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Mpox: Information for Providers

Severe Disease and Death from Mpox

Severe illness and rare deaths have occurred among people who are severely immunocompromised, most often due to advanced HIV.

Test all sexually active people being evaluated for suspect mpox for HIV if their status is unknown. Immediately start tecovirimat for patients that have a CD4 count <200, are newly diagnosed with HIV, are living with HIV but have an unknown immune status, or are otherwise immunocompromised. Tecovirimat can be initiated for patients with a clinically compatible illness prior to confirmatory test results. For patients newly diagnosed with HIV, immediately start HIV treatment.

The Centers for Disease Control and Prevention recently released a Health Alert Network Health Update (PDF) about Clade I mpox cases caused by human-to-human transmission in the Democratic Republic of the Congo. Clade I has been observed to be more transmissible and to cause more severe infections. No Clade I mpox infections have been reported in the United States but if a medical provider suspects mpox in a patient with travel to the Democratic Republic of the Congo in the previous three weeks, they should call the Provider Access Line (866-692-3641).

See further guidance under Patient Management and Treatment.

STOMP Clinical Study Information

Providers should inform patients with mpox about the Study of Tecovirimat for Mpox (STOMP) for their voluntary participation. Multiple study sites are available in NYC and remote enrollment across the U.S. is available. Access to oral tecovirimat is also available for patients with mpox who meet eligibility criteria (such as patients who have severe disease or involvement of anatomic areas that might result in serious sequelae or are at high risk for severe disease) under CDC’s expanded access protocol in accordance with CDC’s Guidance for Tecovirimat Use.

Mpox Care for Minors

In New York State, minors can receive mpox testing, treatment and vaccination without a parent’s consent.

Upcoming Webinars

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NYC Health Advisories and Provider Letters

2023

Health Advisory #25: CDC Advisory Update on Mpox Caused by Human-to-Human Transmission of Mpox Virus with Geographic Spread in the Democratic Republic of the Congo (PDF, December 13)

2022

Health Advisory #30: CDC Advisory Update on Managing Mpox in Patients Receiving Therapeutics (PDF, November 22)
Letter to Providers: NYC MPV Vaccination Updates (PDF, November 14)
Letter to Providers: Considerations for MPV and Pregnant, Recently Pregnant and Breastfeeding Patients (PDF, October 17)
Health Advisory #25: CDC Advisory Severe Manifestations of Mpox Among People Who Are Immunocompromised Due to HIV or Other Conditions (PDF, October 5)
Letter to Providers: Considerations for Mpox Testing of Pediatric Patients (PDF, August 30)
Commissioner Letter: Providing Care for Patients with Mpox (PDF, July 18)
Health Advisory #13: Update on Mpox in New York City (PDF, July 18)
Health Advisory #11: Mpox Transmission and Detection in New York City (PDF, June 10)

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 last 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

Information on transmission and clinical presentation, including photos of mpox lesions, are available on CDC’s Clinical Recognition and Clinician FAQ webpages.

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 and CDC’s Advice for Mpox Patients to Reduce Transmission.

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.

Refer to CDC Clinical Guidance for information on managing patients with mpox, including tailored guidance for the following populations:

CDC guidance on treatment and pain management:

Providers may contact the CDC Clinical Escalations team at eocevent482@cdc.gov 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.

Antiviral Treatment

Providers should inform patients with mpox about the Study of Tecovirimat for Mpox (STOMP) for their voluntary participation. Multiple study sites are available in NYC and remote enrollment across the U.S. is available. Access to oral tecovirimat is also available for patients with mpox who meet eligibility criteria (such as patients who have severe disease or involvement of anatomic areas that might result in serious sequelae or are at high risk for severe disease) under CDC’s expanded access protocol 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 mpox 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 mpox 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 Emergency Operations Center at (7790) 488-7100 or poxvirus@cdc.gov to discuss additional treatment options and resistance testing.

Consider antiviral treatment of mpox infection for people with:

Severe disease, including confluent lesions or lesions in anatomical areas at special risk of scarring or stricture (e.g., near or involving the eye, mouth, rectum or urethra).
Illness complications including proctitis (particularly with tenesmus, challenges in pain control or rectal bleeding), urethritis and phimosis.
Increased risk for progression to severe disease, including people who are immunocompromised, pregnant or breastfeeding, have atypic dermatitis or other exfoliative skin conditions, and children.

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 under CDC’s expanded access protocol to eligible patients refer to: CDC: Information for Healthcare Providers: Tecovirimat (TPOXX) for Treatment of Mpox. 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
Phone 917-444-1985
Fax 718-504-4811

If your e-prescription system does not have tecovirimat listed, prescriptions are accepted by phone or fax.

Prescriptions confirmed by 3 p.m. on weekdays, or by noon on Saturdays will be delivered the same day. Prescriptions sent after noon on Saturday will be delivered on Monday.

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^TM 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, 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 mpox should get two doses of the JYNNEOS^TM 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.

The standard regimen for JYNNEOS^TMis two doses administered subcutaneously 28 days apart. An alternative regimen of two lower doses administered intradermally is available to persons aged 18 and over pursuant to an emergency use authorization. This lower dose was found to produce an immunologically similar response compared to the standard dose administered subcutaneously. For both regimens, peak immunity from vaccination is expected two weeks after the second dose. People with a history of keloid scarring should receive subcutaneous administration.

Although further study is needed to determine the magnitude and durability of protection, study evidence indicates that JYNNEOS vaccination provides protection against mpox. Among 9,544 men ages 18 to 49 reported with mpox in the U.S, 87.2% of cases were among people who were not vaccinated. The analysis also suggested no difference in vaccine performance between subcutaneous and intradermal administration.

For more information, see CDC: Mpox Vaccine Information for Healthcare Professionals.

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 and if they visited the Democratic Republic of the Congo in the previous three weeks of symptom onset. For clade I testing and treatment of a suspected mpox case patient who reports travel to the Democratic Republic of the Congo, New York City providers should call the Provider Access Line (866-692-3641).

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.