Mpox Information For Health Professionals

On this page:
Reporting mpox
Clinical presentation
Testing and specimen submission
Infection prevention and control
Vaccine
Treatment
Health advisories and resources

Reporting mpox

Reporting Orthopox Virus
Mpox (monkeypox) is caused by an Orthopoxvirus. All suspected cases of orthopox virus must be reported to MDH immediately 24 hours a day, seven days a week.

Clinical presentation

Clinical disease may start with a prodrome lasting one to four days prior to rash. Prodrome often includes lymphadenopathy, malaise, headache, myalgia, fever, and fatigue. The rash can be deep-seated, vesicular, or pustular with lesions that are well circumscribed and umbilicate. The evolution of the rash usually progresses through four stages: macular, papular, vesicular, to pustular before scabbing over and resolving. Lesions are often described as painful until the healing phase when they become itchy (crusts).

Classically, the rash was noted to progress through the four stages synchronously across the body. Recent mpox cases suggest a less classic symptom presentation, which includes:

• Absence of the typical prodrome period of fever, tiredness, or swollen lymph nodes.
• Atypical rash presentation:
  • Few lesions, sometimes small, and present very similar to herpes viruses, syphilis, chickenpox, and other rash differentials.
  • Starts around the anus or genitals and does not always result in a disseminated rash across the body.
  • Stages of rash do not always progress in a synchronous fashion.
• Symptoms such as anorectal pain, tenesmus, and rectal bleeding caused by ulcerative skin lesions and proctitis have been reported.
• Dual infection with syphilis, HSV or VZV has been reported in individuals with mpox. Testing lesions consistent with mpox should be performed even if lesions from other infections are observed or identified.
• Immunocompromised patients, particularly those with uncontrolled HIV infection are at risk for severe and sometimes fatal mpox.

More information is available on CDC: Mpox: Clinical Recognition.

MDH also encourages evaluating and testing for other common rash illnesses including syphilis, herpes simplex, and chickenpox if indicated.

Testing and specimen submission

Dry swabs of lesion fluid, lesion surface and/or lesion crust are acceptable specimen types. Dry swabs are required (do not put swab in viral transport media). Lesion crusts may be submitted with a dry swab specimen but are not required.

• Use only dry nylon, polyester, or Dacron swabs.
• Vigorously swab the lesion with a sterile dry swab.
• Submit two swabs per lesion: one for screening at MDH-PHL and one for additional testing as required. If more than one lesion type is present sample two different sites.
• Place the paired swabs into a single, dry, sterile tube or vial (i.e., 15mL Falcon tube or similar; not a urine cup) for each leison or site swabbed.
• Keep specimens cold:
  • Refrigerate within one hour of collection.
  • Ship at refrigeration temperature. Ice packs may be used to maintain refrigeration temperature during shipment.
• Label each vial with:
  • Two unique patient identifiers (e.g., patient name, date of birth) that match the patient information provided on the specimen submission form.
• For each specimen (i.e., each vial containing 2 swabs), fill out:
  • "General Infectious Disease Laboratory Submission Form."
  • Form is available at Forms for the Infectious Disease Laboratory.
• If any of the above criteria are not met, the sample(s) will be rejected.
• Send specimens to arrive Monday-Friday between 8:00 a.m. and 4:30 p.m. to:
  MDH Public Health Laboratory
  Attn: Biological Accessioning
  601 Robert St. N
  St. Paul, MN 55155-2531
• For help with packaging and shipping, call MDH-PHL Biological Accessioning at 651-201-4953

For more information on collecting and submitting specimens visit Mpox Sample Submission Update. Consider testing for other rash illnesses, such as syphilis, herpes simplex, and varicella, using your standard reference laboratory if indicated.

Infection prevention and control

Health care providers entering the room of individuals for suspected or confirmed mpox should wear the following PPE: Gown, gloves, eye protection (i.e., goggles or a face shield that covers the front and sides of the face) and NIOSH-approved particulate respirator equipped with N95 filters or higher.

Per CDC guidance:

• “A patient with suspected or confirmed mpox infection should be placed in a single-person room; special air handling is not required. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Transport and movement of the patient outside of the room should be limited to medically essential purposes. If the patient is transported outside of their room, they should use well-fitting source control (e.g., medical mask) and have any exposed skin lesions covered with a sheet or gown.”
• Intubation, extubation, and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
• Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim. Soiled laundry should be gently and promptly contained in an appropriate laundry bag and never be shaken or handled in manner that may disperse infectious material.
• Activities such as dry dusting, sweeping, or vacuuming should be avoided. Wet cleaning methods are preferred.
• CDC: Information for Healthcare Professionals
  Information for clinicians on mpox treatment and vaccine guidance.

Vaccine

JYNNEOS® vaccine is approved and recommended by the Advisory Committee on Immunization Practices (ACIP) for people 18 years of age and older at risk for mpox. It is licensed as a two-dose series, administered 28 days (four weeks) apart, subcutaneously. It may also be administered intradermally to people 18 years of age and older under the current FDA Emergency Use Authorization (EUA).

JYNNEOS® can be administered to people under 18 years of age at risk for mpox under the current EUA, but only by subcutaneous injection.

Risk factors for mpox infection

• Persons who are gay, bisexual, and other MSM, transgender or nonbinary people who in the past 6 months have had:
  • A new diagnosis of at least one sexually transmitted disease.
  • More than one sex partner.
  • Sex at a commercial sex venue.
  • Sex in association with a large public event in a geographic area where mpox transmission is occurring.
• Persons who are sexual partners of the persons described above.
• Persons who anticipate experiencing any of the situations described above.

People exposed to known or presumed mpox cases should be prioritized for post-exposure prophylaxis (PEP). PEP vaccination should be received within 4 days of the first day of exposure to prevent disease but can be given up to day 14 to reduce the severity. After 14 days, clinicians should consider the benefits of receiving vaccine on a case-by-case basis.

Vaccination is not routinely recommended for clinical laboratory and health care personnel due to their very low occupational risk when using recommended infection control practices. Vaccination, including booster doses, is recommended for research laboratory personnel who directly handle cultures or animals contaminated or infected with mpox virus.

The JYNNEOS® vaccine is available on the commercial market in the United States.

More information

• CDC: Immunization Schedules
• CDC: Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines during the 2022 U.S. Mpox Outbreak
• FDA: Mpox Vaccine Emergency Use Authorization (EUA)
  Information for health care provider and recipient mpox vaccine factsheets
• CDC: Vaccine Information Statements (VISs)
• CDC: ACIP Smallpox and Mpox Vaccine Recommendations
• CDC: Mpox Vaccine Recommendations
• JYNNEOS Vaccine for Mpox: What You Need to Know (PDF)

Treatment

There is currently no specific treatment that is either FDA approved or has an emergency use authorization (EUA) for mpox infection. However, antivirals developed for use in the treatment of smallpox, such as tecovirimat (TPOXX), may prove beneficial for some individuals (see information about NIH STOMP trial and about CDC expanded access-investigational new drug (EA-IND) below).

For patients with intact immune systems, supportive care and pain control may be enough. However, in certain individuals, including those that are immunocompromised, who have severe disease or are at risk for severe disease based on underlying conditions, supportive care and pain control may not be enough. In these cases, treatment should be considered. Treatment guidelines for mpox can be found at CDC: Mpox Treatment Information for Healthcare Professionals.

Tecovirimat (TPOXX)

Tecovirimat (TPOXX) is an antiviral developed for the treatment of smallpox that is currently available through EA-IND the CDC for certain eligible patients. TPOXX is still in investigational status, although evidence suggests it is well tolerated, with few side effects. Refer to MMWR: Clinical Use of Tecorvirimat (Tpoxx) for Treatment of Monkeypox Under an Investigational New Drug Protocol for more information.

Current eligibility criteria for the use of tecovirimat in patients is based on the current EA-IND, Version 6.4, dated June 5, 2024. In summary, the following individuals can be considered for treatment with tecovirimat:

1. Patients with severely immunocompromised conditions, defined as:
   • HIV with CD4 <200 cells/mm3.
   • Leukemia or lymphoma.
   • Generalized malignancy.
   • Solid organ transplantation.
   • Therapy with alkylating agents within 180 days prior to mpox illness onset.
   • Taking antimetabolites within 180 days prior to mpox illness onset.
   • Having radiation therapy within 180 days prior to mpox illness onset.
   • Taking tumor necrosis factor inhibitors within 180 days prior to mpox illness onset.
   • Taking high-dose corticosteroids (equivalent of 20 mg or greater of prednisone for at least 14 days) within 90 days prior to mpox illness onset.
   • 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.
   • Other comparable severe immunocompromise.
   • Patients with severe immunocompromise are known to be at high risk for protracted or life-threatening manifestations of mpox, regardless of disease severity at presentation.
2. Patients in the following categories:
   • Those with active skin conditions that place them at higher risk for disseminated infection, defined as atopic dermatitis, active exfoliative skin condition(s), such as eczema, burns, impetigo, active varicella zoster virus infection, psoriasis, or Darier disease (keratosis follicularis).
   • Pregnant or lactating patients, regardless of illness severity or underlying comorbidities at presentation.
   • Children (<18 years) regardless of illness severity or underlying comorbidities at presentation.
   • These patients might be at high risk for protracted or life-threatening manifestations of mpox based on prior experience from other orthopoxvirus infections in humans.
3. Patients with protracted or life-threatening manifestations of mpox at presentation, as defined by one of the following:
   • Lesions affecting 25% or more of body surface that may be confluent, necrotic, and/or hemorrhagic in appearance or cause sepsis.
   • Disease resulting in airway compromise or affecting the nervous system.
   • Cardiac [e.g., myocarditis] and or neurologic disease [e.g., encephalitis] which might occur in a small number of patients with mpox.
   • Ocular or periorbital infection, regardless of the time since infection onset.
   • Because the full scope of protracted or life-threatening infections is not known at this time, tecovirimat may also be considered on a case-by-case basis for an unusual situation wherein the treating clinician can request consult with CDC to discuss the case and decide whether treatment under the EA-IND may potentially be beneficial. Such consideration is expected to be rare and intended for unusual situations associated with disease that could result in clear long-term sequelae, such as urethral stricture.

Because TPOXX is an investigational drug, it is otherwise only available through enrollment in the STOMP trial. Individuals who are ineligible for STOMP or decline enrollment, or who require intravenous tecovirimat treatment, and meet treatment eligibility under the EA-IND protocol (e.g., have severe disease or involvement of anatomic areas that might result in serious sequelae, are at high risk for severe disease), should contact MDH to inquire about prepositioned oral tecovirimat supply that may be available within their jurisdiction. 

If there is no local supply of tecovirimat, health departments can request tecovirimat by calling the CDC Emergency Operations Center (EOC) at (770) 488-7100 or poxvirus@cdc.gov. Providers, in conjunction with state health departments, can also request a clinical consultation regarding management of hospitalized patients with mpox by calling the CDC EOC or poxvirus@cdc.gov.

Further information regarding tecovirimat is available at CDC: Tecovirimat (TPOXX) IND Information of Mpox.

Vaccinia Immune Globulin Intravenous (VIGIV)

VIGIV is licensed by FDA for the treatment of complications due to vaccinia vaccination. CDC holds an expanded access protocol that allows the use of VIGIV for the treatment of orthopoxviruses (including mpox) in an outbreak. Refer to thee Package Insert – VIGIV for more information.

If there is a patient you think meets clinical criteria for VIGIV treatment, providers should contact the MDH infectious disease line at 651-201-5414 for more information.

Cidofovir (also known as Vistide)

Cidofovir is an antiviral medication that is approved by the FDA for the treatment of cytomegalovirus (CMV) retinitis in patients with Acquired Immunodeficiency Syndrome (AIDS). Data are not available on the effectiveness of cidofovir in treating human cases of mpox. However, it has shown to be effective against orthopoxviruses in in vitro and animal studies. CDC holds an expanded access protocol that allows for the use of stockpiled cidofovir for the treatment of orthopoxviruses (including mpox virus) in an outbreak.

If there is a patient you think meets clinical criteria for VIGIV treatment, providers should contact the MDH infectious disease line at 651-201-5414 for more information.

Mpox health advisories and resources

• CDC: COCA Monkeypox: Updates about Clinical Diagnosis and Treatment
  CDC Clinician Outreach and Communication Activity Call - June 29, 2022
• Health Advisory: Monkeypox (PDF)
  Minnesota Department of Health, Health Alert Network - May 24, 2022
• MLS Laboratory Update: Monkeypox testing at MDH-PHL (PDF)
  Minnesota Department of Health, Public Health Laboratory, May 25, 2022.
• National Coalition of STD Directors: Monkeypox Command Center
  Resources, news, and updates to help STD programs, clinicians, and professionals respond to the emerging outbreak of monkeypox in the U.S.
• CDC: Emergency Preparedness and Response: What Clinicians Need to Know about Monkeypox in the United States and Other Countries
  Clinician Outreach and Communication Activity (COCA) Call, May 24, 2022.