Sumāmary
CDPH Sexually Transmitted Diseases Control Branch is issuing this California Health Alert Network (CAHAN) Health Update to notify clinicians and local health departments (LHD) about the geographic spread of clade I MPXV within Africa and recommendations for practice, diagnostic testing, and surveillance for mpox.
MPXV has two distinct genetic clades: clade I and clade II MPXV. Clade I MPXV is endemic in central Africa and has historically been associated with increased transmissibility (generally via non-sexual routes), more severe mpox infections, and higher case fatality rates compared to clade II MPXV. A subtype of clade II MPXV, clade IIb, which is endemic in West Africa, is responsible for the ongoing global mpox outbreak that began in 2022. Clade IIb mpox continues to circulate globally and in the United Statesāincluding Californiaāand has predominately affected gay, bisexual, and other men who have sex with men (GBMSM).
On August 7, 2024, the Centers for Disease Control and Prevention (CDC) issued a Health Update as clade I mpox cases have continued to increase within the DRC and have now been confirmed in neighboring non-endemic countries. The Republic of Congo reported an outbreak of clade I in April 2024 and there have recently been confirmed clade I cases in the Central African Republic, Rwanda, and Uganda and suspected cases with possible link to DRC in Burundi. Although clade I is endemic to the Republic of Congo and the Central African Republic, it is not endemic in Rwanda, Uganda, or Burundi. This is an update to a previously released CDCāā Health Alert (12/7/2023) regarding cases of sexually acquired clade I mpox infections occurring in the DRC. To date, no cases of clade I mpox have been identified outside of Africa.
According to the CDC, the risk of clade I mpox importation to the United States is very low due to the limited number of travelers and lack of direct flights to the US or California from the DRC or neighboring countries, however healthcare providers are advised to have a heightened index of suspicion for clade I mpox in patients with recent travel to Africa and present with signs and symptoms consistent with mpox.
For more information, see CDC Health Update: Mpox Caused by Human-to-Human Transmission of Monkeypox Virus in the Democratic Republic of the Congo with Spread to Neighboring Countries released August 7, 2024 and CDC 2023 Outbreak in Democratic Republic of the Congoā for ongoing updates on the situation in the DRC.
Recommendāations for Providers and Local Health Departments
Evaluation and Diagāānosis
CDPH encourages California providers to consider mpox as a possible diagnosis in patients presenting with lesions consistent with mpox in patients with epidemiological risk factors or in any patient āwith clinical suspicion for mpox as patients may not wish to disclose their risk factors. Mpox infection can occur in people vaccinated for or previously diagnosed with mpox. Clinical presentations of mpox may look similar to other exanthems and severity can vary.
Patients being considered for mpoāāx infection should be screened for possible clade I mpox exposure (i.e., suspicion should be high for individuals with recent travel to Africa or close contact to travelers from Africaāincluding sexual contact or household contactā within the prior 21 days). If clade I mpox is suspected, providers should notify their LHD immediately and collect specimens for clade-specific testing.
Testināg
Specimens from suspected clade I mpox patients should be sent to a public health laboratory that can differentiate clade I from clade II MPXV. Contact your local public health laboratory (PHL) (rather than a commercial lāāaboratory) or the CDPH Viral Rickettsial Disease Laboratory (VRDL) if the local PHL does not provide clade-specific MPXV testing. Providers should follow specimen collection guidelines including:
Collector should wear appropriate personal protective equipment, which includes gown, gloves, eye protection, and fit-tested NIOSH-approved particulate respirator with N95 filters or higher.
Use 2 sterile, synthetic swabs (including, but not limited to, polyester, nylon, or Dacron) as specified by lab submission criteria. Do not use cotton swabs.
Vigorously swab the lesion with 2 separate swabs to collect adequate DNA and place into appropriate sterile container as specified in lab submission criteria. Do not de-roof or aspirate lesion(s) due to risk of sharps injury and exposure.
Ideally, test 2-3 lesions in different locations or at different stages using separate swabs and tubes for each lesion.
For specimen submission criteria and shipping instructions to CDPH VRDL, see CDPH VRDL MPXV PCR Test Order. Contact information for the CDPH VRDL: (510) 307-8585 or VRDL.Submittal@cdph.ca.govā.
Treatment
Medical countermeasures (e.g., TPOXX, brincidofovir, and vaccinia immune globulin intravenous) that have been used during the ongoing clade IIb mpox outbreak in the United States are available and expected to be effectivāe for clade I mpox infections. TPOXX remains available through the STOMP trial and CDC-held Emergency Authorization Investigational New Drug (EA-IND) protocolā.
Prevenātion
CDPH recommends that providers and LHDs encourage vaccination for their patients who may be at risk for mpox. Vaccination coverage in California remains low, with less than half of people who are eligible to receive the vaccine having received both doses of JYNNEOS.
The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for people ā„18 years of age who may be at risk for mpox with two doses of the JYNNEOS vaccine (at least 28 days apart). Patients who have only received one dose of the JYNNEOS vaccine should receive the second dose of JYNNEOS as soon as possible for the most protection. There are no changes or updates to mpox vaccine recommendations at this time.
As a reminder, JYNNEOS may be given to patients who are immunocompromised (including untreated HIV or AIDS) and therefore at higher risk for more severe mpox disease or complications. JYNNEOS may also be given as post-exposure prophylaxis to asymptomatic persons who have not already received two doses of vaccine or been previously diagnosed with mpox (CDCā).ā
Infecāātion Control and Preventiāāon
Healthcare personnel who evaluate and provide care to patients with suspected mpox and laboratory personnel should continue to follow existing CDC guidance on infection prevention and control of mpox and Cal/OSHA Aerosol Transmissible Disease (ATD) Standardā (PDF) as applicable. These are effective in minimizing transmission.
Recommendations
Recommendations āfoār Laboratories
Public health authorities are being encouraged to enhance surveillance efforts to aid detection of clade I MPXV should it occur in the United States.
Specimens collected from patients with suspected clade I mpox should be sent to the CDPH VRDL or their local PHL as expeditiously as possible. The VRDL offers diagnostic MPXV testing that will discriminate between clade I and clade II. Providers are advised to work with their local health department to send appropriate specimens to the VRDL for MPXV testing. For specimen submission criteria and shipping instructions, see CDPH VRDL Mpox PCR Test Order (PDF). Contact information for VRDL: (510) 307-8585 or VRDL.Submittal@cdph.ca.gov.
Laboratories should alert their LHD, CDPH, and CDC (poxvirus@cdc.gov) if they detect clade I MPXV. All regulations should be followed for packaging and transporting specimens (PDF) from suspect mpox patients as Category B for diagnostic testing. Please refer to the most recent CDC guidance for submitting specimens to CDC. Specimens that cannot be accepted for clinical testing under Clinical Laboratory Improvement Amendments (CLIA) will be redirected for surveillance purposes and tested, helping to provide critical data on the MPXV clade(s) circulating in the United States. Specimens tested under surveillance will not have patient reports sent back to the submitter.
Recommendations for the Puāāblic
The risk of clade I mpox spreading to the United States is very low at this time per the CDC, due to limited travelers and no direct flights to the US or California from the DRC or neighboring countries. However, travelers to affected regions and healthcare providers are advised to remain vigilant. Clade IIb MPXV continues to circulate in the United States, including in California.
CDPH continues to recommend people who may be at risk for acquiring mpox receive two doses of the JYNNEOS vaccine, as the vaccine is expected to be effective at preventing mpox from both clade I and clade II. Individuals who have only received one dose of JYNNEOS should receive a second dose for the most protection. See CDPH Mpox Vaccination to find mpox vaccines near you.
CDC has issued a Travel Health Notice for people traveling to the DRC and neighboring African countries where mpox cases have been identified. Travelers are recommended to take measures to protect themselves by avoiding close contact with people who have skin or genital lesions; avoiding contact with dead or live wild animals, materials used by sick people such as clothing, bedding, or in health care; avoiding materials that came into contact with wild animals; and avoiding eating or preparing meat from wild animals (bushmeat), or using products made from wild animals in countries where mpox occurs in animals. Individuals should seek care immediately if they develop symptoms of mpox like a rash or sores.ā
Resourāāces
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