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Last Updated: 1 September 2022

Monkeypox

Monkeypox Photo

Since 14 May 2022, the Monkeypox (MPX) outbreak has affected multiple countries resulting in a public health emergency declaration by the World Health Organization (WHO) and the U.S. This MPX outbreak has disproportionately, but not exclusively, affected men who have sex with men. Cases within the Navy and Marine Corps community have been identified, and additional cases will likely continue to emerge. Recent analysis shows 99% of cases in the U.S. have been male, with 94% of cases self-reporting as bisexual, gay, or other men who have sex with men. A small number of infections are being reported in women and in children, though sustained transmission in these populations does not appear to be occurring.

The Navy and Marine Corps Public Health Center (NMCPHC) is engaged and tracking this situation closely. Public health response measures in the current outbreak are evolving. Public health guidance for Navy and Marine Corps medical departments, fleet and operational units, installations, and personnel and their families can be found below via the listed links and will be updated routinely as needed.

Recognizing Monkeypox (MPX)

Providers at all levels should be aware of the clinical presentation of MPX, details of which can be found on the Centers for Disease Control and Prevention (CDC) clinical recognition website at https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html. MPX should be suspected in patients presenting with or without influenza-like symptoms and a new rash, which may initially look like pimples or blisters and potentially similar to skin changes seen with syphilis, herpes, or varicella zoster/chickenpox. People with underlying immune deficiencies may have a more severe illness presentation. If a history of high-risk activity and/or contact with a suspected or confirmed MPX patient is reported, non-variola orthopox virus testing should still be strongly considered in addition to testing for other pathogens in the differential diagnosis. Additional clinical guidance may be provided by the Defense Health Agency (DHA) or found in NMCPHC’s Fleet Guide at https://olb.navy.awesp.health.mil/sites/nmcphc/pps/SiteAssets/WebPartPages/Monkeypox-Toolbox.aspx.

High-risks include:

Intimate contact with new, multiple, and/or anonymous partners;
Direct skin-to-skin contact with MPX rash, sores, or scabs;
Direct contact with contaminated objects, fabrics (e.g., soiled/dirty clothing, bedding, or towels), and surfaces that have been used by someone with MPX; and
Prolonged close contact (within 6 feet for greater than 3 hours) with a person who has MPX.

Reporting

Suspected cases of MPX should be reported to Preventive Medicine immediately in order to begin contact tracing as early as possible Report suspect, probable, and confirmed DoD MPX cases via Disease Reporting System internet (DRSi) using the Centers for CDC case definitions at https://www.cdc.gov/poxvirus/monkeypox/clinicians/case-definition.html.

Additional information on DRSi can be found at https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/ or by contacting the DRSi helpdesk at usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-ndrs@mail.mil.

Operational units without adequate internet access can seek assistance with reporting from the nearest Navy Environmental Preventive Medicine Unit (https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Field-Activities/).
Notification of MPX cases should also be made to U.S. state or county/local public health officials. If outside the U.S., refer to Status of Forces Agreements (SOFAs) for notification protocol.

Contact Tracing

If clinical suspicion for MPX is high, contact tracing should begin even before laboratory testing results are received in order to maximize post-exposure prophylaxis (PEP; medicine to prevent or minimize disease after possible exposure) options. Assess risk based on CDC’s risk assessment for persons exposed in the community (https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html).

Potentially exposed persons at risk include all who had:

Direct contact with skin or lesions of a MPX patient (to include intimate contact, kissing, or sexual activities);
Direct contact with items/materials contaminated by patients with MPX (e.g., clothing, bedding, shavers/razors, eating/drinking utensils, and smoking implements); or
Close prolonged face-to-face contact within 6 feet for 3 hours or more (e.g., with potential for transmission via respiratory secretions) with a MPX patient.

The CDC recommends using your state or county/local health department reporting form or CDC’s short case report form (https://www.cdc.gov/poxvirus/monkeypox/pdf/sCRF-Short-Form.pdf) for collecting information during patient interviews for probable and confirmed cases.

Isolation

Cases should be isolated from other people and from pets, in accordance with CDC guidance (https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html), until symptoms resolve, the scabs have fallen off, and a fresh layer of intact skin has formed. This could take 2-4 weeks. Isolate cases in a separate room with a separate bathroom if possible to minimize risk of exposure. Although time outside of isolation should be minimized, modified isolation may be considered in specific circumstances (e.g., to do laundry, exercise outside alone, attend medical appointments, or seek emergency care) only after consultation and coordination with medical or public health/preventive medicine and after fever and respiratory symptoms resolve. Clinical presentation of lesions should inform allowable activities. Cases should wear well fitted surgical type masks and cover all lesions when around others if close contact cannot be avoided. Uninfected people should also wear a surgical type mask when in close contact (within 6 feet) with a case. Physical distancing of cases should be observed, to include avoiding congregate (e.g. gyms) and crowded settings, and not sharing personal items such as shavers/razors, eating/drinking utensils, and smoking implements.

Cleaning, Disinfection, and Laundry

Ensure use of disinfectant products that are registered by the EPA for Emerging Viral Pathogens, tier 1 (https://www.epa.gov/pesticide-registration/disinfectants-emerging-viral-pathogens-evps-list-q). Routinely clean and disinfect commonly touched surfaces and items such as counters, tables/furniture, hand rails, and light switches to eliminate the virus. Persons with MPX should use separate bathrooms and toilets if possible, and all surfaces should be cleaned and disinfected routinely after use including shared bathroom/toilet spaces. Infected persons should do their own laundry if possible. If Navy issued mesh laundry bags are used, bags should be washed along with clothing/bedding. Follow CDC guidance for home infection control and laundry handling (https://www.cdc.gov/poxvirus/monkeypox/specific-settings/home-disinfection.html), including proper use of personal protective equipment.

Vaccination

Vaccine may be an effective method to protect against MPX infection and/or severe illness related to infection. There is currently a limited supply of vaccine, but supply is increasing. Pre-deployment preparation should include working with military Medical Treatment Facilities (MTFs) or Navy Environment Preventive Medicine Units (NEPMUs) to assist high risk crew members in accessing vaccine if criteria for vaccination are met.

Additional Information for Installations

Installations are strongly encouraged to prepare designated spaces for isolation and ensure a Public Health Emergency Officer (PHEO) has been appointed. Commanders should also ensure adequate handwashing and other hygiene supplies are available in all heads and common areas. Berthing spaces, heads, work spaces, and high traffic areas should be regularly disinfected as indicated above. Routine habitability and sanitation inspections should be reviewed to identify potential infection control issues that may introduce transmission within high-traffic or commonly used spaces. Education campaigns should be conducted to include plan-of-the-day messages and/or educational lectures. Focus education on safe sex practices, proper hygiene, and the importance of not sharing personal items with others.

Additional Information for Fleet and Operational Units

Detailed guidance on MPX prevention and control measures for Fleet and operational units can be found in the NMCPHC MPX toolbox: https://olb.navy.awesp.health.mil/sites/nmcphc/pps/SiteAssets/WebPartPages/Monkeypox-Toolbox.aspx.
Currently, neither MPX testing nor treatment are readily available in a forward deployed operational setting. Units should identify suspected cases, isolate them, and move them for care at an MTF as quickly as possible to minimize exposure to others and ensure that definitive testing and treatment can occur. Contact tracing should be conducted early; even before lab testing results are received, if clinical suspicion for MPX is high. PEP (medicine to prevent or minimize disease after possible exposure) vaccination should be considered for close contacts as quickly as possible for maximum effectiveness and based on availability.

Consider having individuals at higher risk for severe disease, or who confidentially report behaviors that are high risk for infection, avoid sharing crowded or common sleeping spaces (e.g. cot, bunk, berth) when possible. NMCPHC modeling of shipboard spread suggests the threat of MPX to Navy operations remains low; spread on a ship or operational unit is anticipated to be limited, and large outbreaks are not expected.

Privacy and Reducing Stigma

Be aware that diagnosis of MPX can be a sensitive issue. Apply the utmost discretion in protecting the privacy of individuals diagnosed with MPX. Personal information should only be shared with those who have a need to know under existing privacy laws. For tips on disseminating information and engaging your community, see the CDC’s reducing stigma webpage: https://www.cdc.gov/poxvirus/monkeypox/reducing-stigma.html.

Consultation

MTF infectious disease specialists and the DHA Immunization Healthcare Division (through a 24/7 answering service at 877-438-8222) can assist with clinical consultation, vaccine access, and treatment.
NEPMUs (contact information available at https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Field-Activities/) can provide consultative assistance with contact tracing, mitigation, isolation measures, education, and messaging.

Additional Resources

CDC MPX webpage: https://www.cdc.gov/poxvirus/monkeypox/index.html
WHO MPX webpage: https://www.who.int/emergencies/situations/monkeypox-oubreak-2022
NMCPHC’s MPX and Sexual Health Fact Sheet: https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/images/program-and-policy-support/monkeypox/Monkeypox-and-sexual-health.PNG

Information for Navy and Marine Corps Personnel and their Families

While Monkeypox (MPX) can infect anyone, the vast majority who have been infected in the current outbreak are men who self-identify as men who have sex with men. If you are engaging in intimate direct skin-to-skin contact, particularly with new, multiple, and/or anonymous partners, you are at increased risk. Additional risks include direct contact with contaminated objects, fabrics (e.g., soiled/dirty clothing, bedding, or towels), and surfaces that have been used by someone with MPX, as well as close working/living quarters and prolonged close contact (within 6 feet for greater than 3 hours) with a person who has MPX. Without these high-risk behaviors and exposures, the risk of becoming infected with MPX is believed to be low.

To prevent becoming infected:

Avoid close intimate contact (e.g., kissing and sexual activities) with new, multiple, and/or anonymous partners (note that condoms alone may not be enough to prevent the spread of MPX);
Avoid close, skin-to-skin contact with those who have a new rash, sores, or scabs;
Wash your hands often with soap and water or use an alcohol-based hand sanitizer; and
When caring for someone with MPX, apply proper disinfection and cleaning protocols.

If you think you have MPX or have been exposed to someone who has MPX:

Contact your healthcare provider or your local health department immediately if you believe you are experiencing MPX symptoms;
Isolate at home, staying in a separate room or area away from people or pets you live with; and
Once symptoms begin, you can potentially spread the infection to others, including some pets, until all skin lesions have crusted over and new, healed skin has developed.

If you are diagnosed with MPX, follow Centers for Disease Control and Prevention (CDC) infection control guidance for the home (https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-home.html). This includes handling and treatment of soiled/dirty laundry of a person infected with MPX separate from laundry of others. It also includes information on cleaning/disinfecting potentially contaminated and high trafficked surfaces.

Treatment of MPX generally involves symptom management. Medication or vaccine may be available to help prevent or reduce severity of MPX infections, particularly for those at high risk of severe infection.

Do you have more questions and need additional information? Take a look at the resources below!

NMCPHC’s MPX and sexual health fact sheet: https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/images/program-and-policy-support/monkeypox/Monkeypox-and-sexual-health.PNG
CDC’s webpage: https://www.cdc.gov/poxvirus/monkeypox/index.html

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