Centers for Disease Control and Prevention
Center for Preparedness and Response
Mpox Update: Stay Up to Date on Testing,
Treatment, and Vaccination
Clinician Outreach and Communication Activity (COCA) Call
Thursday, May 18, 2023
Continuing Education
▪ Continuing education is not offered for this webinar.
▪ Using the Zoom Webinar System
– Click on the “Q&A” button
– Type your question in the “Q&A” box
– Submit your question
▪ If you are a patient, please refer your question to your healthcare provider.
▪ If you are a member of the media, please direct your questions to CDC Media
Relations at 404-639-3286 or email med[email protected].
To Ask a Question
Today’s Presenters
John T. Brooks, MD
Chief Medical Officer
Division of HIV Prevention
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Chris Braden, MD
Incident Manager
2022 Multinational Mpox Response
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention
Mpox Update: Stay Up to Date on
Testing, Treatment, and
Vaccination
Clinician Outreach and
Communication Activity Call
(COCA)
John T. Brooks, MD and Chris Braden, MD
May 18, 2023
Key Learning Objectives Today
In light of limited clusters of new mpox cases
1. Renew clinical awareness for early recognition of potential cases of mpox
2. Review basic clinical presentation and management of mpox
3. Highlight that tecovirimat should first be requested through STOMP study
4. Promote vaccination of people at risk for mpox
5. Share update about recent infections reported from Chicago
6
Mpox Virus: Divided into Two Main Clades
Clade I
• Formerly Congo basin clade
• More virulent (CFR ~10%)
Clade II
• Formerly West African clade
• Less virulent (CFR <1%)
• 2022 outbreak strain is sub-clade IIb
Source: Likos et al. J Gen Virol, 2005. Chen et al. Virology 2005. CFR = case fatality rate.
9
Mpox: Course of Illness
• Incubation period: 3–17 days
1
• Illness duration: 2–4 weeks
2
• Development of initial symptoms marks beginning of prodromal period
─ Fever, malaise, headache, weakness, myalgia
• Febrile prodrome lasts 1–4 days
• Lymphadenopathy: generalized or localized to several areas
• Rash lesions:
─ Progress predictably through stages: macule, papule, vesicle, pustule, crust
─ Pustules typically well circumscribed, deep seated, and often umbilicated
─ Are frequently painful, then become pruritic during the healing phase
10
Source: CDC [2022], Signs and Symptoms webpage. CDC [2022], Clinical Recognition webpage.
Clade IIb Mpox Outbreak: Clinical Characteristics
• Disproportionately affecting young MSM*, including MSM with HIV
• Transmission predominately linked to sexual contact
• Rash:
▪ Lower burden of lesions
▪ Distribution more centrifugal (abdomen/pelvis) than centripetal (arms/legs/face)
▪ Affects both skin and mucosa, especially anus, genitalia and oropharynx
• Fewer “prodromal” symptoms; they could be absent or follow rash onset
• Immunocompromised experience more severe and more prolonged illness,
especially persons with HIV and low CD4 cell counts or unsuppressed viral loads
*MSM = gay, bisexual, same gender-loving, and other men who have sex with men
12
Clade IIb Rash Presentation
Site of skin lesions
Number (%)*
Anogenital area
383 (73)
Face
134 (25)
Trunk or limbs
292 (55)
Palms or soles
51 (10)
*More than one site per person may have been reported.
Mucosal lesions present—no. (%) 217 (41)
Site of mucosal lesions Number/Total Number (%)
Anogenital only 148/217 (68)
Oropharyngeal only 50/217 (23)
Anogenital and oral 16/217 (7)
Nasal and eye 3/217 (1)
Penile and Vulvovaginal Lesions
Oral Lesions
Anorectal Lesions
Source: Thornhill 2022, N Engl J Med. Ogoina 2022, Qeios (pre-print)
14
Patients at Risk for Severe Mpox
• People with
─ Underlying medical conditions
o Inadequately treated HIV (CD4+ counts < 350 cells/mm3)
o Immunosuppression (e.g., organ transplant, therapy for autoimmune
disorder, chemotherapy)
o Moderate or severe primary immunodeficiency
─ History of atopic dermatitis, eczema, or extensive breaks in the dermal barrier
16
Mpox: Severe Complications
• Ophthalmologic: conjunctivitis, corneal ulceration and scarring
• Neurologic: confusion, seizure, encephalomyelitis
• Cardiovascular: myocarditis, pericarditis
• Rheumatologic: acute arthritis/synovitis
Conjunctival lesion with
corneal ulceration
Abnormal T2/fluid attenuated
inversion recovery signal
Inferior and anterolateral
T-wave inversions
Synovitis with subchondral
demarcation zone (red circle)
Source: Pastula 2022, MMWR. Badenoch 2022, Eclin Med .Rodriguez-Nava 2022, Emerg Infect Dis. Fonti 2022, Lancet Rheumatol.
17
Mpox: Severe Complications Continued…
18
• Obstructions (most often in the lungs or gastrointestinal tract) secondary to
─ Ulcer-related strictures
─ Severe lymphadenopathy
─ Edema of surrounding tissue
• Sepsis/hemorrhagic disease
• Death
Transmission
Mpox: Transmission
• Spread person-to-person through direct contact
─ Physical contact with infectious skin rash or scabs
─ Anogenital/oropharyngeal mucosal contact
─ Touching heavily soiled items (e.g., clothing, linens)
─ Placental transfer to fetus
• Patients can be infectious up to 4 days before symptoms begin,
(whether prodromal or rash symptoms) and remain infectious
until lesions form scabs, scabs fall off, and a fresh layer of skin forms
20
Sources: CDC [2022], Science Brief: Detection and Transmission of Mpox, webpage.
CDC [2022], Isolation and Prevention Practices for People with Mpox, webpage. Beeson 2023, Lancet Microbe.
Mpox: Transmission Continued…
• Risk of infection through contact with low-level contaminated surfaces or
objects in household or healthcare setting is considered low
• Transmission during brief interactions or between people in close
proximity and for a long duration (such as passengers seated near a
person with mpox on an airplane) is unlikely
• How often mpox virus is spread via respiratory secretions is unknown
21
Sources: CDC [2022], Science Brief: Detection and Transmission of Mpox, webpage.
CDC [2022], Isolation and Prevention Practices for People with Mpox, webpage. Beeson 2023, Lancet Microbe.
Physical Examination, Specimen
Collection, and Testing
Mpox: Examination and Diagnosis
Frontline clinicians may first encounter patients with mpox
• Collect a complete sexual, social, and travel history for past 21 days
• Perform a thorough skin and mucosal examination (e.g., genital, anal, oral)
in a room with good lighting
• Consider a broad differential such as syphilis, varicella zoster, herpes simplex,
molluscum contagiosum, pharyngeal group A streptococcus
• Evaluate for STIs per the 2021 CDC STI Treatment Guidelines
─ Persons with monkeypox may have other STIs including acute HIV
• Notify the health department of suspected, probable, and confirmed cases
23
Mpox: Specimen Collection
• Wear recommended personal protective equipment (PPE)
─ Do not unroof or aspirate lesions (or use sharp
instruments for mpox testing) due to the risk
for sharps injury
─ In severe cases, the CDC Infection Diseases
Pathology Branch can assist when a biopsy is
performed
24
Sources: CDC [2022], Infection Prevention and Control of Mpox in Healthcare Settings, webpage.
CDC [2022], Tips for Adequate Collection of a Lesion Specimen from a Suspect Monkeypox, webpage,
CDC [2022], Guidelines for Collecting and Handling Specimens for Mpox Testing, webpage.
CDC [2022], Additional Testing of Biopsy Tissues in Severe Mpox Infections, webpage.
Mpox: Testing
• Skin lesion material is the recommended specimen for initial laboratory testing
at either
─ Commercial laboratories
─ At a facility within the Laboratory Response Network
• Contact the appropriate public health department or commercial laboratory to
determine criteria for acceptable specimens, as this may vary
• There is a specific protocol for submitting specimens to the CDC, which may
differ from that of local health departments
• High clinical suspicion is sufficient to initiate treatment
25
Other Infections Causing Rash or Proctitis
• Syphilis
• Herpes zoster
• Disseminated varicella zoster
• Disseminated herpes
• Molluscum contagiosum
• Lymphogranuloma venereum (LGV)
• Disseminated fungal infections
• Disseminated gonococcal infection
• Scabies
• Hand, foot, and mouth disease
• Chancroid
• Granuloma inguinale
Clinicians should be aware that patients may have concurrent infections.
26
Diagnostic Evaluation for both Genital Ulcers
and Proctitis
• Initial evaluation
• Syphilis serologic tests
─ If available, darkfield examination or nucleic acid amplification test (NAAT)
from lesion exudate or tissue
• NAAT for gonorrhea and chlamydia
• NAAT* or culture for genital herpes type 1 and 2
Clinicians should be aware that patients may have concurrent infections.
*Preferred
27
Treatment
Mpox: Clinical Management
• Mpox infection is often mild and self-limiting without specific antiviral therapy
• Pain management, skin care, and wound care are often vital components of
mpox treatment plans
29
Sources: CDC [2022], Treatment Information for Healthcare Professionals, webpage.
CDC [2022], Clinical Considerations for Pain Management of Mpox , webpage.
American Academy of Dermatology [2022], Mpox Caring for the Skin, webpage.
Tecovirimat (aka TPOXX): Background
• Antiviral approved by the FDA for treatment of human smallpox (not mpox)
─ May be used for non-variola orthopoxvirus infection (e.g., mpox) under a
CDC-held Expanded Access Investigational New Drug Protocol for adults
and children weighing at least 3 kg
• Mpox treatment efficacy
─ Animal studies suggest mortality benefit
─ Human case reports report anecdotal evidence of reduced severity and
duration of illness and viral shedding
─ HOWEVER human efficacy remains unknown
• Mpox postexposure prophylaxis (PEP) efficacy is unstudied
30
Source: CDC [2022], Guidance for Tecovirimat Use, webpage.
Tecovirimat: Availability
• Available through
─ Study of Tecovirimat for Human Mpox Virus ( )
─ Some health departments (limited supplies)
• Oral capsules
─ Must be taken with a full, fatty meal for adequate absorption
─ May be opened and mixed with soft food for pediatric patients <13kg
• Oral and intravenous (IV) formulations available through the Strategic National
Stockpile (SNS) via consultation/email with state/local health authorities or
CDC as needed
31
Source: CDC [2022], Guidance for Tecovirimat Use, webpage. NIH [2022], Study of Tecovirimat for Human Mpox Virus, webpage.
Mpox: Clinical Management
• Patients with underlying immunocompromise
(esp. advanced HIV) are at risk for severe,
systemic, protracted illness and death and
likely need combination therapy
• CDC is available for clinical consultation, as
needed
• CDC Emergency Operations Center
─ Phone: 770-488-7100
─ Email: poxv[email protected]
• Prompt consultation with CDC is
recommended for immunocompromised
patients and patients at risk for severe mpox
Photo Credits: Photo appears in
Miller MJ et al.
32
Optimize Immune Function
• For immunocompromised patients
─ Optimize native immunity (e.g., ensure persons with HIV are receiving
effective antiretroviral therapy)
─ Limit the use of immunocompromising therapies (e.g., chemotherapy,
corticosteroids)
33
Source: CDC [2022], Update on Managing Monkeypox in Patients Receiving Therapeutics, webpage.
Mpox Vaccination
JYNNEOS Vaccine
• Live virus vaccine produced from the replication-deficient vaccinia virus strain
─ Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN)
─ Also known as IMVAMUNE, IMVANEX, MVA
• FDA licensed in 2019 to prevent smallpox and mpox in adults ≥18 years old
1
• May be administered intradermally or subcutaneously for persons ≥18
─ Subcutaneously for persons <18 under Emergency Use Authorization
• Administration in 2 doses at least 4 weeks apart
• Can be used either:
─ Before potential exposure (pre-exposure prophylaxis)
─ After exposure (post-exposure prophylaxis)
35
Sources: FDA [2022], Jynneos, webpage.
CDC [2022], JYNNEOS Smallpox and Monkeypox Vaccine Intradermal Administration, webpage with pdf.
CDC [2022], JYNNEOS Smallpox and Monkeypox Vaccine Subcutaneous Administration, webpage with pdf.
JYNNEOS Vaccine: Safety
• Safe for use in those who are immunocompromised or have atopic dermatitis
• Demonstrated to be safe in current outbreak
• Safety not established in:
─ Pregnant persons, breastfeeding persons, or children
• Animal models using high doses showed no harm to a developing fetus
• Contraindicated in patients with prior severe allergic reaction to JYNNEOS
• Use with caution in those with allergy to eggs, gentamicin, or ciprofloxacin
─ Produced using chicken embryo fibroblast cells
─ Contains small amounts of gentamicin and ciprofloxacin
36
Sources: FDA [2022], Jynneos, webpage.
CDC [2022], JYNNEOS Smallpox and Monkeypox Vaccine Intradermal Administration, webpage with pdf.
CDC [2022], JYNNEOS Smallpox and Monkeypox Vaccine Subcutaneous Administration, webpage with pdf.
JYNNEOS Vaccine: Efficacy
Vaccine performance
▪ Vaccine effectiveness (VE) ranged
▪ No differences observed between intradermal or subcutaneous routes
Study population
Cases;
Controls
Vaccination status
VE for 2 doses
(95% CI)
VE for 1 dose
(95% CI)
Epic national dataset
case
-control study
2,193 cases;
8,319 controls
Full: 3%,
Partial: 11%,
Unvaccinated: 86%
66%
(47-88%)
36%
(22-47%)
Multi
-jurisdictional
case
-control study
309 cases;
608 controls
Full: 23%
Partial: 32%
Unvaccinated: 45%
86%
(74-92%)
75%
(61-84%)
New York state
case
-control study
252 cases;
255 controls
Full: 0.8%
Partial: 8%
Unvaccinated: 91%
89%
(44-98%)
68%
(25-87%)
Sources: Deputy 2023, N Engl J Med. Dalton 2023, MMWR. Rosenberg 2023, MMWR.
37
Vaccination Prior to Exposure
Mpox Vaccination Indications: Sexual History
Risk Factors (1/2)
Offer mpox vaccination to adults/adolescents, who over the last 6 months:
Were diagnosed with a sexually
transmitted infection
Had a new sex partner
OR AND
Are gay, bisexual, or are other
men who have sex with men
Are transgender or nonbinary
OR
Source: CDC [2023]. Mpox Vaccination Basics, webpage
39
Mpox Vaccination Indications: Sexual History
Risk Factors (2/2)
• Offer mpox vaccination to anyone
─ Who has had sex during the last 6 months
o At a commercial sex venue or other social gathering
o In association with a large public event in an area with ongoing mpox
transmission
o With a partner with the above risks
─ Who has HIV infection or other causes of immunosuppression who have
had recent or anticipate possible future risk of mpox exposure
Source: CDC [2023]. Mpox Vaccination Basics, webpage
40
Vaccination After to Exposure
Mpox Vaccine Postexposure Prophylaxis
• Risk exposure assessment determines need for vaccination of close contacts
• Initiate post-exposure prophylaxis (PEP)*
─ Within 4 days of suspected exposure to minimize disease incidence
─ From 4–14 days after suspected exposure to reduce illness severity
*Based on data from live, replicating vaccinia virus vaccines for smallpox
42
Sources: CDC [2022]. Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines, webpage.
CDC [2022], Monitoring and Risk Assessment for Persons Exposed in the Community, webpage with pdf.
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348 www.cdc.gov
For clinical consultation, please contact
CDC Emergency Operations Center Phone: (770) 488-7100
Email: poxvirus@cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
43
www.cdc.gov/mpox
CDC’s Ongoing Mpox Response
Update
44
Mpox cases reported to CDC: Epi Curve (since 2023) with
7-day moving average (As of 05/10/2023 at 2pm ET)
• Body Copy
45
Mpox cases in IL
Situation as of 5/15/2023
▪ March 18 through May 15, 2023— 21 cases reported to the Chicago Dep. of
Public Health
─ All male
▪ 17 cases (of 21 with information) were vaccinated
─ 11 with 2 dose JYNNEOS, 1 with ACAM2000, 5 with 1 dose JYNNEOS
▪ 5 had well controlled HIV
▪ None were hospitalized
▪ 6 (of 18 with information) had recently traveled (U.S. destinations and Mexico)
46
Rosalind J. Carter, PhD
Clinical Liaison
2022 Multinational Mpox Response
Centers for Disease Control and Prevention
Agam Rao, MD, FIDSA
CAPT, U.S. Public Health Service
Lead, Advisory Committee on Immunization Practices
Centers for Disease Control and Prevention
Joining the Q&A Session
Andrea McCollum, PhD
Epidemiology Team Lead
2022 Multinational Mpox Response
Centers for Disease Control and Prevention
Brett Petersen, MD, MPH
Deputy Chief
National Center for Emerging and Zoonotic Infectious
Diseases
Centers for Disease Control and Prevention
▪ Using the Zoom Webinar System
– Click on the “Q&A” button
– Type your question in the “Q&A” box
– Submit your question
▪ If you are a patient, please refer your question to your healthcare provider.
▪ If you are a member of the media, please direct your questions to CDC Media
Relations at 404-639-3286 or email med[email protected].
To Ask a Question
▪ When: A few hours after the live call ends*
▪ What: Video recording
▪ Where: On the COCA Call webpage
https://emergency.cdc.gov/coca/calls/2023/callinfo_051823.asp
*A transcript and closed-captioned video will be available shortly after the original video recording posts at the above
link.
Today’s COCA Call Will Be Available to View On-Demand
