Mpox Outbreak and Update for Idaho Clinicians

November 17, 2023

Idaho is experiencing a new mpox (previously known as monkeypox) outbreak. After a year of no reported cases, 5 cases have been reported in the last month and 2 other reports are under investigation, all in Treasure Valley residents. Providers are reminded to:

1. Vaccinate patients at increased risk of exposure to protect them from mpox.

2. Keep mpox on your differential diagnosis for patients presenting with a compatible rash illness (see https://www.cdc.gov/poxvirus/mpox/clinicians/clinical-recognition.html).

JYNNEOS mpox vaccine

The CDC recommends vaccination with JYNNEOS for people determined to be at increased risk for mpox infection. Mpox vaccine may be given as post-exposure prophylaxis (PEP), ideally within 4 days after exposure, but up to 14 days after may still provide some protection. About 1 in 3 Idaho residents who received the first dose of JYNNEOS do not have a recorded second dose.

· Please consider sending reminders or recalling patients with only one recorded dose to receive a second dose. · Contact the Idaho Immunization Program at IIP@dhw.Idaho.gov for additional information about ordering JYNNEOS vaccine. · The website https://www.cdc.gov/poxvirus/mpox/vaccines/vaccine-recommendations.html lists sites that carry the mpox vaccine; Central District Health may be able to assist.

Two doses of JYNNEOS vaccine given 4 weeks apart (28 days ± 3 days) are recommended regardless of route (intradermal or subcutaneous). The subcutaneous route with 0.5 mL injection volume may be used for people of any age; however, contact your local public health district first prior to administration of JYNNEOS to children under six months of age. It is acceptable to administer JYNNEOS subcutaneously over either the deltoid or the triceps area.

The intradermal route with 0.1 mL injection volume may be used for people 18 years of age and older. Intradermal administration may be performed in the inner aspect of the forearm, at the upper back below the scapula, or at the deltoid. See https://www.cdc.gov/poxvirus/monkeypox/interim-considerations/jynneos-vaccine.html for guidance on use of JYNNEOS. When indicated, JYNNEOS PEP and pre-exposure prophylaxis (PrEP) with JYNNEOS vaccine should be offered to individuals who are pregnant or breastfeeding who are otherwise candidates.

Collecting and Shipping Specimens

· Specimen requirements vary by laboratory. Before specimen collection, view requirements of the specific laboratory to confirm collection, storage, and shipment instructions. Ship specimens as Category B.

· Providers may order testing (orthopoxvirus or mpox virus by PCR) through commercial labs without prior consultation with public health district or state epidemiologists. · Submission of specimens to Idaho Bureau of Laboratories (IBL) for non-variola orthopoxvirus testing may only be done with prior approval from public health district or state epidemiologists. Submission to IBL should be considered only when fast turn-around is needed (e.g., the patient or a contact of the patient is at increased risk of severe illness and a rapid result is needed to inform clinical decisions) or for patients who are uninsured or under-insured.

· Swab 2-4 lesions, using 2 swabs per lesion. If the lesion surface is not swabbed vigorously to collect adequate DNA, test results may be inconclusive or false-negative. De-roofing or lancing the lesion before swabbing is not recommended. Healthcare providers have been exposed to mpox virus from needle sticks during deroofing attempts.

Interpreting Orthopoxvirus Results

A positive Orthopoxvirus test suggests Mpox infection: no other Orthopoxviruses that cause systemic disease are circulating within the United States.

Treatment

Patients with mpox benefit from supportive care, including pain control. For most patients with mild disease and intact immune systems, supportive care alone may be sufficient. Certain patients may benefit from additional treatment; see Treatment Information for Healthcare Professionals.

Tecovirimat (TPOXX or ST-246) is approved by the Food and Drug Administration (FDA) for treating human smallpox disease caused by Variola virus in adults and children of all ages. Tecovirimat is available through the STOMP trial and an expanded access investigation new drug protocol.

STOMP trial. Oral tecovirimat for treatment of mpox is available through enrollment in the Study of Tecovirimat for Human Mpox Virus (STOMP). Providers should inform patients with mpox about STOMP. The STOMP trial is designed to help determine if tecovirimat is safe and effective for the treatment of mpox. Patients do not have to have severe mpox or be at increased risk of severe illness to enroll. Although there are no research centers in Idaho, remote enrollment is possible, and interested participants should call the STOMP call center (1-855-876-9997) for more information.

Expanded Access Investigational New Drug (EA-IND) Protocol Providers with patients who decline enrollment or are ineligible for STOMP, or require IV tecovirimat, AND meet treatment eligibility under the Centers for Disease Control and Prevention’s (CDC’s) EA-IND protocol may request tecovirimat by calling the CDC EOC at 770-488-7100 or emailing poxvirus@cdc.gov. Eligibility includes patients who have severe mpox disease, involvement of anatomic areas which might result in serious sequelae, or are at increased risk for severe disease (see the most recent TPOXX EA-IND protocol, version 6.3 approved May 5, 2023, at https://www.cdc.gov/poxvirus/mpox/pdf/Tecovirimat-IND-Protocol-CDC-IRB.pdf). Providers and affiliated facilities must be registered in the TPOXX IND Online Registry as participating providers/sites under the CDC EA-IND. A limited supply of oral and IV tecovirimat is also currently available within the state and can be used in accordance with the EA-IND protocol while supplies last. For assistance, please contact: Central District Health at 208-327-8625.

Interim Clinical Treatment Considerations for Severe Manifestations of Mpox

See guidance updated since the last Idaho health alert about mpox at https://www.cdc.gov/mmwr/volumes/72/wr/mm7209a4.htm. The use of tecovirimat, brincidofovir, cidofovir, trifluridine ophthalmic solution, and vaccinia immune globulin intravenous are reviewed.

For More Information

Contact Central District Health at 208-327-8625 or the DPH Epidemiology Section at 208-334-5939 if you have any questions or suspect a patient may have mpox. For urgent clinical consultation after hours, clinicians may contact CDC’s Emergency Operations Center (770-488-7100) to discuss the case with a clinician.