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EDMUND G. BROWN JR.
Governor

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


October 7, 2022


TO:
All Californians

SUBJECT:
Mpox Guidance for Congregate Living Settings


​Mpox Guidance for Congregate Living Settings

Congregate living settings are residential facilities or other housing where people who are not related reside in close proximity and share at least one common room (e.g., sleeping room, kitchen, bathroom, living room).

Congregate living settings can include:

  • Emergency, and domestic violence shelters and transitional housing.
  • Group homes.
  • Dormitories at institutions of higher education (IHE) such as colleges and universities.
  • Seasonal worker housing.
  • Residential substance use treatment facilities.
  • Assisted living communities.
  • Hotels, motels, and hostels

and other similar non-healthcare settings where people live. Given that each setting may have unique characteristics and business practices, each setting should consider this guidance as providing general prevention strategies, and focus efforts on areas that are most relevant for their setting. For example, in settings that do not provide medical case management of clients or residents, focus should be on providing information for managing the care of a person with known or suspected mpox infection.

This includes the importance of contacting their healthcare provider immediately if they develop symptoms or must isolate, understanding how to properly isolate in the setting, when they may return to work or school, and prevention strategies to mitigate the risk of spread to others in the community

Healthcare settings or other settings providing healthcare should refer to Information for Healthcare Professionals | Mpox | Poxvirus | CDC. Additional information, including the CDPH Clinical Assist Tool for Mpox Evaluation, can be found on the CDPH Information for Health Care Providers site.

For homeless shelters and shelter providers, see Mpox Guidance for Homeless Service Providers. For schools and childcare settings, see Mpox Consideration for Childcare and School Settings. Correctional facility guidance is forthcoming.

Some workplaces may be covered by the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF) and should consult those regulations for additional applicable requirements.

Local health jurisdictions (LHJs) may continue to implement additional requirements that go beyond this statewide guidance based on local circumstances, including in certain higher-risk settings or during certain situations that may require additional infection prevention and control measures (for example, during active outbreaks in high-risk settings).

The current mpox situation is rapidly evolving, and the information below will be updated as new information emerges. CDPH is closely monitoring mpox transmission in the U.S. and California to ensure rapid identification of cases. The risk of mpox to the public is currently very low based on the information available. While mpox virus can infect anyone, most of the recent cases in 2022 have occurred among persons self-identifying as men who have sex with men (MSM).

Mpox Symptoms

Mpox often starts with flu-like symptoms such as fever, fatigue, swollen lymph nodes, and general body aches. Within 1 to 5 days (sometimes longer) after the appearance of fever, the infected person can develop a rash or sores (lesions). The 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 mpox 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 check for lesions in these areas, particularly if pain, drainage or blood is noted. However, genital or anal lesions may not be visible without examination by healthcare provider.

Transmission

Mpox spreads primarily through direct contact with infectious lesions or body fluids, including during sex, as well as activities like kissing, and skin to skin contact during hugging, massaging, and cuddling.

Mpox can also spread through touching materials used by a person with mpox that have not been cleaned, such as clothing, towels, bedding, utensils, and cups. It can also possibly be 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.   

Mpox is currently a relatively rare disease; unlike COVID-19 and other respiratory illnesses, mpox virus is not easily transmitted except through direct contact of skin with lesions, body fluids, or items contaminated by the lesions or body fluids of an infected person such as towels, bedding, cups and eating utensils. Most cases currently being identified in California have involved transmission through close, intimate, or sexual contact. 

General Prevention Strategies

  • Communicate with residents/clients and workers 

Provide clear information to residents/clients and workers about mpox prevention, including the potential for transmission through close physical contact, such as sexual activity.  

Facilities and settings should consult the Return to Work section of the Mpox Home Isolation Guidance for the General Public (ca.gov) for recommendations regarding return to work if workers have a confirmed case of mpox.   

Communication to workers and residents/clients should be fact-based to avoid introducing stigma when communicating about mpox.

Please see the following communication materials:

Ensure access to hand hygiene for all residents/clients and workers. Soap and water or hand sanitizer with at least 60% alcohol should be always available and at no cost to all residents/clients and workers. Anyone who touches lesions or clothing, linens, or surfaces that may have had contact with mpox lesions should wash their hands or use an alcohol-based hand sanitizer immediately.

  • Dining and other activities / Communal spaces

No additional cleaning, beyond what the facility may currently be doing, is recommended within communal areas (such as dining, shared bathrooms that are not part of a shared living space, indoor recreation areas, lobbies) unless a mpox case is identified and has been in those areas. 

If there is a suspected exposure to mpox, or a mpox case has been identified in a congregate living setting, consider the following actions:

  • Suspected mpox cases

Residents/clients or workers who develop any symptoms of mpox should isolate immediately and contact a health care provider for clinical evaluation.

Clinical evaluation should include assessing the person for signs and symptoms of mpox, including a thorough exam of the skin, mouth, and genitals, in good lighting. If mpox is still suspected after clinical evaluation, testing for mpox should be performed.

Health care providers can provide testing and care for people who are known or suspected to have mpox. Most cases are mild and resolve on their own, but in specific cases a health care provider might recommend and arrange for treatment. Reach out to a health care provider or your LHJ with any questions.

  • Respond to confirmed cases

Consider the following actions to respond to cases in the facility:

    • Isolate infected people

Anyone who is identified to have mpox should isolate away from others per  CDPH Mpox Home Isolation Guidance for the General Public.

    • Isolation of workers

Workers who have mpox should isolate at home per CDPH Mpox Home Isolation Guidance for the General Public.

Flexible, non-punitive sick leave policies for workers are critical to prevent spread of mpox. The home isolation guidance should be shared with infected workers isolating at home. 

    • Isolation of residents/clients

Some congregate living settings may be able to provide isolation on-site while others may need to move residents/clients off site to isolate. It may be necessary to coordinate transportation to medical care as well as isolation locations for residents/clients who contract mpox.

If you are unable to establish an on-site isolation area, work with your LHJ 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 resident/client population.
        1. If a dedicated bathroom is not possible, ensure thorough cleaning and disinfection following manufacturer recommendations with an EPA approved disinfectant after each use by the resident/client with mpox.

      • Multiple residents/clients with mpox can share an isolation space but should be discouraged from skin to skin contact.
      • Residents/clients with mpox who do not meet the "return to work/school" criteria in the CDPH Mpox Home Isolation Guidance should stay in the isolation space as much as possible during their isolation period.
        1. If there is a need to leave the isolation space (for example, to participate in group activities or to resume limited activities outside of the setting that do not involve physical contact with others), residents/clients should cover all skin lesions and wear a well-fitting mask .

      • Only workers essential to operations wearing appropriate personal protective equipment (see below) should enter isolation areas.
      • Dedicated laundry space should be identified for residents in isolation. If dedicated laundry space cannot be identified, refer to Cleaning and Disinfecting Your Home, Workplace, and Other Community Settings for Mpox for additional laundering options. 
  • Identify people who might have been exposed to mpox

Facilities should work with their LHJ to identify and monitor the health of any residents/clients or workers who might have been exposed to someone who has mpox. While broad notifications are generally not recommended, they can be considered in certain instances (such as to combat misinformation) after consulting the LHJ.

If issuing a facility-wide notification, special care should be taken to avoid perpetuating stigma or providing any information which might identify the infected person. Such notifications should be non-specific, provide scientific facts, and confront and oppose stereotypes and stigma. They can also be a general reminder for all to not return to work if they have new, unexplained symptoms until it is clear that symptoms are mild and improving or are due to a non-infectious cause. Facility administrators are strongly encouraged to work with their LHJ for assistance with any notifications.  

    • Visitors to residents/clients with mpox infection should be limited to those essential for the resident/client's care and wellbeing (e.g., parents of a child, spouse).
    • Decisions about who might visit, including whether the visitor stays or sleeps in the room, should take into consideration the infected person's age, their ability to advocate for themselves, ability of the visitor to adhere to infection prevention and control recommendations, whether the visitor has already been exposed to the infected resident/client, and other aspects.
    • In general, visitors with contagious diseases should not be visiting uninfected residents/clients, nor should visitors be visiting residents/clients with contagious diseases to minimize the risk of transmission to others.
  • Testing resources

Testing is only currently recommended for persons with lesions suspicious for mpox and should be done following consultation with a health care provider. Settings should consult with their LHJ regarding need for any additional testing. Identification of exposure clusters and effective isolation of suspect cases will help reduce spread.

  • Transportation of infected or suspected residents/clients

    • During transportation of residents/clients with mpox, all skin lesions should be covered with clothing, bandages, or gloves and a well-fitting mask should be worn.
    • After transport, vehicles should be cleaned and disinfected per CDC guidance.
    • If a setting does not provide transportation, and the resident/client must use public transportation to isolate at an off-site location, the resident/client should be instructed to cover all lesions with clothing, bandages, or gloves and wear a surgical mask while in transport and until they arrive at their final destination.
  • Treatment resources

Supportive care and treatment of symptoms should be initiated for all persons with mpox infection, including medicines or other clinical interventions to control itching, nausea, vomiting, and pain. For more information, see Supportive Care Suggestions for persons with mpox.

Tecovirimat (also called TPOXX) is available at an increasing number of sites in California. Contact your LHJ if you need information about sites where you can refer your resident/client. For more information on prescribing or accessing tecovirimat, please contact your LHJ or submit an inquiry to CDPH.

  • Waste management

Generally, management of waste should continue as normal. Facilities should comply with state and local regulations for handling, storage, treatment, and disposal of waste. Healthcare facilities should follow guidance specifically for that setting.

    • The person with mpox should use a dedicated, lined trash can in the room where they are isolating. Any gloves, bandages, or other waste and disposable items that have been in direct contact with skin should be placed in a sealed plastic bag, then thrown away in the dedicated trash can.

    • The person with mpox or other facility staff should use gloves when removing garbage bags and handling and disposing of trash.

    • If professional cleaning services are used, treat and/or dispose of waste in accordance with applicable state, local, tribal, and territorial laws and regulations for waste management.

For more information, the Department of Transportation has mpox-specific information in Appendix F-2 of this document.

  • Cleaning and disinfection

Clean and disinfect the areas where people with mpox spent time per CDC recommendations. Avoid activities that could spread dried material from lesions (e.g., use of fans, dry dusting, sweeping, or vacuuming) in these areas.

Perform disinfection using an EPA-registered disinfectant with an Emerging Viral Pathogens claim, which may be found on EPA's List Q. Follow the manufacturer's directions for concentration, contact time, and care and handling.

Thoroughly launder all clothing, towels, and bedding and clean and disinfect all surfaces and shared items such as utensils and cups that have been in contact with someone who has an active mpox infection. 

    • Soiled laundry can be laundered using regular detergent and warm water.  
    • Soiled laundry should be gently and promptly contained in a laundry bag. 
    • Avoid shaking laundry and use personal protective equipment including gloves, gowns, a fit-tested respirator, and eye protection (goggles or face shield) when working with soiled laundry.
  • Personal protective equipment

Provide appropriate personal protective equipment (PPE) for workers and residents/clients. Employers are responsible for ensuring that workers are protected from exposure to mpox virus and that workers are not exposed to harmful levels of chemicals used for cleaning and disinfection.

Specified high-risk settings must continue to comply with current CDPH COVID-19 masking guidance. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended in these settings.

PPE should be worn by workers or residents/clients in these circumstances:

    • When entering isolation areas — Workers who enter isolation areas to provide care requiring direct physical contact (such as physical therapy, assistance with transfers, toileting, bathing or dressing) should wear a gown, gloves, eye protection, and a fit-tested, NIOSH-approved particulate respirator equipped with N95 or higher level filtration.

      • If disposable gowns are not readily available, long-sleeved clothing is acceptable as long as the clothing is immediately removed and laundered after close contact with a case.

      • When entry into the isolation areas will not require direct physical contact, full PPE may not be necessary, but all workers should continue to wear surgical masks or higher-level respirators.

    • When handling soiled laundry — When handling soiled laundry from people with known or suspected mpox infection, workers, or residents/clients should wear a gown, gloves, eye protection, and a fit-tested, NIOSH-approved particulate respirator equipped with N95 or higher level filtration.

      • PPE is not necessary after the wash cycle is completed.

      • If disposable gowns are not readily available, long-sleeved clothing is acceptable as long as the clothing is removed and laundered immediately after handling soiled laundry.

    • When performing cleaning and disinfection for mpox — Workers or residents/clients should wear a gown, gloves, eye protection, and a fit-tested, NIOSH-approved particulate respirator with N95 or higher level filtration when cleaning areas where people with mpox spent time. 

Additional Employee Health & Safety Requirements

In some congregate setting workplaces, employers are subject to the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF), and Bloodborne Pathogens (CA State 5193),  and should consult those regulations for additional applicable requirements. Also, see: Cal/OSHA Protecting Workers from Mpox for Employers and Workers Covered by the Aerosol Transmissible Diseases Standard (PDF). 

  • Access to care for workers:  Not all workers have employer-sponsored health insurance, and many workers may face financial hardship due to medical expenses. Workers who are employed or actively looking for work and who are unable to do their regular or customary work for at least eight days may qualify for financial support from California's State Disability Insurance (SDI) program. Note that the affected individual must be under the care and treatment of a licensed physician/practitioner who must complete the medical certification portion of disability claim.

  • Financial support for workers: Due to the duration of the mpox illness (up to 4 weeks), it may be difficult for workers to comply with isolation due to financial hardship.  For more information about paid leave options, please see the California Employment Development Department site and the Leave Benefits | U.S. Department of Labor (dol.gov)

Reporting Requirements

If the employer or facility manager is aware of a mpox case among residents/clients or workers, it should be reported to the LHJ for their assistance with contact investigation and any potential required notification.

Employers in settings in which the Cal/OSHA ATD Standard is applicable (including shelters, correctional settings, and most healthcare settings) are required to report a single case of mpox in the workplace.

Although the employer may not know the details of an employee's health conditions, employers are required to report any known serious illness (e.g., hospitalization) from a communicable disease like mpox in an employee to Cal/OSHA. See: Cal/OSHA Protecting Workers from Mpox for Employers and Workers Covered by the Aerosol Transmissible Diseases Standard (PDF).

Additional information

Additional information regarding infection control and managing the spread of mpox in your facility can be found here:



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