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EDMUND G. BROWN JR.
Governor

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


January 29, 2024


TO:
All Californians and Local Health Departments

SUBJECT:
Mpox Guidance for Congregate Living Settings, Homeless Shelters, and Correctional Facilities

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​Mpox Guidance for Congregate Living Settings, Homeless Shelters, and Correctional Facilities

Go to: General Prevention Strategies | Suspect or Confirmed Cases | Exposure Management | Additional Considerations for Homeless Service Providers | Employee Health Considerations​

The following is provided as considerations for managing mpox suspect or confirmed cases in congregate settings. For more information, see the CDC’s Considerations for Reducing Mpox Transmission in 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:

  • Correctional and detention facilities
  • Homeless, 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

For guidance on healthcare settings please refer to CDC Infection Control: Healthcare Settings.

Given that each setting may have unique characteristics and business practices, each setting should consider this guidance as providing general prevention strategies and should 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 preventive measures and providing information.

Local health departments (LHDs) 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 clusters and/or outbreaks).

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

Mpox Overview

Mpox is a viral infection caused by the monkeypox virus that can cause flu-like symptoms and a rash. The infection is spread primarily through close, personal, often skin-to-skin contact with infectious lesions or body fluids. Mpox can also spread through touching contaminated materials (clothing, towels, bedding, utensils, and cups) used by a person with mpox or by respiratory secretions during prolonged, unmasked close, face-to-face contact. These modes of transmission appear to be less common in the current outbreak.

Most mpox cases identified in California have involved direct, skin-to-skin contact. Certain populations have been disproportionately impacted, with data suggesting that gay, bisexual, and other men who have sex with men make up most of the cases (CDC | Mpox | How it Spreads, CDC | Mpox | Prevention). While not frequently seen in this outbreak, infectious diseases involving person-to-person contact may spread more easily in congregate settings among staff and residents (CDC | Considerations for Reducing Mpox Transmission in Congregate Living Settings).

General Prevention Strategies

Communicate with Residents/Clients and Workers

  • Provide clear information about mpox prevention and symptoms, including the potential for transmission through close physical contact, such as sexual activity.
  • ​Communication to workers and residents/clients should be fact-based to avoid introducing stigma when communicating about mpox. See the California Department of Public Health (CDPH) Mpox Communications Toolkit for educational materials.

H​and Hygiene

  • ​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.

Routine Cleaning and Disinfection

  • ​No additional cleaning is recommended for mpox prevention within communal areas (such as dining, shared bathrooms that are not part of a shared living space, indoor recreation areas, lobbies) for unless an mpox case is identified and has been in those areas.

Refer Symptomatic Persons for Care Promptly

  • Residents/clients or workers who develop any symptoms of mpox​ should isolate immediately and contact a health care provider for clinical evaluation. If transported off-site to a clinic, all skin lesions should be covered with clothing, bandages, or gloves and a well-fitting mask should be worn. Facility vehicles should be cleaned and disinfected per CDC guidance and transporting staff should wear appropriate PPE as outlined below.
  • Clinical evaluation should include a thorough, full-body physical exam. If mpox is suspected after clinical evaluation, testing for mpox should be performed and the person should continue to isolate until the results are confirmed. Testing can be done at most outpatient clinics.

Responding to Suspect or Confirmed Mpox Cases

Contact your LHD with questions regarding suspect or confirmed mpox cases or exposures. Typically, LHDs will lead the response and provide recommendations on next steps, including assessing possible exposures, exposure notifications, symptom monitoring, isolation plans, and/or vaccination. The CDPH mpox team is available for consults and can be reached at mpoxadmin@cdph.ca.gov.

The following are considerations for managing suspect or confirmed mpox cases in congregate settings:

Isolation

  • Symptomatic residents/clients should be removed from shared spaces and isolate as soon as mpox symptoms are observed, while waiting for testing and results.
    • Isolation spaces should have a door that can be closed and a dedicated bathroom that other residents do not use. Additional considerations can be found at CDC | Considerations for Reducing Mpox Transmission in Congregate Living Settings.
    • ​Residents/clients with laboratory-confirmed mpox should continue isolation​ until all sores and rashes have scabbed over and new skin has formed. This can take up to 4 weeks. Facilities should consult with their LHD regarding on-site isolation spaces and determining an isolation end date.
    • ​Ideally, residents/clients should not be moved or transferred to other institutions while in isolation; if unavoidable, transfers should be coordinated with the LHD.
    • Contact with others who do not have mpox should be avoided during isolation. Potential considerations for visitation are outlined here; consult LHD for guidance.
  • Staff with mpox should isolate away from congregate settings until fully recovered per CDC.
    • The decision about when to return to work should be made with the occupational health program and potentially with input from public health authorities as recommended by CDC.
    • ​Since it could take as long as 4 weeks for complete healing to occur, it is reasonable to consider temporarily re-assigning staff to remote work or to a position with minimal contact with other staff and clients (e.g., administrative work in a private office).

Treatment

  • Facilities may need to assist in monitoring the client/resident for severe symptoms while they are in isolation and coordinating delivery of treatment(s) with the clinical provider. Treatment options should be discussed with a medical provider at time of diagnosis and again if symptoms worsen.
  • Treatment of symptoms is mainly supportive and should be initiated for all persons with mpox infection, including medicines or other clinical interventions to control any itching, nausea, vomiting, or pain in consultation with a medical provider. For more information on supportive care options see CDPH Supportive Care Suggestions for Persons with Mpox​.
  • ​Antiviral therapy for mpox is also available. If symptoms worsen, facilities should ensure resident/client’s clinical care provider is notified for consideration of antiviral treatment.

Personal Protective Equipment

  • ​Personal protective equipment (PPE) to protect against mpox exposure includes a gown, gloves, eye protection, and a fit-tested, NIOSH-approved particulate respirator equipped with N95 or higher-level filtration. PPE is indicated when: engaging in direct physical contact or patient care of a person with suspect or confirmed mpox; entering isolation areas; handling soiled laundry or trash; or performing cleaning and disinfection of areas where people with mpox spent time.​

Disinfection and Waste Management

Reporting

  • If the employer or facility manager is aware of a suspect or confirmed mpox case among residents/clients or workers, it should be reported to the LHD for their assistance with contact tracing and any potential required notifications. Certain settings may have additional licensing or regulatory reporting requirements.
  • ​Employers in settings in which the Cal/OSHA ATD Standard (PDF) is applicable (including shelters, correctional settings, and most healthcare settings) are required to report a single case of mpox or significant exposure in the workplace to the local health officer of the LHD​.

Communication

  • ​​In all communications, staff should be mindful to avoid language that further stigmatizes any group or individual; anyone can get mpox. Ensure that staff members are trained in trauma-informed care principles to avoid exacerbating existing trauma. All communications must respect resident confidentiality.
  • ​While broad notifications are generally not recommended, they can be considered in certain instances (such as to combat misinformation) after consulting the LHD. Such notifications should be non-specific and provide scientific facts; special care should be taken to avoid perpetuating stigma or providing any information which might identify the infected person. Notifications can also be a general reminder for all to report if they have new, unexplained symptoms. Facility administrators are strongly encouraged to work with their LHD for assistance with any notifications.

Mpox Exposure Management

Consult with your LHD regarding management of potential on-site exposures. In certain situations, facilities may be advised to establish a line list of both infected and exposed staff and residents/clients to track symptom monitoring, isolation, post-exposure prophylaxis, and treatment.

Steps for monitoring mpox exposures may include:

  • ​Conducting case interviews to identify potential staff and resident exposures as mentioned above.
  • Identifying staff and residents/clients who may be at higher risk of exposure given the high contact nature of their employment, such as medical, janitorial, and laundry workers.
  • Screening exposed and potentially exposed staff and residents/clients for symptoms and post-exposure prophylaxis eligibility, in consultation with the LHD.
  • Immediately isolating any individuals with symptoms, arranging mpox testing, and ensuring access to treatment, if indicated.
  • ​Maintaining confidentiality in all staff and resident communications.

Generally, exposed persons do not need to restrict or change behavior as long as they are asymptomatic (CDC | If You’re a Close Contact). Facilities should consult with their LHD for guidance regarding any reported exposures including recommendations for symptom monitoring and/or post-exposure prophylaxis with the vaccine.

Symptom Monitoring

  • Anyone who may have been exposed to mpox should be monitored for mpox symptoms for 21 days following their last exposure. Monitoring can include providing education to residents/clients so that they can self-monitor, or by conducting verbal symptom checks.
  • ​Of note, many cases in California have reported genital, oral, or anal lesions, so contacts who are self-monitoring should check for rash, pain, or drainage in these areas.

Post-Exposure Prophylaxis (PEP) with Vaccination

  • Getting the mpox vaccine​ (JYNNEOS) promptly after exposure is recommended for unvaccinated individuals with significant, close contact exposure as it may prevent infection and reduce the risk of severe illness (CDC | Mpox | Vaccine Considerations).
  • ​Individuals who report community exposures or are otherwise interested in getting the vaccine may make free appointments online on MyTurn.

Other Considerations for Exposed Residents/Clients and Staff

  • Exposed residents/clients should ideally not be transferred to other institutions during the 21-day monitoring period; if transfer is unavoidable, continuation of monitoring should be ensured by the receiving institution. Generally, there are no restrictions to resident movement or placement within the facility itself as long as they remain asymptomatic, unless otherwise directed by the LHD
  • Exposed staff should follow their employee health symptom monitoring protocol and can continue to work if they do not have symptoms. See the Cal/OSHA Mpox Guidance for further information: Cal/OSHA Guidance on Mpox Virus for Employers Covered by the Aerosol Transmissible Diseases Standard (PDF).
  • ​Regardless of exposure risk level, staff or residents/clients who develop any symptoms of mpox should isolate immediately and be seen by a health care provider for clinical evaluation.

Additional Considerations for Homeless Service Providers​

Homeless service providers are encouraged to support and care for individuals who have symptoms of mpox and are experiencing homelessness. In addition to the above, homeless providers should:

  • Provide clients a safe space to isolate and should not deny shelter to clients due to contracting or being exposed to mpox infection.
  • ​Consult with their LHD to identify a location where a person with mpox can isolate during recovery without exposing others.

Companion animals: Because mpox 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 mpox virus.
  • If a client with mpox 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.
  • An infected person isolating with an animal should:
    • Avoid sharing food or a bed with the animal;
    • 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.
  • Uninfected people providing care for the animal should wear a gown, gloves, respirator, and eye protection.
  • Exposed animals should be kept away from all other animals for the entire duration of the isolation period and 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.
  • Animals that develop symptoms should be evaluated by a veterinarian as soon as possible.
  • ​CDC guidance on pets whose owners have mpox can be found here: Pets in the Home | Mpox | Poxvirus | CDC

General Considerations for 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) (PDF), and should consult those regulations for additional applicable requirements. Settings not covered by these standards still must protect their employees under other laws and regulations. See Cal/OSHA Protecting Workers from Mpox for Employers and Workers Covered by the Aerosol Transmissible Diseases Standard (PDF).​

Resources

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