible after exposure to monkeypox to prevent disease or reduce severity. Vaccine administered within 4 days may prevent disease.  Vaccine administered from 4-14 days after exposure may reduce illness severity. Vaccine is not recommended for persons who have already developed monkeypox symptoms, like a rash.  For more information about the JYNNEOS vaccine see CDPH JYNNEOS vaccine FAQ, or Visit the CDC's Monkeypox and Smallpox Vaccine Guidance for more information. Note that there is currently extremely limited availability of vaccines in the United States.

Treatment

  • Health care providers seeing persons withs suspected or confirmed monkeypox can provide supportive care and treatment of symptoms. This may include medicines or other clinical interventions to control itching, nausea, vomiting, and pain.

  • Providers should consider treating high-risk suspect or confirmed cases who have pending lab testing results with TPOXX (tecovirimat), an antiviral medication available through an expanded access Investigational New Drug (EA-IND) protocol for the treatment of monkeypox infection.  Antiviral treatment of monkeypox infection should be considered for people with severe infection, illness complications, and risk factors for progression to severe infection (children <8 years of age, pregnant or immunocompromised individuals, or those with a history of atopic dermatitis or eczema).

  • TPOXX is approved by the FDA for the treatment of smallpox in adults and children but is not currently approved for monkeypox. Under an authority called Expanded Access Investigational New Drug (EA-IND) or compassionate use, TPOXX is authorized for physicians to use in treating patients with monkeypox. Supplies of TPOXX are maintained by the Strategic National Stockpile (SNS) in the Office of the Assistant Secretary for Preparedness and Response. The process to obtain medications from the SNS differs from the usual commercial means used by clinicians and healthcare care pharmacists to order other drugs.

  • CDC recently posted information clarifying the current TPOXX ordering process: Obtaining and Using TPOXX (Tecovirimat) | Monkeypox | Poxvirus | CDC. The web posting clarifies that forms and other documentation required for obtaining TPOXX can be submitted after clinicians receive the drug and begin patient treatment. CDC and FDA are working to further simplify the protocol with additional reductions in data collection and reporting requirements that will be made available soon.

  • For more information on prescribing or accessing TPOXX for your patients, please contact your local health department Local Health Services/Offices or monkeypox@cdph.ca.gov.

  • For additional information on treating monkeypox, see: 

Additional Information and Resources:


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