HEALTH ADVISORY: Monkeypox Update Regarding Testing, Isolation, Treatment, and Vaccination

Situational Update

The monkeypox virus (MPX) epidemic continues to impact residents of Santa Clara County As of August 23, there are over 41,000 cases in 95 countries reported globally, 15,433 cases reported in the US, and 2663 cases reported in California. The County of Santa Clara has identified 117 cases among its residents. As seen throughout California and the US, County of Santa Clara cases continue to predominantly occur among gay, bisexual, and other men who have sex with men and among transgender individuals, spreading through either sexual contact or other intimate skin-on-skin contact. Transmission to individuals outside of these networks, including to household members, has also been reported, although rarely, and transmission via fomites or respiratory droplets continues to be considered a possibility, although not yet documented among our cases.

The most up-to-date MPX information for healthcare providers can be found here: https://publichealthproviders.sccgov.org/diseases
 

Providers should be aware of the following updates and resources:

1. Remain alert to the possibility of MPX infection in all individuals who present with a characteristic rash illness, regardless of travel history, gender or sexual orientation.

Familiarize yourself with the clinical presentation and typical appearance of MPX lesions, and be sure to collect social history including travel, sexual history, and contact with persons diagnosed with MPX when assessing patients with new onset of rash. If  genital, anal, or oral lesions or body rash are observed, complete evaluation for other sexually transmitted infections (STIs) as per CDC recommendations.

2. Testing can be obtained through all major commercial laboratories.

Use of commercial laboratories may allow faster turnaround time and streamlined laboratory and resulting for providers. Appropriate specimens must be collected by swabbing lesions on the skin or mucous membranes; patients without lesions should not be tested. Saliva or nasal swabs specimens are not validated for MPX testing and should not be collected. Refer to your usual laboratory point of contact for specimen collection instructions. If utilizing the County’s Public Health Laboratory, complete this MPX Specimen Requisition Form; a suspect case report form is no longer necessary.

3. Report confirmed cases to Public Health within 1 business day by calling 408-885-4214.

Reporting of suspected (non-confirmed) cases is no longer required, but providers may contact Public Health if concern for widespread exposure exists or other assistance is needed. Cases identified after hours may be reported on the next business day.
 
Limited support is available through Public Health for people with MPX who are experiencing homelessness or others who may not be able to safely isolate at home. For people who need emergency housing support over the weekend, contact the Office of Supportive Housing by calling 408-278-6420 (available Saturday/Sunday 9 AM – 6 PM).
 
4. Provide updated isolation guidance to suspected and confirmed cases. 

On August 18, CDPH published Updated Monkeypox Home Isolation Guidance for the General Public. The County of Santa Clara recommends alignment with this guidance and urges all providers to proactively offer this guidance at the time of evaluation of any suspected MPX case. 

  • Initially, all cases must isolate at home (except to seek healthcare), ensure all lesions are covered, and wear a mask.
  • After resolution of fever and respiratory symptoms for 48 hours AND no new lesions have appeared for 48 hours AND any lesions that cannot be covered have completely healed:
    • Cases may resume limited activities outside the home with all lesions covered and wearing a mask
    • Cases must avoid crowded settings and direct skin-to-skin contact.
    • Cases may return to work if it does not require physical contact with others, is not in a high-risk setting, and cannot be performed virtually.
  • Cases may resume all non-sexual activities once all lesions are fully healed.
  • Use of condoms during sexual activity is strongly recommended for 12 weeks after infection due to unknown risk of prolonged shedding in genital excretions.

Clearance by the Public Health Department is not required to end isolation except to return to certain high-risk settings (e.g., shelters, health care, LTCFs, jails, and early childcare and education).
 
5. The antiviral tecovirimat (Tpoxx) is available at three healthcare entities in the County of Santa Clara. 

Tecovirimat (Tpoxx) is an antiviral medication that is FDA approved for the treatment of smallpox and is now being used to treat MPX under the CDC Expanded Access Investigational New Drug protocol. Not all infected patients are eligible for Tpoxx treatment. Tpoxx should be considered for individuals with one or more of the following:   

  • Severe disease i.e., hemorrhagic disease, sepsis, or encephalitis;
  • High risk of severe disease i.e., immunocompromised, pediatric populations, history of atopic dermatitis or other active exfoliative skin conditions, pregnant or breastfeeding;
  • Lesions in anatomical areas at special risk of scarring or stricture, such as those near or directly involving the eye, mouth, rectum, or urethra;
  • Complications, such as urethritis and proctitis, particularly with tenesmus or rectal bleeding;
  • Challenges in pain control.

 
Tpoxx is only supplied through hospitals and by working directly with our local public health department. Health care partners who are interested in obtaining and dispensing Tpoxx can email [email protected].  
 
Currently, Tpoxx is only available at Stanford, Kaiser San Jose, Kaiser Santa Clara, and the County Health System. Providers working within these systems should refer to their health system leadership for instructions. For providers external to these health systems or referring patients outside their system, please refer as follows: 

  • Patients empaneled with a County Health System provider and uninsured patients not empaneled at Kaiser or Stanford may be referred to Valley Medical Center for Tpoxx by completing a referral to Infectious Disease in Docusign, which will route automatically to the authorization center.
  • Insured patients who are not already empaneled at Kaiser or the County Health System may be referred to Stanford Health System by submitting an urgent referral for MPX through their Referral Center website.
  • Kaiser Permanente (KP) San Jose and Santa Clara are providing Tpoxx treatment to eligible KP members. KP members in need of MPX care may be instructed to contact their KP care team via kp.org or the KP advice and appointment call center.
     

6. Jynneos vaccine is indicated for MPX PEP or PrEP for limited populations.

While vaccine supply is still extremely limited, several major health systems in the county have received allocations and are presently able to administer pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) to eligible populations. Eligibility criteria are available here. Eligible patients that belong to systems providing vaccination should be directed internally to schedule vaccination appointments. Those without a care provider may be directed to www.sccfreevax.org to schedule appointments as available at County Health System vaccination locations.

Although the approved vaccine regimen requires two doses, due to the current limited supply, all allocations are being used for first doses only, with the exception that patients who are moderately to severely immunocompromised may receive a second dose. Patients who have received their first dose will be contacted when there is sufficient supply to provide their second dose. In addition, the County requires all vaccinating agencies to use the FDA-approved method of intradermal injection except where contraindicated. All current data suggests this method is likely to be equally effective and safe while allowing broader community access to vaccination due to the smaller dose required.

We encourage all providers to sign up for health alerts from SCCPHD and CDC to keep updated on this fast-evolving situation, and to refer to the CDPH and CDC monkeypox (MPX) websites for updated information.

 

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Sign up for County of Santa Clara Public Health Department alerts: www.publichealthproviders.sccgov.org/home

Sign up for CDC health alerts: https://emergency.cdc.gov/han/
 
CDPH monkeypox website: www.cdph.ca.gov/Programs/CID/DCDC/Pages/Monkeypox.aspx

CDC monkeypox website: www.cdc.gov/poxvirus/monkeypox/outbreak/current.html
 
CDC Genital Ulcer Evaluation: https://www.cdc.gov/std/treatment-guidelines/genital-ulcers.htm

CDC STI Screening Recommendations: https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm

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