Key points
- Regardless of clade, monkeypox can be spread, treated, and prevented the same way.
- Consider monkeypox as the cause of a diffuse or localized rash, particularly if there's recent travel to an outbreak area; evaluate any individual presenting with certain ulcers or rash for HIV and STIs.
- Conduct thorough patient and sexual histories to assess possible exposure to monkeypox.
- Provide patients with supportive care and pain control early in the illness.
Evaluating patients with suspected monkeypox
Patient history and physical examination
Clinicians should conduct a thorough patient history to assess possible monkeypox exposures or epidemiologic risk factors. We know that both monkeypox clades and all subclades (Ia, Ib, IIa, IIb) can be spread, treated, and prevented the same way, but the risk factors and locations of sustained transmission can be very different.
| Clade la | Clade lb | Clade Ila | Clade llb | |
|---|---|---|---|---|
| Geography | Endemic to Central Africa, including Republic of the Congo, Gabon, Democratic Republic of the Congo (DRC), Central African Republic, and southeastern Cameroon | Newly identified in the DRC with spread to nearby countries; travel-associated cases around the world | Endemic to West Africa, including northwestern Cameroon, Nigeria, Ghana, Cote d'Ivoire, Liberia, and Sierra Leone. | Endemic to West Africa (identified originally in Nigeria); spread to more than 100 non-endemic countries as part of the ongoing global outbreak that began in 2022 |
| Current Situation | Outbreak in Central Africa from 2023 to present | Outbreak in Central and Eastern Africa. There have been travel-associated cases in other parts of Africa, Asia, Europe, and North America, including the United States | Insufficient data | Caused the ongoing global monkeypox outbreak that began in 2022; still circulating globally at low levels, including in the United States |
| Population Primarily Affected in Outbreaks since 2022 | Both adults and children | Adults (often sex workers and their contacts); subsequent spread through day-to-day household contact | Both adults and children | Adults, particularly men who have sex with men in global outbreak |
| What's Known about How it's Spread | Primarily by contact with infected live or dead wild animals. Transmission can also occur via mother to fetus or close skin-to-skin contact, including intimate (e.g., massage, kissing) and sexual contact. | Primarily via close skin-to-skin contact, including intimate (e.g., massage, kissing) and sexual contact. Transmission can also occur via mother to fetus, or within households. | Primarily by contact with infected live or dead wild animals. Transmission can also occur via mother to fetus or close skin-to-skin contact, including intimate (e.g., massage, kissing) and sexual contact. | Primarily via close skin-to-skin contact, including intimate (e.g., massage, kissing) and sexual contact. Transmission can also occur via mother to fetus, or within households. Transmission to healthcare workers from sharps injuries and fomite transmission are rare but have been documented. |
| Mortality Rate | From more recent outbreaks, the mortality rate is ≤ 2.5%. Most deaths occur in people with immunocompromising conditions including children with malnutrition and other health conditions. | Mortality rate is less than 0.5% in Central and Eastern Africa. Most deaths occur in people with immunocompromising conditions. No mortality has been seen with travel associated cases outside Africa, but data are limited. | Mortality rate is around 1% but has limited data. Available data suggest lower CFR than clade I monkeypox | Mortality rate is less than 0.1%. Most deaths occur in people with immunocompromising conditions. |
| Vaccine | 2 doses of JYNNEOS vaccine; 1 dose of ACAM2000 for specific populations | |||
| Other Prevention Considerations | Avoid direct or skin-to-skin contact with people who have a rash that looks like monkeypox, including during sex or intimate contact; avoid objects or materials a person with monkeypox has used; avoid wild animals and animal products (lotions, bushmeat, etc.) in areas where monkeypox occurs regularly; wash hands regularly | |||
| Treatment | Healthcare professionals should assess pain in all patients with monkeypox and recognize that substantial pain may exist from mucosal lesions not evident on physical exam. Additional treatments may be needed for people at higher risk of severe disease. | |||
| Other Therapeutic Considerations | Most people recover with supportive care (nutritious food, fluids, antibiotics for secondary skin infections) and pain control (over-the-counter medications like acetaminophen and ibuprofen, topical steroids and anesthetics like lidocaine for local pain relief; prescription pain medications for short-term management of severe pain). | |||
Monkeypox is usually transmitted from person to person through close, sustained physical contact. In the current clade I outbreak originating in Central Africa, transmission has occurred through sexual activity, day-to-day household contact, and in healthcare settings when PPE was not available. In the ongoing clade II monkeypox outbreak, transmission has been almost exclusively associated with sexual contact. It is critical that clinicians take a detailed sexual history and travel history for any patient with suspected monkeypox.
Clinicians should perform a complete physical examination, including a thorough skin and mucosal (e.g., oral, genital, anal) examination for the characteristic vesiculo-pustular rash of monkeypox. This allows the clinician to detect lesions of which the patient may be unaware.
Monkeypox should be considered when a clinician is trying to determine the cause of a diffuse or localized rash. Other considerations include herpes simplex virus (HSV; genital herpes), syphilis, herpes zoster (shingles), disseminated varicella-zoster virus infection, molluscum contagiosum, scabies, lymphogranuloma venereum, allergic skin rashes, and drug eruptions.
Prevention
Managing patients exposed to monkeypox
Monkeypox vaccine can be given as post-exposure prophylaxis (PEP) both to people with known or presumed exposure to monkeypox virus. PEP can also be given to people with certain risk factors and recent experiences that might make them more likely to have been exposed to monkeypox. As PEP, vaccine should be given as soon as possible, ideally within four days of exposure; administration 4 to 14 days after exposure may still provide some protection against monkeypox and should be offered.
Persons exposed to monkeypox through sexual contact who are asymptomatic should also be tested for HIV and other sexually transmitted infections.
Discuss and facilitate access to HIV pre-exposure prophylaxis (PrEP) for people who are HIV negative and at risk for HIV.
Managing patients at increased risk for monkeypox exposure
Based on available data from the 2022-2023 outbreak, CDC also recommends vaccinating additional populations with risk factors for exposure to monkeypox virus. Disproportionately affected populations should remain the focus of the current vaccination efforts. Monkeypox vaccination should be offered to people with the highest potential for exposure to monkeypox.
To be most effective, monkeypox vaccination should be included as part of broader prevention activities and sexual health care. Such efforts should have health equity principles as a foundation and include strategies such as allowing individuals to self-attest vaccine eligibility (i.e., providing monkeypox vaccination without requiring individuals to specify which criterion they meet), community outreach, holding vaccination events on-site in locations where groups of people disproportionately impacted by monkeypox may convene, education efforts, and communication about behavioral strategies to minimize risk.
Monkeypox vaccination strategies are likely to be most effective when designed and implemented in partnership with communities and groups that are disproportionately affected.
Diagnostic testing based on clinical impression
Monkeypox testing
Specimens should be obtained from lesions (including those inside the mouth, anus, or vagina), if accessible, and tested for monkeypox.
Other sexually transmitted infection (STI) testing
Evaluate any individual presenting with genital, anal, or perianal ulcers, proctitis syndrome, or diffuse rash for STIs per the 2021 CDC STI Treatment Guidelines. The diagnosis of another STI does not exclude monkeypox, as a concurrent infection may be present.
Anogenital ulcers
Specific evaluation of genital, anal, or perianal ulcers includes 1) syphilis serology tests, and, if available, darkfield examination of lesion exudate or tissue, or nucleic acid amplification test (NAAT); 2) NAAT or culture for genital herpes type 1 or 2; and 3) serologic testing for type-specific HSV antibody.
Proctitis
All persons with proctitis should be evaluated for herpes simplex (preferably by NAAT of rectal lesions), gonorrhea (NAAT or culture), chlamydia (NAAT), and syphilis (darkfield of lesion and serologic testing).
Diffuse rash
The differential diagnosis for patients presenting with diffuse rash can be broad, and its evaluation in sexually active adults and adolescents should include diagnostic and treatment considerations for the following STIs: syphilis, HSV (genital herpes), molluscum contagiosum, disseminated gonococcal infection, and scabies.
Additional HIV/STI considerations for patients with suspected or confirmed monkeypox
All sexually active adults and adolescents in whom monkeypox is suspected should be evaluated for HIV and other STIs, with appropriate care offered to those with positive test results. In the ongoing clade II monkeypox outbreak, HIV infection and other STIs have been highly prevalent among persons with monkeypox. Furthermore, people with HIV-associated immunocompromise are at risk for severe manifestations of monkeypox.
Test for other STIs including syphilis, gonorrhea, and chlamydia in every sexually active adult and adolescent in whom monkeypox is suspected or confirmed.
Test for HIV in every sexually active adult and adolescent in whom monkeypox is suspected or confirmed if current HIV status is unknown.
Ensure those with HIV and with suspected or confirmed monkeypox are on effective antiretroviral therapy and linked to care to optimize immune function.
Discuss and facilitate access to HIV pre-exposure prophylaxis (PrEP) for those who are HIV negative and at risk for HIV.
Instruct patients with suspected monkeypox to follow isolation recommendations and avoid close contact with other people and with animals, including pets.
Patient management
Treatment
Patients with monkeypox benefit from supportive care and pain control that is implemented early in the illness. Illness depends on a person's immune response. Monkeypox can commonly cause severe pain and can affect vulnerable anatomic sites, including the genitals and oropharynx, which can lead to other complications.
Assess pain in all patients with monkeypox virus infection and recognize that substantial pain may exist from mucosal lesions not evident on physical exam. Topical and systemic strategies should be used to manage pain. Pain management strategies should be individualized and patient-centered, tailored to the needs and context of an individual patient.
Treatment should be considered for use in people who have severe disease or involvement of anatomic areas that might result in serious sequelae that include scarring or strictures. Treatment should also be considered for use in people who are at high risk for severe disease. For patients at high risk for progression to severe disease, treatment should be administered early in the course of illness along with supportive care and pain control.
Counseling message on condoms
It is not known whether condoms prevent the transmission of monkeypox. If rashes are confined to the genitals or anus, condoms may help. However, since infectious respiratory secretions may be present, condoms alone are probably not enough to prevent monkeypox. Condoms are effective at preventing the transmission of some infections, such as chlamydia, gonorrhea, and HIV. The World Health Organization advises that people with monkeypox use condoms for 12 weeks after they recover until more is known about levels of the virus and potential infectivity in semen during the period that follows recovery.