Monkeypox Treatment & Management

Updated: Aug 17, 2022
  • Author: Mary Beth Graham, MD, FIDSA, FACP; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

Also see Guidelines.

The disease is usually self-limited; resolution occurs in 2-4 weeks. In the African cases, the mortality rate was 1-10%, and death was related to the patients' health status and other comorbidities. Most patients died of secondary infections. No fatalities were reported in the 2003 US outbreak.

Patients often feel poorly during the febrile stage of the illness; therefore, bedrest along with supportive care may be necessary. Hospitalization may be necessary in more severe cases; a negative pressure room is preferable.

To avoid infection of health care workers and close contacts, airborne and contact precautions should be applied. See the current CDC recommendations at Infection Prevention and Control of Monkeypox in Healthcare Settings.

Isolation must be continued until the last crust is shed. 

Also see, CDC Monkeypox resources for healthcare professionals

Antiviral Agents

Tecovirimat 

Tecovirimat (TPOXX) is approved by the FDA and is indicated for treatment of human smallpox disease caused by variola virus. Also, the CDC holds an expanded access investigational new drug (EA-IND), also called compassionate use, that allows for the use of stockpiled tecorvirimat to treat monkeypox during an outbreak. Tecovirimat is currently stockpiled by the US federal Strategic National Stockpile, but administration of the drug is under an IND exemption application. [44, 45]

Cidofovir 

Data on the effectiveness of cidofovir in human cases of monkeypox are not available. It is indicated for cytomegalovirus in the United States. Although cidofovir has proven activity against poxviruses in in vitro  and animal studies, it is not known whether or not a patient with severe monkeypox infection will benefit from treatment. The CDC holds an EA-IND that allows for the use of stockpiled cidofovir for the treatment of orthopoxviruses (including monkeypox) in an outbreak. [44]  

Brincidofovir

Brincidofovir (Tembexa) is indicated for treatment of smallpox caused by virola virus in adults and children, including neonates. Brincidofovir is a prodrug of cidofovir diphosphate. Cidofovir diphosphate selectively inhibits orthopoxvirus DNA polymerase-mediated viral DNA synthesis. Brincidofovir may have an improved safety profile over cidofovir as severe renal toxicity or other adverse events have not been observed during treatment of cytomegalovirus infections with brincidofovir in comparison to treatment using cidofovir. The CDC is currently developing an EA-IND for to help facilitate use of brincidofovir as a treatment for monkeypox. [44, 45]  

Vaccinia immune globulin (VIG)

Data are not available on the effectiveness of VIG in treatment of monkeypox complications. Use of VIG is administered under an EA-IND for treatment of orthopoxviruses (including monkeypox) in an outbreak. It is not known whether a patient with severe monkeypox infection will benefit from VIG treatment.

VIG can be considered for prophylactic use in a monkeypox-exposed person with severe immunodeficiency in T-cell function for which smallpox vaccination following monkeypox exposure is contraindicated. [44]

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Prevention

Immunization

In September 2019, the FDA approved an attenuated, live, nonreplicating smallpox and monkeypox vaccine (Jynneos) for immunization of adults at high risk for smallpox or monkeypox infection. Approval was determined in a clinical study comparing the immune responses in study participants who received either Jynneos or ACAM2000, an FDA-approved vaccine for the prevention of smallpox. The study included approximately 400 healthy adults, aged 18-42 years who had never been vaccinated for smallpox. Half of the study participants received 2 doses of Jynneos administered 28 days apart, and half received 1 dose of ACAM2000. The group vaccinated with Jynneos had an immune response that was not inferior to immune responses to ACAM2000. [17, 18, 45]  

The FDA granted emergency use authorization (EUA) August 9, 2022 for Jynneos to expand vaccine supply by administering a 0.1-mL intradermal dose to adults. The EUA also expands use to include children aged 18 years and younger to receive the subcutaneous 0.5-mL dose.    

Individuals who should receive vaccine

The Advisory Committee on Immunization Practices (ACIP) recommends that people whose jobs may expose them to orthopoxviruses, such as monkeypox, get vaccinated with either ACAM2000 or monkeypox vaccine to protect them if they are exposed to an orthopoxvirus. [46]  

Widespread vaccination during the 2022 outbreak is not recommended; however, the CDC recommends vaccination for individuals who have been exposed to monkeypox and those who may be more likely to become infected.

People more likely to get monkeypox include:

  • People identified by public health officials as a contact of someone with monkeypox 
  • People who are aware that one of their sexual partners in the past 2 weeks was diagnosed with monkeypox 
  • People who had multiple sexual partners in the past 2 weeks in an area with known monkeypox 

People whose jobs may expose them to orthopoxviruses, such as: 

  • Laboratory workers who perform testing for orthopoxviruses 
  • Laboratory workers who handle cultures or animals with orthopoxviruses 
  • Some designated healthcare or public health workers 

Immunization following exposure 

CDC recommends that the monkeypox vaccine be given within 4 days from the date of exposure in order to prevent onset of the disease. If given between 4-14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease. [46]  

A 2010 report describes experimental low-dose intranasal infection in a STAT1-deficient C57BL/6 mouse model that caused 100% mortality. However, vaccination with modified vaccinia virus Ankara, followed by a booster vaccination, was protective against intranasal infection and produced a more vigorous immune response compared with a single vaccination. [47]  Other mouse models are being used to investigate monkeypox pathogenesis, disease progression, viral shedding, and virulence, with the possible aim of testing antivirals and next-generation vaccines. [48]  

Animal Importation

Importation of exotic animals as domestic pets poses a threat to the health of both people and animals by introducing nonindigenous pathogens. Animals, especially those implicated above (see Causes) or those in contact with them, demonstrating signs of respiratory distress, mucocutaneous lesions, rhinorrhea, ocular discharge, and/or lymphadenopathy should be quarantined immediately. Avoidance of contact, especially bites, scratches, and exposure to fluids/secretions, is essential. Guidance can be obtained from veterinarians, state/local authorities, and the CDC. See the current CDC recommendations at Monkeypox Infections In Animals: Updated Interim Guidance for Veterinarians. 

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Long-Term Monitoring

Outpatient management is appropriate and cost-effective in most cases of human infection, but care must be taken to follow recommended quarantine procedures at home.

Contact and respiratory isolation precautions should be exercised to prevent the spread of disease. Direct contact with skin lesions or fomites is considered infectious until the crust detaches from the last skin lesion. Patients and unexposed contacts should wear masks until respiratory symptoms resolve.

Health care workers and others who are asymptomatic and in contact with patients who are infected must closely monitor their symptoms and their temperature for 21 days after the last known contact. See the current CDC recommendations at Infection Prevention and Control of Monkeypox in Healthcare Settings.

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