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EDMUND G. BROWN JR.
Governor

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


September 8, 2022


TO:
California Local Health Departments

SUBJECT:
Recommendations for Management of Persons with Possible Exposure to Someone with Monkeypox (MPX) in Community Settings



Background

The current MPX outbreak is rapidly evolving. The guidance below is based on current scientific understanding and is subject to change as new evidence emerges. 

The California Department of Public Health (CDPH) is closely monitoring MPX transmission in the U.S. and California to ensure rapid identification of cases. Based on California's experience to-date, MPX spreads primarily through direct contact with infectious lesions, scabs, or body fluids. MPX can infect anyone, and most recent cases have occurred among persons self-identifying as men who have sex with men (MSM). The risk of MPX to people without known "Exposure" (as defined below) to a case is low.

The following recommendations are intended for California's public health officials guiding persons with varying degrees of exposure to MPX virus in community settings. Exposures to MPX in healthcare settings should follow CDC guidance on Infection Prevention and Control of MPX in Healthcare Settings. Persons with confirmed MPX should follow CDPH MPX Home Isolation Guidance for the General Public.

Individuals exposed to MPX in all categories below can continue their routine daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with MPX.

Types of Exposure & Recommended Actions [1]

Exposed Persons

"Exposed Persons" are those whose mucous membranes or broken skin came into contact with:

  • The lesions or body fluids of a person with MPX; OR

  • Materials that have contacted the lesions or body fluids of a person with MPX

Activities that may result in being "Exposed" include sex of any kind (including oral, anal, or vaginal sex), kissing, providing or receiving physical care without the use of personal protective equipment (PPE), sharing cups, utensils, towels, clothing, and bedding, and engaging in sports with a very high degree of skin-to-skin contact. "Exposed Persons" may include sexual or intimate partners, household members, physical care providers or recipients, and wrestling, grappling, or sparring partners.

Whenever possible, "Exposed  Persons" should be notified and monitored (see below for more regarding notification and monitoring). Also, because "Exposed Persons" have the greatest risk of exposure, post-exposure prophylaxis (PEP) should be offered, especially to intimate partners and persons providing or receiving direct physical care from a case (e.g., parent-to-young child), as the majority of MPX transmission observed in the current outbreak to-date has occurred in these contexts.

Potentially Exposed Persons

"Potentially Exposed Persons" are those whose intact skin or clothing came into contact with:

  • The lesions or body fluids of a person with MPX; OR

  • Materials that have contacted the lesions or body fluids of a person with MPX


Persons who may be considered "Potentially Exposed" include household members who would not otherwise be considered "Exposed" (e.g., roommates), persons who have gathered socially in crowded settings where limited clothing is worn, and persons who contacted the lesions or bodily fluids (or handled materials that have contacted the lesions or body fluids) of a person with MPX without the use of PPE, such as house cleaners, barbers, hairdressers, nail salon workers, massage therapists, and adult-care and child-care workers.

While the risk of contracting MPX for persons who are "Potentially Exposed" is very low based on current knowledge, it is recommended that such persons be notified and recommended to self-monitor. PEP can be considered after consultation with a healthcare provider and/or the Local Public Health Department (LHD), and is primarily recommended based on the degree of exposure and/or for persons at increased risk of severe disease, such as immunocompromised persons, persons with HIV, or persons who have immunocompromised or HIV-infected household members.

Persons with Low Risk of Exposure

Persons with "Low Risk of Exposure" are those who entered the living space of a person with MPX (regardless of whether the person with MPX was present), in the absence of any exposures above. Of note, schools and workplaces without sleeping quarters are not considered living spaces.  

Persons with "Low Risk of Exposure" include people who enter homes, dormitories, or other living spaces of cases. Based on current knowledge, the risk of contracting MPX in this manner is exceedingly low. However, out of caution and in alignment with the CDC guidance, notification can be considered for such individuals, along with a recommendation to self-monitor. PEP is not recommended.

 Table 1.  Summary of Recommendations for Management of Persons with Possible Exposure to Someone with MPX in Community Settings [2] 

Exposure Status CriteriaExamples of Activities and/or Persons Meeting CriteriaRecommended Actions for Persons Meeting Criteria
Exposed Persons

Those whose mucous membranes or broken skin came into contact with:

  • Lesions or body fluids of a person with MPX; OR
  • Materials that have contacted the lesions or body fluids of a person with MPX.

Activities:

  • Sex (including oral, anal, or vaginal sex)
  • Kissing, sharing cups, utensils, towels, clothing, and bedding.
  • Providing or receiving physical care without using PPE.
  • Engaging in sports with a very high degree of skin-to-skin contact.

     

    Exposed Persons may include intimate partners, household members, physical care providers or recipients, and wrestling, grappling, or sparring partners.

Persons:

  • Can continue their daily activities (e.g., go to work or school) as long as they do not have signs or symptoms. consistent with MPX.
  • Should be notified*
  • Should be monitored*
  • Should be offered PEP, especially to intimate partners and persons providing or receiving direct physical care from a case (e.g., parent-to-young child).

     

    *See sections below on notification and monitoring.
Potentially Exposed

Those whose intact skin or clothing came into contact with:

  • The lesions or body fluids of a person with MPX; OR
  • Materials that have contacted the lesions or body fluids of a person with MPX.
  • Household members who might not otherwise be considered Exposed. (e.g., roommates)
  • Persons who have gathered socially in crowded settings where limited clothing is worn.
  • Persons who contacted the lesions or bodily fluids (or handled materials that contacted the lesions or body fluids) without using PPE (e.g., house cleaners, barbers, hairdressers, nail salon workers, massage therapists, and adult-care and child-care workers).

Based on current knowledge, the risk of contracting MPX in this manner is very low.

 

Persons:

  • Can continue their daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with MPX.
  • May be notified
  • May be recommended to self-monitor.
  • PEP can be considered based on risk factors.
Low Risk of ExposureThose who entered the living space of a person with MPX (regardless of whether the person with MPX was present), in the absence of meeting criteria to be considered Exposed or Potentially Exposed

Guests into homes, dormitories, or other living spaces of cases.

 

Schools and workplaces without sleeping quarters are not considered living spaces.  

 

Based on current knowledge, the risk of contracting MPX in this manner is exceedingly low. 

 

Persons:

  • May be notified
  • May be recommended to self-monitor
  • PEP is not recommended


Notification

Typically, LHDs will lead MPX contact tracing efforts to identify people who may have been exposed, determine the exposure type, and provide recommendations on next steps, including whether notification and PEP should be considered.

Institutions (workplaces, schools, etc.) who come to know that persons with MPX were within their settings should contact their LHD for further assistance and if requested, they should support the health department in contact tracing efforts.

Individuals who do not meet any of the exposure definitions above do NOT need to be notified. Dissemination of any facility-wide notification should be strongly weighed against the possibility of inadvertently disclosing protected health information and perpetuating stigma.

If facility-wide notices are considered (to combat misinformation, for example), it is recommended they be non-specific, provide scientific facts, confront and oppose perpetuation of stereotypes and stigma, and serve as a general reminder for all to not return to work/school if they have new, unexplained symptoms until it is clear that symptoms are mild and improving or are due to a non-infectious cause (e.g., allergies), as should always be the case.

Monitoring 

What to monitor

In general, exposed persons should self-monitor for skin and mouth lesions as well as systemic symptoms for 21 days after last exposure. Some infected people have flu-like symptoms (such as fever, chills, headache, or fatigue) or swollen lymph nodes. Exposed persons who develop signs and symptoms of MPX infection should seek evaluation by a healthcare provider and follow CDPH isolation and transmission prevention practices.

If symptoms are noticed, medical evaluation should include assessing the person for signs and symptoms of MPX, including a thorough exam of the skin, mouth, and genitals, in good lighting.

How to monitor

Decisions on how to monitor exposed persons are at the discretion of the LHD. In general, self-monitoring is usually sufficient unless there are concerns about a high-risk situation or setting. Ultimately, the person's exposure risk level, their reliability in reporting signs or symptoms that might develop, any sensitive occupation or situation of the exposed person, the number of people needing monitoring, time since exposure, and receipt of PEP are all factors when determining the type of monitoring to be used.

Activities

As noted above, individuals exposed to MPX virus can continue their routine daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with MPX.

To date, there have been no cases of MPX transmitted by blood transfusion, organ transplantation, or implantation, transplantation, infusion, or transfer of human cells, tissues, or cellular or tissue-based products (HCT/Ps). As a precaution, patients with exposures should not donate blood, cells, tissue, breast milk, or semen while they are being monitored for symptoms.

Given the morbidity and mortality among individuals awaiting organ transplantation, persons who have been exposed, but who are asymptomatic and without evidence of MPX infection, could be considered for organ donation following appropriate risk-benefit considerations.

 

[1] While the exposure types listed above were adapted from CDC guidance for Monitoring and Risk Assessment for Persons Exposed in the Community (released August 11, 2022), they differ in a few ways. 

For example, CDC recommends that persons who were "within 6 feet for a total of 3 hours or more (cumulative) of an unmasked person with MPX without wearing a surgical mask or respirator" have an "Intermediate Degree of Exposure" for which monitoring is recommended, and PEP can be considered. 

Investigation of MPX cases in California to-date, has not corroborated that prolonged close proximity alone (without direct contact with skin lesions, body fluids, or contaminated materials) poses sufficient independent risk of MPX transmission to recommend notification, monitoring, or consideration of PEP. 

Accordingly, outside of living settings (e.g., households, dormitories) where there is greater potential to interact with contaminated materials, California does not recommend additional measures for persons who were, for example, in close proximity but without direct physical contact with a clothed person whose MPX lesions were covered, such as by clothing, bandages or gloves.

[2] California has not adopted the CDC terminology of "Higher", "Intermediate", and "Lower" categories and instead recommends referring to persons in the context as noted in Table 1.



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