Health Advisory

Date:      July 5, 2022

This Health Advisory provides updated information to the Monterey County Health Department’s Health Advisory released May 24, 2022.  Cases of monkeypox continue to be identified in several non-endemic countries including the U.S.  As of July 1, 2022, there have been 460 cases of monkeypox virus infection reported among U.S. residents, with 95 being reported in California.  There has currently been one confirmed case of monkeypox reported among Monterey County residents.

Monkeypox is a zoonotic illness endemic to several Central and West African countries.  Disease symptoms include a characteristic rash, which is described as firm, well-circumscribed, deep-seated and umbilicated skin lesions.  Thus far, cases in the U.S. have some notable features including:

• All cases have developed a rash.
• The rash has often begun in mucosal, genital, or perianal areas.
• The lesions have at times been scattered or localized to a body site rather than diffuse in nature.
• Lesions have sometimes been in different stages of progression.
• Not all cases have had classic prodromal symptoms.
• Presenting symptoms have included anorectal pain, tenesmus, and rectal bleeding associated with perianal lesions and proctitis.

Average incubation period has been 3 to 13 days.  A person is considered infectious from the onset of symptoms through when lesions have thoroughly crusted and a fresh layer of healthy skin has formed underneath.

The California Department of Public Health (CDPH) and Monterey County Health Department (MCHD) request that medical providers report and test suspected cases of monkeypox virus infection as outlined below:

• Suspect monkeypox virus infection in patients with suggestive history including:
  • Close contact with a person or persons with a similar appearing rash or with a person who has received a diagnosis of confirmed or probable monkeypox, and/or
  • Close or intimate in-person contact with persons in a social network experiencing monkeypox infection. This includes men who have sex with men (MSM) who meet partners through an online website, digital application (“app”), or a social event (e.g., a bar, bathhouse, or party).
• Report suspected cases by phone to the Monterey County Health Department’s Communicable Disease Unit:
  • During normal business hours: 831-755-4521.
  • Outside of normal business hours:  831-755-5100 and ask for the Hazardous Materials Team; they will connect you with on-call public health staff.
• Collect lesion swabs and submit to the Monterey County Public Health Laboratory: 
  • Collect dry swabs of lesions using sterile nylon, polyester, or Dacron swabs with plastic or aluminum shafts:
    • Vigorously swab or brush lesion with two separate sterile dry swabs.
    • Break off swabs into separate 1.5- or 2-mL screw-capped tubes with O-ring or place each entire swab in a separate empty sterile container.
      • Container may be dry or contain viral transport media (VTM). No other type of transport medium is acceptable.
    • Up to 3 different lesions should be sampled, preferably from different body sites.  (This would result in 6 swabs total.)
    • Please mark/label each set of 2 swabs with an identical number so they are easy to distinguish from separate lesion collections (e.g., Swab #1 from Left Thigh, Swab #2 from Left Thigh).
    • Lesion crusts or scabs may be submitted dry in separate sterile containers.
    • Store at 4^◦C if transferring to the Monterey County Public Health Laboratory within 24 to 72 hours; otherwise, store at -20 to -80^◦C.
  • Suspected cases must be reported to the Monterey County Health Department’s Communicable Disease Unit before submitting specimens to the Public Health Laboratory.
• Use appropriate infection control procedures with patients presenting with suspected monkeypox:
  • Patient should be placed in a single-person exam room with the door closed or in an airborne isolation room, if available.  The patient should remain masked, as tolerated, and any exposed skin lesions should be covered with a sheet or gown.
  • Healthcare personnel (HCP) should wear the following PPE:  gloves, gown, eye protection, and an N95 or equivalent.  HCP should don PPE before entering the patient’s room and use for all patient contact.  HCP should remove and discard gloves, gown and eye protection and perform hand hygiene prior to leaving the patient’s room; the N95 respirator should be removed, discarded, and replaced with a mask for source control (or respirator as required by facility protocols) after leaving the patient’s room and closing the door.
  • Any EPA-registered hospital-grade disinfectant should be used for cleaning and disinfecting environmental surfaces.  If a standard examination room was used, the exam room should not be used for at least 2 hours following the patient’s departure from the room.
• Most patients have mild disease and recover without medical intervention. 
• Please instruct patients who do not require hospitalization to isolate at home (https://www.cdc.gov/mpox/hcp/infection-control/at-home.html?CDC_AAref_Val=https://www.cdc.gov/poxvirus/mpox/clinicians/infection-control-home.html) and that the Health Department will contact them with further instructions. 
• Per CDC guidance, an investigational antiviral medication, tecovirimat (also known as TPOXX or ST-246, https://www.cdc.gov/mpox/hcp/clinical-care/?CDC_AAref_Val=https://www.cdc.gov/poxvirus/mpox/clinicians/treatment.html) can be considered to treat severe disease or those at high risk for severe disease.  Tecovirimat is available only at limited facilities that are able to carry out the requirements of the Emergency Investigation New Drug (EIND).  Treatment may be facilitated by calling the Monterey County Health Department.
• Jynneos vaccine can be considered for post-exposure prophylaxis (PEP) in people who have had a high- or intermediate-risk exposure to monkeypox to prevent or reduce severity of disease.  PEP should be given, if possible, within 4 days of exposure to prevent disease but may still reduce severity of disease if given up to 14 days after exposure.  Monterey County Health Department will conduct case and contact investigations for all reported monkeypox cases in Monterey County and can facilitate vaccination as PEP while supplies are limited. 

• Monterey County Health Department’s Communicable Disease Unit: normal business hours - 831-755-4521; after hours - 831-755-5100 and ask for the Hazardous Materials Team. They will transfer you to the on-call public health professional.
• Monterey County Public Health Laboratory:  831-755-4516.
• CDPH Healthcare Provider Health Advisory: Managing Monkeypox Virus Infection in California, updated June 23, 2022: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Health-Advisory-Monkeypox-Virus-6-23-22.aspx
• CDC Monkeypox Website: https://www.cdc.gov/mpox/?CDC_AAref_Val=https://www.cdc.gov/poxvirus/mpox/index.html
• Printable copy of this Health Advisory click here

Health Alert:  Warrants immediate action or attention.   Health Advisory:  Provides information for a specific incident or situation; may not require immediate action. Health Update:  Provides updated information regarding an incident or situation; unlikely to require immediate action.

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