Mpox (monkeypox) Overview

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Introduction   

Mpox (formerly called “monkeypox”) is an orthopoxvirus, meaning that it infects vertebrates (mammals, including humans) and arthropods (insects, crustaceans, arachnids, myriapods. The mpox virus is in the same family as the variola virus and causes a disease similar to the smallpox virus, but with a lower rate of mortality [4]. The virus was first discovered in 1958 when monkeys used in research were infected with a pox-like disease, and the first human case of mpox virus was noted in 1970 in a child from the Democratic Republic of Congo (DRC) [4,12]. The mpox virus is endemic to Western and Central Africa, but it has migrated to the Western Hemisphere via the exotic pet trade and international travel [1,5,13].  

The rise of mpox has been associated with the waning smallpox virus vaccination that previously protected individuals against the mpox virus, sociopolitical and ecological changes in endemic regions that have increased human exposure to animal reservoirs, and the high-risk practices of the men having sex with men (MSM) population [5,13,17]. In 1984, routine smallpox virus vaccination ended, which left more than half of the world’s population unprotected from the virus [12]. Household members of those infected with the mpox virus who were not vaccinated for smallpox virus are at greater risk of acquiring the mpox virus than those who were vaccinated for smallpox virus [2]. The virus is most prevalent in persons younger than 50 years of age since they did not receive the smallpox virus vaccination.  

The current outbreak of mpox primarily affects the MSM population, particularly those who have multiple partners [2,17]. Roughly 40% of mpox cases have occurred in clients with human immunodeficiency virus (HIV) [14]. 

The virus is spread via direct contact with contaminated body fluids, fomites, respiratory droplets, and skin injuries [4,12,13,18]. Mpox has a case fatality rate of up to 17%, and children, pregnant women, and immunocompromised individuals are at higher risk for poor outcomes [2,17]. 

However, there are vaccines available to help prevent the spread of the mpox virus. 

Similar to the smallpox virus, the mpox virus can be a source of biological warfare, which is spurring the development of vaccinations [2,12]. The virus’s easy transmission makes it important for nurses to recognize the signs and symptoms of mpox virus and to implement effective nursing interventions to prevent the spread. 

Etiology, Epidemiology, and Pathophysiology 

Mpox virus is a brick-shaped organism surrounded by a lipoprotein envelope that belongs to the Poxviridae family, chordopoxvirinae subfamily, orthopoxvirus genus, and mpox virus species [2,14]. Two kinds of the virus cause mpox: clade I and clade II [1,7]. Each of the clades has subclades: Ia, Ib, and IIb. Subclade Ia is most prevalent in Central Africa and is transmitted via infected live or dead animals, among members of crowded households, and via medical care of infected clients. A high number of cases have been reported in children 15 years and younger [2,7]. Subclade Ib is being spread in the DRC through sexual contact among members of the MSM population and those men who engage in heterosexual relations with sex trade workers [1,7]. Subclade Ib has a lower fatality rate than subclade Ib mpox virus [7]. The clade II mpox virus has affected more than 100,000 individuals in 122 countries, including 115 countries where mpox was not previously reported [7]. 

The Centers for Disease Control and Prevention (CDC) has posted a global map with the number of confirmed mpox cases, which they update regularly: https://www.cdc.gov/mpox/situation-summary/index.html. 

After entering the host from the oropharynx, nasopharynx, or intradermal routes, the mpox virus replicates at the site of entry and then spreads to local lymph nodes and other organs. Specifically, the virus spreads from animals in Africa to humans, particularly via primates (monkeys and apes), pigs, hedgehogs, mice and rats, squirrels, and prairie dogs [12,13]. Humans transmit the virus to one another via respiratory droplets, fomites, and direct contact with the lesions of an infected individual [4,12,13]. Anal and oropharynx swabs taken from clients infected with mpox virus indicate sexual transmission, and the virus is also spread via saliva, urine, feces, and semen [2,13].  

More specifically, the mpox virus is transmitted via [4,17,18]: 

• Direct contact with the lesions or scabs on a client’s skin who is infected with mpox virus. 
• Contact with objects (writing utensils, eating utensils, hairbrushes, electronic devices), fabrics (clothing, bedding, towels), and surfaces (countertops, furniture) that have been touched or used by clients with mpox virus. 
• Respiratory secretions via prolonged, face-to-face contact with a client with mpox virus. 
• Oral, anal, and vaginal sex, or touching the anus or genitals of an individual with mpox virus. 
• Kissing, hugging, or talking closely with an infected client. 
• Sharing fetish gear and sex toys with a client with mpox virus. 
• Pregnancy, in which the mpox virus is transmitted via the placenta to the fetus. 

The mpox transmission cycle begins with the virus affecting the respiratory epithelium and then spreading through the lymph system to the major organs where it replicates. Little or no virus is detected in this primary viremia stage because the virus is removed by the reticuloendothelial system. Secondary viremia follows the primary stage during which the infected organs and lymph tissue release the virus, and it travels to the cornified layer of the skin and mucosal epithelium where it causes lesions [2].  

The virus is most prevalent in the DRC in Central Africa and was first identified in captive monkeys, but data now indicates that African rodents were the first reservoir [12,13]. Mpox started appearing in humans located outside of Africa on several occasions: via prairie dogs imported from Ghana to homes in the Midwestern United States (as house pets), a man who traveled from Nigeria to Israel, and a family that returned to the United Kingdom after traveling to Nigeria [12,13]. As of November 2024, there is an outbreak of clade I mpox in Central and Eastern Africa, including Burundi, the Central African Republic, DRC, Rwanda, and Uganda [1,7]. Cases have also been confirmed in Germany, India, Sweden, Thailand, and the United Kingdom [1]. 

There is an increase in mpox virus cases in multiple countries on several continents, particularly among the MSM population [2,13]. In Spain, during 2022, 99% of cases were in the MSM population, and Germany reported over 1,000 cases during the same year in the same population [13].  

Children are susceptible to the mpox virus in Central and Western Africa due to their contact with wild animals that are in reservoirs [7]. The virus then spreads quickly within the children’s crowded households where the lack of disinfection and hygiene supplies is an issue, as well as malnutrition and lack of medical care [7]. The CDC states that they do not anticipate a similar situation in the United States due to fewer family members living under the same roof, greater access to disinfection and hygiene supplies, and more robust availability of healthcare [7].  

According to the CDC, the mpox virus occurs in three stages or periods [4,5,9]: 

1. Incubation period: The client does not have symptoms and may feel normal. The client is not contagious during this period, which lasts one to two weeks. However, nurses should monitor clients until the upper incubation period limit of 21 days is reached. 
2. Prodrome period: Fever, headache, malaise, sore throat, cough, and lymphadenopathy in the submandibular, cervical, axillary, and groin regions can occur on one or both sides of the body. The client is contagious during this period and should isolate. 
3. Rash period: Lesions develop and progress from macules, papules, vesicles, and pustules to crusts (scabs). The client is contagious until all crusts have fallen off and a fresh layer of intact skin has formed. Local and state health departments guide clinicians in deciding the discontinuation of isolation precautions. 

Signs and Symptoms 

Mucosal and skin lesions are the main clinical symptoms of mpox. The lesions are generally found on or near the penis, testicles, labia, vagina, and anus, as well as the hands, feet, face, mouth, and chest [4].  

Lymphadenopathy is found in clients with mpox virus but not in those with smallpox virus, making it a differential diagnostic factor, and inguinal lymphadenopathy is a predominant feature that suggests sexual transmission [13]. Roughly 90% of clients with mpox virus experience lymphadenopathy in the submandibular, cervical, postauricular, axillary, or inguinal lymph nodes, either singly or in combination [2]. The enlarged lymph nodes are firm, tender, and occasionally painful, with their size measuring approximately one to four centimeters, similar to the size of a pigeon’s egg.  

Prodromal symptoms such as fever and lymphadenopathy can occur before the lesions appear, and infected clients may be contagious at this time [4,5]. However, some clients experience a rash of lesions first, followed by other symptoms, while other clients only experience the lesions [4].  

Initial signs and symptoms of mpox virus include [2,4,5,9,13,17,18]: 

• Fever 
• Chills 
• Headache 
• Myalgia 
• Fatigue 
• Lymphadenopathy 
• Respiratory symptoms (sore throat, nasal congestion, cough) 

After a day or two, mucosal lesions develop in the mouth and skin lesions develop on the face, extremities, palms of the hands, and soles of the feet. The lesions can spread to other areas of the body and can range from a few to thousands. They typically develop and evolve together on any given body part. Mpox lesions are rubbery to firm, well-circumcised, and deep-seated, and develop a dot, or umbilication, on top of the lesion.  

During the following two to four weeks, the skin lesions evolve through macular, papular, vesicular, and pustular phases every two days [5]. During this time, nausea and vomiting can also be noted, which can result in severe dehydration. After roughly a week in the pustular phase, the lesions form crusts, which slough off over the following week to two weeks. After these crusts slough off, the client is no longer considered infectious [4,13]. The total illness trajectory typically lasts two to four weeks [4,5]. 

In the MSM population, the lesions are prevalent in the genital and perianal areas and tend to form in clusters. Bloody or purulent stools, rectal pain, and rectal bleeding can accompany the lesions in the rectal area [5].  

The table below details the typical mpox virus lesion progression, but the timeline can vary from client to client [5]. 

Mpox Virus Lesion Stages [5] 

After the crusts have fallen off, the new skin may reveal pitted scars and areas of hypopigmentation and hyperpigmentation. The client is no longer considered contagious at this stage [4]. 

The American Nurses Association states that nurses can expect client symptom onset to begin within three weeks of exposure to the mpox virus, and those individuals who have flu-like symptoms can develop the rash one to four days later [4].  

Mpox is contagious from the onset of symptoms until the lesions have healed and all scabs have sloughed off, revealing a fresh layer of skin, with the entire illness lasting two to four weeks [4]. 

Nursing Assessment 

Nursing professionals play an important role in retrieving client histories and relaying this data to the healthcare team for accurate diagnosis of mpox virus [10]. If the nurse suspects mpox virus while assessing a client, they should notify the facility’s infectious disease team immediately [3]. The nurse should begin the assessment by asking the client about international travel (particularly to Africa), exposure to live or dead wild animals (particularly from Africa), recent contact with any persons infected with smallpox or mpox viruses, and if the client engages in MSM activities [13]. 

The nurse should be aware that mpox virus can be confused with the signs and symptoms of smallpox virus, generalized vaccinia, zoster virus, chickenpox, eczema herpeticum, herpes simplex, syphilis, yaws, scabies, rickettsia pox, measles, bacterial skin infections, and medication skin reactions [4,13]. However, the nurse should recognize that although the symptoms of mpox virus and secondary syphilis symptoms are similar, lesions associated with syphilis are painless, whereas mpox lesions are painful [14]. 

The nurse should assess the client for pain since the skin lesions are painful and then become itchy when the crusts form [5]. The nurse should also assess clients for malnutrition, dehydration, wound infection, systemic infection, and anxiety related to isolation since these are complications associated with the mpox virus [4,14,16,17,18]. 

The nurse should monitor the client’s temperature and other symptoms for 21 days since this is the upper limit of the incubation period.  

Diagnosis 

The CDC implemented the Acute, Generalized Vesicular or Pustular Rash Illness Protocol to determine which clients with mpox virus warrant further testing [13]. The CDC recommends collecting two specimens, each from multiple lesions from different locations on the body [6,8]. Testing should also include non-variola orthopox virus testing, with further diagnostics conducted at the CDC [13]. Mpox virus infection is diagnosed by polymerase chain reaction (PCR) test or isolation in viral culture [13,18]. 

The U.S. Food and Drug Administration (FDA) recommends using swab samples taken directly from lesions versus taking samples from saliva, blood, or other bodily fluids when testing for the mpox virus since the latter-mentioned fluids can lead to false results [15]. If the nurse encounters a situation where the client was tested for mpox virus using an alternate sample type, they should retest the client using a lesion swab sample [15].  

The diagnostic labeling system should identify all specimens, and all specimen handling should follow local health department and CDC guidelines. Healthcare personnel who collect the specimens should use personal protective equipment (PPE) following local health department and CDC guidelines [4].  

Additional diagnostic tests that should be performed on clients suspected of mpox virus include [11,16]: 

• Complete blood count (CBC): Leukocytosis, lymphocytosis, and thrombocytopenia may be present. 
• Blood urea nitrogen (BUN): Blood urea nitrogen can indicate a poor nutritional state that can impair wound healing. 
• Liver function tests (LFTs): Elevated transaminases and hypoalbuminemia may exist. 
• Sexually transmitted infection (STI)/human immunodeficiency virus (HIV) tests: Clients presenting with anal, genital, and perianal lesions should be tested. Mpox virus and STIs can be confused with each other, so differential diagnosis is required. The presence of an STI does not rule out mpox virus. 

Computed tomography (CT) of the abdomen and pelvis can detect anorectal mural thickening while blood cultures can detect bacteremia and confirm superinfection [11]. A malaria antigen test is warranted if the client has traveled to a malaria-endemic region, especially if the client is febrile [11]. 

Treatment and Prognosis 

The healthcare team members who can be involved in treating clients with the mpox virus include physicians, nurses, dermatologists, immunologists, virologists, veterinarians, and public health officials. There is no clinically proven treatment specifically for the mpox virus, but care focuses on symptom management and supportive care, especially pain management and wound care [4,10,12,13,14]. The CDC recommends that one of the first steps of treatment for the client with mpox virus is isolation in a negative pressure room and standard contact, and droplet precautions initiated in the healthcare setting with escalation to airborne precautions if possible [13]. 

There are several medications used in the treatment of the mpox virus. The oral deoxyribonucleic acid (DNA) polymerase inhibitor brincidofovir (Tembexa), oral intracellular viral release inhibitor tecovirimat (TPOXX), intravenous vaccinia immune globulin (VIG), and cidofovir (Vistide) are being used in the treatment of the mpox virus [4,13,16]. Dual therapy with tecovirimat and brincidofovir is being trialed in severe cases. Tecovirimat blocks the release of the virus from infected cells, while brincidofovir is approved for the treatment of smallpox virus in the United States. The effectiveness of VIG is uncertain since it has not been trialed in humans for smallpox or mpox virus [13]. 

Ideally, clients who are at risk for the mpox virus should be vaccinated before exposure to the virus, but vaccination after exposure to the virus can prevent mpox [6].  

Two vaccines are currently used for the prevention of mpox virus, including [6,7,12,13,16]:  

1. Modified vaccinia Ankara (MVA) virus (JYNNEOS and IMVAMUNE vaccines) is FDA-approved and recommended by the CDC and Advisory Committee on Immunization Practices (ACIP) for the prevention of mpox virus (all clades and subclades) and smallpox virus. The vaccine can also be given for postexposure prophylaxis. This is the main vaccine used in the United States today and it is readily available. It is a nonreplicating attenuated vaccine with a large safety margin, which can be administered to immunocompromised clients. Ankara is given as a two-part series with the doses administered four weeks (28 days) apart. The vaccine can be administered subcutaneously at a volume of 0.5 mL or intradermally at a volume of 0.1 mL using a bifurcated needle. It is not advised that more than two doses be given to clients. However, research laboratory personnel who directly handle cultures or animals contaminated or infected with mpox virus are urged to receive a booster at two to ten years. Vaccination is not recommended for clinical laboratory personnel who perform routine chemistry, hematology, and urinalysis testing, including for clients with suspected or confirmed mpox virus infection.  
2. ACAM2000 vaccine is approved for use against smallpox virus and is being investigated in the use against mpox virus. Even though there is a large supply of ACAM2000 available in the United States, it carries more side effects and contraindications than Ankara and is only recommended for healthy individuals. ACAM2000 contains a live vaccinia virus and is given in a single dose via several skin pricks using a two-pronged needle in the upper arm. A red rash occurs at the injection site three days after inoculation, which is a positive sign since it indicates uptake of the vaccine. Vaccination status is acquired in 28 days. Side effects can include myocarditis, pericarditis, dermatitis, erythema, itching, and induration. The vaccine is contraindicated in clients with HIV and cancer. 

The lesions associated with the mpox virus can be painful and should be treated with acetaminophen or non-steroidal anti-inflammatory (NSAID) medications. Clients who experience increased pain can be treated with gabapentinoids and short-course opioids [14]. Stool softeners, sitz baths, and lidocaine gels can ease the pain associated with proctitis caused by lesions [14]. Saltwater and viscous lidocaine gargles are used to manage pharyngitis. Topical and systemic antibiotics are used when bacterial superinfection is suspected [14]. 

Some clients with the mpox virus require volume replacement since the pain associated with oral lesions can demotivate clients to remain hydrated. Additionally, gastrointestinal fluid loss and hypoalbuminemia can occur when systemic infection is present, further contributing to fluid imbalance [2]. In these cases, fluid therapy is required to assist the client in maintaining electrolyte and fluid balance. 

The prognosis depends on the client’s current health status, previous vaccination status, concurrent illness, and comorbidities [4]. The nurse should take into consideration that the client’s immune status, age, pregnancy and breastfeeding status, and dermatologic history also affect prognosis [4]. The West African clade has a case fatality rate below 1%, whereas the Central African clade has a case fatality rate of up to 11%. The remainder of clients typically experience a full recovery within four weeks of symptom onset, aside from discoloration and scarring of the skin [13]. 

Nursing Interventions 

Nurses play an integral role in assisting clients in recovering from the mpox virus, as well as keeping communities safe from the virus. 

Nursing interventions nurses should implement when caring for the client with mpox virus include [3,4,8,10,17,18]: 

• Immediately notify the facility’s infection control team of the client’s diagnosis or suspected diagnosis. 
• Moving the client to a single person/private room with a private bathroom. Special air handling equipment is not required, but the client’s door should remain closed.  
• Consider visitors to the client’s room on an individual basis based on the client’s age and immune status, and the visitors’ previous risk exposure to the client. 
• Refraining from moving the client from their room unless medically necessary. When transported, clients should wear a mask and cover exposed skin lesions with dressings, a gown, or a sheet. 
• Performing intubation, extubation, or any procedures that can spread oral secretions in an airborne infection isolation room. 
• Administering medications, including vaccinations. 
• Ensuring the client receives adequate hydration and nutrition.  
• Caring for wounds and monitoring their healing. Using a digital camera can help document wound healing. 
• Monitoring clients for secondary bacterial infections and other complications. 
• Donning PPE when entering the client’s room. PPE includes a gown, gloves, eye protection (goggles or face shield that covers the front and sides of the face), and a NIOSH-approved particulate respirator equipped with N95 filters or higher. 
• Implementing disinfection procedures using environmental protection agency (EPA)-registered hospital-grade disinfectants that are proven to control viral pathogens. 
• Avoid the use of portable fans in the client’s room to prevent the spread of dried material from the lesions. 
• Notifying the custodial department not to dry dust, sweep, or vacuum in the client’s room since this can cause the spread of dried material from lesions. Wet cleaning is preferred. 
• Disposing of diagnostic samples and clinical waste contaminated with clade I or clade II mpox virus following local and state guidelines for medical waste. 
• Containing soiled laundry (linens, towels, clothing) in an appropriate laundry bag and not shaking or tossing the bag, which can result in dispersing infectious material. 
• Delivering food service items following facility, local, and state protocols. 

Nurses play a pivotal role in supporting clients’ mental and emotional health. Many clients with mpox virus experience fear and anxiety due to the virus’s contagious nature and the client’s subsequent isolation [10]. Stigma linked with the mpox virus can prolong outbreaks since infected clients are hesitant to come forward [18]. Therefore, facilitating communication between clients and family members, addressing the client’s emotional needs, and advocating for the client are compassionate measures that nurses should take [10]. 

Nurses should teach clients with the mpox virus and their family members preventative measures, such as [3,4,8,10,17.18]: 

• Avoid close contact and skin-to-skin contact with infected persons, including sexual contact. 
• Avoid contact with animals. 
• Do not share eating utensils or cups with infected individuals. 
• Do not handle the clothing, bedding, or towels of a client with mpox virus. 
• Do not donate blood, cells, tissue, breast milk, or semen. Organ donation depends on the individual’s risk-benefit situation. 
• Do not pop blisters or scratch lesions, which can increase the spread of the virus and delay healing of the lesions. 
• Do not shave areas with lesions until the scabs have sloughed off and the new skin is visible. 
• Wash hands frequently with soap and water, or use an alcohol-based hand sanitizer, especially before eating and after toileting or touching one’s face. 
• Refrain from going in public, attending social gatherings, or taking public transportation. If venturing in public, wear a well-fitted mask and cover all lesions with dressings. 

The nurse should teach the client diagnosed with mpox virus that they are at an increased risk for developing pneumonia, sepsis, encephalitis, permanent skin scarring, hypopigmentation or hyperpigmentation of the skin, bacterial superinfection of the skin, and permanent corneal scarring that can result in vision loss [13]. Clients should also be taught that painful oral lesions can lead to dehydration due to decreased oral intake, as can widespread skin eruptions that cause insensible fluid loss. Vomiting and diarrhea can also be found in clients with mpox virus, further challenging fluid balance [4,13]. 

Nurses who are exposed to the mpox virus and are asymptomatic do not need to be excluded from work, but they should be monitored at least daily for signs and symptoms for 21 days after their last exposure [8]. If the nurse does have symptoms of mpox virus, they should be excluded from work until a diagnosis is confirmed and ensuing lesions have completely sloughed off and the new skin is present and intact [8]. 

Prevention 

The CDC works in tandem with the government, civil society, and health agencies and partners in Africa to survey the mpox virus, build laboratories, prevent infection, provide community education, and administer vaccinations. The CDC has trained over 100 field epidemiologists in the DRC in Central Africa who detect cases, track and monitor infected individuals, collect and send specimens to laboratories for testing, provide education to community members, and train healthcare workers about mpox [7].  

In the United States, the CDC works with territorial, state, tribal, and local health departments to provide information about the mpox virus. The organization disseminates educational information to healthcare providers and individuals who are traveling internationally, particularly to Central and Eastern Africa. The CDC also collaborates with partner organizations to ensure that the mpox vaccine is readily available to those populations who are at higher risk [7].  

The FDA works with the CDC to make mpox testing more readily available to clients. It also takes measures to expedite distribution of the tests, as well as increase testing capacity of laboratories. Finally, the FDA educates test users, caregivers, healthcare personnel, laboratory personnel, test developers, and the public to help reduce the risk of false test results and increase the spread of the mpox virus [15]. 

Conclusion

It is important for nurses to understand the etiology, pathophysiology, and signs and symptoms of mpox virus since it is similar to other health conditions, including smallpox virus and some sexually transmitted infections. Nurses help determine the client’s diagnosis by asking pertinent questions during assessment and taking effective samples for laboratory testing. The nurse can help alleviate the pain associated with mpox virus lesions by administering oral medications, applying topical medications, and encouraging client self-care practices. The data that nurses collect during client care assist the CDC, FDA, and public health departments with finding effective solutions to the mpox virus global outbreak. 

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