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Monkeypox

Also known as MPX.

Reporting Information

Class B

Report a case, suspected case, and/or positive laboratory result to the local public health department in which the patient resides by the close of the next business day.  If patient residence is unknown, report to the local public health department in which the reporting healthcare provider or laboratory is located.

Director's Journal Entry

In Re: Monkeypox Virus Reporting – Ohio Revised Code 3701.23.

Reporting Form(s) and/or Mechanism

The Ohio Disease Reporting System (ODRS) should be used to report cases and lab findings to the Ohio Department of Health (ODH).  For healthcare providers without access to ODRS, the Ohio Confidential Reportable Disease Form (HEA 3334) may be used.

The Positive Laboratory Findings for Reportable Disease Form (HEA 3333) may be used for laboratories without access to ODRS or electronic laboratory reporting (ELR) to report positive results.

The 2022 MPX Case Report Form is available for use by the local public health department when following up with cases.  Access to the form will be provided by ODH (ORBIT@odh.ohio.gov).

Key Fields for ODRS Reporting

  • Import status: whether the infection was travel-associated or Ohio-acquired.
  • Date of illness onset.
  • Provide a brief summary of the illness as a note or an attachment.
  • Lab test: please specify what kind of test was performed.

Agent

Monkeypox is a disease caused by infection with the monkeypox virus (MPXV).  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.

Infectious Dose

Unknown at present.

Case Definition

Source: Council of State and Territorial Epidemiologists (July 2022).

Background

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 to contact with animals imported from countries where monkeypox commonly occurs.

In 2022, an outbreak of monkeypox spread globally in countries that don't 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 outbreaks identify as gay, bisexual, or other men who have sex with men, anyone who has been in close contact with someone who has monkeypox can get the illness.

Clinical Criteria

  • New onset of a clinically compatible rash; OR
  • Other clinical suspicion for monkeypox.*

* Clinical suspicion may include prodromal symptoms or atypical presentations which, when combined with epidemiologic linkage criteria or other exposure, is deemed to have a higher likelihood of monkeypox infection by the clinician.

Laboratory Criteria for Diagnosis

Confirmatory Laboratory Evidence

  • Detection of MPXV DNA by PCR testing in a clinical specimen; OR
  • Detection of MPXV by genomic sequencing in a clinical specimen.

Presumptive Laboratory Evidence

  • Detection of orthopoxvirus DNA by PCR testing in a clinical specimen AND no evidence of infection with another non-variola orthopoxvirus; OR
  • Detection of presence of orthopoxvirus by immunohistochemistry in tissue; OR
  • Detection of orthopoxvirus by genomic sequencing in a clinical specimen; OR
  • Detection of anti-orthopoxvirus IgM antibody using a validated assay on a serum sample drawn 4-56 days after rash onset, with no recent history (last 60 days) of vaccination.

Supportive Laboratory Evidence

  • N/A.

Note: The categorical labels used here to stratify laboratory evidence are intended to support the standardization of case classifications for public health surveillance.  The categorical labels should not be used to interpret the utility or validity of any laboratory test methodology.

Epidemiologic Criteria

Within 21 days of illness onset:

  • Residence in or travel to a country where monkeypox is endemic; OR
  • Contact with a dead or live wild or exotic pet animal of an African species, or used or consumed a product derived from such animals (e.g., game meat, powders, etc.); OR
  • Contact with a person or persons, animal or animals, with a suspected or known orthopoxvirus or monkeypox infection; OR
  • Contact with items that could serve as fomites that have been in contact with a person or persons, animal or animals, with suspected or known orthopoxvirus or monkeypox infection; OR
  • Work in a non-clinical laboratory that handles MPXV; OR
  • Member of a cohort (as defined by public health authorities) experiencing monkeypox activity.

Case Classification

Suspected

Meets clinical criteria AND epidemiologic criteria.

Probable

Meets presumptive laboratory criteria.

Confirmed

Meets confirmatory laboratory criteria.

Not a Case

This status will not generally be used when reporting a case, but may be used to reclassify a report if investigation revealed it was not a case.  A case may be excluded as a suspected, probable, or confirmed case if there are no presumptive or confirmatory laboratory results and:

  • An alternative diagnosis* can fully explain the illness OR
  • An individual with symptoms consistent with monkeypox does not develop a rash within 5 days of illness onset OR
  • A case where high-quality specimens do not demonstrate the presence of Orthopoxvirus or Monkeypox virus or antibodies to orthopoxvirus.

Criteria to Distinguish a New Case from an Existing Case

For surveillance purposes, a new case of MPXV infection meets the following criteria:

  • A person should be enumerated as a new case of MPXV infection if not enumerated as a confirmed or probable case within the prior 10 years.

Comments

* The characteristic rash associated with monkeypox lesions involve the following: deep-seated and well-circumscribed lesions, often with central umbilication; and lesion progression through specific sequential stages—macules, papules, vesicles, pustules, and scabs.  This can sometimes be confused with other diseases that are more commonly encountered in clinical practice (e.g., secondary syphilis, herpes, and varicella zoster).  Historically, sporadic accounts of patients co-infected with MPXV and other infectious agents (e.g., varicella zoster, syphilis) have been reported, so patients with a characteristic rash should be considered for testing, even if other tests are positive.

For more information, see CDC's Case Definitions for Use in the 2022 Monkeypox Response.

Signs and Symptoms

After infection, there is an incubation period of roughly 1-2 weeks (range 5-21 days).  The development of initial symptoms (e.g., fever, malaise, headache, weakness, lymphadenopathy, etc.) marks the beginning of the prodromal period.  Shortly after the prodrome, a rash appears.  Lesions typically begin to develop simultaneously and evolve together on any given part of the body.  The evolution of lesions progresses through four stages—macular, papular, vesicular, to pustular—before scabbing over and resolving.  The illness typically lasts 2-4 weeks.  The severity of illness can depend upon the initial health of the individual, the route of exposure, and the strain of the infecting virus.  Not all infections follow the typical course.  During the 2022 outbreak, the prodrome was observed to be mild or non-occurring among some individuals.

Diagnosis

PCR testing of dry swabs from lesions is the preferred diagnostic test.  The non-variola Orthopoxvirus PCR test is available at the ODH Lab and several commercial labs.  Positive specimens are forwarded to the CDC for additional characterization (monkeypoxvirus-specific PCR test).

For testing at the ODH Lab, collect 4 swabs (2 from each of 2 lesions) using a sterile dry polyester, Dacron, or Rayon swab.  Place each swab individually in a sterile screw-capped tube.  Do not use any kind of transport media.  Freeze immediately at -20°C or colder.  Ship to ODH Lab overnight using 5 pounds of dry ice.  Approval from ODH and an ODRS number for the specimen are needed before shipping.  To submit a specimen to ODH and for complete information on collecting, handling, and shipping specimens, please see the 2022 Monkeypox Testing Approval Form.

Questions about submitting specimens to ODH Lab can be directed to ORBIT@odh.ohio.gov or (614) 995-5599.

Other diagnostic testing involving virus detection or IgM antibody testing may be available at the CDC through ODH Lab.  Contact ODH ORBIT for further information.

Epidemiology

Source

Monkeypox virus is spread from infected humans and animals.  The reservoir of monkeypox is unknown, but African rodents are suspected.

Occurrence

Monkeypox is endemic in several central and western African countries.  In the 2022 outbreak, cases have been reported from many non-endemic countries due to the movement of infected humans and subsequent spread.

Mode of Transmission

Monkeypox is transmitted by symptomatic individuals through close contact with lesions, bodily fluids, or respiratory secretions and objects that have had contact with lesion crusts or bodily fluids (e.g., contaminated linens, bandages, dishes).  It is also possible for transmission to occur from contact with animals, either by being scratched or bitten by the animal, or by preparing or eating meat or using products from an infected animal.

Period of Communicability

Monkeypox can spread from the time symptoms start (prodrome or rash) until all lesions have crusted, crusts have separated, and a new intact layer of skin has formed.

Incubation Period

The incubation period is roughly 1-2 weeks (range 5-21 days).

Public Health Management

Case

Investigation

The 2022 MPX Case Report Form should be completed by the local public health department in which the patient resides.  Currently, the 2022 MPX Case Report Form is housed within REDCap; access to the form will be granted by ODH ORBIT (ORBIT@odh.ohio.gov).  Contacts should be identified during case investigation.  See Contacts below for more information on contact tracing, monitoring, and vaccination.

Treatment

Tecovirimat (TPOXX) is an antiviral medication that is approved by the United States Food and Drug Administration (FDA) for the treatment of smallpox in adults and children.  Data are not available on the effectiveness of TPOXX in treating monkeypox infections in people, but studies using a variety of animal species have shown that TPOXX is effective in treating disease caused by orthopoxviruses.  Clinical trials in people have shown the drug is safe and has only minor side effects.  CDC holds an expanded access protocol (sometimes called "compassionate use") that allows for the use of stockpiled TPOXX to treat monkeypox during an outbreak.  TPOXX is available as a pill or an injection.

Many people infected with monkeypox virus have a mild, self-limiting disease course in the absence of specific therapy.  However, the prognosis for monkeypox depends on multiple factors, such as previous vaccination status, initial health status, concurrent illnesses, and comorbidities among others.  Patients who should be considered for treatment following consultation with CDC might include:

  • People with severe disease (e.g., hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization).
  • People who may be at high risk of severe disease:
    • People with immunocompromise (e.g., human immunodeficiency virus/acquired immune deficiency syndrome infection, 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.
    • People with a history or presence of atopic dermatitis, persons 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]).
    • Pregnant or breastfeeding women.
    • 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).
  • People with monkeypox virus aberrant infections that include accidental implantation in eyes, mouth, or other anatomical areas where monkeypox virus infection might constitute a special hazard (e.g., the genitals or anus).

For more information, see CDC's Treatment Information for Healthcare Professionals.

To request TPOXX, contact ODH at ORBIT@odh.ohio.gov or (614) 995-5599.

Isolation

For all patients with monkeypox, infection prevention measures should be continued until all lesions have crusted, crusts have separated, and a fresh layer of intact skin has formed.  The illness typically lasts 2-4 weeks.  For patients associated with healthcare settings or congregate living settings, isolation precautions should be maintained for the duration of illness.

General infection control considerations for patients hospitalized with suspected monkeypox infection include:

  • Notify infection prevention and control personnel of patients with suspected monkeypox infection.
  •  Recommended personal protective equipment (PPE) for healthcare providers includes: gown, gloves, eye protection, NIOSH-approved particulate respirator equipped with N95 filters or higher.
  • Place patient in single-person room with a dedicated bathroom; special air handling is not required.
  • Conduct aerosol-generating procedures or procedures likely to spread oral secretions in an airborne infection isolation room.
  • In general, in-person visitation should be limited while the patient is infectious and alternative modes of communication encouraged.  Visitors entering the patient room should be provided with instruction and use of appropriate PPE.
  • If tolerated, the patient should wear a surgical mask and cover any exposed skin lesions to the extent possible.

For additional information on infection control in healthcare settings, see CDC's website Infection Prevention and Control of Monkeypox in Healthcare Settings.

For the general public, patients who do not require hospitalization should stay home except to receive medical care, isolate in a room or area separate from others, and limit contact with other family members and pets when possible.  If a patient is unable to isolate for the full duration of their illness, they should remain isolated while symptomatic with fever or any respiratory symptoms (including sore throat, nasal congestion, or cough); in the absence of respiratory symptoms, patients should continue the following precautions while a rash persists:

  • Cover all parts of the rash with clothing, gloves, and/or bandages.
  • Wear a well-fitting mask to prevent the wearer from spreading oral and respiratory secretions when interacting with others until the rash and all other symptoms have resolved.
  • Do not share items that are worn or handled with other people or animals.  Launder or disinfect items that have been worn or handled and surfaces that have been touched by a lesion.
  • Avoid close physical contact, including sexual or close intimate contact, with other people.
  • Avoid sharing utensils or cups.  Items should be cleaned and disinfected before use by others.
  • Avoid crowds and congregate settings.
  • Wash hands often with soap and water or use an alcohol-based hand sanitizer, especially after direct contact with the rash.

For additional information at home isolation, see CDC's websites Isolation and Infection Control: Home and Isolation and Prevention Practices for People with Monkeypox.

Contacts

During the case interview, close contacts since symptom onset should be elicited.  Airline contacts (persons who traveled on a plane in proximity to a case) may be identified by CDC and reported to ODH, who then notify the local health department.  Monitoring and vaccine may be recommended for some close contacts.  Considerations for exposure risk assessment in community and healthcare settings are provided below:

For Individuals in Community Settings
Type of Contact Definition Recommendations
Contacts with a high degree of exposure Contact between an exposed person's broken skin or mucous membranes with the skin, mucous membranes, or bodily fluids of a person with monkeypox, or contact between an exposed person's broken skin or mucous membranes with contaminated materials. Monitoring and vaccine are recommended.
Contacts with an intermediate degree of exposure Contact between an exposed person's intact skin or clothing with the skin or bodily fluids of a person with monkeypox, contact between an exposed person's intact skin or clothing with contaminated materials, or being within 6 feet of an unmasked person with monkeypox for a total of 3 hours or more (cumulative time) without wearing a surgical mask or respirator. Monitoring recommended; vaccine can be considered.
Contacts with a low or uncertain degree of exposure Entering the living space of a person with monkeypox, or being within 6 feet of an unmasked person with monkeypox for a total of less than 3 hours (cumulative time) without wearing a surgical mask or respirator. Monitoring is recommended; vaccine not recommended.

Refer to the CDC website for more details on determining the degree of exposure in community settings.

For Individuals in Healthcare Settings
Type of Contact Definition Recommendations
Contacts with a high degree of exposure Unprotected contact between an exposed person's broken skin or mucous membranes with the skin, bodily fluids, or soiled materials of a person with monkeypox, or being inside the room or within 6 feet of a patient with monkeypox during an aerosol generating procedure without adequate respiratory and eye protection. Monitoring and vaccine are recommended.
Contacts with an intermediate degree of exposure Unprotected contact between an exposed person's intact skin or clothing and the skin, bodily fluids, or soiled materials of a person with monkeypox, or being within 6 feet of an unmasked person with monkeypox for a total of 3 hours or more (cumulative time) with monkeypox without wearing a facemask or respirator. Monitoring recommended; vaccine can be considered.
Contacts with a low or uncertain degree of exposure Entry into the room or patient care area of a person with monkeypox without wearing all recommended PPE, or being within 6 feet of an unmasked person with monkeypox for a total of less than 3 hours (cumulative time) without wearing a facemask or respirator. Monitoring is recommended; vaccine not recommended.

Refer to the CDC website for more details on determining the degree of exposure in healthcare settings.

Monitoring

Contacts should be monitored for symptoms for 21 days (maximum incubation period) after the last date of exposure to the monkeypox case.

Key symptoms of concern include: fever >100.4°F (38°C), chills, lymphadenopathy, or new skin rash.  If symptoms develop, the contact should self-isolate at home and immediately contact the health department.  In general, symptomatic contacts without a rash should isolate for 5 days after the development of new symptoms and continue to monitor for any additional symptoms, including a rash or lesions.  In healthcare settings, patients with symptoms should be placed on empiric isolation precautions until further monitoring or evaluation for monkeypox is conducted.

Contacts who remain asymptomatic can generally be permitted to continue routine daily activities (e.g., go to work, school).  Limitations to activities may be recommended in certain circumstances where it might be difficult to discern symptom onset (e.g., young children); factors including the individual's risk of exposure and risk of transmission should be considered. 

Contact ODH ORBIT to access the REDCap project that facilitates data recording for persons being monitored: ORBIT@odh.ohio.gov or (614) 995-5599.

For additional details on contact monitoring, see CDC's Monitoring and Risk Assessment for Persons Exposed in the Community and Infection Prevention and Control of Monkeypox in Healthcare Settings.

Vaccination

Two vaccines licensed by the U.S. Food and Drug Administration (FDA) are available for preventing monkeypox infection – JYNNEOS (also known as Imvamune or Imvanex) and ACAM2000.  Currently, the JYNNEOS supply is limited and states are receiving allotments from the Strategic National Stockpile (SNS).  Considerations for monkeypox vaccination are available on the CDC website.

For the JYNNEOS Vaccine Information Statement, see Smallpox/Monkeypox VIS.

To discuss monkeypox vaccination under the CDC considerations, contact ODH at ORBIT@odh.ohio.gov or (614) 995-5599.

Prevention and Control

Take the following steps to prevent getting monkeypox:

  • Avoid close, skin-to-skin contact with people who have a rash that looks like monkeypox.
    • Do not touch the rash or scabs of a person with monkeypox.
    • Do not kiss, hug, cuddle, or have sex with someone with monkeypox.
    • 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.
  • In Central and West Africa, avoid contact with animals that can spread monkeypox virus, usually rodents and primates.  Also, avoid sick or dead animals, as well as bedding or other materials they have touched.

For people who are sick with monkeypox:

  • Isolate at home except to receive medical care, especially if you have a fever or other respiratory symptoms such as a sore throat, nasal congestion, or cough.
  • If you have an active rash or other symptoms, stay in a separate room or area away from people or pets you live with, when possible.

Vaccination

CDC recommends vaccination for people with a high degree of exposure to someone who has been diagnosed with monkeypox and people who are at higher risk of being exposed to monkeypox, including:

  • People who have been identified by public health officials as a contact of someone with monkeypox.
  • People who may have been exposed to monkeypox, such as:
    • People who are aware that one of their sexual partners in the past 2 weeks has been diagnosed with monkeypox.
    • People who had multiple sexual partners in the past 2 weeks in an area with known monkeypox.
    • People whose jobs may expose them to orthopoxviruses, such as:
      • Laboratory workers who perform testing for orthopoxviruses.
      • Laboratory workers who handle cultures or animals with orthopoxviruses.
      • Some designated healthcare or public health workers.

For more information, see CDC's prevention website.

Revised 8/16/2022.