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Message ID:   2081      Public Message
Subject:   Monkeypox Update for Idaho Clinicians 8/26/2022
Sent By:   PHD7 Date Sent:   8/26/2022 11:19:19 AM
Priority:   Advisory Status:   Sent (Delivered)
PHIN Specific Data:
Severity:   Moderate Delivery Time:   15 Minutes
PHIN Status:   Actual Message Type:   Alert
Sensitivity:   Non Sensitive Acknowledgement:   No
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Message Text:

Monkeypox Update for Idaho Clinicians

8/26/2022

 

As of 8/25/22, ten cases of monkeypox have been reported in Idaho and community transmission has been identified. Idaho case counts are on https://healthandwelfare.idaho.gov/health-wellness/diseases-conditions/monkeypox. Please see below for updated recommendations and resources.

 

Collecting and Shipping Specimens

·         Swab 2-4 lesions, using 2 swabs per lesion. Swab lesion surface vigorously so that an adequate specimen is collected; otherwise, test results may be inconclusive or false negative. De-roofing or lancing the lesion before swabbing is not necessary.

·         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.

 

Interpreting Orthopoxvirus Results
A positive Orthopoxvirus test s
uggests Monkeypox virus infection: no other Orthopoxviruses that cause systemic disease are circulating within the United States. Clinical care and prevention precautions should begin based on the Orthopoxvirus test result. If a patient has no known risk factors or epidemiologic criteria, positive results should be verified with repeat or confirmatory testing.

Testing Laboratories and Billing
Commercial laboratories—including
Labcorp, Aegis Science, and Sonic Healthcare—are processing non-variola orthopoxvirus testing. Quest Diagnostics and ARUP Laboratories are performing monkeypox-specific testing. Providers may order testing through commercial labs without prior consultation with public health district or state epidemiologists.

 

Idaho Bureau of Laboratories (IBL) will perform non-variola orthopoxvirus testing 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 high risk of severe illness and a rapid result is needed to inform clinical decisions) or for patients who are uninsured or under-insured.

 

Commercial laboratories will bill private insurance, Medicaid or Medicare for all testing performed. Those who are underinsured or uninsured will receive a bill for testing at commercial laboratories. Clinicians may find the relevant CPT code for orthopox or monkeypox testing on each commercial laboratory’s website. Testing at IBL is free.

 

Tecovirimat Expanded Access Investigational New Drug (EA-IND) Protocol
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. CDC has an expanded access Investigational New Drug protocol (EA-IND) to allow access to and use of TPOXX to treat monkeypox in adults and children of all ages. CDC recommends consideration of treatment for patients with severe disease, those at risk of severe disease, and patients with lesions in anatomically sensitive areas. See CDC clinical guidance for more information.

The EA-IND provides an umbrella regulatory coverage so that clinicians and facilities do not need to request and obtain their own INDs. The EA-IND provides liability protection under the PREP Act for clinicians prescribing, administering, or dispensing TPOXX and the ability for patients to seek compensation if they are seriously injured by TPOXX through the Countermeasures Injury Compensation Program (CICP).

 

A revised TPOXX EA-IND protocol (Version 6.1, approved August 10, 2022) for treating patients with monkeypox includes instructions for mixing TPOXX capsules with food and makes outcome reporting as well as blood and lesion samples and lesion photos optional. See requirements at https://www.cdc.gov/poxvirus/monkeypox/clinicians/obtaining-tecovirimat.html. Informed consent must be obtained before treatment begins. Requested forms can be returned to CDC after treatment begins.

Obtaining Tecovirimat (TPOXX)

  • Currently, clinicians and healthcare facility pharmacists can contact the Bureau of Communicable Disease Prevention, Epidemiology Section, at 208-334-5939 to request TPOXX.

 

JYNNEOS monkeypox vaccine

·         JYNNEOS may now be administered to children <18 years of age by the subcutaneous route only under the FDA EUA without completing the EA-IND process.

·         JYNNEOS may now be administered to adults 18 years of age or greater by the intradermal route at 0.1 mL injection volume under the FDA EUA as an alternative regimen.

·         Fact sheets about JYNNEOS administration under the EUA for healthcare providers and vaccine recipients and caregivers and updated guidance are available at https://www.cdc.gov/poxvirus/monkeypox/interim-considerations/jynneos-vaccine.html.

 

If you have a patient eligible for JYNNEOS vaccine, please contact Southeastern Idaho Public Health at 208-478-6303 to learn about options for vaccination for your patients. Criteria for JYNNEOS include being a known contact to someone with monkeypox in the last 14 days, or being a person who had sex with a man who has sex with men and has had any of the following: sex with multiple partners, sex at a commercial sex venue, or sex where monkeypox transmission is occurring.

 

Monkeypox in Individuals with HIV

Interim Guidance for Prevention and Treatment of Monkeypox in Persons with HIV Infection — United States, August 2022

Persons with advanced HIV or who are not virologically suppressed with antiretroviral therapy might be at higher risk for severe or prolonged monkeypox disease and higher likelihood of a confluent or partially confluent rash (rather than discrete lesions). Both viral suppression and CD4 count should be considered when weighing the risk of severe outcomes from monkeypox for any patient with HIV.

The rash of monkeypox can be confused with other rash illnesses that are considered in people with HIV. Immunocompromised persons, including persons with advanced, untreated, or inadequately suppressed HIV, may present with an atypical rash, including a disseminated rash that may make diagnosis more challenging.

The safety and immunogenicity of JYNNEOS has been specifically established in individuals with HIV, Immunogenicity remains unknown among individuals with HIV who have CD4 counts <100 cells/mm3 or who are not virologically suppressed. ACAM2000, a replicating viral vaccine, should not be given to individuals with HIV (regardless of immune status). Antiviral treatments for monkeypox have few interactions with ART. ART and opportunistic infection prophylaxis should be continued in all individuals with HIV and monkeypox.

Monkeypox in Children and Adolescents

The rash of monkeypox can be confused with other rash illnesses that are commonly considered in children.

When indicated, pediatric patients should be offered PEP with JYNNEOS. Vaccinia immune globulin may be offered for PEP under EA-IND, particularly for infants <6 months of age. When vaccine is contraindicated, antivirals, primarily tecovirimat, can be considered for use as PEP; however, their effectiveness for PEP is unknown.

Monkeypox in Pregnant or Breastfeeding Individuals

Monkeypox virus can be transmitted to the fetus during pregnancy and to the newborn by close contact during and after birth. Adverse pregnancy outcomes, including spontaneous pregnancy loss and stillbirth, preterm delivery, and neonatal monkeypox infection have been reported; the frequency and circumstances for these outcomes are unknown. Monkeypox virus may be transmitted through close contact during breastfeeding; it is unknown if it is present in breast milk.

When indicated, PEP and pre-exposure prophylaxis (PrEP) with JYNNEOS vaccine should be offered to individuals who are pregnant or breastfeeding who are otherwise candidates. ACAM2000 should not be used in individuals who are pregnant or breastfeeding.

Individuals who are pregnant, recently pregnant, or breastfeeding should be prioritized for medical treatment, if needed, because of the probable increased risk of severe disease during pregnancy, risk of transmission to the fetus during pregnancy or to the newborn by close contact during and after birth, and risk of severe infection in newborns. Risks and benefits of treatment should be discussed with the patient using shared decision-making.

For More Information

Contact the DPH Epidemiology Section at 208-334-5939 or Southeastern Idaho Public Health at 208-478-6303 if you have any questions or suspect a patient may have monkeypox. For urgent clinical consultation after hours, clinicians may contact CDC’s Emergency Operations Center (770-488-7100) to discuss the case with a clinician.