Risk stratification and management after an exposure to mpox (monkeypox)

Exposure category	Community	Health care setting	Management*
Higher (known exposure)	Any sexual or intimate contact involving mucous membranes (eg, kissing, oral-genital, oral-anal, vaginal, or anal sex [insertive or receptive]) with a source patient who has mpox or Contact between an exposed individual's broken skin or mucous membranes with either: The skin lesions or bodily fluids from a source patient with mpox Materials (eg, linens, clothing, objects, sex toys) that have contacted the skin lesions or bodily fluids of a source patient with mpox without having been disinfected or laundered^¶^Δ	Unprotected contact between an exposed HCP's broken skin or mucous membranes and either: The skin lesions or bodily fluids from a patient with mpox (eg, inadvertent splashes of patient saliva to the eyes or mouth of HCP, needlesticks) Soiled materials (eg, linens, clothing) or Being inside the patient's room or within 6 feet of a patient with mpox without wearing a NIOSH-approved particulate respirator with N95 filters or higher and eye protection during either: Medical procedures that may create aerosols from oral secretions (eg, tracheal intubation and extubation, tracheotomy, bronchoscopy, noninvasive ventilation) Activities that may resuspend dried exudates (eg, shaking of soiled linens)	Post-exposure vaccination warranted^◊ Monitor for 21 days
Higher (presumed exposure)	Gay, bisexual, or other men who have sex with men, or transgender and gender diverse people who have sex with men, who have had any of the following within the past 14 days: Sex with multiple partners (or group sex) Sex at a commercial sex venue Sex in association with an event, venue, or defined geographic area where monkeypox virus transmission is occurring	N/A	Post-exposure vaccination^◊^§ Monitor for 21 days
Intermediate	Being within 6 feet for 3 hours or more (cumulative) of an unmasked person with mpox without wearing a surgical mask or respirator or Contact between an exposed individual's intact skin with either: The skin lesions or bodily fluids from a source patient with mpox Materials (eg, linens, clothing, objects, sex toys) that have contacted the skin lesions or bodily fluids of a person with mpox without having been disinfected or laundered^Δ or Contact between an exposed individual's clothing with either:^¥ The person with mpox's skin lesions or bodily fluids The person with mpox's soiled linens or dressings	Being within 6 feet for a total of 3 hours or more (cumulative) of an unmasked patient with mpox without wearing a surgical mask or respirator or Unprotected contact between an exposed individual's intact skin and the skin lesions or bodily fluids from a patient with mpox or soiled materials (eg, linens, clothing) or Activities resulting in contact between an exposed HCP's clothing and the patient's skin lesions or bodily fluids or their soiled materials while not wearing a gown^¥	Post-exposure vaccination determined on a case-by-case basis^◊^‡ Monitor for 21 days
Lower	Entry into the living space of a person with mpox (regardless of whether the person with mpox is present) and in the absence of any exposures above	Entry into the contaminated room or patient care area of a patient with mpox without wearing all recommended PPE and in the absence of any exposures above^†	Monitor for 21 days
No risk	No contact with the person with mpox, their potentially infectious contaminated materials, or entry into their living space	No contact with the patient with mpox or their contaminated materials No entry into the contaminated patient room or care area

This table is to be used in conjunction with UpToDate content on mpox, orthopoxvirus vaccines, and infection prevention. It provides a framework for determining risk after an exposure; however, institutional policies may vary.

In November 2022, the World Health Organization changed the name of the disease referred to as "monkeypox" to "mpox." The virus that causes mpox continues to be referred to as monkeypox virus.

HCP: health care personnel; PPE: personal protection equipment.

* During the 2022 global outbreak, post-exposure vaccination is not indicated for those who received pre-exposure prophylaxis and those who already developed mpox during the outbreak. In addition, if mpox develops after the first vaccine dose, the second dose should be deferred.

¶ This includes activities such as sharing food or handling or sharing of linens used by a person with mpox.

Δ For appropriate disinfection, individuals should use a disinfectant registered with the US Environmental Protection Agency (EPA) with an emerging viral pathogens claim.

◊ Post-exposure prophylaxis generally refers to vaccination with the modified Ankara vaccina (MVA) vaccine (sold as JYNNEOS in the United States), which requires two doses 28 days apart. A replication-competent vaccine (ACAM2000) can also be considered for post-exposure prophylaxis in select patients but can be associated with severe adverse reactions.

§ Vaccination in this setting is referred to as expanded post-exposure prophylaxis (PEP) or PEP++. Eligibility is typically dictated by local public health authorities and depends in part on the availability of vaccine. Some jurisdictions have expanded eligibility beyond the risk groups listed in the table. For example, in Philadelphia, sex workers, regardless of gender, are eligible to receive vaccination.

¥ This type of contact may occur during turning, bathing, or assisting with transfer.

‡ The decision to vaccinate depends on the specific details of the exposure as well as the exposed individual's risk of developing severe disease.

† The authors consider HCP who use appropriate PPE and follow recommended infection control precautions to have no recognized exposure, and for this population we do not recommend monitoring. Appropriate PPE includes use of a gown, gloves, eye protection (goggles or face shield), and a National Institute for Occupational Safety and Health (NIOSH)-approved N95 filtering facepiece or equivalent or higher-level respirator. While there is no epidemiologic evidence to date that monkeypox virus is spread by the airborne route, at this time the CDC recommends respiratory protection be used.

Adapted from:

Monitoring and Risk Assessment for Persons Exposed in the Community. United States Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html (Accessed on August 23, 2022).
Infection Prevention and Control of Monkeypox in Healthcare Settings. United States Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html (Accessed on August 23, 2022).
Monkeypox: Vaccination Strategies. United States Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/poxvirus/monkeypox/interim-considerations/overview.html#anchor_1660077319531 (Accessed on August 23, 2022).

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Risk stratification and management after an exposure to mpox (monkeypox)