2022 United States Monkeypox Case | Monkeypox | Poxvirus

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2022 United States Monkeypox Case | Monkeypox | Poxvirus


Overview

Scientists at the Centers for Disease Control and Prevention (CDC) are collaborating with the Massachusetts Department of Public Health to investigate a situation in which a United States. resident tested positive for monkeypox on May 18 after returning to the United States. from Canada.

CDC is also tracking multiple clusters of monkeypox that have been reported in early- to mid-May in several countries that don’t normally report monkeypox, including in Europe and North America.

It’s not clear how people in those clusters were exposed to monkeypox but cases include people who self-identify as men who have sex with men. CDC is urging healthcare providers in the United States. 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.

What people should do:

People who may have symptoms of monkeypox should contact their healthcare provider. This includes anyone who:

  1. traveled to central or west African countries, parts of Europe where monkeypox cases have been reported, or other areas with confirmed cases of monkeypox during the month before their symptoms began,
  2. reports contact with a person with confirmed or suspected monkeypox, or
  3. is a man who regularly has close or intimate contact with other men, including men who meet partners through an online website, digital application (“app”), or at a bar or party.

  • If clinicians identify patients with a rash that can be consistent with monkeypox, especially those with a recent travel history to central or west African countries, parts of Europe where monkeypox has been reported, or other areas reporting monkeypox cases, monkeypox should be considered as a possible diagnosis.
  • 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.
  • The rash associated with monkeypox can be confused with other diseases that are encountered in clinical practice (e.g., secondary syphilis, herpes, chancroid, and varicella zoster).  However, a high index of suspicion for monkeypox is warranted when evaluating people with a characteristic rash, particularly for men who report sexual contact with other men and who present with lesions in the genital/perianal area or for individuals reporting a significant travel history in the month before illness onset or contact with a suspected or confirmed case of monkeypox.
  • Information on infection prevention and control in healthcare settings is provided on the CDC website Infection Control: Hospital | Monkeypox | Poxvirus | CDC.  CDC is currently reviewing this information to consider the need for updates.
  • Clinicians should first consult their state health department (State Contactsexternal icon) or CDC through the CDC Emergency Operations Center (770-488-7100) as soon as monkeypox is suspected.

All specimens should be sent through the state/territorial public health department, unless authorized to send them directly to CDC.

  • If monkeypox is suspected, CDC should be consulted through the CDC Emergency Operations Center (770-488-7100).
  • Appropriately collected samples can be sent to CDC or an appropriate Laboratory Response Network (LRN) laboratory for testing by PCR.
  • Laboratory Response Network laboratories are able to provide orthopoxvirus testing on lesion specimens that clinicians obtain from suspected patients; confirmatory monkeypox virus-specific testing at CDC requires a dry lesion swab specimen.
    1. Vigorously swab or brush lesion with two separate sterile dry polyester or Dacron swabs;Collect multiple specimens for preliminary and confirmatory testing as follows:
    2. Break off end of applicator of each swab into a 1.5- or 2-mL screw-capped tube with O-ring or place each entire swab in a separate sterile container. Do not add or store in viral or universal transport media.

Case Definitions For Use: Monkeypox 2022

Person Under Investigation

  • Persons under investigation (PUI) are individuals who are reported as suspicious but have not been tested in an LRN laboratory. This includes cases that health departments have been consulted on because of clinician concern.

Possible Case

  • Meets one of the epidemiologic criteria AND has fever or new rash AND at least one other sign or symptom with onset 21 days after last exposure meeting epidemiologic criteria

Probable Case

  • Meets one of the epidemiologic criteria AND has new rash with or without fever AND at least one other sign or symptom with onset 21 days after last exposure meeting epidemiologic criteria AND
  • Demonstration of detectable levels of anti-orthopoxvirus IgM antibody during the period of 4 to 56 days after rash onset

Confirmed Orthopoxvirus Case

  • Meets possible case definition AND
  • Demonstration of orthopoxvirus DNA by polymerase chain reaction testing of a clinical specimen OR demonstration of presence of orthopoxvirus using immunohistochemical or electron microscopy testing methods

Confirmed Monkeypox Case

  • Meets possible case definition AND
  • 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

Clinical Criteria

  • New rash (any of the following)
    • Macular
    • Papular
    • Vesicular
    • Pustular
    • Generalized or localized
    • Discrete or confluent
  • Fever (either of the following)
    • Subjective
    • Measured temperature of ≥100.4° F [>38° C]
  • Other signs and symptoms:
    • Chills and/or sweats
    • New lymphadenopathy (periauricular, axillary, cervical, or inguinal)

Epidemiologic Criteria

Within 21 days of illness onset:

  • Report having had contact with a person or people who have a similar appearing rash or received a diagnosis of confirmed or probable monkeypox OR
  • Is a man who regularly has close or intimate in-person contact with other men, including through an online website, digital application (“app”), or social event (e.g., a bar or party) OR
  • Traveled to a country with confirmed cases of monkeypox AND at least one of the above criteria OR
  • Traveled to country where MPXV is endemic OR
  • Contact with a dead or live wild animal or exotic pet that is an African endemic species or used a product derived such animals (e.g., game meat, creams, lotions, powders, etc.)

Exclusion Criteria

A case may be excluded as a possible, probable, or confirmed monkeypox case if:

  • An alternative diagnosis* can fully explain the illness OR
  • An individual with symptoms consistent with monkeypox but who does not develop a rash within 5 days of illness onset OR
  • A case where specimens do not demonstrate the presence of orthopoxvirus or monkeypox virus or antibodies to orthopoxvirus as describe in the laboratory criteria

†Categorization may change as the investigation continues (e.g., a patient may go from PUI to probable)

* The rash associated with monkeypox can be confused with other diseases that are more commonly encountered in clinical practice (e.g., secondary syphilis, herpes, chancroid, and varicella zoster). Historically, sporadic reports of patients co-infected with monkeypox virus and other infectious agents (e.g., varicella zoster, syphilis).

Orthopoxvirus Vaccine Guidance for Persons at Risk for Occupational Exposure

On November 3, 2021, the Advisory Committee and Immunization Practices (ACIP) voted to recommend vaccination for select persons at risk for occupational exposure to orthopoxviruses. Such persons include:

  • Research laboratory personnel1, clinical laboratory personnel performing diagnostic testing for orthopoxviruses2, and for designated response team members at risk for occupational exposure to orthopoxviruses3.
  • Healthcare personnel who administer ACAM2000 or care for patients infected with replication competent orthopoxviruses based on shared clinical decision-making4.

Persons who are at continued risk5 for occupational exposure to more virulent orthopoxviruses like variola virus or monkeypox virus should receive booster doses of JYNNEOS every 2 years after the primary JYNNEOS series. Persons who are at continued risk5 for occupational exposure to replication competent orthopoxviruses like vaccinia virus or cowpox virus should receive booster doses of JYNNEOS at least every 10 years after the primary JYNNEOS series. Persons who are at continued risk5 for occupational exposure to orthopoxviruses, and who received an ACAM2000 primary vaccination, should receive a booster dose of JYNNEOS as an alternative to a booster dose of ACAM2000.

Additional ACIP recommendations are available here.

Two orthopoxvirus vaccines are available from CDC Drug Service for persons at risk for occupational exposure.

  • JYNNEOSexternal icon is a live, non-replicating vaccine licensed by the United States. Federal Drug Administration (FDA) for prevention of smallpox and monkeypox disease in adults 18 years of age and older determined to be at high risk for smallpox or monkeypox infection.
  • ACAM2000external icon is a live vaccine for active immunization against smallpox disease licensed by the United States. FDA for persons determined to be at high risk for smallpox infection.

Requests for vaccine, including the reason for the request, should be referred to the CDC Emergency Operations Center at 770-488-7100.

1 Research laboratory personnel are those who directly handle 1) cultures or 2) animals contaminated or infected with replication-competent vaccinia virus, recombinant vaccinia viruses derived from replication-competent vaccinia strains (i.e., those that are capable of causing clinical infection and producing infectious virus in humans), or other orthopoxviruses that infect humans (e.g., monkeypox, cowpox, and variola).

2 Clinical laboratory personnel who perform routine chemistry, hematology, and urinalysis testing, including for suspected or confirmed patients with orthopoxvirus infections, are not included in this recommendation as their risk for exposure is very low.

3 Public health authorities, at their own discretion, may approve a cohort of healthcare and/or public health personnel to receive primary vaccination against orthopoxviruses for preparedness purposes (e.g., first responders who might participate in a smallpox or monkeypox outbreak).

4 For example, those caring for patients enrolled in clinical trials for replication-competent orthopoxvirus vaccines and those caring for persons with suspected or confirmed orthopoxvirus infections (e.g., clinicians and environmental services personnel).

5 Continued risk refers to persistent risk due to occupational work performed. Designated public health and healthcare worker response teams approved by public health authorities are not at “continued risk” because they are vaccinated for the purposes of preparedness.


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