​Since May 2022, there has been an outbreak of mpox 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 and Prevention (CDC), local health departments (LHDs) and health care providers on the ongoing mpox outbreak impacting the United States and other countries. For the most up to date information regarding signs/symptoms, transmission, and prevention of mpox please refer to the CDPH Mpox Landing Page or go directly to CDPH's Mpox Questions & Answers Page.

This guidance is intended to provide state and local correctional facilities the information necessary regarding the risks associated with mpox to ensure the health and well-being of their staff and residents of these facilities. Medical personnel in correctional settings should follow CDC recommendations for Mpox Infection Prevention and Control in Healthcare Settings wherever applicable.

Correctional service providers are encouraged to coordinate with their public health officials, local governments, inpatient and outpatient healthcare providers, and other health care partners to share information and stay apprised of new developments.

Mpox Background

Mpox is a rare viral infection, similar to smallpox (but milder), that can spread from infected humans, animals, and materials contaminated with the virus.

In the current outbreak, mpox is primarily spread by close, personal, and primarily skin-to-skin contact (including sexual contact) with people who have mpox symptoms, such as rashes and sores.

Mpox Symptoms

Mpox 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 infected person can develop a rash or sores. The sores will go through several stages, including scabs, before healing. They can look like pimples or blisters, may be painful and itchy and can last up to four weeks. 

Anyone exposed or potentially exposed to mpox should monitor themselves for symptoms for 21 days after last exposure. Many cases in California have reported genital or anal rashes or sores, 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 healthcare provider, and can present with pain, discomfort, discharge or blood from the region.

Mpox Transmission

Mpox spreads primarily through direct contact with infectious sores, scabs, or body fluids, including during sex, as well as activities like kissing, hugging, massaging, and cuddling. Mpox can also spread through touching materials used by a person with mpox that haven't been cleaned, such as clothing, towels and bedding.

Mpox is currently a relatively rare disease in most populations. Unlike COVID-19 and other respiratory illnesses, the virus is not easily transmitted except through direct contact with infected lesions or materials. Most cases currently being identified in California have involved transmission through close, intimate or sexual contact. Less commonly, transmission has been identified in household settings in people who are providing or receiving care or sharing personal items. The risk of spread to persons who do not have close or intimate contact appears to be low.

Exposure to Mpox

Facilities, in coordination with their LHD, should use CDPH Exposure Management Guidance to determine any staff or residents that have had a significant exposure that requires monitoring for symptoms and/or prophylaxis with vaccination to help prevent infection and/or severe disease.

Anyone, including residents, visitors and staff, who may have been exposed to someone with mpox should be monitored for rash and other mpox symptoms for 21 days following their last exposure.

Exposed staff should follow their employee health symptom monitoring protocol, the Cal/OSHA Mpox Guidance for further information: Cal/OSHA Guidance on Mpox Virus for Employers Covered by the Aerosol Transmissible Diseases Standard (PDF) and CDPH Exposure Management Guidance. Exposed residents should be actively monitored with verbal symptom checks as well as encouraged to self-monitor, at least once daily for 21 days after last exposure. Cases are considered infectious once they have developed symptoms of mpox, including flu-like symptoms that often precede rashes and sores until the rashes and sores have completely healed and new skin has formed. Exposed staff can continue to work and exposed resident movement or interactions with other incarcerated individuals does not need to be restricted as long as they do not develop symptoms.

Exposed residents 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. Health care providers and LHDs may also recommend a vaccine for those who are exposed to help prevent infection or decrease the seriousness of the illness.

Correctional service providers and staff should consult the latest CDPH and LHD guidance on vaccine post-exposure prophylaxis eligibility. To be effective as post-exposure prophylaxis, vaccine must be given as soon as possible after exposure.

If exposed staff or residents regardless of risk level develop any symptoms of mpox, they should isolate immediately and be seen by a health care provider for clinical evaluation.

See section below on isolation for additional details on resident isolation. Additionally, please consult CDPH Mpox Home Isolation Guidance for details on duration and precautions for staff isolation and return to work criteria. Consult a knowledgeable health care provider or your LHD with any questions.

Notification of exposure 

In consultation with their LHD, facilities should provide same day notification to exposed workers/clients/residents that meet the definition of exposed person, as defined in CDPH Exposure Management Guidance.

Notification of exposure should not include the name of the infected individual or other legally protected health information unless it is required to protect the health and safety of others. 

The purpose of notification is to provide exposed individuals education about symptom monitoring and access timely medical care, including prophylaxis and treatment, if indicated.

Prevention

Correctional service providers should share and post information about mpox throughout their facility. Please see the following communication materials

• CDPH Safer Sex and Mpox (PDF)
  
• CDPH What is Mpox (PDF)
  
• CDC Social Gatherings, Safer Sex and Mpox
  
• CDC Event Organizer Letter Template (attached DOCX)
  
• CDPH Mpox Communications Toolkit
  

Incoming residents should be screened for symptoms of mpox, known mpox exposures and eligibility for vaccination based on local protocols during the booking or reception process.

Those with mpox symptoms should be isolated and tested immediately prior to entry into general populations and should remain isolated while awaiting test results.

Exposed incoming residents should be monitored for symptoms for 21 days following last exposure and should be considered for post-exposure prophylaxis per latest LHD and CDPH post-exposure prophylaxis recommendations.

Prior to experiencing cases, facilities should work with their LHD to identify an appropriate location for residents to medically isolate.

Considerations for isolation spaces should include:

• Door that can be closed and dedicated bathroom not used by general resident population.
• If dedicated bathroom not possible, ensure thorough cleaning of bathroom and shower following manufacturer recommendations with EPA approved disinfectant after each use by resident with mpox.
• Multiple residents with mpox can share an isolation space, but should be discouraged from skin-to-skin contact.
• Residents should stay in the isolation space as much as possible during their isolation period. If needing to leave the space, residents should wear a well-fitting mask and cover all skin lesions with clothing, bandages or gloves.
• Only staff essential to operations wearing appropriate PPE should enter isolation areas.

Medical staff should also work with their LHD to ensure that a protocol has been developed for access to vaccination for exposed persons and treatment of cases if a case of mpox is identified within their facility.

See CDC Guidelines on Mpox in Congregate Settings and CDPH Guidance for Congregate Settings for additional considerations.

Isolation & Infection Control

Residents should be removed from shared housing and isolated as soon as mpox symptoms are observed, prior to testing. Residents with laboratory-confirmed mpox should be isolated until all sores and rashes have scabbed over and new skin has formed over sores and rashes, which can take up to 4 weeks.

While in isolation, residents should be monitored for development of severe symptoms and eligibility for treatment with the antiviral tecovirimat (TPOXX).

Residents should not be moved or transferred to other institutions while in isolation. Staff should follow CDPH Mpox Home Isolation Guidance for isolation and return to work considerations.

If a case of mpox is identified in your correctional facility, staff should:   

• Interview case to identify potential staff and inmate exposures. See CDPH Mpox Exposure Management Guidance for guidance on exposure definitions.
• Maintain a spreadsheet of exposed and infected staff and residents to ensure appropriate symptom monitoring, access to prophylaxis and treatment, clearance from isolation and return-to-work.
• Identify staff who may be at higher risk of exposure given the high contact nature of their employment, such as medical, janitorial, and laundry workers.
• Exposed and potentially exposed staff and residents should be screened for symptoms and considered for post-exposure prophylaxis with vaccination, in consultation with the LHD.
• Immediately isolate any exposed individuals with symptoms, arrange for testing and ensure access to treatment, if indicated. 
• Follow protocols for worker health and safety, including use of masks and respirators, outlined under "Employee Health and Safety Requirements," in accordance with Cal/OSHA guidance and requirements. 
  
• See Cal/OSHA Protecting Workers from Mpox for Employers and Workers Covered by the Aerosol Transmissible Diseases Standard (PDF).
• Ensure access to adequate and timely hand hygiene. Soap and water or hand sanitizer with at least 60% alcohol should be available at all times and at no cost to all staff, volunteers, and residents. Anyone who touches lesions or clothing, linens, or surfaces that may have had contact with lesions should wash their hands immediately.

For workers, the Cal/OSHA ATD (PDF) standard contains additional requirements for respirator use for staff in contact with residents with suspected or confirmed mpox; providers and staff should ensure they are following these requirements.

Laundry: The CDC recommends that soiled laundry should be gently and promptly contained in an appropriate laundry bag and never be shaken or handled in a manner that may disperse infectious material. Linens can be laundered using regular detergent and warm water.

Cleaning and Disinfection: Clean and disinfect the areas where people with mpox spent time. 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. Wet cleaning methods are preferred, following the considerations in the instructions above for cleaning chemical choice and use.

When choosing a disinfectant, it is important to consider any potential health hazards, and do not mix disinfectants or add other chemicals. More considerations can be found at: Hazard Communication for Disinfectants Used Against Viruses | NIOSH | CDC.

Avoid spraying to minimize inhalation of chemicals by others. Focus on disinfecting only those items and surfaces that were in direct contact with the skin of the person with mpox during isolation.

Caring for Residents with Mpox

Correctional facility employees are encouraged to support and care for residents who have symptoms of mpox. In all communications, correctional service providers 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. Health care providers should familiarize themselves with latest supportive care and treatment protocols from CDPH and their LHD in order to provide effective medical care to residents with mpox.

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. Also, see: Cal/OSHA Protecting Workers from Mpox for Employers and Workers Covered by the Aerosol Transmissible Diseases Standard (PDF).

• PPE should be worn by staff, volunteers, or residents in these circumstances: 
  
• Mpox symptom screening—If staff are performing symptom screening for exposed residents who do not report symptoms, gloves and a gown should be worn if the bare skin of exposed residents is going to be touched.
• If symptoms or lesions are reported, or if otherwise indicated, eye protection and a fit-tested NIOSH-approved particulate respirator with N95 filters or higher should also be donned.
• If gloves and a gown are worn, staff should remove them and perform hand hygiene after symptom screening is complete; fresh gloves and gown should be donned for screening a different individual.
• Entering Mpox isolation areas—Staff who enter mpox isolation areas should wear a fit-tested NIOSH-approved particulate respirator equipped with N95 filters or higher. Staff who will have close contact with a known mpox case or perform activities defined as high risk (see exposure guidance) should additionally wear a gown, gloves, and eye protection. 
• Once these activities are complete, staff should remove gloves and gown and perform hand hygiene; fresh gloves and gown should be donned for contact with a different mpox case.
• If gowns are not available, skin should be fully covered with long sleeves and long pants, and clothing should be immediately removed and laundered afterwards.
• Laundry—When handling dirty laundry from people with known or suspected mpox infection, staff, volunteers, or residents should wear a gown, gloves, eye protection, and a fit-tested respirator. PPE is not necessary after the wash cycle is completed. 
  
• Cleaning and disinfection—Staff, volunteers, or residents should wear a gown, gloves, eye protection, and a fit-tested respirator when cleaning areas where people with mpox spent time. 
  
• For employees who are exposed to mpox, employers must ensure timely access to a medical evaluation with a knowledgeable medical provider. This should be planned in advance, with instructions recorded in the ATD plan for the worksite and communicated to both managers and workers as a part of health/safety training and exposure notification.
• Access to care for workers: Not all workers have employer-sponsored health insurance, and many workers may face financial hardship due to medical expenses.

If a worker believes they contracted mpox at their workplace, they may have a right to workers' compensation benefits. Encourage workers to notify their employer and file a workers' compensation claim if they think they contracted mpox at work.

• 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).
• 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.
• Required documentation and reporting: Employers should maintain a spreadsheet of exposed and infected employees. Employers subject to the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF) should consult those regulations for additional applicable requirements. Correctional facilities are required to report a suspected and/or confirmed case of mpox to the LHD, including demographic and health information requested by the LHD.
  

• Additional workplace safety questions can be directed here:
• Cal/OSHA Safety and Health Training and Instruction Requirements for Employers lists the topics, suggested educational materials, the types of workers needing training, and the required frequency of that training.
• Employers must comply with OSHA's standards on Bloodborne Pathogens (CA State 5193), PPE, Respiratory Protection, and other requirements, including those established by state plans, whenever such requirements apply. and other requirements, including those established by state plans, whenever such requirements apply.
• Cal/OSHA Consultation Services
• Toll-free assistance number 1(800) 963-9424 or email at InfoCons@dir.ca.gov.

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

• Cal/OSHA Mpox Virus
• Cal/OSHA Protecting Workers from Mpox for  Employers and Workers Covered by the Aerosols Transmissible Diseases Standard (PDF) 
  
• CDC Considerations for Reducing Mpox Transmission in Congregate Living Settings
• CDC Mpox Isolation and Infection Control at Home
• CDC Interim Guidance for Household Disinfection of Mpox Virus (PDF)
  
• CDC Infection Prevention and Control of Mpox in Healthcare Settings
• CDPH Clinical Assist Tool for Mpox Evaluation
  

If a correctional facility needs assistance connecting to their local public health department or for general questions, submit an inquiry (monitored during Monday through Friday 8am–5pm).