Monkeypox (MPX) Resources for Providers

The County of Santa Clara Public Health Department continues to work closely with healthcare providers, hospitals, and partners to protect the public and keep the community informed about MPX. 
 

Health Alerts 


FAQ


    MPX (Monkeypox) is transmitted by direct contact with the rash, sores, or body fluids of a person with the disease, especially with mucous membranes. Less commonly, it may be spread by contact with objects (clothes, sheets, towels) that have been in contact with the rash or fluids for an extended period and haven’t been cleaned. Sex is one of the ways that MPX can be spread, in part because of the close contact that occurs during sex. Researchers are still studying if MPX can be spread through semen or other body fluids. In the current MPX outbreak, the virus is spreading primarily through close personal contact, especially between sexual partners. However, any sustained skin-on-skin contact with someone who has MPX can spread the virus. The contact does not have to be exclusively intimate or sexual.


    Yes. Contact with oral lesions or oral contact with anogenital lesions from a person with MPX can put patient at risk of acquiring MPX. Researchers are still studying if contact with oral secretions or oral contact with other fluids without sores present could also transmit the virus. 


    ​​​​​​​Condoms may reduce client’s risk of MPX through preventing contact with lesions on or inside the penis, vagina, rectum, or mouth. However, because MPX can cause rashes and sores on other parts of the body as well, it is best to abstain from any sexual or close contact with a person with MPX or to use other options to reduce risk of MPX during sex. 


    For assistance to confidentially or anonymously inform partner(s) of MPX diagnosis, please call 408-885-4214, option 3 to talk to an MPX investigator. 


    STIs and HIV infection have been reported to be highly prevalent among current global MPX outbreak. It is important to consider routine screening for HIV and STIs and other preventative care for all persons being evaluated for MPX.


    In the U.S, it has been reported that HIV or recent STIs are common among persons with MPX. Therefore, HIV PrEP should be considered and offered to all eligible persons seeking a MPX evaluation.

     

    1. Isolate the individual:

    • Patients presenting with suspected MPX should be placed promptly in a single-person exam room with the door closed. The patient should remain masked and any exposed skin lesions should be covered with a sheet or gown.
    • Healthcare workers evaluating patients with suspected MPX should wear the following: gloves, gown, eye protection (goggles or face shield), and a N95 or equivalent or higher-level respirator. PPE should be donned before entering patient’s room. Remove gloves, gown, and eye protection and perform hand hygiene prior to leaving the room. Remove and discard the N95 after leaving the room and closing the door. Replace with a mask.
       

    2. Test: 

    • If MPX is suspected, consider consultation with your organization’s infectious disease specialist or infection control practitioner to determine whether MPX testing is warranted. 
    • The County of Santa Clara Public Health Department is available for clinical consultation for providers seeking additional guidance on testing of individual cases.
    • Use of commercial laboratories may allow faster turnaround time and streamlined laboratory and resulting for providers. Refer to your usual laboratory point of contact for specimen collection instructions.
    • For the County of Santa Clara Public Health Laboratory, specimen collection instructions are as follows: 1) vigorously swab or brush lesion with two separate sterile dry polyester or Dacron swabs; 2) place both swabs into a single 15 ml dry sterile tube. We recommend swabbing two to three lesions from different anatomic locations to increase yield. Do not add or store in viral or universal transport media.
    • All specimens being sent to the Santa Clara Public Health Laboratory must be accompanied by a MPX Laboratory Specimen submission form.
    • For samples being sent to County of Santa Clara Public Health Laboratory, the Suspect Case Report Form is NO LONGER REQUIRED. 
      • For suspect patients: Reporting 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.
      • For confirmed positive cases: Call Public Health within one business day via phone (408) 885-4214. 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).

    3. Evaluate for Treatment Indications:

    • Antivirals developed for use in patients with smallpox may prove beneficial against MPX. Tecovirimat (TPOXX, ST-246) is currently available in Santa Clara County for the treatment of MPX at specific hospital sites which have applied for approval for its use under an investigational 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 
      • High risk of severe disease 
      • Lesions in anatomical areas at special risk of scarring or stricture
      • Complications, such as urethritis and proctitis, particularly with tenesmus or rectal bleeding;
      • Challenges in pain control

    For detailed guidance on eligibility, see the FAQ below: Are my patients eligible for MPX treatment with Tpoxx?

    4. Household Isolation Guidance

    • If discharged home, patients should be provided with Home Isolation Guidance and be instructed to remain isolated until test results return.
       

    5. Notification of test results

    • Upon receipt of positive laboratory results, contact the patient immediately and confirm continued compliance with isolation instructions.
    • Inform the patient that County of Santa Clara Public Health Department will contact them for additional follow-up.
       

    6. Reporting confirmed cases

    • Report all confirmed MPX cases to the County of Santa Clara Public Health Department within one business day by phone by calling (408) 885-4214 during regular business hours. Cases identified after hours may be reported on the next business day.

     

    • Testing may be available through one of the five commercial laboratory companies recently approved by the federal government: Aegis Science, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics and Sonic Healthcare. Use of commercial laboratories may allow faster turnaround time and streamlined laboratory and resulting for providers.
    • Testing is also available through some local hospitals and academic centers that offer a laboratory developed test.
    • For the County of Santa Clara Public Health Laboratory, specimen collection instructions are as follows: 1) vigorously swab or brush lesion with two separate sterile dry polyester or Dacron swabs; 2) place both swabs into a single 15 ml dry sterile tube. We recommend swabbing two to three lesions from different anatomic locations to increase yield. Do not add or store in viral or universal transport media.
    • All specimens being sent to the Santa Clara Public Health Laboratory must be accompanied by a  MPX Laboratory Specimen submission form.
    • For samples being sent to County of Santa Clara Public Health Laboratory, the Suspect Case Report Form is NO LONGER REQUIRED. 
      • For suspect patients: Reporting 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.
      • For confirmed positive cases: Call Public Health within one business day via phone (408) 885-4214. 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).


    On September 15, 2022, CDC updated their guidance, based upon data from published literature and recently released data from the FDA, which suggest that broad use of the antiviral drug, tecovirimat (Tpoxx), could promote resistance and render antiviral drugs ineffective for some patients both for MPX and in the future should the drug ever be needed for smallpox treatment. 

    For most individuals with a healthy immune system, supportive care and pain control may be sufficient treatment without Tpoxx. Individuals meeting CDC clinical criteria as described below may be initiated on Tpoxx treatment.

    Tpoxx should be considered for individuals who have the following clinical manifestations: 

    • Severe disease — consider severe disease when a patient has conditions such as hemorrhagic disease; large number of lesions such that they are confluent; sepsis; encephalitis; ocular or periorbital infections; or other conditions requiring hospitalization
    • Involvement of anatomic areas which might result in serious sequelae that include scarring or strictures — these include lesions directly involving the pharynx causing dysphagia, inability to control secretions, or need for parenteral feeding; penile foreskin, vulva, vagina, urethra, or rectum with the potential for causing strictures or requiring catheterization; anal lesions interfering with bowel movements (for example, severe pain); and severe infections (including secondary bacterial skin infections), especially those that require surgical intervention such as debridement.

    Tpoxx should also be considered for use in people who are at high risk for severe disease:

    • People currently experiencing severe immunocompromise due to conditions such as advanced or poorly controlled human immunodeficiency virus (HIV), leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, or high-dose corticosteroids, being a recipient of a 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 people
    • People with a condition affecting skin integrity — conditions such as atopic dermatitis, 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)

    In light of the news of potential Tpoxx resistance, it is important that all patients are counseled to take Tpoxx as directed. Tpoxx should be taken within 30 minutes after a full meal containing moderate or high fat to optimize absorption and lower the potential risk of resistance.

    More information can be found on CDC’s Interim Clinical Guidance for the Treatment of MPX page.

     

    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.

    If you are a provider interested in obtaining  Tpoxx treatment for  provider dispensing of the medication at your office or if your patient does not fall in the above categories, please email [email protected]

     

    CDC allows healthcare providers to provide Tpoxx treatment to patients with MPX under their Expanded Access IND protocol. The process has been streamlined to reduce the number of required forms and give patients the options to virtually see their doctors.

    Additionally, care facilities and/or  providers may prescribe and dispense to patients, even if they  do not have an in-house  pharmacy or emergency department, if all of the following conditions are met: 

    1. Provider  administers or dispenses Tpoxx to patient under their own care in accordance with the EA-IND protocol
    2. Provider administers or dispenses Tpoxx with appropriate labeling (BPC § 4076) to the patient directly (i.e., MA and nurses may not hand patient the medication on behalf of the provider) 
    3. All Santa Clara County reporting requirements and CDC reporting requirements are followed. Required forms are indicated in the table below: 
     
    Required by Form Frequency Details
    CDC FDA Form 1572 Once
    • Complete form with the name of the main provider (must be a physician) in section 1.
    • Optional step for clinics with multiple prescribers: List all other providers under section 6. Additional providers do not need to be listed to prescribe, however, each prescriber will be responsible for managing their own supply which they will then dispense to their own patients
    • Email completed forms to [email protected] – there is no formal approval process
    CDC Patient Consent Form Every patient
    • Obtain prior to treatment  
    • Patient consent may be obtained via physical signature or electronic signature
    • No submission to CDC required – keep with patient’s chart 
    CDC Form A: 
    Patient Intake Form
    Every patient
    • Obtain prior to treatment, but may submit form to CDC within 7 calendar days of treatment initiation
    • Email completed form to [email protected] or upload to ShareFile
    CDC MedWatch Form 
    (serious adverse events)
    Within 72 hours of awareness
    Santa Clara County Qualtrics Report Weekly
    • Weekly survey to report inventory on hand, usage, and upcoming need

    *In general, all reporting requirements must be submitted within 7 days of treatment initiation

    If you meet the conditions above and can safely store and handle the medication at your clinic, reach out to [email protected] to express interest and get the process started!

     

    All requests for Tpoxx need to be submitted to [email protected] using a local order form. Once the request is approved, you will receive an email from our redistribution team with pick-up instructions. Delivery of the medication is not offered at this time. 

    For a copy of the order form, please email [email protected].

     

    The following groups are eligible for vaccination. However, not everyone in these communities may be at risk for MPX. Many people testing positive for MPX have recently had new or multiple sex partners, so we especially encourage vaccination for these individuals.

    Eligible groups include:

    • Men or trans people who have sex with men or trans people, including gay or bisexual men and gender diverse people.
    • Sex workers and people who have survival sex or exchange sex, of any sexual orientation or gender identity.
    • Persons who have had close contact with someone with suspected or confirmed MPX.
    • Persons who had close contact with others at a venue or event or within a social group where a suspected or confirmed MPX case was identified. This includes persons who received notice from a venue or event of a potential exposure.

    Eligible individuals can visit vax.sccgov.org to register for upcoming vaccine clinics operated by the County of Santa Clara or contact your usual doctor to inquire if they can provide MPX vaccination.

     

    The FDA has issued an emergency use authorization (EUA) to allow vaccination of appropriate pediatric populations with Jynneos for prevention of MPX infection before or after exposure. Pediatric vaccination must be performed subcutaneously (not intradermally). All County sites are able to serve pediatric patients who otherwise meet the above criteria for MPX vaccination.

     

    California law allows minors who are 12 years of age or older to consent to medical care related to the prevention of a sexually transmitted disease. (Fam. Code, § 6926, subd. (b).) While it is also spreading non-sexually, the County of Santa Clara Health Officer has determined that MPX is a sexually transmitted disease based on a number of considerations, including, but not limited to the following: (1) the vast majority of MPX transmission has occurred through sexual contact; (2) some MPX cases have reported that their only known exposure to MPX was through sexual contact with an asymptomatic MPX case; and (3) assessment for MPX vaccine eligibility includes assessing exposure risk through sexual contact. This means that minors 12 and older can consent to receiving the vaccine themselves and health care providers can’t inform a parent or legal guardian without the minor’s consent. 

    Please Note: Due to state vaccine reporting requirements, parents or legal guardians may be able to view/obtain vaccine records, including a record of the MPX vaccination.

     

    • At this time, most clinicians in the United States and laboratorians not performing the orthopoxvirus generic test to diagnose orthopoxviruses, including MPX, are not advised to receive orthopoxvirus PrEP.
    • Proper use of personal protective equipment and infection control practices are effective at reducing the risk of spread of the MPX virus when examining a patient or handling contaminated materials.
    • The Advisory Committee on Immunization Practices (ACIP) recommends that people whose jobs may expose them to orthopoxviruses, such as MPX, get vaccinated to protect them if they are exposed to an orthopoxvirus. This is known as pre-exposure prophylaxis (PrEP). People who should get PrEP include:
      • Clinical laboratory personnel who perform testing to diagnose orthopoxviruses, including those who use polymerase chain reaction (PCR) assays for diagnosis of orthopoxviruses, including MPX  virus
      • Research laboratory workers who directly handle cultures or animals contaminated or infected with orthopoxviruses that infect humans, including MPX virus, replication-competent Vaccinia virus, or recombinant Vaccinia viruses derived from replication-competent Vaccinia virus strains
      • Certain healthcare and public health response team members designated by public health authorities to be vaccinated for preparedness purposes
    • Major health systems have been allocated Jynneos vaccine to support vaccination of eligible staff and personnel. Eligible individuals may also visit  vax.sccgov.org  to register for upcoming vaccine clinics operated by the County of Santa Clara.

     

    As more MPX vaccine supply becomes available from the federal government, additional recommendations about pre-exposure prophylaxis (PREP) for certain groups are anticipated. Eligible individuals can visit  vax.sccgov.org  to register for upcoming vaccine clinics operated by the County of Santa Clara.

     

    If you serve patients who meet the eligibility criteria and are a provider interested in offering the Jynneos vaccine at your practice, please email [email protected] with your interest.

    All vaccine providers are required to administer the vaccine intradermally to eligible individuals as described in the EUA. Additionally, MPX vaccine providers are required to complete the following reporting requirements in accordance with SCC and HHS requirements

    Item Frequency Details
    CAIR Daily Allowable methods: electronic health record data exchange, manual data entry, Mass Vax module 
    Qualtrics Survey Weekly Santa Clara County requirement to assess administration and inventory 
    Temperature Excursions As needed Contact manufacturer to assess vaccine viability; inform [email protected] of any wasted doses due to temperature excursions 
    VAERS As needed Report vaccine administration errors and serious adverse events or as listed in FDA EUA Fact Sheet 

     

     

    • Hospital infection control and occupation health teams should review and follow CDC’s guidance on infection prevention and control recommendations in healthcare settings.
    • If an exposure occurs, healthcare providers should utilize the CDC exposure risk assessment to characterize exposure risk as high, intermediate, low/uncertain for both exposed patients and healthcare workers. 
    • Healthcare providers who have unprotected exposures to patients with monkeypox do not need to be excluded from work but should undergo active monitoring.
    • Healthcare providers who have cared for patients with monkeypox while adhering to recommended infection control precautions may undergo self-monitoring or active monitoring. 

     

    Additional Resources

     

    Clinical Recognition

     

    Treatment Indications and Protocols

     

    Infection Prevention and Control

     

    CDC Clinician Outreach and Communication Activity

     

    Public Health Alerts

     

    Public Health Websites

     

    Resources for MPX Vaccine Providers

     

    Education Resources Materials for My Patients

     

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