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In the current global outbreak, including in NYC, most people diagnosed with monkeypox (MPV) have been men who have sex with men. Transmission is primarily occurring through sex and other intimate contact. However, anyone can get MPV, so consider this diagnosis in all patients with consistent signs or symptoms.
The incubation period is typically three to 17 days, and illness typically last two to four weeks.
Lesions can be very itchy and painful, especially those in the oral, anogenital, or rectal areas, and may interfere with eating, urination, and/or defecation. Supportive care, including pain management, should be offered to all people with MPV.
Advise patients with MPV to follow precautions until all the scabs that form on the skin have fallen off and a fresh layer of skin has formed. This can take two to four weeks from when the lesions first appear.
Refer patients to the Health Department’s Monkeypox: What to Do When Sick page for guidance, and CDC’s Advice for Monkeypox Patients to Reduce Transmission.
Most people diagnosed with MPV have not required hospitalization during this outbreak. However, severe illness and rare deaths have occurred among people with MPV and severe immunocompromise, most often due to poorly controlled HIV. Test all sexually active people being evaluated for monkeypox for HIV (including acute HIV infection) if their HIV status is unknown, and for other sexually transmitted infections (e.g., syphilis, genital herpes, gonorrhea, and chlamydia).
Refer to CDC Clinical Guidance for information on managing patients with MPV, including tailored guidance for the following populations:
CDC guidance on treatment and pain management:
Providers may contact the CDC Clinical Escalations team at firstname.lastname@example.org to discuss clinical management strategies, including the use of tecovirimat, vaccinia immune globulin intravenous (VIGIV), brincidofovir and cidofovir. For immediate consultation regarding hospitalized patients with or who are at risk for severe manifestations, call the Clinical Escalations team directly at 770-488-7100.
Providers should inform patients with MPV about the Study of Tecovirimat for Human Monkeypox Virus (STOMP) for their voluntary participation. Multiple study sites are available in NYC. If enrollment in STOMP is not feasible for a patient (e.g., a clinical trial site is not accessible), tecovirimat use under CDC’s expanded access protocol should be in accordance with CDC’s Guidance for Tecovirimat Use.
To avoid progression to severe disease, tecovirimat should be started immediately for patients with a CD4 <200 or who are otherwise immunocompromised, are new diagnosis of HIV, or living with HIV but have an unknown immune status at the time of monkeypox evaluation; do not wait until receipt of laboratory results (e.g., viral load and CD4 count) in case the patient is at risk for progressing to severe monkeypox disease during that time. Strongly consider prolonged tecovirimat treatment until patient has achieved immune reconstitution. For patients newly diagnosed with HIV (based on either a lab test or a point-of-care HIV test), immediately start HIV treatment. For patients with progressive or non-resolving lesions while on tecovirimat, providers should consult the CDC Clinical Escalations team at email@example.com to discuss additional treatment options and resistance testing.
Consider antiviral treatment of MPV infection for people with:
Tecovirimat is provided at no cost by the federal government. Patients should not be charged for the medicine, but providers may bill for the encounter.
To prescribe tecovirimat to eligible patients refer to: CDC: Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Monkeypox. Providers can now register as a participating site/provider under the CDC-held EA-IND and submit forms to the CDC through the online Tecovirimat (TPOXX) IND Registry.
At this time outpatient tecovirimat can only be prescribed through Pharmex Pharmacy, who will deliver to the patient’s preferred address at no cost within New York City.
Pharmex Pharmacy Inc.
142-08 Rockaway Blvd.
Jamaica NY 11436
Black and Latino men who have sex with men, as well as transgender and gender non-conforming people, may have less equitable experiences with health care.
Providers should ensure that everyone, especially patients who are low-income, Black, or Latino, receives equitable access to testing and proper care that includes access to vaccines, antiviral treatment, pain management, and mental health care.
We encourage providers and their staff to use trainings and other resources to help them counter their own implicit biases.
The JYNNEOSTM vaccine is now available in NYC to anyone who considers themselves to be at risk for MPV through sex or other intimate contact. Vaccination is strongly recommended for men who have sex with men, people with HIV, and other groups that may have an elevated risk of exposure.
People who are identified as close contacts of a person with MPV should get two doses of the JYNNEOSTM vaccine as post-exposure prophylaxis (PEP), particularly if they are immunocompromised due to HIV or other conditions. Vaccination within four days of exposure provides the best chance to prevent MPV, and vaccination within five to 14 days of exposure may reduce symptoms for people who go on to develop MPV illness.
The standard regimen for JYNNEOSTMis two doses administered subcutaneously 28 days apart. An alternative regimen of two lower doses administered intradermally is available to persons aged 18 and over, and this regimen is being used currently in the context of the national public health emergency. This lower dose was found to produce an immunologically similar response compared to the standard dose administered subcutaneously. For both regimens, full immunity is expected two weeks after the second dose. People with a history of keloid scar formation may request subcutaneous injection.
In an early observational study, unvaccinated people were 14 times more likely to get MPV than people who had received their first dose of JYNNEOSTMvaccine. Counsel vaccinated patients to continue other prevention measures, such as limiting their number of sexual partners and avoiding close physical contact with people who have symptoms of MPV. See the CDC's Safer Sex, Social Gatherings, and Monkeypox page.
For more information, see CDC: Monkeypox Vaccine Information for Healthcare Professionals.
Submit specimens for MPV testing to a participating commercial laboratory, including LabCorp, Mayo Clinic Laboratories, Aegis Science, Sonic Healthcare or Quest Diagnostics, or to a health care system laboratory that has been approved to conduct MPV testing by New York State. Refer to the lab's specimen collection and submission guidance.
Testing is also available through the NYC Public Health Laboratory if prior approval is obtained by calling the Provider Access Line at 866-692-3641. See Monkeypox Testing at the NYC Public Health Lab (PDF) for specimen collection and handling guidance. Providers must give MPV test results to patients. The NYC Health Department cannot provide test results to patients, even when testing is done at the Public Health Lab.
We encourage providers to be judicious about ordering and interpreting results of MPV testing for patients who have a very low risk for exposure. False-positive test results may lead to unnecessary treatment or isolation. Consider other diagnoses (including hand, foot, and mouth disease, molluscum contagiosum, acne and folliculitis) in people with a rash who are not sexually active and have no known household or other exposure to someone with MPV.