Mpox is rare disease caused by the monkeypox virus, a type of orthopox virus related to variola and vaccinia viruses.
Transmission typically occurs through skin-to-skin contact including direct contact with mpox rash and scabs or body fluids such as saliva and upper respiratory secretions. Individuals with mpox are infectious from the time symptoms begin until lesions have healed and a fresh layer of skin has formed. Some people may also spread mpox 1-4 days prior to symptom onset.
Clinical presentation
Symptoms of monkeypox infection start approximately 7-14 days after exposure but can range from 3-17 days. People with mpox infection may develop fever, malaise, headache, sore throat, cough, or swollen lymph nodes before or after a rash occurs.
Key Characteristics for Identifying Mpox
Lesions are firm, well circumscribed, deep seated, and often develop umbilication
Lesions often occur in the genital and anorectal areas or in the mouth
Rash is not always disseminated across many body sites and may only include one or a small number of lesions
Lesions are often described as painful until they crust and become itchy
Rectal symptoms, such as bloody stools, rectal pain, and rectal bleeding have been frequently reported
Lesions typically begin to develop simultaneously and evolve together
The rash progresses through 4 stages – macular, papular, vesicular, to pustular – before scabbing over and resolving; this process happens over a period of 2-4 weeks
Lesion examples
Key Features of the Rash
A person is contagious from the onset of the enanthem through the scab stage.
Stage
Stage Duration
Characteristics
Enanthem
Sometimes lesions develop on the tongue and in the mouth first
Macules
1 - 2 days
Macular lesions appear
Papules
1 - 2 days
Lesions progress from macular to papular
Vesicles
1 - 2 days
Lesions become vesicular (raised and filled with clear fluid)
Pustules
5-7 Days
Lesions become pustular (filled with opaque fluid), sharply raised, usually round, and firm to the touch (deep seated)
Lesions will develop a depression in the center (umbilication)
The pustules will remain for approximately 5 to 7 days before beginning to crust
Scabs
7 - 14 days
By the end of the second week, pustules have crusted and scabbed over
Scabs will remain for about a week before beginning to fall off
Testing/Specimen Collection
Diagnostic Testing As part of national efforts to expand monkeypox diagnostics, commercial laboratories are authorized to perform monkeypox virus testing. If your commercial lab does not offer orthopox or monkeypox virus testing, continue to reach out as they could be partnered with an alternative reference lab. See IDPH SIREN about commercial laboratory testing for monkeypox.
For Chicago residents, CDPH approval or notification is not required when submitting specimens to commercial reference laboratories. Public health approval continues to be required when requesting testing through the IDPH laboratory - please complete the CDPH suspect case report form if testing is being request through the public health laboratory: https://redcap.link/reportmpx.
Commercial reference laboratories are automatically electronically reporting test results to public health. CDPH will therefore receive results and pursue appropriate contact tracing and other public health follow up. For Chicago residents, healthcare providers do not need to routinely report cases to CDPH - as with all diagnostic testing, it remains the responsibility of the healthcare provider to notify the patient of their result and pursue all relevant clinical assessments and treatment.
In addition to commercial labs, testing through the IDPH laboratory remains available for certain priority situations. Providers who have established monkeypox diagnostic testing with a commercial reference laboratory may still wish to pursue testing through the IDPH laboratory in certain cases, particularly urgent situations based on the clinical picture (e.g. severe disease, lesions in unusual anatomical sites like the eyes, or in a patient being considered for immediate Tecovirimat for any other reason); individual risk (e.g. immunocompromise, pediatric patients, people who are pregnant or breastfeeding); or public health risk (e.g. residents of congregate settings like homeless shelters or jails). To request public health testing, please complete the CDPH suspect case report form: https://redcap.link/reportmpx and indicate why the test is urgent.
Specimen Collection For Chicago residents, CDPH approval is not required for commercial laboratory testing, but is still required for testing being requested through the public health laboratory. To request public health testing, please complete the CDPH suspect case report form: https://redcap.link/reportmpx.
A Job Aid is available for monkeypox testing here.
Personnel who collect specimens should use personal protective equipment (PPE) in accordance with recommendations for healthcare settings. The optimal PPE includes: gown, gloves, eye protection (e.g. goggles or a face shield that covers the front and sides of the face) and a NIOSH-approved N95 filtering facepiece or equivalent or a higher-level respirator
Use a sterile nylon, polyester, or Dacron swab with a plastic, or thin aluminum shaft. Flocked swabs or Eswabs are acceptable. Do not submit wooden or other types of swabs, or swabs in collection/transport media.
Vigorously swab or brush lesion. It is not necessary to de-roof the lesion before swabbing.
Place each specimen in a separate sterile container (e.g. by break off end of applicator of each swab into a 1.5- or 2-mL screw-capped tube with O-ring, or placing in a sterile urine cup, or 15cc/50cc conical tube). Do not add or store in viral or universal transport media.
Sample the same lesion 2 times, then repeat across 1 other location on the body or a lesion with a different appearance. Use a new swab for each specimen. Each specimen should be stored in its own container. Four specimens should be collected (two lesions, each collected twice).
Label each specimen container with:
Patient Name
Medical Record Number
Lesion Location (e.g. right foot, abdomen, left thigh)
Collection date
Freeze (-20°C or lower) specimens within an hour after collection. If freezing is unavailable, refrigerate at (2–8°C).
Store refrigerated specimens for up to 7 days and frozen specimens for up to 60 days.
If testing is approved, CDPH will provide Requisition Forms, instructions on how to fill them out, and shipping instructions.
Treatment
Patients with mpox benefit from supportive care and pain control that is implemented early in illness.
Pain may exist from mucosal lesions not evident on physical exam
Over-the-counter medications such as NSAIDS are recommended for general pain control
Topical steroids and anesthetics can be considered for local pain relief, but should be used with caution on broken skin or open wounds
Prescription pain medications such as gabapentin and opioids have been used in some circumstances for short-term management of severe pain. Benefits of use should be balanced against the risk of side effects
Proctitis has been frequently reported
Stool softeners should be considered to reduce pain associated with bowel movements
Oral acetaminophen, NSAIDs, or topical anesthetics may offer symptomatic relief
In some cases, hospitalization and neuropathic pain agents may be necessary to provide relief
Warm sitz bath (warm bath of water and baking soda or Epsom salt) can be considered for symptomatic relief
Genital lesions are common and severe penile or urethral complications can occur
General pain control considerations should be taken and vigilance for secondary bacterial infections should be maintained
Topical steroids can be considered to reduce localized swelling
Oropharyngeal lesions
Consider rinsing the mouth with clean saltwater 4 times per day
Oral antiseptic, local anesthetic, and prescription analgesic mouth can be considered
Pruritis/Itching
Oral antihistamines may provide some relief
Topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal may improve symptoms
Antiviral Treatment: Tecovirimat Tecovirimat (TPOXX or ST-246) is an antiviral medication that is FDA-approved to treat smallpox. In animal studies, TPOXX has been shown to decrease the chance of dying from infections with orthopoxviruses when given early in the disease course. In people, efficacy studies have been limited to drug levels in blood and a few case studies. In a case series of people with mpox infection, one patient received TPOXX with results suggesting TPOXX might shorten duration of illness and viral shedding, though efficacy is unknown (Adler, 2022).
ENROLLMENT IN THE STOMP TRIAL In the U.S., TPOXX is available through a study protocol called STOMP (Study of Tecovirimat for Human Monkeypox Virus) and in some cases through a non-research expanded access Investigational New Drug protocol organized by the CDC. Informed consent is required for all patients treated with TPOXX.
All patients who are being considered for treatment with TPOXX should first be offered enrollment in the STOMP study. Research staff will discuss enrollment in a randomized control arm (in which participants are enrolled 2:1 in favor of treatment) or an open-label arm (for those with severe disease or immune suppressed). There is the possibility of cross over to the open label treatment arm for participants enrolled in the randomized trial if symptoms become more severe. There are several enrollment sites in Chicago and there are additional sites that can enroll patients remotely. Patients can call the STOMP call center at 855-876-9997 to initiate the process.
Requesting TPOXX Patients may call the STOMP call center at 855-876-9997 to inquire about study enrollment. Some patients may be eligible to receive TPOXX through the EA-IND via a collaborating clinical partner. For more information on prescribing or accessing TPOXX for your patients, MPXtherapeutics@cityofchicago.org.
Other Therapeutic Agents Other therapeutic options are under investigation and include the antivirals cidofovir and brincidofovir, as well as Vaccinia Immune Globulin Intravenous (VIGIV). The use of cidofovir has been limited by serious renal toxicity. To date, use of VIGIV has no proven benefit in the treatment of mpox and it is unknown whether a person with severe mpox infection will benefit from treatment with VIGIV. More information and updates on the status of these therapeutics in mpox treatment can be found on CDC Monkeypox Treatment Information for Healthcare Professionals webpage.
References
Adler H, Gould S, Hine P, Snell LB, Wong W, Houlihan CF, Osborne JC, Rampling T, Beadsworth MB, Duncan CJ, Dunning J. Clinical features and management of human monkeypox: a retrospective observational study in the UK. The Lancet Infectious Diseases. 2022 May 24. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00228-6/fulltext
The Chicago Department of Public Health may change recommendations as the situation evolves. Updated 05/31/23.
Post-Exposure Prophylaxis and Extended Post exposure Prophylaxis
Discussion of mpox risk and vaccination should be included as part of a comprehensive strategy for promoting sexual health in those who are eligible.
Eligibility criteria for the JYNNEOS vaccine includes those living in Chicago and Illinois, including students enrolled in Chicago’s universities/colleges, who meet one of the following criteria AND have not previously been infected with mpox:
Anyone who has had close contact (e.g., household member with close physical contact or intimate partner) with someone diagnosed with mpox regardless of sex, gender, or sexual orientation.
OR
Sexually active bisexual, gay and other men who have sex with men, and transgender persons,
Especially consider vaccinating individuals who: met through online applications or social media platforms (such as Grindr, Tinder or Scruff), or at clubs, raves, sex parties, saunas, or exchange goods or services for sex.
Standard Precautions should be applied for all patient care, including for patients with suspected monkeypox.
A patient with suspected or confirmed monkeypox infection should be placed in a single-person room with a dedicated bathroom. The door should be kept closed if safe to do so.
Special air handling is not required unless performing an aerosol-generating procedure (e.g., intubation), in which case an airborne infection isolation room should be used.
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.
PPE used by healthcare personnel who enter the patient’s room should include a gown, gloves, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), and a NIOSH-approved N95 or equivalent respirator.
Patient waste can be managed as Regulated Medical Waste.
Exception: If the patient traveled to Central Africa within the prior 21 days, waste should be managed as a Category A infectious substance.
Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant on List Q.
Soiled laundry (e.g., bedding, towels, personal clothing) should be gently and promptly contained in an appropriate laundry bag and never be shaken or handled in a way that may disperse infectious material. Care should be taken to avoid contact with lesion material that may be present on the laundry.
Activities that could resuspend dried materials from lesions (e.g., use of portable fans, dry dusting, sweeping, and vacuuming) should be avoided.
Visitors to patients with monkeypox should be limited to those essential for the patient’s care and wellbeing (e.g., parents of a child or spouse).
In Home Settings
As much as possible, do not leave the home. Avoid crowds and congregate settings.
If a person with monkeypox is symptomatic with a fever or any respiratory symptoms (e.g., sore throat, nasal congestion, cough), they should remain home unless it is necessary to seek medical care or for an emergency. If leaving the home for medical care or an emergency, the individual should avoid public transportation.
Avoid close physical contact, including sexual and/or intimate contact, with other people.
Limit contact with household members who are not ill.
It is particularly important to avoid close prolonged contact with young children, pregnant women, and immunosuppressed people as they may be at higher risk for serious illness.
Isolate in a room separate from other household members if experiencing respiratory symptoms or extensive sores that cannot be covered.
If possible, use a separate bathroom from other household members.
When in close contact with others, wear a well-fitting mask to prevent the spread of oral and respiratory secretions. Masks should fit closely on the face without any gaps along the edges or around the nose and be comfortable when worn properly over the nose and mouth.
If it is not feasible for the person with monkeypox to wear a mask, other household members should wear a well-fitting mask when in close contact (i.e., within 6 feet) for more than a brief encounter with the person who has monkeypox.
Avoid contact with pets and other animals.
Cover all parts of the rash/lesions with clothing, gloves, and/or bandages.
Do not share potentially contaminated items, such as bedding, clothing, towels, drinking glasses, or eating utensils with other people or animals.
Launder or disinfect items and surfaces before use by others.
Laundry may be washed in a standard washing machine with warm water and detergent. Contaminated laundry, which is used by a person with mpox, should not be mixed with other laundry. Do not shake soiled laundry.
For disinfection of items and surfaces, use an EPA-registered disinfectant product (see List Q) in accordance with the manufacturer’s instructions.
Wash hands often with soap and water or use an alcohol-based hand sanitizer, especially after direct contact with the rash.
Restrict visitors to those who are essential to being in the home, especially if they have not been previously exposed.
Avoid use of contact lenses to prevent inadvertent infection of the eye.
Avoid shaving rash-covered areas of the body, as this can lead to spread of the virus.
After ending isolation, use safe sex and barrier practices (e.g., wearing condoms) for at least 8 weeks.
Healthcare providers can now administer the JYNNEOS monkeypox vaccine by intradermal injection. This could increase the number of available doses by up to five-fold.
Learn about this update and how to administer the vaccine with this webinar.
Contact Information Outside of business hours (after 5pm through before 8am, and on City holidays), collect specimens, and approval will be provided during normal business hours.
If you have a need for urgent public health guidance, please call 311 (or 312-744-5000 if outside the City of Chicago) and ask for the CDPH medical director on call.
Mpox Reporting
For Questions: Contact the CDPH Disease Reporting Hotline at 312-743-9000.
For Testing: Testing should be performed through a commercial laboratory. To request public health testing for urgent situations, please complete the CDPH suspect case report form at https://redcap.link/reportmpx.
To Report Suspect or Confirmed Cases
Suspect or confirmed cases of mpox must be reported within 24 hours. Commercial laboratories automatically report test results to public health electronically. To report additional information, please report via I-NEDSS (Illinois Notifiable Electronic Disease Surveillance System), if you have access to that electronic system. For all other questions, contact the CDPH Disease Reporting Hotline at 312-743-9000.
*After hours (4:30pm – 8:30am), weekends, and holidays, call 311 (or 312-744-5000 from outside the City of Chicago) and ask for the CDPH Medical Director on call.
