Since late May 2022 the Centers for Disease Control and Prevention (CDC) has been tracking cases of monkeypox that have been reported in the U.S. and other countries without a history of monkeypox activity. As of August 2, 2022, there have been 6,326 confirmed or probable monkeypox cases reported in the U.S. Current
U.S. map and case counts are available here. As of August 3, 2022, West Virginia has reported 3 confirmed or probable cases.
Clinical Information
Monkeypox is a rare disease of the orthopoxvirus family that is caused by infection with the monkeypox virus. Symptoms of monkeypox can include flu-like prodrome followed by a rash. In this outbreak, many of the cases have started with a rash followed by other symptoms, while others only experience a rash. These rashes can appear like pimples or blisters often in mucosal areas such as the mouth and anogenital or rectal areas which may remain limited to these areas or even spread to the face, torso, or extremities. Lesions go through different stages of healing and typically last 2-4 weeks. The progression of these lesions can be seen here.
There can be a significant amount of pain associated with symptoms. Pain may interfere with basic functions such as eating, urination, and defecation which can cause distress and compound problems for the patient. Clinical presentation of monkeypox may be similar to other common infections (e.g., varicella zoster, syphilis, herpes). Clinicians should perform a thorough skin and mucosal (e.g., anal, vaginal, oral) examination for the characteristic vesicular-pustular rash of monkeypox; this allows for detection of lesions the patient may not have been previously aware of. This is particularly important when evaluating patients who have epidemiologic risk factors for monkeypox.
Monkeypox can spread in a variety of ways. In this outbreak, the most common way individuals spread monkeypox is through direct contact with infectious rash, scabs, and/or body fluids. It is also possible to contract monkeypox through respiratory secretions during face-to-face contact, or during intimate physical contact. Spread can also occur by touching clothing or linens that have been contaminated with infectious rash or body fluids. While anyone can catch monkeypox, populations that are disproportionally being impacted by the ongoing outbreak are currently gay, bi-sexual men, or other men who have sex with men.
Laboratory Testing
All suspect cases of monkeypox are required to be reported by healthcare providers to their local health department immediately. Monkeypox is a Category I Disease which is immediately reportable. If you are unable to reach your local health department, please contact the Office of Epidemiology and Prevention Services (OEPS) at 1-800-423-1271, ext. 1; 304-558-5358, ext. 2; or the 24/7 answering service at 304-342-5151.
Testing for monkeypox is available free for anyone meeting the suspect case definition through the West Virginia public health laboratory, Office of Laboratory Services (OLS). Testing submission must be done in consultation with the local health department and OEPS prior to specimen submission. Healthcare personnel who enter a patient’s room should use personal protective equipment (PPE) including gowns, gloves, eye protection, and N95 or higher-level respirators.
At a minimum, collect two swabs from each lesion site sampled as follows:
- Use a sterile synthetic swab to swab the lesion vigorously to collect adequate DNA. Do not use cotton swabs as cotton can inhibit real time PCR assays. Be sure to properly label the container with one patient identifier including lesion collection site (e.g., face, neck, left hand, etc.).
- Place swabs in individual sterile Do not add any viral or universal transport media.
- Freeze (-20°C or lower) specimens within an hour after collection (if you do not have access to a -20°C or lower freezer, then refrigerate specimens within 1 hour). Shipping on dry ice is strongly recommended, however, refrigeration and shipping on ice packs for any facility that doesn’t have access to a -20°C freezer or dry ice is acceptable.
- Complete the WV Office of Laboratory Services Bioterrorism Lab Clinical Specimen Submission form, https://dhhr.wv.gov/ols/labs/Documents/BT/BTClinicalTestRequestForm_8-07.pdf.
- Package the sample swabs in an insulated Category B box, with dry ice. If you do not have access to dry ice, samples may be shipped with several frozen packs.
- For additional instructions on specimen collection and shipping, visit the OEPS monkeypox site at https://oeps.wv.gov/monkeypox/pages/default.aspx.
Commercial testing for orthopoxvirus is now available in West Virginia. National laboratories including LabCorp, Aegis Sciences Corporation, Mayo Clinic, Quest Diagnostics, and Sonic Healthcare have increased testing capacity and access. Questions about testing at these facilities should be directed to the appropriate laboratories. Please be aware public health is not responsible for laboratory costs arranged through commercial testing.
Treatment and Prophylaxis
Currently there is no treatment approved specifically for monkeypox. However, antivirals developed for use in patients with smallpox may prove beneficial against monkeypox. The CDC holds an expanded access investigational new drug (EA-IND) protocol that allows for the use of stockpiled TPOXX (also called Tecovirimat), an antiviral drug that can be used under special circumstances to treat patients with monkeypox.
TPOXX is available for use in West Virginia patients to treat monkeypox who meet the CDC clinical criteria. To request TPOXX, healthcare providers may reach out directly to the CDC (Emergency Operations Center at 770-488-7100 or poxvirus@cdc.gov) or may contact the OEPS at 1-800-423-1271, ext. 1; 304-558-5358, ext. 2; or the 24/7 answering service at 304-342-5151.
Treatment with TPOXX can begin upon receipt of the medication and after obtaining informed consent. No pre- registration is required for healthcare providers. Forms requested under the expanded access investigational new drug (EA-IND) can be returned to the CDC after treatment begins. For more information on obtaining and using TPOXX for the treatment of monkeypox see the CDC protocol.
Close contacts of individuals with probable or confirmed monkeypox should be monitored for symptoms for 21 days after their last exposure. As part of the public health investigation, the local health department will interview the case patient and assess the degree of exposure of the individuals they have been in contact with. Transmission of monkeypox requires prolonged close contact with a symptomatic individual. Based on the degree of exposure, public health may recommend post exposure prophylaxis. Symptoms of concern include fever, chills, new lymphadenopathy, and new skin rash.
For the current outbreak, as part of the public health investigation, people can be vaccinated following exposure to monkeypox to help prevent monkeypox illness. This approach is considered standard post exposure prophylaxis for close contacts. Vaccine for close contacts is available through working with your local health department. It is recommended that vaccine be given within 4 days from the date of exposure for the best chance to prevent onset of the disease. If given between 4 and 14 days after the date of exposure, vaccination may reduce the symptoms of monkeypox. Healthcare workers who care for a monkeypox patient should also be evaluated for their risk of exposure and be alert for the development of symptoms, especially within the 21 day period after the date of care, and should notify infection control and the local health department if symptoms develop.
Close contacts will be instructed by the local health department to monitor their temperature twice daily. If fever or rash develop, close contacts should be instructed to self-isolate and contact their local health department immediately. Close contacts that remain asymptomatic can continue routine daily activities such as work and school, but should not donate blood, cells, tissue, breast milk, semen, or organs while under symptom surveillance.