Skip Navigation LinksConsiderations-for-Expanded-Monkeypox-Post-Exposure-Prophylaxis

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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


August 3, 2022


TO:
California Local Health Jurisdictions

SUBJECT:
Considerations for Expanded Monkeypox Post-Exposure Prophylaxis (PEP++)



The Centers for Disease Control and the California Department of Public Health (CDPH) recommends those that are highest risk for monkeypox as defined within the guidance get vaccinated as supply allows. This will help protect vaccinated persons against monkeypox illness and slow down the spread of disease. CDPH is coordinating with local health jurisdictions (LHJs) in distributing vaccines to vulnerable communities.

Additional supplies of JYNNEOS monkeypox vaccine under the next phases will reduce but not eliminate vaccine scarcity. Vaccination should expand to reach as many individuals at highest risk of monkeypox as possible to the extent permitted by limited supply.  

During these vaccine phases, local health jurisdictions should:  

  • Continue post-exposure prophylaxis (PEP) for persons known to be exposed to monkeypox.
  • Continue pre-exposure prophylaxis (PrEP) for occupational groups recommended for vaccination by ACIP.
  • Expand vaccination efforts, as supplies allow, in accordance with the CDC's PEP++ approach outlined in the CDC Clinical Considerations for Monkeypox Vaccination and reflected in this guidance.
  • Consider vaccine equity when planning vaccination activities. Vaccines may be shared with medical providers and/or CBOs that can reach diverse populations at risk of monkeypox exposure.
  • Due to vaccine limitation, prioritize first doses for upcoming vaccination activities.
  • Consider using a portion of allocated doses for regional activities. Local health jurisdictions may request to have their doses shipped to other local health jurisdictions in their regions through usual ordering process (Salesforce request through the Medical Health Operational Area Coordinator (MHOAC)).
  • Plan events in accordance with their available vaccine supply, including any doses that may be provided for these events by other counties in the region.

Populations to Prioritize for Vaccination Efforts

Each local health jurisdiction should assess the unique circumstances within its respective jurisdiction. According to the PEP++ framework, individuals with risk factors that increase their likelihood for exposure in areas where monkeypox is spreading may be considered for vaccination, even if they have not had known exposure to someone with a confirmed or probable monkeypox infection. The following populations should be considered for prioritization.

Tier I Priority Groups:

Gay, bisexual, and other men (including cisgender and transgender men) who have sex with men (MSM) or transgender women who meet at least one of the following criteria:

  • Have been diagnosed with a bacterial sexually transmitted disease (e.g., chlamydia, gonorrhea, syphilis) in the past 3 months, OR
  • Have engaged in chemsex or group sex with other men, OR
  • Have had sex recently with anonymous male partners, OR
  • Have attended sex-on-premises venues (e.g., saunas, bathhouses, sex clubs), OR
  • Have engaged in survival and/or transactional sex, OR
  • Are part of other populations who are at highest risk of monkeypox exposure, as identified through local epidemiological investigations.

Among this group, individuals who are living with HIV (particularly those with CD4 count < 200/mm3 or an opportunistic infection) or other conditions that cause immunocompromise should be prioritized for vaccination, including second doses. 

Efforts should be made to reach Tier 1 populations that have barriers in accessing care, for example, engaging community organizations and trusted messengers for outreach and offering vaccines at non-clinical venues where individuals already attend (e.g., bathhouses, bars, clubs, Pride events). 

Tier II Priority Groups:

Gay, bisexual, and other men (including cisgender and transgender men) who have sex with men (MSM) or transgender women who do not meet Tier I criteria but meet one of the following criteria:

  • Have been diagnosed with a bacterial sexually transmitted disease (e.g., chlamydia, gonorrhea, syphilis) between the past 4- 12 months, OR
  • Use or are recommended to use HIV PrEP, OR
  • Are living with HIV and are considered at risk for monkeypox exposure.

Additional Priority Groups:

LHJs should consider PEP++ efforts depending on local epidemiologic analyses and the detection of cases and/or risk of transmission in these groups. CDPH is available for consultation regarding implementation of PEP++ efforts.

Other groups to consider include:

  • Persons at high risk of exposure who are incarcerated and are being housed in a congregate setting (e.g., pods), such as correctional facilities or detention centers within the jurisdiction or in nearby jurisdictions from where persons who are incarcerated may be transferred. Priority should be considered for jail facilities that house persons at high risk for exposure to monkeypox.
  • Persons who are currently experiencing homelessness or persons. experiencing intermittent homelessness who frequent shelter services.
  • Persons who live in congregate housing or dormitories.
  • Persons living in residential substance use treatment centers.

Venues to Consider for PEP/PEP++ Administration

When determining how and where to offer vaccinations, consideration should be provided to locations that are acceptable and familiar to community members. Focused outreach, as opposed to open access, may ensure prioritized populations are more effectively reached. In non-urbanized areas, sites should be in discreet locations, whenever feasible. 

Suggested venues include:

  • STD and/or sexual health clinic sites
  • LGBTQ+ health clinics or community organizations
  • Sex-on-premises sites (e.g., saunas, bathhouses, sex clubs), in locations that are discreet yet distanced from primary areas of activity
  • Large events or venues, including Pride events, where sexual activity may be more likely
  • Medical practices that provide focus on HIV care
  • Providers and/or medical practices that offer HIV PrEP
  • Local health jurisdiction clinics
  • Gyms, bars, or clubs that cater to communities at high risk
  • Other locations, as deemed appropriate by LHJs

Health Education Considerations

Vaccination sites and/or health education informational material, such as flyers or QR codes linking to monkeypox vaccine information, should be prioritized in the following settings.

  • Cruising grounds (e.g., men's restrooms in airports, train stations, truck stops, university libraries, parks)
  • Sexual health clinics where individuals may obtain testing or treatment for sexually transmitted infections
  • LGBTQ+ health clinics for routine healthcare needs
  • Sex-on-premises sites (e.g., saunas, bathhouses, sex clubs)
  • Large events, such as Pride gatherings
  • Cell phone apps (e.g., Grindr)
  • Social media platforms targeting priority populations (e.g., Facebook, Twitter)
  • Other locations, as deemed appropriate by LHJs

This guidance is subject to change to reflect the current status of the response, future allocations of additional vaccine doses, and other guidance from the CDC.

Definitions

MSM: Men who have sex with men.
PEP: Postexposure prophylaxis. Administration of vaccine to persons who have been exposed to a disease in order to prevent or lessen the severity of disease.
PEP++: Postexposure prophylaxis (also called expanded PEP) with an emphasis on vaccinating persons at high risk of exposure in the absence of a known exposure.
JYNNEOS: Smallpox and monkeypox vaccine; Live, Nonreplicating.