Since May 2022, there has been a rapid rise in cases of monkeypox (MPX) in regions where it had historically been very rare, including California. The California Department of Public Health (CDPH) continues to work with the Centers for Disease Control & Prevention (CDC), local health departments (LHDs) and healthcare providers on the ongoing domestic MPX situation impacting the United States and other countries not endemic for MPX. For the most up to date information regarding signs/symptoms, transmission, and prevention please refer to the CDPH Monkeypox Landing Page or go directly to CDPH's Monkeypox Questions & Answers Page.
This guidance is intended to provide congregate shelters, including homeless service providers, the information necessary regarding the risks associated with MPX to ensure the health and well-being of their staff and of people experiencing unsheltered and sheltered homelessness.
Homeless service providers are encouraged to coordinate with their local public health officials, local governments, federally qualified health centers, and other health care partners to share information and stay apprised of new developments.
What is MPX?
MPX is a historically rare viral infection, similar to smallpox (but milder), that can spread from infected humans, animals, and materials contaminated with the virus. MPX is primarily spread by close, personal, often skin-to-skin contact (including sexual contact) with people who have MPX symptoms, such as skin lesions (rashes and sores).
MPX might start with symptoms like the flu, with fever, low energy, swollen lymph nodes, and general body aches. Within 1 to 5 days (sometimes longer) after the appearance of fever, the person can develop skin lesions. The skin lesions will go through several stages, including scabs, before healing. They can look like pimples or blisters and may be painful and itchy.
Anyone exposed to MPX should monitor themselves for symptoms for 21 days after exposure. Many cases in California have reported genital or anal lesions, so contacts who are self-monitoring should be particularly aware of any new anal or genital lesions. Genital or anal lesions may not be visible without examination by a healthcare provider, and can present with pain, discomfort, discharge or blood from the region.
MPX spreads primarily through direct contact with infectious skin lesions, scabs, or body fluids, including during sex, as well as activities like kissing, hugging, massaging, and cuddling. MPX can also spread through touching materials used by a person with MPX that haven't been cleaned, such as clothing, towels, bedding, utensils and cups. It can also spread by respiratory secretions during prolonged, unmasked close, face-to-face contact, although this mode of transmission appears to be very rare in the current outbreak.
MPX is currently a relatively rare disease; unlike COVID-19 and other respiratory illnesses, the virus is not usually easily transmitted except through direct contact with infected lesions or contaminated items.
Given that most cases currently being identified in California have involved transmission through close, intimate or sexual contact, risk of spread to shelter staff remains low.
Anyone, including asymptomatic staff, who may have been exposed to someone with MPX should monitor themselves for rash and other MPX symptoms for 21 days following their last exposure.
Exposed staff and clients can continue to work and do not need to restrict or change behavior as long as they do not develop symptoms, unless Cal/OSHA standards impose additional requirements for staff, see Employee Health & Safety Requirements section below. Health care providers and LHDs may also recommend a vaccine for those with a high-risk exposure to help prevent infection or decrease the seriousness of the illness.
If staff or clients develop any symptoms of MPX, they should isolate immediately and contact a health care provider for clinical evaluation. Health care providers can provide testing and care for people who are diagnosed with MPX. Most cases are mild and resolve on their own, but in specific cases a healthcare provider might recommend and arrange for treatment. Reach out to a health care provider or your local health department with any questions.
Providers should post and share information about MPX with staff, volunteers and clients, including people served during street outreach and those living in unsheltered encampments. Please see the following communication materials
It may be necessary to coordinate transportation to medical care as well as isolation locations for clients who contract MPX. If you are unable to establish an on-site isolation area, work with your LHD to identify an appropriate location for people to isolate while they recover. Considerations for isolation spaces may include:
- Doors that can be closed and dedicated bathroom not used by the general client population.
- If a dedicated bathroom is not possible, ensure thorough cleaning following manufacturer recommendations with EPA approved disinfectant after each use by client with MPX.
- Multiple clients with MPX can share an isolation space, but should be discouraged from skin-to-skin contact.
- Clients with MPX should stay in the isolation space as much as possible during their isolation period. If there is a need to leave the isolation space, clients should wear a well-fitting mask and cover all skin lesions.
- Only staff essential to operations wearing appropriate personal protective equipment (see below) should enter isolation areas.
See CDC Guidelines on Monkeypox in Congregate Settings for additional considerations. Please refer to the Monkeypox Isolation Guidance for General Public.
Employee Health & Safety Requirements
In some workplaces, employers are subject to the Cal/OSHA Bloodborne Pathogen Standards (PDF) and the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF), and should consult those regulations for additional applicable requirements.
Additional workplace safety questions can be directed here:
Caring for Clients with MPX
Homeless service providers are encouraged to support and care for individuals who have symptoms of MPX and are experiencing homelessness. In all communications, providers should be mindful to avoid language that further stigmatizes or shames any group or individual; anyone can get MPX. Ensure that staff members are trained in trauma-informed care principles to avoid exacerbating existing trauma. All communications must respect client confidentiality.
Additional information can be found here:
If you have a client with MPX, homeless service providers should:
Provide clients a safe space to isolate and should not deny shelter to clients due to contracting or being exposed to MPX infection.
Consult with your local health department to identify a location where the person can isolate during recovery without exposing others.
Designate and use isolation spaces which can be on or off-site; considerations for isolation space are outlined above. Providers should consult the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard for additional isolation space requirements.
Consult your local health department and CDPH for the latest guidance on the duration of isolation and other recommendations.
Consult your local health department and CDPH for guidance on the management of people or animals who may have been exposed to someone with MPX.
Follow protocols for worker health and safety outlined above under "Employee Health and Safety Requirements," in accordance with Cal/OSHA requirements. Ensure access to appropriate face coverings for all clients and visitors. Clients and visitors should continue to follow CDPH Masking Guidance.
Respirators (e.g., N95s, KN95s, KF94s) or surgical masks with good fit are recommended.
Facilities are encouraged to have a supply of respirators or surgical masks to distribute to anyone who arrives without one.
Respirators and masks must not be shared.
Refer to CDPH Get the Most Out of Masking for more information on getting the best fit and filtration for masks.
For workers, the Cal/OSHA ATD standard contains additional requirements for respirator use for staff in contact with clients with suspected or confirmed MPX; homeless service providers should ensure they are following these requirements.
Thoroughly launder all clothing, towels, and bedding and clean and disinfect all surfaces and shared items that have been in contact with someone who has an active MPX infection. Avoid shaking laundry and use protective barriers including gloves, gowns, a fit-tested respirator, and eye protection (goggles or face shield) when working with soiled items.
Staff who must enter isolation areas must wear a gown, gloves, eye protection (goggles or face shield), and a NIOSH-approved particulate respirator equipped with N95 filters or higher.
Companion animals: Because MPX is a zoonotic disease, there is a risk of transmission between humans and other mammals. However, much remains unknown about the risk for domesticated animals in an unhoused setting.
- Do not surrender, euthanize, or abandon pets just because of an exposure or potential exposure to MPX virus.
- If a client with MPX has a pet or service animal with whom they have had close contact (cuddling, petting, sharing sleeping areas, etc.) while symptomatic, staff should arrange lodging that allows the client and their animal to isolate alone together.
- Exposed animals should be monitored for symptoms. Potential signs of illness include lack of energy, lack of appetite, coughing, nasal secretions or crusts, bloating, fever, and/or a pimple- or blister-like skin rash.
- If an animal develops symptoms, uninfected people providing care for the animal should wear a gown, gloves, respirator, and eye protection.
- Animals with symptoms should be evaluated by a veterinarian as soon as possible.
- The exposed animal should also be kept away from all other animals for the entire duration of the isolation period.
- An infected person isolating with an animal should:
- Wear a mask, especially when touching or caring for the animal;
- Wear clothes that cover the skin, such as long sleeves and long pants and cover any lesions that are not covered by clothing with bandages to the extent possible;
- Wear gloves as much as possible - especially when feeding, petting, or changing bedding;
- Try to avoid being face-to-face with the pet, including licking or kissing, even if wearing a mask;
- Not share food with the animal; and
- Not share a bed with the animal.
- CDC guidance on pets whose owners have MPX can be found here: Pets in the Home | Monkeypox | Poxvirus | CDC
Additional information regarding infection control and managing the spread of MPX in your facility can be found here:
A list of communicable disease contacts at local health departments is available on the Communicable Disease Contact List page.
If a homeless service provider needs assistance connecting to their local public health officials, contact email@example.com (monitored Monday through Friday 8am-5pm).