Mpox Monitoring and Risk Assessment for People Exposed in the Community

Who should be monitored and for how long?

Anyone with an exposure to people or animals with mpox should monitor their health for signs or symptoms consistent with mpox for 21 days after their last exposure.

What to monitor

Monitoring should include assessing the person for signs and symptoms of mpox, including a thorough skin and mouth (oral) exam in good lighting. The skin examination can be performed by the person in isolation, a caregiver, or a healthcare provider and should include examination of the genitals and anus for rash or lesions.

If rash, signs, or symptoms develop

During the 21-day monitoring period:

• If a rash occurs:
  • An individual should follow isolation and prevention practices until (1) the rash can be evaluated by a healthcare provider, (2) testing is performed, if recommended by their healthcare provider, and (3) results of testing are available and are negative.
• If other signs or symptoms are present, but there is no rash:
  • An individual should follow isolation and prevention practices for 5 days after the development of any new sign or symptom, even if this 5-day period extends beyond the original 21-day monitoring period. If 5 days have passed without the development of any new sign or symptom and a thorough skin and oral examination reveals no new skin changes such as rashes or lesions, isolation and prevention practices for mpox can be stopped.
  • If a new sign or symptom develops at any point during the 21-day monitoring period (including during a 5-day isolation if applicable), then a new 5-day period should begin where the individual follows isolation and prevention practices.

Isolation and prevention practices can end prior to 5 days if a healthcare provider or public health authority believes the rash, signs, or symptoms are not due to mpox and there is a clear alternative diagnosis made that doesn't require isolation. The decision on when to end symptom monitoring and home isolation, either during the 21-day monitoring period or any 5-day extension, should be made with input from public health authorities.

Activity restriction during monitoring

Individuals exposed to a person with mpox 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.

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 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, could be considered for organ donation following appropriate risk-benefit considerations.

How to monitor

Decisions on how to monitor exposed persons are at the discretion of public health authorities. Passive approaches to monitoring might include educating and requesting self-reporting of signs or symptoms of disease to public health authorities, while active approaches might include telephone and video calls for symptom and temperature check-ins or in-person presentation for regular assessments. In general, the type of monitoring recommended reflects the risk for transmission, with more active-monitoring approaches used for people who have had higher-risk exposures, including check-ins on tolerability of and adherence to post-exposure prohylaxis (PEP). Self-monitoring approaches are usually sufficient for people with exposures that carry a lesser risk for transmission. Even higher-risk exposures may be appropriate for a self-monitoring strategy if public health authorities determine that it is appropriate. Ultimately, the person’s exposure risk level, their reliability in reporting signs or symptoms that might develop, the number of people needing monitoring, time since exposure, and receipt of PEP are all factors when determining the type of monitoring to be used.

Monitoring people unable to communicate onset of symptoms

Some people may be unable to communicate onset of symptoms, such as newborns, young children, or people with cognitive disorders. Parents and other caregivers should watch for changes in behavior and temperament that could signal that the person is experiencing uncomfortable symptoms such as fatigue or headache.

• Exposed people do not need to quarantine, but on a case-by-case basis, clinicians or public health officials could consider restricting programs, activities, or events that would pose high risk of transmission to other people (e.g., group play/education environments).
• Decisions about whether to limit activities in people who have been exposed to MPXV but are unable to communicate onset of symptoms should consider the risk of their exposure incident (how likely they are to develop mpox) and the risk that transmission would pose to other people (e.g., immunocompromised family members, young children).

Exposure risk assessment for community settings

Each risk level category in the table below is intended to highlight the need for monitoring and assist with determining the need for postexposure prophylaxis (PEP). The exposure risk level of any incident may be recategorized to another risk level at the discretion of the treating clinician or public health authorities due to the unique circumstances of each exposure incident.

MPXV typically spreads through prolonged close, skin-to-skin contact with a person who has mpox, or their contaminated materials (e.g., clothing, bed sheets). Transmission during quick interactions (e.g., brief conversation), between people in close proximity has not been reported for any persons with mpox. The categories in the table represent situations that, to date, have been associated with transmission or where there is a theoretical risk of transmission. If a specific exposure is not included in the table, that's not intended to imply that there is no risk associated with the exposure. However, based on current evidence, those exposures likely pose a lower risk for transmission than those described below.

There may be settings in which contact tracing is not feasible due to the characteristics of the setting (e.g., level of crowding, types of interactions occurring). In settings where contact tracing is not feasible, people who spent time in the same area as someone with mpox should be considered to have intermediate, uncertain to minimal, or no risk of exposure as determined by public health authorities.

Interim Community Exposure Risk Assessment and Recommendations

For Monitoring and Postexposure Prophylaxis (PEP) in Individuals Exposed to Monkeypox Virus (MPXV) in a Community Setting

High Risk of Exposure

Exposure Characteristics

• Contact between an exposed individual's broken skin or mucous membranes and the skin lesions or bodily fluids from a person with mpox or with materials (e.g., linens, clothing, objects, sex toys) that have contacted the skin lesions or bodily fluids of a person with mpox (e.g., sharing food, handling or sharing of linens used by a person with mpox without having been disinfectedA or laundered). -OR-
• Any sexual or intimate contact involving mucous membranes (e.g., kissing, oral-genital, oral-anal, vaginal or anal sex (insertive or receptive)) with a person with mpox.

Recommendations

• Monitoring: Yes
• PEPB: Yes

Intermediate Risk of Exposure

Exposure Characteristics

Absence of any exposure above AND any of the following:

• Contact between an exposed individual's intact skin or clothing and the skin lesions or bodily fluids from a person with mpox or materials (e.g., linens, clothing, sex toys) visibly contaminated with body fluids or lesions, exudates, or crusts from a person with mpox without having been disinfectedA or laundered. -OR-
• Being within 6 feet of a person with mpox who has laryngeal disease, cough, respiratory symptoms, or oral lesions for an extended period.

Recommendations

• Monitoring: Yes
• PEPB: Informed clinical decision making recommended on an individual basis to determine if the benefits of PEP outweigh the risks.C

Uncertain to Minimal Risk of Exposure

Exposure Characteristics

Absence of any exposure above AND any of the following:

• Entry into the living space of a person with mpox regardless of whether the person with mpox is present (risk classification may vary depending on the extent of the exposed person's interactionC). -OR-
• Contact between a person's intact skin or clothing and the intact skin or clothing of a person with mpox who has completely covered lesions (e.g., bandaged, covered with clothing).

Recommendations

• Monitoring: At discretion of public health authority
• PEPB: No

No Identifiable Risk of Exposure

Exposure Characteristics

Absence of any exposure above AND:

• No contact with the person with mpox, their potentially contaminated materials, and only transient time spent within 6 feet of the person with mpox.

Recommendations

• Monitoring: No
• PEPB: No