Current guidance as of August 5, 2022
DISCLAIMER
The New Jersey Hospital Association (NJHA) has organized this toolkit using federal and state sources, with up-to-date standards and recommendations at the time of publication. NJHA does not intend to provide this information as clinical advice but to serve as a conduit to external guidance. As the 2022 monkeypox outbreak is a rapidly changing concern, readers are advised to check with original sources for updated information.
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Jump down to your area of interest:
Introduction
Identification
Testing
Isolation and Infection Control
Vaccination and Treatment
Communication and Engagement
INTRODUCTION
NJHA’s Monkeypox Toolkit provides information and links to state and federal guidance on recognizing monkeypox, handling identified cases and preventing further infections.
As of December 28, 2022, New Jersey recorded 764 confirmed cases of monkeypox. Updates by state are posted Monday–Friday on the Centers for Disease Control and Prevention (CDC) Situation Summary website.
On August 4, 2022, the White House declared monkeypox a public health emergency, after the United States reached the highest number of confirmed monkeypox cases in the world. This declaration is expected to provide access to resources and flexibilities, expedite state data sharing, and provide more detailed data on testing and hospitalizations. This follows the July 23 statement by the World Health Organization (WHO) Director-General declaring monkeypox a public health emergency of international concern, as well as state-level declarations by California, New York and Illinois.
The CDC advises healthcare providers to be alert for patients who have rash illnesses consistent with monkeypox, and the New Jersey Department of Health (NJDOH) urges providers to report confirmed or suspect cases immediately to their local health department.
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IDENTIFICATION
Monkeypox is a rare disease caused by infection with the monkeypox virus, which is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox symptoms are similar to, but milder than, smallpox symptoms. Monkeypox is rarely fatal, with illness lasting two to four weeks.
Infection with monkeypox virus begins with a one- to two-week incubation period, during which a person does not have symptoms. During a prodrome period, initial symptoms include fever, malaise, headache, weakness and swollen lymph nodes (lymphadenopathy) – a feature that distinguishes monkeypox infection from smallpox. After this period, a rash appears, with lesions progressing through four stages before scabbing over and resolving.
Key characteristics for identifying monkeypox include:
- Fever before rash
- Lymphadenopathy common
- Disseminated rash is centrifugal (more lesions on extremities, face)
- Lesions on palms and/or soles
- Lesions are well circumscribed, deep seated and often develop umbilication (resembles a dot on the top of the lesion)
- Lesions are relatively the same size and same stage of development on a single site of the body
- Lesions are often described as painful until the healing phase when they become itchy (crusts)
In addition, a high index of suspicion for monkeypox is warranted when evaluating people with a characteristic rash, particularly for men who report sexual contact with other men and who present with lesions in the genital/perianal area or for individuals reporting a significant travel history in the month before illness onset or contact with a suspected or confirmed case of monkeypox.
CDC case-finding guidance provides more details on identification and classification of characteristics.
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TESTING
When monkeypox is suspected, healthcare providers should immediately notify their local health department. If the local health department cannot be reached, contact NJDOH at 609-826-5964 during business hours or 609-392-2020 on evenings, weekends and holidays. The provider should complete and submit a Monkeypox Investigation Form along with photographs of the lesions to assist with the consultation.
Healthcare providers can then proceed with collecting specimens for monkeypox testing. Commercial testing is available through Aegis Sciences Corporation, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics and Sonic Healthcare.
NJ Public Health and Environmental Laboratory (PHEL) continues to be available and may be preferrable to commercial testing for those without insurance and for those clinicians who may have difficulty sending a specimen to a commercial lab. Providers should follow the NJDOH Public Health and Environmental Laboratories (PHEL) technical guidance regarding specimen collection. However, testing at PHEL requires prior approval by the local health department. Specimens submitted without prior approval will be rejected.
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ISOLATION AND INFECTION CONTROL
Because human-to-human transmission of monkeypox virus occurs by direct contact with lesion material or from exposure to respiratory secretions, CDC recommends implementation of Standard Precautions and the following procedures:
| Activity | Recommendations for Monkeypox Infection Prevention and Control |
|---|
| Appropriate healthcare facilities |
No monkeypox-designated healthcare facilities. Patients can be safely evaluated by healthcare providers if the proper infection control precautions are taken.
|
| Isolation |
Any individual with suspected or confirmed monkeypox should be isolated, and if admitted should be placed in a single-person room.
|
| Patient placement |
Single-person room with dedicated bathroom. Keep door closed, if safe to do so.
|
| Air handling |
No special air handling required.
|
| Intubation/extubation |
Any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
|
| PPE |
- Gown
- Gloves
- Eye protection
- NIOSH-approved particulate respirator equipped with N95 filters or higher
|
| Patient transport |
Limit transport to only medically necessary. If patient is transported out of their room, place a procedural mask on patient and cover any exposed skin lesions with sheet or gown.
|
| Visitation |
Visitation should be limited to those essential for the wellbeing of the patient (e.g., parents, caregivers).
|
| Waste management |
Required waste management practices and classification depend on monkeypox virus clade (strain):
- West African clade – should be managed as UN3291 Regulated Medical Waste (RMW)
- Congo Basin clade – should be managed as a Category A infectious substance
Facilities should ensure the protection of environmental services staff by implementing PPE and other protocols in compliance with OSHA standards.
|
| Environmental infection control |
Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim (from List Q). Activities that could resuspend dried material from lesions (e.g., use of portable fans, dry dusting, sweeping, or vacuuming) should be avoided.
|
Duration of Precautions – Decisions regarding discontinuation of suspected or confirmed monkeypox patients should be made in consultation with local health department. Isolation precautions should be maintained until all lesions are crusted, those crusts have separated and a fresh layer of healthy skin has formed underneath.
Monitoring Healthcare Workers – Healthcare workers who have unprotected exposures (i.e., not wearing PPE) to patients with monkeypox do not need to be excluded from work duty, but should undergo active surveillance for symptoms, which includes measurement of temperature at least twice daily for 21 days following the exposure and daily interview for evidence of fever or rash prior to reporting for work. Healthcare workers who have been in direct or indirect contact with monkeypox patients while adhering to recommended infection control precautions should adhere to active monitoring as determined by the local health department.
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VACCINATION AND TREATMENT
As of July 22, 2022, CDC, in partnership with FDA, made it easier for healthcare providers to provide tecovirimat (TPOXX) treatment to patients with monkeypox under the expanded access investigational new drug (EA-IND) protocol. The streamlined process allows healthcare providers to start treatment before the paperwork is submitted; reduces the number of forms, patient samples and photos required; and gives patients the option to see their doctor virtually.
On July 19, 2022, NJDOH announced that New Jersey has a limited number of doses of the monkeypox vaccine JYNNEOS. Access to this vaccine is prioritized for residents with known exposure to a person with monkeypox and those at high risk for having been exposed to monkeypox in the past 14 days, namely:
- Individuals that attended an event where known monkeypox exposure occurred
- Individuals that identify as gay, bisexual, or men who have sex with men (MSM), and/or transgender, gender non-conforming, or non-binary and who have a history of multiple or anonymous sex partners within the past 14 days.
In addition to the local health departments, vaccine appointments for this expanded post-exposure prophylaxis (PEP) program are available through:
- Bergen New Bridge Medical Center, Annex 2 (white tent structure), 230 East Ridgewood Ave, Paramus: www.newbridgehealth.org
- Cooper Vaccine & Testing Clinic, Cooper University Hospital, 300 Broadway, Camden. (At the intersection of Broadway and MLK Boulevard. Entrance off of MLK Boulevard. Follow the signs; do not drive into the parking garage.) Appointment only: call 856-968-7100, Monday through Thursday, 7 a.m. to 8 p.m., and Friday, 7 a.m. to 5 p.m., or go online at any time through MyCooper
- Hyacinth AIDS Foundation/Project Living Out Loud!, Jersey City: 201-706-3480
- The Prevention Resource Network, a program of the Visiting Nurse Association of Central Jersey, Asbury Park: 732-502-5100
- North Jersey Community Research Initiative (NJCRI), Newark: 973-483-3444, ext. 200.
The monkeypox vaccine, and to some extent the smallpox vaccine, are believed to be effective at protecting people against monkeypox when given before exposure. Even if vaccinated after exposure, it may prevent the disease or at least make it less severe.
Pre-exposure prophylaxis (PrEP) is only being administered for those at highest risk, such as laboratory workers who handle specimens that might contain monkeypox virus. Most clinicians are not advised to receive monkeypox vaccine PrEP at this time.
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COMMUNICATION AND ENGAGEMENT
Healthcare providers are encouraged to keep their communities informed about monkeypox with messaging that provides information on what it is and how it can spread and encourages seeking health care if experiencing monkeypox-like symptoms. The CDC has developed informational print resources that providers can distribute to their communities, as well as a communication planning tool with helpful messaging and dissemination recommendations.
Recognizing the importance of reaching disproportionately affected communities, such as gay and bisexual men, with sensitivity, the CDC also recommends following its guiding principles for inclusive communications.
Good communication is also critical when engaging with patients and their families/caregivers. Precautions taken at home can help prevent the spread of the infection. CDC guidance on home isolation and household disinfection provide helpful instructions related to isolation; hand hygiene, source control and PPE; and household disinfection, laundry and waste disposal. This information can be an important part of discharge planning conversations with patients and families/caregivers.
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