Monitoring and Risk Assessment for Persons Exposed in the Community

Person feeling ill

This guidance is intended for people who have had monkeypox exposures in the community. These recommendations can apply to the workplace. Employers can learn more on the Workplaces and Businesses page. Guidance for exposures in healthcare settings can be found here: Infection Prevention and Control of Monkeypox in Healthcare Settings.

Who should be monitored and for how long?

Anyone with an exposure to people or animals with monkeypox should monitor their health or be monitored for signs or symptoms consistent with monkeypox for 21 days after their last exposure. Information about human-to-human transmission of monkeypox virus is described in How it Spreads | Monkeypox | Poxvirus | CDC.

What to monitor

Monitoring should include assessing the person for signs and symptoms of monkeypox, including a thorough skin and mouth (oral) exam in good lighting. 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.

Learn more about signs and symptoms of monkeypox infection.

Development of rash, signs, or symptoms

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 monkeypox 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 be ended prior to 5 days if a healthcare provider or public health authority believes the rash, signs, or symptoms are not due to monkeypox 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 monkeypox virus 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 monkeypox.

To date, there have been no cases of Monkeypox 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 monkeypox virus infection, 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. 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. 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 post exposure prophylaxis (PEP) are all factors when determining the type of monitoring to be used.

How to monitor 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 monkeypox but are unable to communicate onset of symptoms should consider the risk of their exposure incident (how likely they are to develop monkeypox infection) 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.

Monkeypox typically spreads through prolonged close, skin-to-skin contact with a person who has monkeypox, 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 monkeypox.

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 monkeypox should be considered to have intermediate or lower degree of exposure.

Interim Community Exposure Risk Assessment and Recommendations

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

High Degree of Exposure

Exposure Characteristics

  • Contact between an exposed individual’s broken skin or mucous membranes with the skin lesions or bodily fluids from a person with monkeypox -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 monkeypox -OR-
  • Contact between an exposed individual’s broken skin or mucous membranes with materials (e.g., linens, clothing, objects, sex toys) that have contacted the skin lesions or bodily fluids of a person with monkeypox (e.g., sharing food, handling or sharing of linens used by a person with monkeypox without having been disinfected† or laundered)

Recommendations

  • Monitoring: Yes
  • PEP: Recommended
Intermediate Degree of Exposure

Exposure Characteristics

  • Being within 6 feet for a total of 3 hours or more (cumulative) of an unmasked person with monkeypox without wearing a surgical mask or respirator -OR-
  • Contact between an exposed individual’s intact skin with the skin lesions or bodily fluids from a person with monkeypox -OR-
  • Contact between an exposed individual’s intact skin with materials (e.g., linens, clothing, sex toys) that have contacted the skin lesions or bodily fluids from a person with monkeypox without having been disinfected† or laundered -OR-
  • Contact between an exposed individual’s clothing with the person with monkeypox’s skin lesions or bodily fluids, or their soiled linens or dressings (e.g., during turning, bathing, or assisting with transfer)

Recommendations

  • Monitoring: Yes
  • PEP: Informed clinical decision making recommended on an individual basis to determine if the benefits of PEP outweigh the risks
Lower Degree of Exposure

Exposure Characteristics

  • Entry into the living space of a person with monkeypox (regardless of whether the person with monkeypox is present), and in the absence of any exposures above

Recommendations

  • Monitoring: Yes
  • PEP: None
No Risk of Exposure

Recommendations

  • Monitoring: No
  • PEP: None

Exposure Characteristics

  • No contact with the person with monkeypox, their potentially infectious contaminated materials, nor entry into their living space

¶ JYNNEOS and ACAM2000 are available for PEP

† Disinfection using a disinfectant registered with the U.S. Environmental Protection Agency (EPA), such as those with an emerging viral pathogens claim found on EPA’s List Q

Factors that may increase the risk of monkeypox transmission include (but are not limited to): the person with monkeypox had clothes that were soiled with bodily fluids or secretions (e.g., discharge, skin lesion crusts or scabs on clothes) or was coughing while not wearing a mask or respirator, or the exposed individual is not previously vaccinated against smallpox or monkeypox. People who may be at increased risk for severe disease include (but are not limited to): young children (<8 years of age), individuals who are pregnant or immunocompromised, and individuals with a history of atopic dermatitis or eczema.