Health Advisory

Summary

• Given monkeypox and smallpox viruses are genetically similar, antiviral drugs developed to protect against smallpox may be used to prevent and treat monkeypox virus infections. Antivirals, such as tecovirimat (TPOXX), may be recommended for people who are more likely to get severely ill -- for example -- patients with weakened immune systems or severe disease (clinical criteria listed below).
• The CDC, in partnership with FDA, has made it easier for healthcare providers to provide tecovirimat (TPOXX) treatment to patients with monkeypox under an expanded access Investigational New Drug (EA-IND) protocol. The streamlined process reduces the number of required forms, patient samples, and photos, and gives patients the option to see their doctor virtually (links to forms on page two).
• Healthcare providers in Virginia who require the antivirals for treatment should direct all requests for TPOXX to the Virginia Department of Health by completing the online form.

Suggested Actions

Tecovirimat may be considered for treatment in people infected with Monkeypox virus:

• With severe disease (e.g., hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization)
• Who are at high risk of severe disease:
  • People with immunocompromising conditions (e.g., HIV/AIDS, leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient with hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component)
  • Pediatric populations, particularly patients younger than 8 years of age
  • Pregnant or breastfeeding women
  • People with a history or presence of atopic dermatitis, people with other active exfoliative skin conditions (e.g., eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease [keratosis follicularis])
  • People with one or more complication (e.g., secondary bacterial skin infection; gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; concurrent disease or other comorbidities)
• With aberrant infections involving accidental implantation in eyes, mouth, or other anatomic areas where Monkeypox virus infection might constitute a special hazard (e.g., the genitals or anus)
• TPOXX can also be considered for early empiric treatment prior to testing confirmation if monkeypox is highly suspected. Patients should still meet the clinical criteria listed on above.
• Full guidance can be found online. 
• If patients meet the criteria above, healthcare providers in Virginia should direct all requests for TPOXX to the Virginia Department of Health by completing the online form.
• The updated process allows healthcare providers to start treatment before the CDC paperwork is submitted, and reduces the number of required forms, patient samples, photos. All required forms for administering medication can be found on the CDC website. Please remember, in Virginia, the method to request and obtain the medication is through the Virginia Department of Health at link above. 
• Contact the Health Department’s Communicable Disease/Epidemiology Program at 703-246-2433 for consultation and guidance on monkeypox testing, treating, and infection control measures.

Additional Information

Case counts of monkeypox continue to increase across the United States and in the National Capitol Region. The highest rate of disease in the US is found in the District of Columbia, suggesting continued transmission in our community. Updated local case counts can be found on the VDH website.  

• Monkeypox is an immediately reportable disease. All suspect cases (any case in which testing was conducted) must be reported to public health via VDH’s disease reporting portal. 
• Testing for monkeypox is now widely available at commercial laboratories. Healthcare providers who suspect monkeypox infections can submit patient specimens for testing through commercial labs.
• At this time, monkeypox vaccination is only available through public health given limited vaccine supply. Individuals who are at higher risk of transmission can contact their local health department to check vaccine qualifications and availability (See Health Advisory). 
• Standard Precautions should be applied for all patient care, including for patients with suspected monkeypox. If a patient seeking care is suspected to have monkeypox, infection prevention and control personnel should be notified immediately. PPE used by healthcare personnel who enter the room of a patient with suspected or confirmed monkeypox should include gown, gloves, eye protection and an N-95 respirator. Additional CDC infection control guidance can be found on the CDC website.