Monkeypox (MPV) Clinician Job Aid and Treatment Guidelines

Monkeypox (MPV) is, like smallpox, an orthopox virus that causes a disease characterized by systemic symptoms like fever and adenopathy and a vesicular to pustular rash. Since a gathering in Europe in April, a major portion of the world has been experiencing a growing outbreak of this malady. Unlike spread of MPV in its native Africa, in this outbreak the population at risk almost exclusively identifies as gay, bisexual or men who have sex with men. As such, 99+% of the cases are in males. The mode of spread is by close, intimate contact.

Respiratory spread, spread by fomites and more casual contact is possible but is distinctly unusual in this outbreak. Although the MPV rash can spread to any part of the body classically, including the hands and feet, the rash in the current outbreak is more commonly found in the genital area, anal area or in the oropharynx. This distribution can lead to very painful sore throats that can hamper getting adequate nutrition and hydration and painful proctitis that can lead to severe constipation. 

TPOXX or tecavirimat is an orally available medication that is approved for treating smallpox and has been made available by the CDC through an investigational new drug protocol for treatment of MPV. In collaboration with University of Washington, the VMC Infectious Disease Clinic has access to this medication for selected patients with MPV. The following patients may qualify for treatment:

• Patients with painful, widespread, test-positive rash
• Patients with severe pharyngitis or proctitis related to MPV (even if the exterior rash is minimal)
• Patients with test-positive MPV and severe underlying immune compromise (transplant, cancer on chemotherapy, HIV with T helper less than 200, immune compromising therapy such as used in severe rheumatology diseases including prednisone >20 mg, primary immune compromising disease among others)
• Persistent, painful, test-positive rash

Testing, which will soon be available through Labcorp and will have an available order on EPIC, is very helpful if it can be done. It is not absolutely needed for referral for treatment if the patient has:

• Either been exposed to a test-positive MPV case or identifies as gay, bisexual or a man who has sex with men and
• Has a characteristic problem as noted above.

If a provider has a patient that is test-positive for MPV or is at high risk AND has a clinical syndrome eligible for treatment as noted above, contact the Infectious Disease Clinic to consider treatment with TPOXX. This can be done by:

• Paging the on call provider (available on Amion and through operator) or
• VOALTE messaging

The Infectious Disease Clinic will use telehealth if the patient has been already tested, or have the patient come in for an evaluation if no testing has been done to enroll the patient in the protocol and obtain medication for the patient. 

The Infectious Disease Clinic can also be helpful for providing information to test-positive patients who are not candidates for treatment. A recently published job aid on MPV also has advice for MPV positive patients.