​Updates as of January 5, 2023:

• Revised guidance based on latest WHO update for exposed individuals to avoid sexual contact with others during the monitoring time frame of 21 days.

• Post-Exposure Prophylaxis can be an option for all, based on latest CDPH guidance on considerations for mpox vaccination. 
  

Background

The current mpox outbreak continues to evolve. The guidance below is based on current scientific understanding and is subject to change as new evidence emerges. 

The California Department of Public Health (CDPH) is closely monitoring mpox transmission in the U.S. and California to ensure rapid identification of cases. Based on California's experience to date, mpox spreads primarily through direct contact with infectious lesions, scabs, or body fluids. The risk of mpox to people without known "Exposure" (as defined below) to a case is low, however anyone can be infected if exposed.

The following recommendations are intended to assist California's public health officials in guiding persons with varying degrees of exposure to mpox virus in community settings. Exposures to mpox in healthcare settings should follow CDC guidance on Infection Prevention and Control of Mpox in Healthcare Settings. Persons with confirmed mpox should follow CDPH Mpox Home Isolation Guidance for the General Public.

Individuals exposed to mpox in certain settings can continue their routine daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with mpox.

Types of Exposure & Recommended Actions [1]

Exposed Persons

"Exposed Persons" are those whose mucous membranes or broken skin came into contact with:

• The lesions or body fluids of a person with mpox; OR
  

• Materials that have contacted the lesions or body fluids of a person with mpox
  

Activities that may result in being "exposed" include sex of any kind (including oral, anal, or vaginal sex), kissing, providing or receiving physical care without the use of personal protective equipment (PPE), sharing cups, utensils, towels, clothing, and bedding, and engaging in sports with a very high degree of skin-to-skin contact. "Exposed Persons" may include sexual or intimate partners, household members, physical care providers or recipients, and wrestling, grappling, or sparring partners.

Whenever possible, "Exposed  Persons" should be notified and monitored for 21 days, and should avoid sexual contact with others during this time (See below for additional details regarding notification and monitoring). Also, because "Exposed Persons" have the greatest risk of infection, post-exposure prophylaxis (PEP) is highly encouraged, especially for intimate partners and persons providing or receiving direct physical care from a case (e.g., parent-to-young child), as the majority of mpox transmission observed in the current outbreak to-date has occurred in these contexts.

Potentially Exposed Persons

"Potentially Exposed Persons" are those whose intact skin or clothing came into contact with:

• The lesions or body fluids of a person with mpox; OR

• Materials that have contacted the lesions or body fluids of a person with mpox
  

Persons who may be considered "Potentially Exposed" include household members who would not otherwise be considered "Exposed" (e.g., roommates), persons who have gathered socially in crowded settings where limited clothing is worn, and persons who had contact with the lesions or bodily fluids (or handled materials that have contacted the lesions or body fluids) of a person with mpox without the use of PPE, such as house cleaners, barbers, hairdressers, nail salon workers, massage therapists, and adult-care and child-care workers.

While the risk of contracting mpox for persons who are "Potentially Exposed" is very low based on current knowledge, it is recommended that such persons be notified and recommended to self-monitor for 21 days. PEP can be considered after consultation with a healthcare provider and/or the Local Public Health Department (LHD), and is primarily recommended based on the degree of exposure and/or for persons at increased risk of severe disease, such as immunocompromised persons, persons with HIV, or persons who have immunocompromised or HIV-infected household members.

Persons with Low Risk of Exposure

Persons with "Low Risk of Exposure" are those who entered the living space of a person with mpox (regardless of whether the person with mpox was present), in the absence of any exposures above. Of note, schools and workplaces without sleeping quarters are not considered living spaces.  

Persons with "Low Risk of Exposure" include people who enter homes, dormitories, or other living spaces of cases. Based on current knowledge, the risk of contracting mpox in this manner is exceedingly low. However, out of caution and in alignment with the CDC guidance, notification can be considered for such individuals, along with a recommendation to self-monitor for 21 days. PEP can be an option.

 Table 1.  Summary of Recommendations for Management of Persons with Possible Exposure to Someone with mpox in Community Settings [2] 

Notification

Typically, LHDs will lead mpox contact tracing efforts to identify people who may have been exposed, determine the exposure type, and provide recommendations on next steps, including whether notification and PEP should be considered.

Institutions (workplaces, schools, etc.) that come to know that persons with mpox were within their settings while infectious should contact their LHD for further assistance and if requested, they should support the health department in contact tracing efforts.

Individuals who do not meet any of the exposure definitions above do NOT need to be notified. Dissemination of any facility-wide notification should be strongly weighed against the possibility of inadvertently disclosing protected health information and perpetuating stigma.

If facility-wide notices are considered (to combat misinformation, for example), it is recommended they be non-specific, provide scientific facts, confront and oppose perpetuation of stereotypes and stigma, and serve as a general reminder for all to not return to work/school if they have new, unexplained symptoms until it is clear that symptoms are mild and improving or are due to a non-infectious cause (e.g., allergies), as should always be the case.

Monitoring 

What to monitor

In general, exposed persons should self-monitor for skin and mouth lesions as well as systemic symptoms for 21 days after last exposure. Some infected people have flu-like symptoms (such as fever, chills, headache, or fatigue) or swollen lymph nodes. Exposed persons who develop signs and symptoms of mpox infection should seek evaluation by a healthcare provider and follow CDPH isolation and transmission prevention practices.

If symptoms are noticed, medical evaluation should include assessing the person for signs and symptoms of mpox, including a thorough exam of the skin, mouth, and genitals, in good lighting.

How to monitor

Decisions on how to monitor exposed persons are at the discretion of the LHD. In general, self-monitoring is usually sufficient unless there are concerns about a high-risk situation or setting. Ultimately, the person's exposure risk level, their reliability in reporting signs or symptoms that might develop, any sensitive occupation or situation of the exposed person, the number of people needing monitoring, the time since exposure, and receipt of PEP are all factors when determining the type of monitoring to be used.

Activities

As noted above, individuals exposed to mpox virus can continue their routine daily activities (e.g., go to work or school) as long as they do not have signs or symptoms consistent with mpox during the 21 days monitoring period.

To date, there have been no cases of mpox transmitted by blood transfusion, organ transplantation, or implantation, transplantation, infusion, or transfer of human cells, tissues, or cellular or tissue-based products (HCT/Ps). As a precaution, patients with exposures should not have sexual contact with others, donate blood, cells, tissue, breast milk, or semen while they are being monitored for symptoms.

Given the morbidity and mortality among individuals awaiting organ transplantation, persons who have been exposed, but who are asymptomatic and without evidence of mpox infection, could be considered for organ donation following appropriate risk-benefit considerations.

[1] While the exposure types listed above were adapted from CDC guidance for Monitoring and Risk Assessment for Persons Exposed in the Community (released August 11, 2022), they differ in a few ways. 

For example, CDC recommends that persons who were "within 6 feet for a total of 3 hours or more (cumulative) of an unmasked person with mpox without wearing a surgical mask or respirator" have an "Intermediate Degree of Exposure" for which monitoring is recommended, and PEP can be considered. 

Investigation of mpox cases in California to date, has not corroborated that prolonged close proximity alone (without direct contact with skin lesions, body fluids, or contaminated materials) poses sufficient independent risk of mpox transmission to recommend notification, monitoring, or consideration of PEP. 

Accordingly, outside of living settings (e.g., households, dormitories) where there is greater potential to interact with contaminated materials, California does not recommend additional measures for persons who were, for example, in close proximity but without direct physical contact with a clothed person whose mpox lesions were covered, such as by clothing, bandages or gloves.

[2] California has not adopted the CDC terminology of "Higher", "Intermediate", and "Lower" categories and instead recommends referring to persons in the context as noted in Table 1.