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Mpox: Information for Providers

NYC Health Advisories and Provider Letters

Clinical Information

During the 2022 outbreak, including in NYC, most people diagnosed with mpox have been men who have sex with men. Transmission has primarily occurred through sex and other intimate contact. However, anyone can get mpox, so consider this diagnosis in all patients with consistent signs or symptoms.

The incubation period is typically three days to three weeks, and illness typically lasts two to four weeks.

Lesions may:

Be solitary or emerge in groups
Involve both skin and mucous membranes
Be most prominent in the anogenital area or mouth

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 mpox.

Advise patients with mpox 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 Mpox: What to Do When Sick page for guidance.

Patient Management and Treatment

Most people diagnosed with mpox have not required hospitalization. However, severe illness and rare deaths have occurred among people with mpox and severe immunocompromise, most often due to advanced HIV. Test all sexually active people being evaluated for mpox for HIV (including acute HIV infection) if their HIV status is unknown, and for other sexually transmitted infections, including syphilis, genital herpes, gonorrhea, and chlamydia.

Antiviral Treatment

The compassionate use of tecovirimat (TPOXX), an investigational drug for the treatment of viruses related to smallpox virus, is for patients with laboratory-confirmed or suspected mpox who have or are at high risk for severe illness, as outlined in CDC’s expanded access investigational drug (EA-IND) protocol. Providers and affiliated facilities must be registered online as participating providers/sites.

Per the protocol, eligible groups include the below groups. Providers should consult the EA-IND protocol for more detailed definitions:

Patients with severely compromised conditions;
Patients with active skin conditions that place them at higher risk for disseminated infection;
Pregnant or lactating patients, regardless of illness severity or underlying comorbidities at presentation;
Children (under 18 years) regardless of illness severity or underlying comorbidities at presentation; and
Patients with protracted or life-threatening manifestations of mpox at presentation.

For patients with protracted or life-threatening manifestations or at high risk for protracted or life-threatening manifestations of mpox due to severe immunocompromising conditions, tecovirimat treatment should be administered early in the course of illness along with supportive care and pain control. Initiating tecovirimat treatment in these patients in combination with either IV cidofovir or oral brincidofovir (the prodrug of cidofovir) and/or Vaccinia Immune Globulin (VIGIV) can also be considered.

Strongly consider prolonged tecovirimat treatment until patient has achieved immune reconstitution.

Equity in Care

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.

See data on mpox cases from the 2022 outbreak.

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.

Vaccination

The JYNNEOS vaccine is available in NYC to anyone who considers themselves to be at risk for mpox through sex or other intimate contact. Vaccination is strongly recommended for:

Men who have sex with men, and trans, nonbinary, genderqueer or gender non-conforming people who have sex with men;
People planning to visit a country where clade I mpox is spreading and who anticipate sex with a new partner while traveling (regardless of sexual orientation or gender identity);
Other groups that may have an elevated risk of exposure.

The standard regimen for JYNNEOS is two doses administered subcutaneously 28 days apart. Peak immunity from vaccination is expected two weeks after the second dose. The estimated vaccine effectiveness of JYNNEOS for preventing mpox disease has ranged from 66-89% for the two-dose series.

People who are identified as close contacts of a person with mpox should get two doses of the JYNNEOS 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 mpox, and vaccination within five to 14 days of exposure may reduce symptoms for people who go on to develop mpox illness.

Testing

Submit specimens for mpox 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 mpox 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 Mpox Testing at the NYC Public Health Lab (PDF) for specimen collection and handling guidance. Providers must give mpox test results to patients. The NYC Health Department cannot provide test results to patients, even when testing is done at the Public Health Lab.

People with suspicious lesions should be asked about recent travel, including if they traveled internationally in the previous three weeks before symptom onset, had close contact with an international traveler in the three weeks before symptom onset, or had close contact to a clade I mpox case. For testing and management of a suspected clade I mpox case-patient, New York City providers should call the Provider Access Line (866-692-3641). The NYC Health Department can arrange clade-specific testing.

We encourage providers to be judicious about ordering and interpreting results of mpox 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 mpox.