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What Is Monkeypox?

Human monkeypox is a viral disease caused by the monkeypox virus, which belongs to the same family of viruses as smallpox. Monkeypox symptoms are less severe than smallpox (eradicated in 1980), less contagious, and rarely fatal. Monkeypox is not related to chickenpox. Since May 2022, Monkeypox has started to spread globally, including in the United States.

Public health efforts are aimed at keeping the disease from becoming endemic[1] in the U.S. and worldwide.  The new rapid spread may indicate that the virus has mutated to become more contagious.

The current outbreak in the United States is associated with the virus’s less virulent West African “clade” (genetic group).  It is rarely fatal but painful and can cause permanent scarring.  People with weakened immune systems, the elderly, children under age 8, people with a history of eczema, and people who are pregnant or breastfeeding are at higher risk for severe outcomes.

Healthcare workers are at a potentially higher risk of exposure to the monkeypox virus if infected patients are present at their facility.  While monkeypox is much less infectious than COVID-19 and does not spread through brief encounters infection control protocols should be implemented by employers to identify cases, protect workers, and reduce transmission.

According to the Centers for Disease Control and Prevention (CDC), “Transmission in healthcare settings has been rarely described.” The CDC has developed the guidance document ‘Infection Prevention and Control of Monkeypox in Healthcare Settings’[2] which provides guidance on the following topics:

• Precautions for Preventing Monkeypox Virus Transmission
• Patient Placement
• Personal Protective Equipment (PPE)
• Waste Management
• Environmental Infection Control
• Duration of Isolation Precautions for Patients with Suspected or Confirmed Monkeypox Infection
• Management of Patients with a Monkeypox Virus Exposure
• Visitation
• Assessing Risk of HCP with Monkeypox Virus Exposures to Guide Monitoring and Recommendations for Postexposure Prophylaxis
• Definitions
• Additional Resources

Transmission

Monkeypox can spread to anyone through close, personal, often skin-to-skin contact, including:

• Direct contact with a monkeypox rash, scabs, or body fluids from a person infected with monkeypox,
• Touching objects, fabrics (clothing, bedding, towels, bandages, dishes), and surfaces used by someone with monkeypox,
• Contact with respiratory secretions from an infected person,
•  The virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth. 

According to the CDC, you may be at an increased risk of contracting monkeypox if you were exposed to an infected person who was coughing while not wearing a mask or respirator, or if you were not previously vaccinated against smallpox or monkeypox.[3]

Researchers do not yet know if monkeypox can be transmitted through semen, vaginal fluids, urine, or feces.  Monkeypox is not considered a sexually transmitted disease (STD) at this time. Anyone can be infected through close personal contact. It is critical that our efforts do not stigmatize

monkeypox, which may result in people failing to seek medical care, an increase infection spread, and stalled contact tracing. 

Incubation and Infectious Period

• The incubation period is usually one to two weeks but can last up to 21 days.
• People are not thought to be infectious during the incubation period, but this is being studied. The known infectious period is from the onset of symptoms until all lesions have crusted over, the crusts have separated, and a fresh layer of healthy skin has formed. This can take two to four weeks. 
• Patients must isolate during the infectious period and avoid contact with people and animals.

Symptoms

Most people infected with monkeypox get a rash that develops into pustules on or near the genitals (penis, testicles, labia, and vagina) or anus and could be on other areas like the hands, feet, chest, face, or mouth.  Many people also experience fever, chills, sore throat, headache, muscle aches, and swollen lymph nodes.  The swollen lymph nodes can help to diagnose monkeypox because measles and chickenpox do not include that symptom.  Some people may experience severe pain; others will have fewer symptoms.  Complications can include pneumonia, encephalitis, and eye infections.

The CDC urges healthcare providers to be on the lookout for rash illnesses consistent with monkeypox[4].

Treatment

Many infected people can isolate themselves at home with advice from their healthcare provider about over-the-counter topical agents, antihistamines, and pain medication.  Some patients will need to be hospitalized and treated with antiviral drugs developed for smallpox or with Vaccinia Immune Globulin Intravenous (VIGIV) therapy.  Tecovirimat (TPOXX), a new investigational drug, is available from the Strategic National Stockpile.

Vaccination

Two vaccines – JYNNEOS or ACAM2000 – may be used to prevent monkeypox disease as a pre-exposure prophylaxis and can also be used for treatment as post-exposure prophylaxis.  

• No data is currently available on the clinical efficacy or effectiveness of these vaccines in the current outbreak.

• Because there are limitations in our knowledge about the effectiveness of these vaccines in the current outbreak, people who are vaccinated should continue to take steps to protect themselves from infection by avoiding close, skin-to-skin contact, including intimate contact, with someone who has monkeypox.

• Vaccinated individuals should take precautions to reduce their exposure to monkeypox until immune protection from vaccines has reached its maximum.

The “CDC is not currently encouraging pre-exposure vaccination for most U.S. healthcare workers.”[5]  According to its’ ‘Clinician FAQs: Questions and Answers about Monkeypox for Healthcare Professionals:’ The ‘CDC Monkeypox and Smallpox Vaccine Guidance,” issued on June 2, 2022, for healthcare professionals, may change, however, based on vaccine supply and the outbreak evolution.

“The risk of monkeypox for most front-line healthcare workers is currently low.  Monkeypox virus primarily spreads through close contact and does not spread as easily as respiratory viruses (e.g., influenza and SARS-CoV-2 viruses).  Proper use of personal protective equipment and infection control practices are likely to be effective at reducing the risk of transmission of the monkeypox virus when examining a patient or handling contaminated materials.  However, healthcare workers who have been exposed to monkeypox may benefit from post-exposure prophylaxis with the JYNNEOS vaccine, ideally within four days.”

Pre-Exposure Prophylaxis to Prevent Monkeypox[6]

The CDC’s Advisory Committee on Immunization Practices (ACIP) recommend that people whose jobs may expose them to orthopoxviruses, such as monkeypox, get vaccinated with either ACAM2000 or JYNNEOS to protect them if they are exposed to an orthopoxvirus.  This is known as pre-exposure prophylaxis (PrEP).

People who should get PrEP include:

• Clinical laboratory personnel who perform testing to diagnose Orth poxviruses, including those who use polymerase chain reaction (PCR) assays for diagnosis of Orth poxviruses, including Monkeypox virus.
• Research laboratory workers who directly handle cultures or animals contaminated or infected with Orth poxviruses that infect humans, including Monkeypox virus, replication-competent.

• Vaccinia virus, or recombinant Vaccinia viruses derived from replication-competent Vaccinia virus strains.
• Certain healthcare and public health response team members who are designated by public health authorities to be vaccinated for preparedness purposes.
• Healthcare personnel who administer ACAM2000 or JYNNEOS or who anticipate caring for many patients with monkeypox.

Health and Safety Protections for Healthcare Workers

The following PPE should be worn by healthcare staff when handling patients with suspected or confirmed monkeypox—this includes direct care staff and staff who handle soiled clothing, linen, used dishes, trash, and waste:

• Gown
• Gloves
• Eye protection (goggles or a face shield that covers the front and sides of the face)
• NIOSH-approved and fit-tested N95 respirator or higher respirator

Employer Responsibilities

Employers should implement protocols to safely care for potentially infected patients and patients with confirmed infections of the monkeypox virus. The CDC has provided recommendations for infection control in healthcare settings[7] which includes training for direct care staff and environmental services staff. Employers should also offer paid leave to employees infected with the monkeypox virus.

• Identification and Isolation

• Implement a screening tool for patients who present with rashes and/or flu-like symptoms.
• Develop a triage protocol to rapidly isolate persons under investigation (PUI).  A patient with suspected or confirmed monkeypox infection should be placed in a single-person room; special air handling is not required.
• Limit patient transport outside of the room.  If the patient is transported outside their room, they should use well-fitting source control (e.g., a medical mask) and have any exposed skin lesions covered with a sheet or gown.
• Provide training to clinical staff involved in triage, isolation, and care on case identification, isolation policies, and infection-control protocols.  Case Definitions† for Use in the 2022 Monkeypox Response | Monkeypox | Poxvirus | CDC

• Ensure adequate supplies of PPE and training.

• Environmental Services Workers

• Provide PPE for environmental services (EVS) workers including training on donning and doffing procedures as needed.
• Provide updated training to EVS staff on cleaning and infection-control (IC) protocols.
• Use wet cleaning methods according to IC protocols.  Avoid cleaning practices that may aerosolize the virus, including vacuuming, dusting, and sweeping.
• Cleaning products used should be included in EPA’s list of disinfectants for Emerging Viral Pathogens
• Soiled laundry should be gently and promptly contained in the laundry bag designated for infectious material.  Avoid contact with lesion material that may be present in the laundry according to facility infection-control procedures.  Soiled laundry and trash receptacles must never be shaken.
• Trash bags should be removed before full and tied off without “burping” the air out.

• Waste Management

Transportation of contaminated medical wastes should be performed in accordance with the U.S. Department of Transportation (DOT) Hazardous Materials Regulations (HMR; 49 CFR parts 171-180.)

Required waste management practices and waste classification currently differ depending on the monkeypox virus clade (strain).  The DOT indicates that waste contaminated with the West African clade[8] of monkeypox virus should be managed as UN3291 Regulated Medical Waste (RMW) in the same manner as other potentially infectious medical waste (e.g., soiled dressings, contaminated sharps).  Facilities should also comply with state and local regulations[9] for handling, storage, treatment, and disposal of waste, including RMW.

• Clinicians and Laboratory Workers

Laboratory workers should consult with laboratory biosafety officers and supervisors to identify risks and precautions, depending on the type of work they are doing.  Regardless of whether a PrEP vaccine is received, clinicians and laboratorians should use recommended infection control practices; these are important to prevent any infection. 

Notification and Contact Tracing Recommendations

The information presented in this section would be implemented at the discretion of the medical facility or as required by local public health authorities.  Notification policies could be a subject of impact bargaining.

• Employers should report all staff and patients with confirmed monkeypox to the local department of public health for contact tracing purposes.  
• Employers should maintain records of infected staff including documentation on the source individual.
• Within 24 hours, notify any employee exposed to confirmed monkeypox cases and who provided direct care without proper PPE (gown, gloves, facemask, or eye protection).
  • Exposure would include skin-to-skin contact, contact with bodily fluids, or contact with materials, including sheets, clothing, and towels, that can carry infection (fomites).  
    • Research is being done to determine if monkeypox can be transmitted in urine or feces.  Until this is known, healthcare workers should be protected under the precautionary principle.

• Visitors should be limited to those essential for the patient’s care and well-being.  Visitors should be required to sign in and out for contact tracing purposes. 

References

Centers for Disease Control and Prevention (CDC)

• General Information

• Infection Control Clinicians

• Infection Prevention and Control of Monkeypox in Healthcare Settings

• Information For Healthcare Professionals

• Considerations for Reducing Monkeypox Transmission in Congregate Living Settings

Environmental Protection Agency (EPA)

• EPA Releases List of Disinfectants for Emerging Viral Pathogens (EVPs) Including Monkeypox | US EPA

For more information, contact the IBT Safety and Health Department at (202) 624-6960 and visit https://teamstersafety.org.

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[1]Endemic refers to the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area. www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html

[2] Infection Control: Healthcare Settings | Monkeypox | Poxvirus | CDC https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html

[3] Infection Control: Healthcare Settings | Monkeypox | Poxvirus | CDC  www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html

[4] What Healthcare Professionals Should Know | Monkeypox | Poxvirus | CDC www.cdc.gov/poxvirus/monkeypox/clinicians/what-hcps-should-know.html

[5] Clinician FAQs | Monkeypox | Poxvirus | CDC www.cdc.gov/poxvirus/monkeypox/clinicians/faq.html

[6] Monkeypox and Smallpox Vaccine Guidance | Monkeypox | Poxvirus | CDC https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html

[7] Infection Control: Healthcare Settings | Monkeypox | Poxvirus | CDC  www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html

[8] Managing Solid Waste Contaminated with a Category A Infectious Substance (dot.gov)

www.phmsa.dot.gov/sites/phmsa.dot.gov/files/docs/transporting-infectious-substances/6821/cat-waste-planning-guidance-final-2019-08.pdf

[9] Healthcare Environmental Resource Center (HERC) (hercenter.org) www.hercenter.org/rmw/rmwlocator.php 

[10] Infection Control: Healthcare Settings | Monkeypox | Poxvirus | CDC www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html#anchor_1660143677200