Since our initial advisory on July 21, 2021, monkeypox has been declared a public health emergency by the U.S. Department of Health and Human Services.  Monkeypox is in the same family of viruses as smallpox but causes a milder infection.  Although it is a rare viral illness, there have been cases of monkeypox in 2022 in locations of the world where it has never occurred in the past, including within the state of Ohio. All Ohio clinicians, including those in EMS, should be aware of the signs and symptoms of monkeypox and the current guidance that has been recommended by the Centers for Disease Control and Prevention (CDC). 

Monkeypox typically begins with a flu-like illness that can include a prodrome of fever, malaise, headache, muscle aches, and swollen lymph nodes.  In 1 to 3 days following the prodrome, a rash that has the appearance of pimples or blisters erupts.  These lesions have a firm, rubbery texture and can affect any part of the body.  The rash can change, turning into scabs before they heal.  The average incubation period is 5 to 13 days and most infections last 2 to 4 weeks.  Transmission of the virus occurs through direct contact with the lesions, respiratory droplets, or direct contact with items that have been contaminated with fluids or contact with sores.  Although antivirals may be beneficial, there is no specific treatment for monkeypox.

As of August 11, 2022, the protective measures that should be taken for patients with suspected or confirmed monkeypox include the following:

• Wear personal protective equipment (PPE) in accordance with the CDC’s recommendations for standard, contact, and airborne precautions
  • Gown
  • Gloves
  • Eye protection (i.e., goggles or a face shield that covers the front and sides of the face)
  • NIOSH-approved particulate respirator equipped with N95 filters or higher
• Take measures to minimize aerosolization and spread of the patient’s respiratory particles (apply a surgical mask to the patient, avoid nebulized medications, and, if available, place the patient in a negative pressure room upon arrival to the receiving facility)
• Communicate the importance of maintaining proper isolation precautions so that infection is not transmitted to them or others
• Standard cleaning and disinfection procedures should be performed with an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim. Wet cleaning methods are preferred.  Avoid dry dusting, sweeping, or vacuuming as this can disperse the virus particles. 

There is no specific treatment for monkeypox; however, antivirals may be beneficial, especially for people who are more likely to get severely ill including patients with weakened immune systems.  The CDC recommends vaccination for people who have been exposed to monkeypox and people who may be more likely to get monkeypox.  Currently, there are two monkeypox vaccines, ACAM2000 and JYNNEOS, that are available.  JYNNEOS is the primary vaccine being used as a part of this outbreak response and was released under Emergency Use Authorization (EUA) which has associated mandatory requirements that include, but are not limited to, documentation of the provision of patient education regarding risks, benefits, and alternative immunization options, acquisition of informed consent, and mandatory reporting of confirmed or unconfirmed adverse effects to the Food and Drug Administration (FDA).  While this vaccine was initially being administered via the intramuscular route, the current recommended route for the administration of the JYNNEOS monkeypox vaccine is intradermal.    

On August 19, 2020, the State Board of Emergency Medical, Fire, and Transportation Services (EMFTS Board) recognized that EMS certificate holders are permitted to administer vaccinations so long as the route of administration is within the scope of practice and the certificate holder administers the vaccine pursuant to medical direction and training on the specific vaccine, which includes adherence to the recommendations and instructions of the Food and Drug Administration.  Please note that the intradermal or percutaneous routes of administration of medications, including vaccines, have not been approved by the EMFTS Board for any level of Ohio EMS certification and; therefore, are not within the Ohio EMS scope of practice.

The Ohio Department of Public Safety, Division of EMS will provide additional information and updated guidance for monkeypox as it becomes available.  While monkeypox is a newly emerging risk in Ohio, please continue to wear the appropriate PPE for all patient encounters as the multitude of other highly contagious pathogens still exists and continues to challenge all first responders and healthcare providers.  As always, thank you for your dedicated service to the residents and visitors of Ohio.