prevention ▪ Patients • All specimens reported outside of endemic countries, to date, West African clade of monkeypox (associated with milder illness) • Supportive care has typically been enough • Antivirals are available through consultation with CDC ▪ Contacts • Monitoring of healthcare personnel should be reported to health departments o Monitoring is for 21 days • Post-exposure prophylaxis with 2 U.S. licensed vaccines a possibility depending on risk level* • Pre-exposure prophylaxis for certain healthcare personnel avail▪ CDC is investigating whether cases may be occurring in communities other than those where the initial cases have been identified https://www.cdc.gov/poxvirus/monkeypox/response/2022/hcp/index.html HAN Health Update: June 14, 2022* * https://emergency.cdc.gov/han/2022/han00468.asp ▪ Alerts healthcare providers about 2 emerging issues: • Symptoms and disease course that differ from what has been seen in past outbreaks in West and Central Africa • Limited number of cases reported in people who had no international travel (often called “community cases”). ▪ These issues raise concern that some infections in the United States may not be recognized and tested Updates May 22 HAN advisory with expanded case definition • New definition intends to encourage testing for monkeypox 2.4 million cases of chlamydia, gonorrhea, and syphilis were reported in the first year of the COVID-19 pandemic Monkeypox cases – 2022 ▪ Reported cases primarily are in men who report sexual contact with other men ▪ Differing presentation? • Genital and/or perianal lesions • Proctitis • Prodromal symptoms may not have appeared ▪ Individuals may present to sexual health clinics for care ▪ Monkeypox is not a sexually transmitted infection in the typical sense, but it can be transmitted during sexual and intimate contact, as well as with personal contact and shared bedding/clothing Genital ulcer disease: Differential diagnosis ▪ Herpes simplex virus ▪ Syphilis ▪ Chancroid ▪ Lymphogranuloma venereum (LGV) ▪ Granuloma Inguinale Infectious Non-infectious ▪ Recurrent aphthous stomatitis ▪ Behcet’s Disease ▪ Trauma ▪ Squamous cell carcinoma ▪ Drug-induced ▪ Other Other infections to consider Diffuse Rash Proctitis ▪ Syphilis ▪ Varicella/VZV ▪ Disseminated herpes ▪ Molluscum contagiosum ▪ Other poxviruses ▪ Disseminated fungal infections ▪ Disseminated gonococcal infection ▪ Gonorrhea ▪ Chlamydia (including LGV) ▪ HSV Distinguishing monkeypox from other rash illnesses ▪ Comprehensive history • History of present illness – typical sequence of clinical manifestations o Usually fever, malaise, headache, sore throat, cough, lymphadenopathy o Macules → papules →vesicles → pustules → scabs o Tongue/mouth → face → arms/legs →hands/feet (including palms/soles) o Pain and pruritis may be prominent • Clinical presentation in current outbreak may not be typical! Distinguishing monkeypox from other rash illnesses ▪ Social history • Travel history – particularly to central and west African countries and other countries where non-endemic monkeypox has been reported • Contact with a person or people with confirmed or suspected monkeypox • Man who regularly has close or intimate in-person contact with other men, including those met through online website, digital application (“app”), or at a bar or party Physical examination ▪ Perform thorough exam of all skin in room with good lighting • Clues may be present in other areas of the body for persons presenting with genital/perianal complaints ▪ Rash may Importance Monkeypox is a zoonotic viral disease, endemic in western and central Africa, which circulates in wild animal hosts and emerges periodically to affect humans, captive or wild nonhuman primates, and other species, particularly rodents. Congo Basin monkeypox viruses are particularly virulent, with human case fatality rates during outbreaks in parts of Africa estimated to be around 10%. West African viruses tend to cause milder disease; however, deaths are seen occasionally in young children, individuals with secondary bacterial sepsis or rare complications such as encephalitis, and people who are immunosuppressed. Monkeypox outbreaks have been reported sporadically in nonhuman primate facilities around the world, especially in the past. Human cases are almost always seen in Africa, but a large outbreak in Nigeria in 2017-2018 resulted in a few imported cases among travelers to Europe and Asia, with one case resulting in person-to-person transmission to a hospital worker. One outbreak occurred in the United States in 2003, associated with virus transmission between exotic pets and from pets in humans. A prompt diagnosis of imported monkeypox can