Health Advisory: Updated Monkeypox Guidance for Testing, Reporting, Treatment and Vaccination Snohomish County
August 5, 2022
• Be aware of the global outbreak of monkeypox with local transmission in Snohomish County.
• Consider monkeypox in all individuals with compatible clinical presentation or epidemiologic link to known cases.
- Symptoms of monkeypox may include prodromal symptoms (e.g. fever, headache, lymphadenopathy, fatigue, chills, sore throat) and a characteristic rash. Most cases of monkeypox will have a rash which can be located in the mouth or the body including the anorectal mucosa. Rashes typically evolve over time beginning as a maculopapular lesion which then progresses to become vesicles and/or pustules (some with umbilication), before scabbing over and falling off.
- Lesions can be mild at first and may be limited to a single relatively small area (particularly the anogenital region). In cases where patients have multiple risk factors (see below criteria for PEP++ below for potential risk factor considerations), lower thresholds for testing should be considered.
- Individuals remain infectious from onset of first symptoms (including prodromal symptoms) until the scabs have fallen off and an intact layer of fresh skin is present for all lesions; typically 2-4 weeks.
- Patients should be counseled by their provider to isolate from time of suspicion of monkeypox until negative test or complete resolution of symptoms.
• Report all cases of monkeypox immediately to Snohomish Health District at the time of suspicion and/or testing (425-339-3503).
• Be aware that testing for monkeypox can now be initiated through several commercial laboratories.
- Commercial testing is available for providers to use through the following partners and does not require Public Health approval of testing:
- University of Washington
- Quest Diagnostics
- Aegis Science Corporation
- Sonic Reference Laboratory
- Washington State Public Health Laboratory (WA PHL) may still be used as an alternative to commercial testing with prior approval from Public Health; without prior approval, specimens may not be tested and results may be delayed.
Vaccination and Post-Exposure Prophylaxis Guidance
- Consider post-exposure prophylaxis (PEP) for people with sexual or close intimate contact with an individual with confirmed monkeypox virus infection.
- To date, Snohomish County has been allocated 760 doses of JYNNEOS vaccine for use, an amount much smaller than demand and need.
- Public Health is prioritizing giving the first dose of vaccine to as many people at high risk of recent exposure as possible with the expectation that we will deliver the second dose as close to the 28 day mark as possible, but second doses may be delayed based on demand and availability.
- Vaccination as PEP is being prioritized for high-risk exposures to a person with diagnosed monkeypox virus infection.
- Vaccination is also prioritized for people who meet both of the following criteria as part of a strategy known as PEP++ (PEP plus plus):
- Gay, bisexual, or other men or transgender people who have sex with men AND at least one of the following:
- More than 10 sex partners in the prior 3 months
- History of early syphilis or gonorrhea in the prior year
- Methamphetamine use in the prior month
- Attendance at a bathhouse, other public sex venue, or group sex (sex including at least 3 people at the same time) in the prior 3 months
- Experiencing homelessness/unstable housing AND currently living in a congregate setting AND had any sexual activity in the prior 3 months.
- Exchange sex for money, drugs, or other purposes in the last 3 months
- Black, Hispanic/Latinx, Native Hawaiian and Other Pacific Islanders, Asian, Indigenous, or American Indian/Alaska Native
- These criteria may be changed in the future as vaccine availability changes or as we learn more about populations at risk for monkeypox virus infection.
If your practice does not have JYNNEOS vaccine available, please refer patient to Snohomish Health District at (425) 339-3503 to speak with a public health nurse. Eligible individuals will be referred to Providence Regional Medical Center.
- Consider treatment for confirmed, probable, and high suspicion monkeypox cases with the antiviral tecovirimat (TPOXX) if patients are experiencing severe disease, or are at high-risk of severe disease
- Tecovirimat, an FDA-approved antiviral treatment for human smallpox disease caused by Variola virus in adults and children, may be considered for treatment in people with monkeypox virus infection. Its use for monkeypox virus infections is not approved by the FDA but is available for use under a non-research expanded access Investigational New Drug (EA-IND) protocol.
- Request tecovirimat and enroll providers in the Investigational New Drug (IND) protocol at Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox | Monkeypox | Poxvirus | CDC
- Severe disease includes those experiencing severe pain, widespread infection, or infection of the eyes.
- Populations at high-risk for severe disease include people with weakened immune systems, children especially those under 8 years of age, people with a history of eczema, and people who are pregnant or breastfeeding.
- The CDC has provided Clinical Guidance | Monkeypox | Poxvirus | CDC which providers may consider using for determining which patient requires treatment
Infection Prevention and Control
- Ensure infection control measures are in place when evaluating patients for monkeypox in your facilities
- Notify infection prevention immediately when a patient seeking assessment for monkeypox is identified.
- Patients with suspected monkeypox should be placed in single-person room and no special air-handling is required; intubation and extubation, and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
- All personnel entering the patient room are recommended to wear gown, gloves, eye protection, and a NIOSH-approved respirator with N95 or higher filter
- Standard cleaning and disinfection procedures should be carried out using EPA registered hospital-grade disinfectant with an emerging viral pathogen claim. Laundry should be handled with standard practices, and promptly contained in a bag and never shaken, avoiding dispersal of infectious lesion materials
- Complete infection prevention guidance may be found at the CDC Infection Prevention page
Monkeypox virus is a DNA virus in the Orthopox genus and is acquired through close contact with an infected person or animal. In the 2022 global outbreak of monkeypox, contact with infected animals has not been established as a means of transmission. After infection, there can be an incubation period of roughly 1-2 weeks. The virus may be transmitted through direct contact or close contact with an infected person, through contact with objects contaminated with the monkeypox virus, and may be transmitted by a pregnant person to their fetus transplacentally. Although in this current outbreak men who have sex with men are overrepresented, anyone who is in close contact with an infected person or objects contaminated with monkeypox is at risk of developing monkeypox. Most infections in this outbreak resolve within 2-4 weeks of onset, even without treatment but severe outcomes are possible. Immunocompromised persons, persons who are pregnant or breastfeeding, and children and adolescents may be at higher risk of severe disease.
Local Case Counts
As of August 5, 2022, a total of 6 cases of monkeypox have been identified in Snohomish County
Local transmission in King County has been ongoing since July, an is presumed to be occurring in Snohomish County as well at this time.
National and Global Case Counts
On July 23, 2022, the World Health Organization (WHO) declared monkeypox a global health emergency. Between May 14, 2022 and August 1, 2022, over 23,600 cases have been identified globally in 80 countries including 7 deaths that have been reported to the WHO. As of August 2, 2022, there are 6,326 cases of monkeypox in the US across 48 states, Washington, DC and Puerto Rico. No deaths have been reported in the US to date.