Mpox (Monkeypox)

Where can I get vaccinated?

The JYNNEOS vaccine is available at most local health clinics, hospitals, or even at our mobile vaccine clinic within the community. To locate a location closest to you please visit: Upcoming Vaccine Clinics | Riverside University Health System (ruhealth.org)

Riverside County continues to work with our healthcare systems and directly communicate to eligible patients to provide details on how and where to access the JYNNEOS vaccine.

How are vaccine doses allocated to local health jurisdictions (LHJ) in California?

California Department of Public Health allows jurisdictions to order any quantity of vials available to them up to their designated threshold. Expanded distribution contracted by the Strategic National Stockpile allows for rapid fulfilment of additional vaccine vials to as many sites as needed. Jurisdictions are confident in ordering enough vials of the vaccine to meet the need of the community.

How can I prevent the spread of monkeypox?

There are number of ways to prevent the spread of mpox, including:

• Getting vaccinated (two-doses) for MPOX. Find a vaccine near you My Turn - Manage your appointments (ca.gov): MPOX Vaccine Locator.
• Continuing to reduce or avoid behaviors that increase risk for MPOX exposure until 14 days after your second dose.
• Talking to your sexual partner/s about any recent illness and being aware of new or unexplained sores or rashes on your body or your partner's body, including on the genitals and anus
• Avoiding close contact, including hugging, kissing, cuddling and sexual activity with people with symptoms like sores or rashes.
• Washing your hands often with soap and water and/or using an alcohol-based hand sanitizer
• Using appropriate PPE (like a mask, gown and gloves) when caring for people with mpox.

If you choose to remain sexually active, see the CDPH fact sheet on safer sex and mpox (PDF) and visit CDC’s Safer Sex, Social Gatherings, and Mpox webpage.

How is the vaccine given?

The JYNNEOS vaccine is given through a shot (injection). The JYNNEOS vaccine can be given in two methods:

1. The standard method is a subcutaneous injection which is a shot given beneath the skin in the upper arm. This method has been approved for people 18 years or older and is also authorized under an Emergency Use Authorization (EUA) for people under 18 years of age.
2. Under newer guidelines from the FDA and CDC, the vaccine can also be given through intradermal injection, in the skin layer underneath the epidermis (which is the upper skin layer) for people 18 years or older. Intradermal injection is typically given in the forearm and requires a smaller amount of vaccine than the subcutaneous injection to create a similar immune response. Intradermal injection can also be given in the upper arm or on the back below the shoulder blade.

   Public health jurisdictions and healthcare providers have the flexibility to offer the intradermal or subcutaneous regimen, balancing optimal vaccine use and acceptance, feasibility of administration, and available vaccine supply. People of any age with a history of developing keloid scars, and individuals younger than 18 years of age, should receive the vaccine via the subcutaneous route. CDC recommends people get two JYNNEOS doses four weeks apart.

   For more information, see the CDC’s Mpox Prevention webpage. If you have symptoms of MPOX, contact your healthcare provider. If you do not have a healthcare provider, email mpox@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.

CDPH Mpox Question and Answers

Actions Requested

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://www.ruhealth.org/mpox 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.

Resources for Healthcare Professionals

Riverside County

• Updated Monkeypox Guidance - May 31, 2023
• Assessment for Temporary Housing Form - September 22, 2022
• Supportive Home Care Guide for Monkeypox - July 27, 2022
• Updated Public Health Advisory - July 19, 2022
• Information For Healthcare Professionals
• Orthopox Virus Laboratory Testing Guidance - June 29, 2022
• Monkeypox Intake & Investigation Form - June 29, 2022

CDPH

• Monkeypox—Transmission

CDC

• Potential for Recurrent Mpox Outbreaks Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2023
• CDC Report- Potential Risk for New Mpox Cases - 05/15/2023
• Monkeypox 2022 Cases
• Sign and Symptoms
• Clinical Recognition
• Specimen Collection
• Treatment
• Infection Control: Healthcare Settings
• Information for Laboratory Personnel
• Information for Veterinarians
• Travelers’ Health-Smallpox and Other Orthopoxvirus-Associated Infections
• Information for Healthcare Professionals
• Monkeypox and Smallpox Vaccine Guidance
• Monitoring People Who Have Been Exposed
• Preventing Monkeypox Spread in Congregate Settings

FDA

• FDA Approves the First Drug with an Indication for Treatment of Smallpox.

World Health Organization (WHO)

• Monkeypox

Trainings

• CDC/IDSA Monkeypox: Updates on Testing, Vaccination & Treatment (idsociety.org)
• Webinar June 29, 2022 - Monkeypox: Updates about Clinical Diagnosis and Treatment (cdc.gov)
• Webinar Tuesday, July 26, 2022 - Monkeypox Outbreak: Updates on the Epidemiology, Testing, Treatment, and Vaccinationd Older (cdc.gov)

Monkeypox Lab Testing

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://www.ruhealth.org/mpox 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.

CDPH

• For local health departments
• Healthcare Provider Monkeypox Health Advisory, May 27, 2022: Monkeypox Virus Infection in the United States and Other Non-endemic Countries

CDC

• Laboratory Procedures and Biosafety Guidelines

Monkeypox For Providers

For Providers

Monkeypox Sexual Health

Monkeypox Facts for People Who are Sexually Active

Sexual Health