Mpox Healthcare Provider Information

If you are not a healthcare provider, you can refer to mpox (mt.gov) for additional information. 

       

MPOX Vaccine Eligibility

Are my patients eligible for the JYNNEOS (mpox) vaccine?

Mpox vaccination is not recommended for the general public, but it is recommended for those at increased risk for infection or at increased risk for developing severe disease. Transmission of mpox primarily occurs from close, personal skin-to-skin contact with someone who has a mpox rash.  Vaccination is available in Montana for people who self-identify as being at increased risk for infection. There is no requirement to specify a reason beyond a self-attestation at the time of vaccination. 

Mpox Vaccine Locator

Below are some examples of individuals that may be at increased risk.

  • Adults 18 years* and older who meet one of the following criteria: 
    • Individuals who have recently had multiple or anonymous sexual partners;  OR
    • Partners of individuals who have recently had multiple or anonymous sexual partners;   OR
    • Sex workers;  OR
    • Staff at establishments where sexual activity occurs (e.g., bathhouses, saunas, sex clubs);   OR
    • Were diagnosed with gonorrhea or early syphilis within the past 12 months;   OR
    • Persons experiencing homelessness with high-risk behaviors;   OR
    • Are on HIV pre-exposure prophylaxis;   OR
    • Are part of high risk cohorts identified by clinical staff in the correctional system;   OR
    • Individuals deemed to be high-risk based on individual risk assessments

Persons who meet the criteria above and are immunocompromised or those who have underlying medical conditions that confer increased risk for severe disease (e.g., atopic dermatitis, eczema, HIV) should be prioritized for vaccination.

Post- Exposure Prophylaxis (PEP):

  • Adults 18+ years and older who have had an exposure to a(n) individual(s) with confirmed orthopoxvirus / mpox virus infection.

Healthcare providers should report all suspect monkeypox cases to your local health department. This will allow public health to quickly begin case investigations and to distribute vaccine to close contacts in the event an individual meets the clinical and/or epidemiologic criteria for a high suspect monkeypox case. 

CDC’s website contains additional information about monkeypox for healthcare providers, include:

Information on infection prevention and control in healthcare settings is provided on the CDC website

Patient Placement

  • Patients with suspected or confirmed monkeypox infection should be placed in a single-person room. The door should be kept closed (if safe to do so).
  • The patient should have dedicated equipment and bathroom.
  • If the patient is transported outside of their room, they should use a well-fitted source control mask and have all skin lesions covered.
  • Intubation and extubation, and any procedures likely to spread oral secretions, should be performed in an airborne infection isolation room.
 

Transmission-Based Precautions 

  • If a patient presents with signs and symptoms for monkeypox, infection prevention and control personnel should be notified immediately.
  • PPE should include a gown, gloves, eye protection that covers the front and sides of eyes (goggles or face shield), and NIOSH-approved particulate respirator N95.
  • Precautions should be maintained until all lesions have crusted, those crusts have separated, and a fresh layer of healthy skin has formed underneath.
 

Environmental Infection Control

  • Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade with an emerging viral pathogen claim, which may be found on EPA's Q List. Follow the manufacturer's direction for concentration, contact time, and care and handling. 

 

Infection prevention and control questions for Monkeypox can be directed to Erika Baldry at erika.baldry@mt.gov.

Correct and consistent use of PPE when caring for a patient with monkeypox infection is highly protective and prevents transmission to HCP.  However, unrecognized errors during the use of PPE (e.g., self-contaminating when removing contaminated PPE) may create opportunities for transmission to HCP. Therefore, in the absence of an exposure described below, HCP who enter a contaminated patient room or care area while wearing recommended PPE, should be aware of the signs and symptoms of monkeypox; if any signs or symptoms of monkeypox occur, HCP should notify occupational health services for further evaluation and should not report to work (or should leave work, if signs or symptoms develop while at work).

MPX Infection Control: Healthcare Settings
Risk level of exposure Exposure characteristics Recommendations
  Monitoring PEP
Higher Unprotected contact between an exposed individual’s broken skin or mucous membranes and the skin lesions or bodily fluids from a patient with monkeypox (e.g., inadvertent splashes of patient saliva to the eyes or mouth of a person), or soiled materials (e.g., linens, clothing) -OR- Yes Recommended

 
Being inside the patient’s room or within 6 feet of a patient with monkeypox during any medical procedures that may create aerosols from oral secretions (e.g., cardiopulmonary resuscitation, intubation), or activities that may resuspend dried exudates (e.g., shaking of soiled linens), without wearing a NIOSH-approved particulate respirator with N95 filters or higher and eye protection
Intermediate Being within 6 feet for a total of 3 hours or more (cumulative) of an unmasked patient with monkeypox without wearing a facemask or respirator -OR- Yes Informed clinical decision making recommended on an individual basis to determine whether benefits of PEP outweigh risks of transmission or severe disease ¶¶
Unprotected contact between an exposed individual’s intact skin and the skin lesions or bodily fluids from a patient with monkeypox, or soiled materials (e.g., linens, clothing) -OR-
Activities resulting in contact between an exposed individual’s clothing and the patient with monkeypox’s skin lesions or bodily fluids, or their soiled materials (e.g., during turning, bathing, or assisting with transfer) while not wearing a gown
Lower Entry into the contaminated room or patient care area of a patient with monkeypox without wearing all recommended PPE, and in the absence of any exposures above Yes None
No Risk No contact with the patient with monkeypox, their contaminated materials, nor entry into the contaminated patient room or care area No None
Resources:

Vaccines are one important strategy to contain monkeypox. Montana has received and placed vaccine at several strategic locations to ensure those needing a dose for PEP or PEP++ can access the vaccine quickly. DPHHS will follow CDC vaccination recommendations for monkeypox vaccination, which may be recommended for the following individuals. 

  • Certain healthcare and public health response team members designated by public health authorities to be vaccinated for preparedness purposes according to ACIP guidance.  

At this time, most clinicians in the U.S. and laboratorians not performing the orthopox generic test to diagnose orthopoxviruses, including Monkeypox virus, are not advised to receive monkeypox vaccine PrEP 

Persons who meet the criteria above and are immunocompromised or those who have underlying medical conditions that confer increased risk for severe disease (e.g., atopic dermatitis, eczema) should be prioritized for vaccination.

  • Certain healthcare and public health response team members designated by public health authorities to be vaccinated for preparedness purposes according to ACIP guidance.  

At this time, most clinicians in the U.S. and laboratorians not performing the orthopox generic test to diagnose orthopoxviruses, including Monkeypox virus, are not advised to receive monkeypox vaccine PrEP 

*For individuals under the age of 18 years, Jynneos may be administered under the current EUA as a 2-dose 0.5 mL subcutaneous injection given 28 days apart.  

The CDC Considerations for Monkeypox Vaccination states “At this time, most clinicians in the United States and laboratorians not performing the Orthopoxvirus generic test to diagnose Orthopoxviruses, including monkeypox virus, are not advised to receive monkeypox vaccine PrEP.”

Jynneos is given as a 2-dose series given 4 weeks apart, however doses may be given up to 4 days before and up to 7 days after the minimum interval of 28 days. Because Jynneos is licensed as a two-dose series, CDC continues to recommend two doses of Jynneos vaccine to confer maximal protection against Monkeypox Initial doses of Jynneos should be administered within 4 days from the date of exposure in order to prevent onset of the disease. If given between 4-14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease.  Healthcare providers must notify their local health department of patients with confirmed or probable monkeypox. Local health jurisdictions must coordinate with the CD Epi Section and the State Immunization Program at DPHHS to request and distribute vaccine. 

Specimen collection details are for pre-approved specimens that have a CDEpi consult and are being sent to the MTPHL. Please refer to the specimen collection instructions linked at the top of the page if using a reference lab.

Starting August 29, 2022, MTPHL will only perform orthopoxvirus testing on Tuesdays and Thursdays, and will begin charging a $55 fee for testing. Only cases that meet both clinical and epidemiologic criteria for testing, determined by consult with CDEpi, may have specimens submitted to the MTPHL for testing. MTPHL will only test high-suspect specimens that have prior approval by CDEpi. Testing at MTPHL may be conducted other weekdays for high-suspect cases that may have a potential for significant public health impact (e.g., numerous potential close contacts, occurred in a sensitive setting, etc.). Consultation with your LHD or CDEpi to arrange alternate testing days is required.

If specimens arrive at MTPHL without a prior epi approval, they will be sent back to the ordering facility. It is the ordering facility’s responsibility to send the specimens to a reference lab. Do not mail specimens (via FedEx or UPS) to MTPHL that will arrive on Saturday or Sunday—the MTPHL does not have staff accepting mail that arrives those days.

If the individual in question has only a low suspicion for monkeypox (e.g., provider is ruling out monkeypox disease, but the clinical index of suspicion is low), please send samples to a reference laboratory. Reference laboratories that can perform monkeypox testing include Quest Diagnostics, LabCorp, Aegis Labs, Sonic Labs, and Mako Medical Laboratories. Please notify your LHD of a positive result.

DPHHS does not supply specimen collection supplies to labs for monkeypox testing. Swabs and sterile tubes can be purchased from almost any medical supply vendor.

At a minimum, collect two lesion swabs from each lesion (in general, 2 different lesions should be sufficient, for a total of 4 swabs). Each swab should be collected as follows: 

  • Personnel who collect specimens should use personal protective equipment (PPE) in accordance with CDC's recommendations for Infection Prevention and Control of Monkeypox in Healthcare Settings.
  • Please consult with your laboratory or microbiology team to confirm you are using the correct specimen collection material.
  • Swab or brush lesion vigorously with two separate sterile synthetic dry swabs (including, but not limited to polyester, nylon, or Dacron) with a plastic, wood, or thin aluminum shaft. Do not use cotton swabs. Multiple lesions should be swabbed (lesions on different parts of body or that look different, two swabs from each lesion). Vigorously swab the lesion to collect adequate DNA. It is not necessary to de-roof the lesion before swabbing.
    • Please note: Serology testing can only be performed by the CDC lab and requires a CDC clinical consultation and prior approval from CDC. Serology testing would only be considered if the lesions are healed over with a fresh layer of skin, making the lesions ineligible for testing, and the person was considered a high suspect case due to a high-risk exposure history and clinical presentation. Please contact CDEpi to discuss serology testing options.
  • Place swabs in individual sterile containers. The sterile container must have a gasketed seal. DO NOT ADD ANY VIRAL OR UNIVERSAL TRANSPORT MEDIA. MTPHL only accepts dry swabs in separate sterile containers, MTPHL cannot accept swabs submitted in transport media.
  • Refrigerate (2-8°C) or freeze (-20°C or lower) specimens within an hour after collection. Refrigerated specimens should be sent within 7 days of collection; frozen specimens should be shipped within 60 days of collection. Shipping on dry ice is strongly recommended. Specimens received at CDC that are >8°C will be rejected.
  • One dry swab will be tested at MTPHL for presumptive results. CDC will provide monkeypox virus-specific testing on the second dry swab specimen if the first dry swab is presumptive positive at MTPHL. 
  • Please send both swabs to MTPHL on Dry Ice as Category B. The swabs need to be in a separate box from any additional samples your facility is sending.
  • Complete one MTPHL laboratory requisition form using hard copy or online through Outreach (formerly known as COPIA).
    • For paper requisitions, mark “Other Confirmation” under Micro Surveillance and write Monkeypox in the comments box. You may view a blank requisition example here: Public Health Laboratory Request Form (mt.gov) 
    • For online orders, use “Orthopox NV PCR” (Orthopoxvirus; Non-Variola PCR). The test can also be found by typing monkeypox.

 

DPHHS urges healthcare providers to be alert for patients who have rash illnesses consistent with monkeypox, regardless of whether they have travel or specific risk factors for monkeypox, and regardless of gender or sexual orientation.

Healthcare providers are required to notify their local health department of high-suspect monkeypox cases and of any positive monkeypox results from reference laboratories, during daytime hours, including weekends (ARM 37.114.201): https://dphhs.mt.gov/publichealth/FCSS/countytribalhealthdepts. Timely communication with your local health department (LHD) will facilitate a coordinated and prompt public health response in the event of a positive result (i.e., contact tracing, vaccination of high-risk close contacts, therapeutics, etc.). Local public health should immediately contact the DPHHS Communicable Disease Epidemiology Program (CDEpi) at 406-444-0273 to notify the program of a high-suspect monkeypox case, and share name and date of birth of the suspect case. For high-suspect monkeypox cases in which vaccination of close contacts or treatment may be needed, LHD and CDEpi are available to discuss suspect monkeypox cases and treatment requests with providers during daytime hours, including weekends. For public health emergencies, providers may contact the afterhours phone numbers.

Given capacity limitations at the Montana Public Health Lab (MTPHL), it is recommended that healthcare facilities designate a reference lab partner to which they can send out specimens for monkeypox testing and communicate this plan with their providers. Providers may send specimens from any suspect monkeypox case to a reference lab, including high-suspect cases; please notify your LHD of high-suspect monkeypox cases. 

Currently, MTPHL will provide orthopoxvirus testing of skin lesion swabs for high suspect cases only that have been approved by a public health epi consult. High suspect cases will have symptoms consistent with monkeypox and meet the CDC epi criteria.

  • Healthcare providers must call the local health department to discuss if a patient is eligible for testing at MPTHL.
  • An epi consult is required prior to submission of specimens to MTPHL, to determine if the patient meets the CDC epi criteria.
  • If the patient does not meet the CDC epi criteria, and the provider still wants to pursue testing, they should send a specimen to a reference laboratory for testing.
    • These lab include: Sonic Labs, Aegis Labs, Quest Diagnostics, Mako, and LabCorp. Please check with the selected reference lab for specific specimen collection requirements prior to collection, as they may vary.
  • If specimens arrive at MPTHL without a prior epi approval, specimens will be sent back to the ordering facility. It is the ordering facility’s responsibility to send the specimens to a reference lab.

 

Follow instructions listed in the Specimen Collection section, below, to collect and submit approved high suspect specimens to MPTHL for testing.

If specimens are positive for orthopoxvirus (the genus of viruses that includes monkeypox virus), the MTPHL and commercial laboratories will send the 2nd specimen swab to CDC to perform viral characterization testing to confirm monkeypox.

A positive orthopoxvirus test result is enough for healthcare providers and public health authorities to take necessary actions for the patient and help prevent additional spread, the same actions they would take for a positive monkeypox test result. 

Public health actions can include isolating the patient, initiating treatment if needed, contact tracing, and offering post-exposure vaccination to contacts while confirmatory tests for monkeypox are under way.

Many mpox infections last 2 to 4 weeks and resolve without treatment. There are no treatments specifically for mpox virus infections. However, the mpox and smallpox viruses are closely related, so treatments developed for smallpox may be used to treat mpox. The antiviral drug tecovirimat was developed to treat smallpox, and the FDA allows CDC to use it to treat mpox during an outbreak. The need for treatment will depend on how sick someone gets, where lesions are located, and whether they are likely to get severely ill, including individuals with weakened immune systems. The CDC offers Treatment Information for Healthcare Professionals, which includes Interim Clinical Guidance for the Treatment of Mpox, outlining populations in which treatment should be considered.  

Oral tecovirimat for the treatment of mpox is available through enrollment in the Study of Tecovirimat for Human Mpox Virus (STOMP). Researchers and clinicians do not know whether tecovirimat is safe and effective for the treatment of mpox. The STOMP trial is designed to collect data to help answer these scientific questions. Participation is available in Montana through remote enrollment. Additional information is available on the CDC Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Mpox.

Providers caring for individuals with mpox who decline enrollment in or are ineligible for STOMP, 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) can request tecovirimat.

DPHHS has pre-positioned supplies of tecovirimat in the state for redistribution, when necessary. The state supply of tecovirimat is limited, so DPHHS will review/approve requests before use. The request process is outlined below.

  • Provider determines if individual is eligible for treatment with tecovirimat, per CDC.
  • Provider contacts DPHHS CDEpi (406-444-0273) to initiate request for an eligible individual.
  • DPHHS will work with the provider’s facility to arrange transfer of tecovirimat supply, when indicated.
  • DPHHS will share a summary of the CDC reporting requirements for tecovirimat use with the treating provider when treatment is released.

 

CDC Mpox Treatment Resources

  1. Guidance for Tecovirimat Use: Discusses treatment considerations, available formulations, adverse reactions, drug interactions, and special populations.
  2. Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Mpox: Discusses accessing tecovirimat through the STOMP Trial; provides information on the Expanded Access IND protocol for tecovirimat and the online registry; and required and optional forms for tecovirimat use.
  3. Tecovirimat IND protocol contains important medication information, including dosing, administration, patient monitoring, special populations, and safety.
  4. Clinical Considerations for Treatment and Prophylaxis of Mpox Infection in People Who are Immunocompromised: Discusses mpox in people who are immunocompromised and the diagnosis, treatment, and vaccination of people with immunocompromising conditions, including HIV.
  5. Clinical Considerations for Mpox in People Who are Pregnant or Breastfeeding: Discusses mpox and pregnancy; signs and symptoms; treatment; vaccine; contact and breastfeeding; and infection control.
  6. Clinical Considerations for Mpox in Children and Adolescents
  7. Patient’s Guide to Mpox Treatment with TPOXX