Presumptive monkeypox case in King County

Actions requested

• Be aware of a recent confirmed case of monkeypox identified in a King County adult male.
• Consider monkeypox infection in patients with compatible symptoms, including those presenting only with an otherwise unexplained characteristic rash:
  • Presenting symptoms typically include fever, chills, the distinctive rash, or new lymphadenopathy; however, rash confined to perianal or genital lesions in the absence of subjective fever has been reported.
  • The rash associated with monkeypox typically appears on mouth and body 1-2 days after the prodrome and involves vesicles or pustules that are deep-seated, firm or hard, and well- circumscribed; the lesions may umbilicate or become confluent and progress over time to scabs.
  • The rash associated with monkeypox can be confused with other diseases and sexually transmitted infections (STI) that are more commonly encountered in clinical practice (e.g., secondary syphilis, genital herpes, chancroid, and varicella zoster)
    
    
• Be aware monkeypox virus does not spread easily between people in the absence of close/intimate contact;transmission can occur through contact with body fluids, monkeypox sores, or shared items (such as clothing and bedding) that have been contaminated with fluids or sores of a person with monkeypox. Monkeypox virus can also spread between people through saliva or respiratory droplets, typically between people in a close setting with prolonged contact.
  • Most, but not all, recent cases have been among men who identify as gay, bisexual, or men who have sex with men (MSM). Virus may have been transmitted during sex from skin-to-skin contact or other intimate contact. However, men who have sex with men are not the only population at risk for monkeypox.
  • Cases are infectious once symptoms begin (whether prodromal or rash as first symptom) and until lesions scab and scabs fall off.
    
    
• Obtain travel and sexual activity history and determine if any contacts have/had a similar rash. Be especially vigilant for anyone with symptoms who:
  • traveled in the last 30 days, to a country that has recently had cases of monkeypox
  • reports contact with a person or people with confirmed or suspected monkeypox
  • is a man who reports sexual contact with more than one man in the past 30 days
    
    
• Counsel patients who might have been exposed, are concerned about preventing exposures, or develop new symptoms with the following:
  • It is not known if others in our area have been infected with monkeypox at this time or how widespread the epidemic could become. Public Health urges limiting the number of sexual partners and close physical contact with others while we learn more about the current outbreak.
  • If anyone develops symptoms consistent with monkeypox, or has been in contact with someone diagnosed with monkeypox, they should be evaluated by a medical provider. They should cover the area of the rash with clothing, wear a mask, and avoid skin-to-skin contact and close contact with others until evaluated. Specifically, they should limit the sharing of drinks, cigarettes or vaping devices, kissing, and other activities where saliva might be exchanged with others prior to evaluation. Self-isolation away from other people and animals should continue until monkeypox is ruled out, or until those diagnosed with monkeypox infection are no longer infectious.
    
    
• Report suspected cases of monkeypox immediately to Public Health at 206-296-4774.
  
  
• Use standard, contact, and droplet precautions for patients presenting with symptoms consistent with monkeypox.
• While not considered airborne, at this time eye protection and N95s are recommended when entering room of person under evaluation. Transmission in healthcare settings has been rarely described.
  • Patients suspected of having monkeypox should be masked and placed in a private examination room in outpatient settings.
  • Patients requiring admission should be admitted to a private room with a dedicated bathroom and door should remain closed. The patient should remain on precautions until 24 hours after resolution of respiratory symptoms and until lesions dry, fall off and a new layer of skin develops (may be 3-4 weeks).
  • Per CDC no special air handling is required but any procedures likely to spread oral secretions such as intubation and extubation, should be performed in a private room with negative airflow (AIIR)
    • PPE used by healthcare personnel who enter the patient's room should include:
    • Gown
    • Gloves
    • Eye protection (I.e., goggles or a face shield that covers the front and sides of the face)
    • NIOSH-approved N95 filtering facepiece or equivalent, or higher-level respirator
  • Environmental infection control
    • Activities that could resuspend dried material from lesions, e.g., use of portable fans, dry dusting, sweeping, or vacuuming should be avoided. Wet cleaning methods are preferred.
    • Standard cleaning and disinfection should be performed using an EPA-registered hospital-grade disinfectant with an emergency pathogen claim.
    • At this time monkeypox is considered Category A for Waste Management purposes.
      
      
  • Management of food service items should be performed in accordance with routine procedures.
    
    
• Coordinate all testing of monkeypox specimens through Public Health at 206-296-4774.
  
  
• Collect specimens with the following instructions:
  • Use appropriate infection control procedures as above, based on CDC guidance.
  • Send separate swabs from at least 2 lesions in individual vials, preferably 3 or more swabs
  • Use sterile synthetic Dacron, polyester or nylon swabs, and a plastic or wire handle
  • If scabbed over, clean the scab with alcohol wipes and rub vigorously with the swab
  • For other lesions clean with alcohol wipes, unroof lesion with a sterile needle or sterile scalpel, and rub the swab vigorously over the base of the lesion to collect patient cells
  • Immediately after collection, place the swab tip into a dry sterile screw-top O-ring vial and aseptically break (at a score line) or cut off the handle. DO NOT ADD VIRAL TRANSPORT MEDIUM. Place each swab in its own vial (one swab per vial).
  • Do not let a swab come into contact with reagents used for other tests
    
    
• Store and ship specimens appropriately:
  • Within an hour of collection, specimens should be refrigerated (2°–8°C); freeze (≤ -70° C) if storage longer than 7 days needed.
  • Specimens should be kept refrigerated between 2–8°C with gel packs during shipping as long as specimens will arrive to WAPHL within 7 days of collection date. Otherwise specimens (not serum) should be frozen at ≤ -70°C and shipped on dry ice to WAPHL.
  • Follow Category A specimen procedures (category B no longer allowed)
  • Each specimen should be accompanied by a completed WAPHL Bioterrorism Laboratory Requisition Form
    
    
• Treatment
  • CDC Interim Clinical Guidance for the treatment of monkeypox
  • Requests for post-exposure-prophylaxis with available vaccines for high-risk exposures should be directed through Public Health.
  • Consultation with an infectious disease specialist is recommended for management and evaluation for potential antiviral treatment persons with or at high risk for severe infection in collaboration with Public Health.