CDC releases interim monkeypox guidance, reports epidemiologic and clinical characteristics

The CDC recently described epidemiologic and clinical characteristics of monkeypox cases and released interim guidance for clinicians on preventing and treating monkeypox in patients with HIV infection.

On Aug. 4, HHS declared the U.S. monkeypox outbreak, which began on May 17, to be a public health emergency. Among 2,891 cases reported through July 22 by 43 states, Puerto Rico, and the District of Columbia, the CDC received case report forms for 1,195 (41%) by July 27, according to an MMWR report published Aug. 5. Of these cases, 99% were among men; among those with available information, 94% reported male-to-male sexual or close intimate contact during the three weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White persons, 28% were among Hispanic or Latino persons, and 26% were among non-Hispanic Black or African American persons.

The report said monkeypox classically occurs in three stages: an incubation period of about one to two weeks, a prodrome characterized by fever and lymphadenopathy, and then a deep-seated vesicular or pustular rash that often begins centrally and spreads to the limbs. Of cases with available data, 46% of patients reported one or more genital lesions during their illness and 41% had HIV infection. The most frequently reported signs and symptoms included rash (100%), fever (63%), chills (59%), and lymphadenopathy (59%). Rash was most frequently reported on the genitals (46%), arms (40%), face (38%), and legs (37%). Reported rectal symptoms included purulent or bloody stools (21%), rectal pain (22%), and rectal bleeding (10%). Among 291 persons with available information about their first symptoms, 58% reported at least one prodromal symptom; for the 42% of patients without prodromal symptoms, illness began with a rash. “Compared with historical reports of monkeypox in areas with endemic disease, currently reported outbreak-associated cases are less likely to have a prodrome and more likely to have genital involvement,” the authors noted.

In its interim guidance, also published Aug. 5 by MMWR, the CDC presented clinical considerations for prevention and treatment of monkeypox in persons with HIV infection, including pre-exposure and postexposure prophylaxis, treatment with tecovirimat, and infection control.

The agency's interim recommendations include the following:

• Clinicians should use clinical judgment and consider both viral suppression and CD4 count in weighing the risk for severe monkeypox-associated outcomes for any patient with HIV infection.
• When vaccination is used for prevention of monkeypox in persons with HIV infection, Jynneos is preferred over ACAM2000; however, its clinical efficacy against monkeypox is unknown. Based on recommendations from the Advisory Committee on Immunization Practices, ACAM2000 is contraindicated in those with HIV infection due to risk for severe adverse effects resulting from the spread of vaccinia virus.
• If high-risk exposures cannot be avoided, immunocompromised patients may receive Jynneos in consultation with their clinician after careful consideration of the risks and benefits.
• Other therapies, including tecovirimat and vaccinia immune globulin IV, can be considered for monkeypox postexposure prophylaxis on a case-by-case basis, in cases of known high-risk exposure to a confirmed or probable case of infection, and in clinical conditions that necessitate an alternative option to postexposure vaccination, such as advanced HIV.
• For individuals with or without HIV, primary prevention of monkeypox includes isolating persons with infection from other persons and their pets, avoiding close contact and sexual activity (including oral, anal, and vaginal sex or sharing of sex toys) with infected persons, and postexposure vaccination.