Monkeypox: Recommendations for Detection and Reporting

This information is provided by the Wisconsin Department of Health Services

Wisconsin DHS Health Alert #44: Monkeypox: Recommendations for Detection and Reporting

Bureau of Communicable Diseases 

June 1, 2022

Key Points

• Since May 13, 2022, several hundred cases of monkeypox have been identified from non-endemic countries across North America, Europe, and Australia, including 18 probable cases detected in U.S. residents. No cases have been identified to date in Wisconsin, and the risk of monkeypox to the general public is currently considered to be low.
• Many, but not all, recent monkeypox cases have been detected among men who have sex with men (MSM), who have sought care in primary care and sexual health clinics.
• Health care providers should suspect monkeypox in any patient who presents with the characteristic monkeypox rash (well-circumscribed, hard or firm, deep-seated lesions that may umbilicate or become confluent and progress over time to scabs), regardless of the patient’s travel or social history, gender, sexual orientation, or the presence of risk factors for monkeypox virus infection.
• A patient with suspected or confirmed monkeypox infection should be placed in a single-person room with a dedicated bathroom; special air handling is not required. PPE including gown, gloves, eye protection, and a N95 (or equivalent) or higher respirator should be used when caring for or collecting specimens from patients with confirmed or suspected monkeypox. Patients who do not require hospitalization for medical indications may be isolated at home using protective measures.
• Clinicians who suspect monkeypox in a patient should immediately contact the DHS Bureau of Communicable Diseases at 608-267-9003 to discuss whether testing or other public health actions are indicated.

Background

Since May 13, 2022, the Centers for Disease Control and Prevention (CDC) has been monitoring clusters of monkeypox in countries where it is not endemic. On May 20, 2022, the CDC issued an official Health Advisory asking clinicians in the U.S. to be vigilant to the symptoms associated with monkeypox infection and to understand that current cases are presenting atypically. The purpose of this health alert is to notify Wisconsin clinicians and public health partners of the possibility that monkeypox cases will occur in Wisconsin during the coming weeks, and to provide guidance about evaluation, testing, infection control, and other public health measures.

Monkeypox is caused by a virus of the orthopoxvirus genus of the Poxviridae family and is endemic in several countries in Central and West Africa. Historically, cases of monkeypox in the U.S. have been rare and travel-associated (2 cases in the U.S. since 2018). The current outbreak, which features cases in multiple non-endemic countries that are not linked to travel or animal contact, is atypical and concerning. Although investigations are still ongoing, person-to-person spread through close, intimate contact is suspected. Despite these epidemiologic differences, genomic sequencing has found the viruses in the current outbreak to be similar to those causing cases exported from endemic areas during 2018 to 2019.

According to CDC and the World Health Organization (WHO), many, but not all, cases in the 2022 outbreak have been among men who identify as gay, bisexual, or men who have sex with men (MSM). Monkeypox is not considered a sexually transmitted infection, but can be transmitted during close personal or intimate contact. Transmission of monkeypox predominately occurs through direct or indirect contact with body fluids or lesions, contact with fomites such as contaminated clothing or linens, or exposure to respiratory droplets. Transmission via respiratory droplets requires prolonged close interaction with a symptomatic person.

Monkeypox usually causes a self-limited illness, but may be severe in some individuals, such as children, pregnant women, or persons with immune suppression due to other health conditions. The typical incubation period for monkeypox is 7-14 days but can range from 5-21 days. A patient with monkeypox is considered infectious from the onset of prodromal symptoms until lesions have crusted and the scabs have separated and have been replaced with a fresh layer of healthy skin. The normal course of illness generally lasts from 2-4 weeks. There is currently no specific treatment for monkeypox. However, antiviral medication used to treat smallpox patients may aid recovery.

Monkeypox infection typically presents as a characteristic rash along with fever, chills, and often lymphadenopathy. Rash is usually preceded by 1-3 days of prodromal symptoms (e.g., fever, lymphadenopathy, and other non-specific symptoms of headache, muscle aches, and malaise). Characteristic rash lesions are round, deep-seated, firm or hard, well-circumscribed, and often umbilicated. Lesions evolve through four stages (macular, papular, vesicular, to pustular) before forming scabs and falling off. Lesions are approximately the same size and at the same stage of development on the same part of the body. Disseminated rash is centrifugal, with more lesions on the extremities and the face. Lesions may occur on the palms and soles.

However, many patients in the current outbreak have presented atypically. Some patients experienced no or mild prodromal symptoms, and some presented with characteristic monkeypox rash lesions in the genital and perianal region without dissemination. These patients have often been diagnosed at outpatient and sexual health clinics due to mild symptoms and confusion of the genital or perianal lesions with more common or sexually transmitted infections like syphilis, chancroid, genital herpes, and varicella zoster.

Case Definition (current as of June 2, 2022)

• For the current outbreak, CDC has defined a Suspect Caseof monkeypox as a patient who has a new characteristic rash OR has high clinical suspicion* for monkey pox AND meets the following epidemiologic criteria within 21 days prior to of illness onset:
  • Reports having contact with a person or people with a similar appearing rash or who received a diagnosis of confirmed or probable monkeypox OR
  • Had close or intimate in-person contact with individuals in a social network experiencing monkeypox activity, this includes men who have sex with men (MSM) who meet partners through an online website, digital application (“app”), or social event (e.g., a bar or party) OR
  • Traveled outside the US to a country with confirmed cases of monkeypox or where monkeypox virus is endemic OR
  • Had contact with a dead or live wild animal or exotic pet that is an African endemic species or used a product derived from such animals (e.g., game meat, creams, lotions, powders, etc.)
• A Probable Caseof monkeypox is defined as a patient who has no suspicion of other recent Orthopoxvirus exposure (such as Vaccinia virus in ACAM2000 vaccination) AND demonstration of the presence of
  • Orthopoxvirus DNA by polymerase chain reaction of a clinical specimen OR
  • Orthopoxvirus using immunohistochemical or electron microscopy testing methods 

OR a patient who has demonstration of detectable levels of anti-orthopoxvirus IgM antibody during the period of 4 to 56 days after rash onset.

• A Confirmed Monkeypox Caseis defined as a patient who has demonstration of presence of monkeypox virus DNA by polymerase chain reaction testing or Next-Generation sequencing of a clinical specimen OR isolation of monkeypox virus in culture from a clinical specimen.

^*High clinical suspicion may exist if presentation is consistent with illnesses confused with monkeypox (e.g., secondary syphilis, herpes, and varicella zoster). Historically, sporadic accounts of patients coinfected with monkeypox virus and other infectious have been reported, so patients with a characteristic rash should be considered for testing, even if other tests are positive.

Recommendations for Clinicians

• Monkeypox is reportable in Wisconsin as a Category I Condition. Immediately consult DHS at 608-267-9003 as soon as monkeypox is suspected.If indicated, testing for orthopoxvirus will be coordinated by DHS at one of Wisconsin’s Laboratory Response Network (LRN) sites, which include the Wisconsin State Laboratory of Hygiene (WSLH) and the Milwaukee Health Department Laboratory (MHDL). Confirmatory testing for monkeypox virus is conducted at CDC.
• Clinicians should suspect monkeypox in any patient who presents with a compatible rash-associated illnessregardless of the patient’s travel or social history, sexual orientation, or the presence of risk factors for monkeypox virus infection.
  • The rash associated with monkeypox involves vesicles or pustules that are deep-seated, firm or hard, and well-circumscribed; the lesions may umbilicate or become confluent and progress over time to scabs.
  • Presenting symptoms typically include fever, chills, the distinctive rash, or new lymphadenopathy; however, onset of perianal or genital lesions in the absence of subjective fever has been reported.
• Check CDC’s website for the most up-to-date information on infection prevention and control of monkeypox in healthcare settings.
  • A patient with suspected or confirmed monkeypox 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 and extubation, and any procedures likely to spread oral secretions, should be performed in an airborne infection isolation room. PPE used by health care personnel who enter the patient’s room should include gown, gloves, eye protection, and an N95 (or equivalent) or higher-level respirator.
• Transmission of monkeypox via respiratory droplets requires prolonged close interaction with a symptomatic person. The majority of health care interactions, including brief interactions and those conducted using appropriate PPE in accordance with standard precautions are not high risk and would not generally warrant post-exposure prophylaxis (PEP) with an approved vaccine. Rare high- or intermediate-risk exposures indicating PEP include unprotected contact with skin or lesions, close unmasked contact during an aerosol generating procedure, or 3 or more hours of unmasked close contact. Vaccines for PEP in the event of a high- or intermediate-risk exposures in health care settings are available from the Strategic National Stockpile and must be authorized for Wisconsin residents by DHS.
• If a patient presents with acute, generalized vesicular or pustular rash illness that might be compatible with smallpox, institute airborne and contact precautions and alert infection control. Follow CDC’s protocol for evaluating patients for smallpox. Report all high risk patients immediately to hospital infection control and to DHS at 608-267-9003.
• Evaluation for other causes of genital rashes, diffuse rashes, or proctitis such as syphilis, herpes simplex virus (HSV) infection, chancroid, varicella zoster, chlamydia/LGV, gonorrhea and others should occur. Clinical consultations for STDs are available from org. However, if laboratory tests are ordered, notify the laboratory prior to any specimen submission as clinical specimens from patients with suspected monkeypox must be handled using special precautions.
• Patients who do not require hospitalization for medical indications may be isolated at home using protective measures.
• Many individuals infected with monkeypox virus have a mild, self-limiting disease course in the absence of specific therapy. However, antiviral treatments are available for use against monkeypox infection and may be indicated for persons at risk of severe disease. Similar to vaccines, antivirals must be authorized by DHS and ordered for Wisconsin residents from the Strategic National Stockpile.

Recommendations for Health Departments

• All local health and Tribal health departments (LTHDs) should become familiar with the symptoms of monkeypox and the epidemiologic considerations for the current situation. If monkeypox is suspected in a community member, LTHDs should consult DHS at 608-267-9003.
• LTHD staff should review the current Monkeypox Case Definitionon the CDC website.
• LTHDs are encouraged to share this HAN with STI clinics and other relevant health care provider networks in their jurisdictions.
• If monkeypox or orthopoxvirus is confirmed in a patient in their jurisdiction, the LTHD should begin contact tracingfor individuals who may have been exposed to the patient. All contacts should be monitored for 21 days after their last known contact with the infected patient. LTHDs should familiarize themselves with CDC’s current guidance for exposure risk assessment, monitoring, and post-exposure prophylaxis.

Recommendations for Testing Laboratories

If your laboratory is notified by a clinician or LTHD of a suspected case of monkeypox:

• Immediately have the clinician consult DHS at 608-267-9003. DHS will conduct screening and consult CDC to determine if testing is necessary and will notify WSLH or MHDL if a test is approved.
• The public health laboratories will conduct PCR testing using CDC Laboratory Response Network (LRN) protocols if testing is approved by DHS. WSLH or MHDL will submit all specimens with non-variola orthopoxvirus positive PCR results to the CDC for monkeypox virus testing.
• Advise clinicians to perform specimen collection per LRN specifications, collecting two dry swabs from multiple lesions. Refer to the WSLH laboratory communication dated May 24, 2022 and CDC’s website.
• Take measures to minimize the risk of laboratory transmissionwhen testing routine clinical specimens for confirmed or suspected monkeypox patients. Perform all specimen manipulations within at least a Class II (or higher) biological safety cabinet using enhanced BSL-3 practices.

Additional Resources

• CDC Website: S. Monkeypox 2022: Situation Summary
• CDC COCA Call: Slides and Recording from the May 24. 2022 CDC COCA call, including recognition of common differential diagnoses for genital and disseminated rash lesions.
• CDC Health Advisory (HAN 466): Monkeypox Virus Infection in the United States and Other Non-endemic Countries—2022
• Clinical Consultation Service, National Network of STD Clinical Prevention Training Centers: STDCCN.org
• CDC Website: Interim Clinical Guidance for the Treatment of Monkeypox

Thank you for your attention to this developing situation.

Sincerely,

Ryan Westergaard, MD, PhD, MPH

Chief Medical Officer and State Epidemiologist for Communicable Diseases

Wisconsin Department of Health Services