MONKEYPOX

If you think you have been exposed to monkeypox, call your healthcare provider for more information.

Monkeypox virus under a microscope

Case Count in Montana: Two cases of monkeypox have been confirmed in Montana.

Updated: 08/17/2022

 DPHHS Announces First Confirmed Case of Monkeypox in Montana (mt.gov)

   Link to information on the Monkeypox situation in the U.S.  Link to information on the Monkeypox situation globally

Information for healthcare providers can be found under the Additional Information section, or here.

If you have new or unexplained rash or other symptoms:
  • Avoid close contact, including sex or being intimate with anyone, until you have been checked out by a healthcare provider.
  • When you see a healthcare provider, wear a mask.
What You Need to Know About Monkeypox

Monkeypox is rare and typically does not spread easily between people without close contact.

What is Monkeypox?

Monkeypox is a viral infection transmitted through close, personal contact, including kissing, sex, and other skin-to-skin or face-to-face contact. Most infections last 2-4 weeks and resolve without specific treatment. The type of monkeypox seen in this outbreak is rarely fatal, and more than 99% of people who get this form of the disease are likely to survive.

What are the Symptoms?

Key Symptoms

Rash, Bumps, or Blisters that may be located on or near the genitals (penis, testicles, labia, and vagina) or anus (butthole) but could also be on other areas like the hands, feet, chest, face, or mouth.

  • The rash will go through several stages, including scabs, before healing.
    • The rash can look like pimples or blisters and may be painful or itchy.
  • The rash may look similar to syphilis, herpes, or other common skin rashes.

Other Symptoms

  • Fever & headaches
  • Muscle aches
  • Swollen lymph nodes
  • Chills
  • Exhaustion
  • Respiratory symptoms

Symptom onset ranges from 5-21 days after exposure to the virus

Anyone can get Monkeypox

The data current show transmission is higher among people in close social networks. People with monkeypox in the current outbreak generally report having close, sustained physical contact with other people who have monkeypox.

Additional Information

Monkeypox Testing Guidance Document for Healthcare Providers 

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 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.

The Montana Public Health Laboratory (MTPHL) in Helena has capacity to test for monkeypox (via a non-variola orthopox test) for high suspect cases in Montana. CDC has also expanded testing capacity in the U.S. by onboarding commercial laboratories. National reference labs including, Sonic Labs, Aegis Labs, Quest Diagnostics, Mayo Clinic, Mako, and LabCorp are already testing for orthopoxvirus and monkeypox.

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, Mayo Clinic, 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.

Specimen collection details are for pre-approved specimens that have a CDEpi consult and are being sent to the MTPHL

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.

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.

Infection Prevention at Home

CDC provides recommendation for non-hospitalized patient infection prevention measures in their document, Isolation and Infection Control

 
Infection Prevention in Healthcare Settings

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.

Vaccines are one important strategy to contain monkeypox. To date, Montana has received an allocation of 750 doses of Jynneos vaccine to be released in stages over the next several weeks. Doses are already in the state and have been placed at  several strategic locations to ensure those needing a dose for PEP or PEP++ can access the vaccine quickly. This allocation is intended to complete the 2-shot series for each individual that receives Jynneos. DPHHS will follow CDC vaccination recommendations for monkeypox vaccination, which may be recommended for the following individuals.

  • Post-exposure prophylaxis (PEP): People who have had exposure to individuals with confirmed orthopoxvirus/monkeypox virus infection. 
  • Expanded post-exposure prophylaxis (PEP++): People with certain risk factors that might make them more likely to have been recently exposed to monkeypox may be considered for PEP++. This may include people that are identified through case investigations/contact tracing, people who are aware that one of their sexual partners from the past 2 weeks has received a monkeypox diagnosis, and individuals that report group sex/sex with multiple partners in the past two weeks in association with certain events, venues, or geographical areas in which monkeypox transmission has been reported.
  • Pre-exposure prophylaxis (PREP):  

    • Adults 18 years* and older who meet one of the following criteria: 
    • Gay, bisexual or transgender people who have sex with men and have recently had multiple or anonymous sexual partners; OR 
    • Partners of gay, bisexual or transgender people who have sex with men who have had multiple or anonymous sexual partners; OR 
    • Sex workers (of any sex); OR 
    • Staff (of any sex) 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.

    Note: eligible persons, per the criteria above, who are immunocompromised (e.g., those with advanced or uncontrolled HIV) or those who have underlying medical conditions that confer increased risk for severe disease (e.g., atopic dermatitis, eczema) could 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.  

    o        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. 

Many monkeypox infections last 2 to 4 weeks and resolve without treatment. There are no treatments specifically for monkeypox virus infections. However, the monkeypox and smallpox viruses are closely related, so treatments developed for smallpox may be used to treat monkeypox. The antiviral drug named tecovirimat was developed to treat smallpox, and the FDA allows CDC to use it to treat monkeypox during an outbreak. The need for treatment will depend on how sick someone gets and whether they are likely to get severely ill, like patients with weakened immune systems. 

DPHHS has pre-positioned a supply of tecovirimat in Helena, Great Falls, Missoula, Billings, Kalispell, Sidney, Butte, and Bozeman 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 contacts DPHHS CDEpi (406-444-0273) to initiate request for an eligible patient, per CDC.
  • DPHHS will work with the provider’s facility to arrange transfer of tecovirimat, when indicated.
  • DPHHS will share a summary of the CDC reporting requirements for tecovirimat use with the treating provider when treatment is released.

CDC provides Guidance for Tecovirimat Use Under Expanded Access Investigational New Drug Protocol during 2022 U.S. Monkeypox Cases and Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox. The Tecovirimat IND protocol contains important medication information, including dosing, administration, patient monitoring, special populations, and safety. CDC offers specific clinical guidance and treatment considerations for people with HIV, people who are pregnant or breastfeeding, and children and adolescents

Healthcare workers who have cared for a monkeypox patient should be alert to the development of symptoms that could suggest monkeypox infection, especially within the 21-day period after the last date of care, and should notify infection control, occupational health, and the health department to be guided about a medical evaluation.

Healthcare workers who have unprotected exposures (i.e., not wearing PPE) to patients with monkeypox do not need to be excluded from work duty, but should undergo active surveillance for symptoms, which includes measurement of temperature at least twice daily for 21 days following the exposure. Prior to reporting for work each day, the healthcare worker should be interviewed regarding evidence of fever or rash.

Healthcare workers who have cared for or otherwise been in direct or indirect contact with monkeypox patients while adhering to recommended infection control precautions may undergo self-monitoring or active monitoring as determined by the health department.

Transmission of monkeypox requires prolonged close contact with a symptomatic individual.  Brief interactions and those conducted using appropriate PPE in accordance with Standard Precautions are not high risk and generally do not warrant PEP. See the link below and/or contact your local or state health department for information.

Resources

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

FAQS

Anyone can get monkeypox, but some people are at a higher risk. Unlike the virus that causes COVID-19, monkeypox does not spread easily between people. Monkeypox is primarily spread through close contact and does not spread through the air over longer distances. Brief interactions that do not involve physical contact and health care interactions conducted using appropriate protective equipment are generally considered low risk.

While the current cases nationally and internationally mainly involve men who have sex with men, anyone who is sexually active with multiple partners or who are partners with someone who has sex with multiple partners can be at risk for being exposed to monkeypox.

Other risk factors may include travel to areas where monkeypox is spreading, close, non-sexual contact with a known case, or contact with sick animals. To protect yourself and others from monkeypox or sexual infectious diseases, DPHHS recommends practicing safe sex methods, practice harm reductions, and avoiding sexual contact with anyone who has open wounds, sores, or rashes

  • See a healthcare provider if you notice a new or unexplained rash or other monkeypox symptoms.
  • Remind the healthcare provider that monkeypox is circulating.
  • Avoid close contact (including intimate physical contact) with others until a healthcare provider examines you.
  • Avoid close contact with pets or other animals until a healthcare provider examines you.
  • If you’re waiting for test results, follow the same precautions.
  • If your test result is positive, stay isolated and observe other prevention practices until your rash has healed, all scabs have fallen off, and a fresh layer of intact skin has formed.
  • Remain isolated if you have a fever or respiratory symptoms, including sore throat, nasal congestion, or cough. Only go out to see a healthcare provider or for an emergency and avoid public transportation.
  • If you need to leave isolation, you should cover the rash and wear a well-fitting mask.

Monkeypox spreads in different ways. The virus can spread from person-to-person through direct contact with the infectious rash, scabs, or body fluids. It also can be spread by respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex. In addition, pregnant people can spread the virus to their fetus through the placenta.

Touching items (such as clothing or linens) that previously touched the infectious rash or body fluids is another way monkeypox spreads. It’s also possible for people to get monkeypox from infected animals, either by being scratched or bitten by the animal or by eating meat or using products from an infected animal.

People who do not have monkeypox symptoms cannot spread the virus to others.

Monkeypox can spread from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

Monkeypox is zoonotic, meaning it can spread between animals and people. However, CDC does not currently believe that monkeypox poses a high risk to pets. We are continuing to monitor the situation closely.

During the 2003 monkeypox outbreak in the United States, we did not see disease spread to domestic animals other than prairie dogs, and we do not have reason to believe that we will see that now. However, we still recommend that people with monkeypox avoid interacting with animals and find someone else to take care of their pets while they recover. 

Evidence of human-to-dog transmission of monkeypox virus - ScienceDirect 

There are two types of monkeypox virus: West African and Congo Basin. Infections in the current outbreak are from the West African type.

Infections with the type of monkeypox virus identified in the 2022 outbreak—the West African type—are rarely fatal.

  • More than 99% of people who get this form of the disease are likely to survive. However, people with weakened immune systems, children under 8 years of age, people with a history of eczema, and people who are pregnant or breastfeeding may be more likely to get seriously ill or die.
  • Although the West African type is rarely fatal, symptoms can be extremely painful, and people might have permanent scarring resulting from the rash.
  • The Congo Basin strain has a fatality rate around 10%. This strain is not associated with the current outbreak.
  • In this current outbreak, no one in the US has died of monkeypox, although, globally, a couple of people have died.

There is no particular group that is more vulnerable to monkeypox than others.

However, people with weakened immune systems, children under 8 years of age, people with a history of eczema, and people who are pregnant or breastfeeding may be more likely to get seriously ill or die.

We encourage anyone who has a rash and thinks they may have had close, skin-to-skin contact with someone who could have monkeypox in the last 21 days to talk to their medical provider and find out if they should be tested.

Because monkeypox and smallpox viruses are genetically similar, vaccines developed to protect against smallpox viruses may be used to prevent monkeypox infections.

The U.S. government has two stockpiled vaccines—JYNNEOS and ACAM2000—that can prevent monkeypox in people who are exposed to the virus. Vaccines may be recommended for people who have had or may have contact with someone who has monkeypox, or for healthcare and public health workers who may be exposed to the virus.

Montana has pre-positioned supply at the DPHHS and several local health departments. 

DPHHS will follow CDC vaccination recommendations for monkeypox vaccination, which may be recommended for the following individuals.

  • Post-exposure prophylaxis (PEP): People who have had exposure to individuals with confirmed orthopoxvirus/monkeypox virus infection. 
  • Expanded post-exposure prophylaxis (PEP++): People with certain risk factors that might make them more likely to have been recently exposed to monkeypox may be considered for PEP++. This may include people that are identified through case investigations/contact tracing, people who are aware that one of their sexual partners from the past 2 weeks has received a monkeypox diagnosis, and individuals that report group sex/sex with multiple partners in the past two weeks in association with certain events, venues, or geographical areas in which monkeypox transmission has been reported.
  • Pre-exposure prophylaxis (PREP):  

    • Adults 18 years* and older who meet one of the following criteria: 
    • Gay, bisexual or transgender people who have sex with men and have recently had multiple or anonymous sexual partners; OR 
    • Partners of gay, bisexual or transgender people who have sex with men who have had multiple or anonymous sexual partners; OR 
    • Sex workers (of any sex); OR 
    • Staff (of any sex) 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.

    Note: eligible persons, per the criteria above, who are immunocompromised (e.g., those with advanced or uncontrolled HIV) or those who have underlying medical conditions that confer increased risk for severe disease (e.g., atopic dermatitis, eczema) could 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.  

    o        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.

If you think you may be eligible for vaccination, contact a healthcare provider or your local health department. They can help you determine if you should get vaccinated.