Monkeypox

Monkeypox is a rare disease caused by infection with the monkeypox virus. Monkeypox virus belongs to the Orthopoxvirus genus in the family Poxviridae. The Orthopoxvirus genus also includes variola virus (which causes smallpox), vaccinia virus (used in the smallpox vaccine), and cowpox virus. Monkeypox is not related to chickenpox.

Monkeypox was first discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of monkeys kept for research. Despite being named “monkeypox”, the source of the disease remains unknown. However, African rodents and non-human primates (like monkeys) may harbor the virus and infect people.

The first human case of monkeypox was recorded in 1970. Since then, monkeypox has been reported in people in several other central and western African countries. Prior to the 2022 outbreak, nearly all monkeypox cases in people outside of Africa were linked to international travel to countries where the disease commonly occurs, or through imported animals.

Talk to your doctor if:

  • You believe you were exposed to Monkeypox
    OR
  • You develop symptoms, such as fever, headache muscle aches, swollen lymph nodes, chills exhaustion or a rash that looks like pimples or blisters

To learn more, or if you believe you have been exposed to Monkeypox, email monkeypox@ruhealth.org or call (951) 358-5107.

Number of Confirmed and Probable Cases

70

Data as of August 9, 2022

NOTE: A confirmed case has tested positive specifically for monkeypox virus. A probable case has tested positive for orthopox virus with no suspicion of other recent orthopox exposure and is pending confirmatory testing.

Monkeypox Update
  • Monitor for symptoms. 
  • Let partner(s) know you have been exposed.
  • Limit close physical contacts during this time.
  • Call your healthcare provider, or 2-1-1, if you do not have a healthcare provider. If you develop symptoms, see a healthcare provider as soon as possible. 
  • Seek out a vaccine if you are told by your partner that they have monkeypox, or someone contacts you to tell you that you were exposed. 
    • We know there are many more people in the LGBTQ+ community who need protection from the vaccine and should get it. Because we have such limited vaccines, we are temporarily asking everyone to prioritize those who have a direct exposure. 
    • Getting a vaccine soon after exposure – ideally within 4 days but up to 14 days after – can help prevent you from becoming infected with the monkeypox virus.
    • If monkeypox symptoms develop, such as a monkeypox rash, vaccination is no longer considered to be effective.
  • You must have a rash with fluid-filled lesions similar to blisters to get a monkeypox test.
  • The monkeypox test is done on your skin with a swab at a clinic by a health care provider. The swab is rubbed against lesions on your skin, or parts of your rash, and then sent to a specialized lab for monkeypox testing. 
  • A preliminary lab test result should be available in a few days. While you are waiting, be sure to take steps to care for yourself and others: 
    • Stay home and away from others. 
    • Put off travel on public transportation and domestic and international travel.
    • Contact your sex partner(s) and people you have had close contact with since the start of your symptoms.
    • Protect any pets.
  • Most people get well from monkeypox without needing any medicines or other treatment. 
  • Vaccination is not a treatment for monkeypox. If you test positive, you are not a candidate for vaccination, but there are other treatment options.
  • The U.S. Food and Drug Administration (FDA) has approved Tecovirimat (TPOXX or ST-246) as a treatment for Monkeypox and it is available from healthcare providers. 
  • Always consult your healthcare provider before seeking or using any medical treatment.

The Federal supply of vaccine remains limited and must be prioritized for specific groups who are at the highest risk. Riverside County is currently prioritizing first doses of vaccine for:

  • People who have been identified by known monkeypox cases as intimate or otherwise close contacts with a person diagnosed with monkeypox
  • Specific laboratory workers who directly process laboratory specimens for monkeypox testing, or healthcare professionals who work regularly in STI clinic environments directly and routinely performing monkeypox testing.
  • People who have had a bacterial sexually transmitted infection (syphilis or gonorrhea) in the last 3 months among people who identify as gay, bisexual, cisgender men who have sex with men, non-binary persons assigned male at birth who have sex with men, or transgender persons who have sex with men.
  • People who engage in transactional sex or survival sex (e.g.: sex in exchange for shelter, food, or other goods and needs)
  • People who work at a sex club, bathhouse, or sauna.

If you have monkeypox specific symptoms or are currently under isolation for monkeypox please do not attend the vaccine clinics. Once a person has monkeypox symptoms, including a rash, the monkeypox vaccine is considered to no longer be effective. If you think you have monkeypox please speak with a healthcare provider and get tested. Consistent with scarce resource allocation strategies Riverside County is temporarily postponing second doses of vaccine to maximize impact of the limited vaccine supply, in specific high risk situations (e.g.: severe immunocompromise) second doses will be made available as supply would allow.

Please continue to monitor this webpage for upcoming vaccination opportunities. Riverside County will work with our healthcare systems and directly communicate to eligible patients to provide details on how and where to access the JYNNEOS vaccine.

The CDPH allocates a certain number of doses per LHJ. Certain formulas are used to allocate the limited number of monkeypox vaccines to LHJs. To determine populations at highest risk of monkeypox transmission, on factor that the formulas include is the number of early syphilis cases among men as a proxy. Riverside County does not determine this formula.

Given the continued limited supply of the Jynneos vaccine, Riverside County will prioritize providing first doses to offer protection to more at-risk Riverside County residents. This strategy allows for more people to get at least a first vaccine until an adequate vaccine supply is received. Additionally, this single dose strategy is consistent with the monkeypox vaccine distribution strategy taken in the California Department of Public Health, New York, United Kingdom (UK), and Canada.

  • Ask your partners about recent illnesses or rashes. Delay or defer close or intimate contact if they have a rash or have been recently sick. 
  • Condoms can help reduce your chance of STIs, but they are not known to reduce the spread of monkeypox. You may be exposed to the virus through bedding, clothing or other physical contact that is not necessarily sexual.
  • Avoid contact with objects and materials that a person with monkeypox has used.
    • Do not share eating utensils or cups with a person with monkeypox.
    • Do not handle or touch the bedding, towels, or clothing of a person with monkeypox.
  • Wash your hands often with soap and water or use an alcohol-based hand sanitizer, especially before eating or touching your face and after you use the bathroom.

To prevent the spread of monkeypox:

  • If you have a rash or feel ill, stay home and contact your healthcare provider, if necessary, especially if you may have been previously exposed to monkeypox. 
  • Practice good hand hygiene after contact with potentially infected animals or humans. Wash your hands with soap and water or use an alcohol-based sanitizer. 
  • Avoid contact with materials (e.g., bedding or laundry) that have been in contact with a sick person or animal. 
  • If you take care of patients, use appropriate personal protective equipment (PPE), which includes a gown, gloves, respirator, and eye protection. 
  • Rapid identification and reporting of possible cases or suspected exposure.

If you have symptoms of monkeypox, contact your healthcare provider. If you do not have a healthcare provider, email monkeypox@ruhealth.org or call (951) 358-5107 for information about getting access to a healthcare provider near you.

Read Frequently Asked Questions for more information.

Frequently Asked Questions

The Centers for Disease Control and Prevention (CDC) states that based on the limited information available, the risk appears to be small for general public, although some groups may be at elevated risk. If you have symptoms of monkeypox, contact your healthcare provider right away. 

The CDC is working with state and local health officials to identify people who have been in contact with monkeypox. This is to help prevent the spread of disease and to monitor the health of individuals who tested positive for monkeypox. It is important to address disease outbreaks while the risk is small to prevent larger outbreaks.

Visual Examples of Monkeypox Rash

MonkeyPox Rash Collage

Photo Credit: NHS England High Consequence Infectious Disease Network

In humans, the symptoms of monkeypox are similar to, but milder than, the signs and symptoms of smallpox.

Monkeypox symptoms begin with: 

  • Fever 
  • Headache 
  • Muscle aches
  • Backache
  • Swollen lymph nodes
  • Chills 
  • Exhaustion

Within 1 to 3 days (sometimes longer) after the appearance of fever, a rash develops, often beginning on the face and then spreading to other parts of the body (like the extremities and genital areas).

The incubation period (time from infection to symptoms) for monkeypox is usually 7-14 days but can range from 5-21 days. The illness typically lasts for 2-4 weeks. 

Anyone who has symptoms of monkeypox, such as unusual rashes or lesions, should contact a healthcare provider right away. 

Painful lesions progress through the following stages before falling off:

  • Macules (flat, discolored areas of skin)
  • Papules (solid or cystic raised spot on the skin that is less than 1 centimeter wide).  
  • Vesicles (small fluid-filled blisters on the skin)
  • Pustules (small, inflamed, pus-filled, blister-like sores on the skin)
  • Scabs
  • Condoms during sex are an important way to protect yourself and others from HIV and other STIs like gonorrhea, chlamydia and syphilis
  • We do not know yet whether condoms reduce the risk of getting or giving someone else monkeypox during sex. 
  • While we learn more about how the monkeypox virus is spread, we want everyone to know that monkeypox can be spread during any close physical contact, including sex, or by face-to-face coughing or sneezing, kissing, licking, skin to skin rubbing, or sharing of sex toys, bedding, towels, clothing, or utensils, among other ways.
  • Monkeypox and smallpox are in the same family of viruses. 
  • According to theCDC, since monkeypox is closely related to the virus that causes smallpox, the smallpox vaccine may provide some protection from getting monkeypox.

However, if you have been exposed to monkeypox and it has been three years or more since your smallpox vaccine, you may not have full protection against monkeypox virus.

 

  • You are able to spread monkeypox to other people from the start of your symptoms (or feeling like you have the flu) or the start of a rash, until all scabs have fallen off and new skin covers all the monkeypox spots.
  • This can take 2 to 4 weeks.

 

Riverside County

CDPH

CDC

FDA

World Health Organization (WHO)

Information For Healthcare Professionals

PUBLIC HEALTH ADVISORY - UPDATED MONKEYPOX GUIDANCE - JULY 19, 2022

This is a rapidly evolving situation. Updates and modification to the below guidance will be provided by Riverside University Health System – Public Health as they become available.

Situation Update

CDC is tracking an outbreak of monkeypox that has spread across several countries that do not normally report monkeypox, including the United States.

People with monkeypox in the current outbreak generally report having close, sustained physical contact with other people who have monkeypox. While many of those affected in the current global outbreak are gay, bisexual, or other men or transgender people who have sex with men, anyone who has been in close contact with someone who has monkeypox can get the illness.

As of July 15, 2022, 1,814 monkeypox cases have been reported in the United States; of those 266 cases were reported for California residents. Locally, in Riverside County, five confirmed/probable cases have been identified.

Background

After an average incubation period of 6 to 13 days (range, 5 to 21 days), flu-like symptoms may appear, and may include fever, headache, lymphadenopathy, myalgia, and fatigue. This is followed approximately 1 to 3 days later by a rash that may affect the face and extremities (including palms and soles). In this outbreak, a number of people have reported not experiencing any prodromal symptoms prior to their rash onset. With regard to the rash, mucous membranes and genitalia may be involved. The appearance and progression of the rash is very characteristic, evolving sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), to vesicles (lesions filled with clear fluid), to pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off.

A person is considered infectious from the onset of symptoms and is presumed to remain infectious until lesions have crusted, those crusts have separated, and a fresh layer of healthy skin has formed underneath.

Human-to-human transmission occurs through direct contact with body fluids or lesion material, as well as through fomites (such as clothing or bedding) contaminated by the virus, or less commonly through large respiratory droplets during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex.

Confirmatory laboratory diagnostic testing for monkeypox is performed using real-time polymerase chain reaction assay on lesion-derived specimens.

Additional information on monkeypox is located at https://www.cdc.gov/poxvirus/monkeypox/

 

Testing Recommendations

Healthcare providers should test any patients with suspected monkeypox. This includes any patient with a new characteristic rash or patients with risk factors for monkeypox and a new rash. The rash associated with monkeypox can be confused with other rashes encountered in clinical practice including herpes, syphilis, and varicella and co-infections have been reported. Providers should wear appropriate personal protective equipment (PPE) to collect specimens (see Infection Control guidance below).

Patients presenting with perianal or genital ulcers, diffuse rash, or proctitis should also be evaluated for STIs. However, the diagnosis of an STI does not exclude monkeypox as a concurrent infection may be present. The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis.

Commercial testing is available

Commercial testing for monkeypox continues to expand. Testing is now available through Quest Diagnostics, LabCorp, Aegis Sciences and Mayo Clinic Laboratories. LabCorp, Mayo Clinic Laboratories, and Aegis Sciences are using the CDC’s orthopoxvirus test (which detects all non-smallpox related orthopoxviruses, including monkeypox). The Quest assay is real time PCR test developed by Quest that detects DNA of non-variola orthopoxviruses and Monkeypox virus (West African clade)—see Quest FAQs. CDC anticipates additional commercial laboratories will come online this month.

Providers should submit specimens through commercial labs if possible. Follow specimen collection instructions provided by the laboratory. Public health approval is not required to submit specimens to a commercial lab, however providers should notify public health about patients suspected to have monkeypox without waiting for results to return to allow for contact tracing efforts to begin expeditiously.

Providers using commercial labs must report all Riverside County residents with orthopoxvirus positive and/or presumptive positive test results (see Reporting).

Public Health Laboratory

Providers that do not have access to commercial orthopoxvirus testing, may request testing for suspected cases by submitting a monkeypox intake form located at https://rivcoph.org/Monkeypox and photos of the rash/lesions via secure email to bcole@ruhealth.org

Testing Guidance

If a patient is evaluated and monkeypox is high on the differential diagnosis, collect two swabs from two different lesions for preliminary and confirmatory testing as follows:

  1. Vigorously swab or brush lesion with two separate sterile dry polyester or Dacron swabs. (two from each lesion)
  2. Break off end of applicator of each swab into a sterile 1.5- or 2-mL screw-capped tube with O- ring or place 2 entire swabs in 2 separate sterile containers. Do not add or store in viral or universal transport media.
  3. The two separate sterile containers should be placed in 2 separate biohazard bags and refrigerated at 4C.

Specimens being tested through Public Health, will be picked by a RUHS courier, within 24 hours Monday through Friday. Store specimens at -80C if it is greater than 72 hours between specimen collection and pickup.

Swabs can be collected and stored at the proper temperature without waiting to discuss the case with Public Health. This will avoid outpatients needing to be recalled should they meet criteria for testing through Public Health.

Infection Control

Patients presenting with suspected monkeypox should be placed, as soon as possible, into a single person exam room with door closed, or an airborne infection isolation room, if available. The patient should remain masked, as tolerated (as currently required for all persons in healthcare settings) and any exposed skin lesions should be covered with a sheet or gown.

Healthcare personnel (HCP) evaluating patients with suspected monkeypox should wear the following personal protective equipment (PPE): gloves, gown, eye protection (goggles or face shield) and a N95 or equivalent or higher-level respirator. HCP should don PPE before entering the patient’s room and use for all patient contact. HCP should remove and discard gloves, gown, and eye protection, and perform hand hygiene prior to leaving the patient’s room; the N95 respirator should be removed, discarded, and replaced with a mask for source control after leaving the patient’s room and closing the door.

Any EPA-registered hospital-grade disinfectant should be used for cleaning and disinfecting environmental surfaces.

All disposable equipment used for obtaining swabs (e.g., scalpel) must be properly discarded according to the facility’s established procedures.

Treatment and Management Considerations

Management and treatment of monkeypox disease includes nonspecific supportive care and treatment of symptoms.

Antiviral treatments and prophylaxis are available from CDC after case-by-case evaluation.

Individuals at high risk of severe disease include:

  • People with immunocompromising conditions (e.g., HIV/AIDS, leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient with hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component
  • Pediatric populations, particularly patients younger than 8 years of age
  • Pregnant or breastfeeding women
  • People with a history or presence of atopic dermatitis, people with other active exfoliative skin conditions (e.g., eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease [keratosis follicularis])
  • People with one or more complications (e.g., secondary bacterial skin infection; gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; concurrent disease or other comorbidities)

Additional information is available at:
https://www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html

If a patient meets criteria and is a good candidate for antiviral therapy, RUHS-Public Health can be contacted at 951-358-5107 for assistance with connecting the patient with the closest Tecovirimat (TPOXX) center. At this time, most patients have not required TPOXX and symptoms have resolved on their own with symptom management strategies.

Bacterial superinfections should be appropriately treated but may be difficult to distinguish from viral inflammation.

Clinicians are encouraged to offer meningitis vaccination (MenACWY) to MSM and transgender persons who have sex with men. Vaccination may be particularly beneficial for these individuals when planning to attend gatherings (especially in crowded venues) with other MSM from around the country, including upcoming PRIDE events. For more information, please see the health alert, available at this link: CAHAN-Meningococcal Vaccine for MSM.

Post-exposure prophylaxis (PEP)

RUHS-PH is currently offering PEP to individuals who have been identified as having skin to skin or prolonged face to face contact with someone with or suspected to have monkeypox. Health care providers (HCP) can call Disease Control at 951-358-5107 during business hours to discuss PEP for their patient.

The above number can be called to discuss PEP for personnel in the health care settings who have had a potential exposure to MKP.

Pre-exposure prophylaxis (PrEP) and Post-exposure prophylaxis ++ (PEP++)

Strategies for PrEP and PEP++ will include clinical or laboratory staff who regularly and directly perform monkeypox specimen collection for testing (i.e. regularly swabbing lesions, or processing laboratory specimens). Additional prioritization will include gay, bisexual, and other cisgender men who have sex with men (MSM), transgender men, and transgender women who meet the specific risk criteria which will be posted and updated on our Riverside County monkeypox website.

Disease Reporting

A patient being tested as a suspect monkeypox case, should be reported immediately, to Disease Control at 951-358-5107 during business hours or 951-782-2974 after hours.

This is important to facilitate Public Health intervention such as obtaining information for contact tracing. The patient should be instructed in home isolation, pending test results.

Case information can be entered in CalREDIE (for healthcare facilities who are enrolled), select “Monkeypox disease” in the drop-down menu. Please enter CMR-level data on the Patient and Case Investigation tabs and add any additional information into the Notes field or upload into the Electronic Filing Cabinet. Please Do Not include any information about the patient’s HIV status in CalREDIE.

Case Definition

Confirmed case: Patient with monkeypox virus detected from a clinical sample.

Probable case: Patient with orthopoxvirus detected from clinical sample.

Suspect case: Patient with an unexplained rash (unlikely to be secondary syphilis, herpes, varicella, molloscum contagiosum, or other diagnosis) that is consistent with monkeypox (firm, well circumscribed, deep-seated, and umbilicated lesions; progresses from macules to papules to vesicles to pustules to scabs) especially in patients who 1) report close contact with a person or people with confirmed or suspected monkeypox and/or with a similar rash; and/or 2) report travel in the past month to an area where confirmed cases have been reported; and/or 3) is a man or transgender person who has sex with men.

Riverside County

Testing Recommendations

Healthcare providers should test any patients with suspected monkeypox. This includes any patient with a new characteristic rash or patients with risk factors for monkeypox and a new rash. The rash associated with monkeypox can be confused with other rashes encountered in clinical practice including herpes, syphilis, and varicella and co-infections have been reported. Providers should wear appropriate personal protective equipment (PPE) to collect specimens (see Infection Control guidance below).

Patients presenting with perianal or genital ulcers, diffuse rash, or proctitis should also be evaluated for STIs. However, the diagnosis of an STI does not exclude monkeypox as a concurrent infection may be present. The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis.

Commercial testing is available

Commercial testing for monkeypox continues to expand. Testing is now available through Quest Diagnostics, LabCorp, Aegis Sciences and Mayo Clinic Laboratories. LabCorp, Mayo Clinic Laboratories, and Aegis Sciences are using the CDC’s orthopoxvirus test (which detects all non-smallpox related orthopoxviruses, including monkeypox). The Quest assay is real time PCR test developed by Quest that detects DNA of non-variola orthopoxviruses and Monkeypox virus (West African clade)—see Quest FAQs. CDC anticipates additional commercial laboratories will come online this month.

Providers should submit specimens through commercial labs if possible. Follow specimen collection instructions provided by the laboratory. Public health approval is not required to submit specimens to a commercial lab, however providers should notify public health about patients suspected to have monkeypox without waiting for results to return to allow for contact tracing efforts to begin expeditiously.

Providers using commercial labs must report all Riverside County residents with orthopoxvirus positive and/or presumptive positive test results (see Reporting).

Public Health Laboratory

Providers that do not have access to commercial orthopoxvirus testing, may request testing for suspected cases by submitting a monkeypox intake form located at https://rivcoph.org/Monkeypox and photos of the rash/lesions via secure email to bcole@ruhealth.org

Testing Guidance

If a patient is evaluated and monkeypox is high on the differential diagnosis, collect two swabs from two different lesions for preliminary and confirmatory testing as follows:

  1. Vigorously swab or brush lesion with two separate sterile dry polyester or Dacron swabs. (two from each lesion)
  2. Break off end of applicator of each swab into a sterile 1.5- or 2-mL screw-capped tube with O- ring or place 2 entire swabs in 2 separate sterile containers. Do not add or store in viral or universal transport media.
  3. The two separate sterile containers should be placed in 2 separate biohazard bags and refrigerated at 4C.

Specimens being tested through Public Health, will be picked by a RUHS courier, within 24 hours Monday through Friday. Store specimens at -80C if it is greater than 72 hours between specimen collection and pickup.

Swabs can be collected and stored at the proper temperature without waiting to discuss the case with Public Health. This will avoid outpatients needing to be recalled should they meet criteria for testing through Public Health.

Infection Control

Patients presenting with suspected monkeypox should be placed, as soon as possible, into a single person exam room with door closed, or an airborne infection isolation room, if available. The patient should remain masked, as tolerated (as currently required for all persons in healthcare settings) and any exposed skin lesions should be covered with a sheet or gown.

Healthcare personnel (HCP) evaluating patients with suspected monkeypox should wear the following personal protective equipment (PPE): gloves, gown, eye protection (goggles or face shield) and a N95 or equivalent or higher-level respirator. HCP should don PPE before entering the patient’s room and use for all patient contact. HCP should remove and discard gloves, gown, and eye protection, and perform hand hygiene prior to leaving the patient’s room; the N95 respirator should be removed, discarded, and replaced with a mask for source control after leaving the patient’s room and closing the door.

Any EPA-registered hospital-grade disinfectant should be used for cleaning and disinfecting environmental surfaces.

All disposable equipment used for obtaining swabs (e.g., scalpel) must be properly discarded according to the facility’s established procedures.

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