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Monkeypox (Mpox)

1 Contact Hour including 1 Advanced Pharmacology Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Tuesday, June 25, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥ 92% of participants will know how to identify and respond to Monkeypox (Mpox) cases.


Upon completion of this course, the learner will be able to:

  1. Define Monkeypox (Mpox).
  2. Describe the process of Monkeypox (Mpox) transmission.
  3. Differentiate between Monkeypox (Mpox) and other differential diagnoses.
  4. Identify complications of Monkeypox (Mpox).
  5. Explain recommended treatment for Monkeypox (Mpox).
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Monkeypox (Mpox)
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
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    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Alyssa King (DNP, APRN, CPNP-PC, PMHNP-BC, CLC, CNE) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)


Monkeypox (Mpox) is an endemic Orthopox virus in West and Central Africa. Mpox is now occurring in other countries, causing major healthcare concerns. Most human Mpox infections are reported in the Congo Basin of the Democratic Republic of Congo (Hughes et al., 2021). Mpox is most commonly found in rural, forested communities with poor sanitation and chronic malnutrition (Beer & Rao, 2019). However, as of January 25th, 2023, there were 30,093 confirmed Mpox/Orthopoxvirus cases in the United States (Centers for Disease Control and Prevention [CDC], 2022b).

In November 2022, the World Health Organization (WHO) sent a news release regarding Mpox. Due to the outbreak expansion over the past year that exposed racist and stigmatizing language, after consultation with several global experts as well as the general public, WHO recommended a new name for "Monkeypox" (World Health Organization [WHO], 2022b). "Mpox" was recommended to become the preferred term to replace "Monkeypox" after one year to allow time for the transitioning of all policies and procedures to reflect the new name as well as for the International Classification of Diseases (ICD) to adopt the new term for medical coding purposes (WHO, 2022b).

Mpox cases are being reported sporadically around the world. It is believed to have spread worldwide due to the lack of immunization after the smallpox vaccine was stopped (Grant et al., 2020). Therefore, people who did not receive a smallpox vaccine (those younger than 40-50) may be susceptible.

Mpox is categorized into two genetic clades. These include the genetic clades of West Africa and Central Africa (also called Congo Basin). These clades have epidemiological and clinical differences. The mortality rate of the West African clade is less than 1%, and there is no human-to-human transmission. The Central African clade is more frequent, can have a mortality of up to 11%, and has a human-to-human transmission (Singh et al., 2021). Beer and Rao (2019) systematically reviewed the research published in English before August 15, 2018. They found an often-quoted 10% mortality rate. This rate came from early 1981-1986 data: 33 deaths out of 338. Data from the Democratic Republic of Congo (2001-2013) consistently reported mortality of <5%. Case fatality rates (CFR) from countries with West African Mpox were mostly 0%. The mortality for the Nigeria outbreak was 2.8%. Six deaths, 4 of whom were immunocompromised, out of 228 suspect cases. The mortality for 47 cases in United States outbreaks was 0%. No deaths have been reported from the April 2018 Cameroon outbreak or the recent Central African Republic outbreak. In reports documenting the cause of death, people in high-risk groups comprised most deaths (Beer & Rao, 2019).

Because of inconsistencies in healthcare and surveillance systems in rural African settings, Mpox data is incomplete and unreliable (Beer & Rao, 2019). This unreliable data is insufficient for statistical analysis (Beer & Rao, 2019). Due to the clinical overlap and insufficient laboratory availability, varicella-zoster virus (VZV) is often misdiagnosed as Mpox, and the conditions may be co-infected in the same patient (Beer & Rao, 2019; Hughes et al., 2021). There is some suggestion that Mpox is increasing in incidence. Data in more developed countries is more reliable.

Below is the Mpox Outbreak Global Map with data as of January 29th, 2023, directly from the CDC:

Image 1:

Mpox Outbreak Global Map

Centers for Disease Control and Prevention (January 29th, 2023)

map graphic showing mpox outbreak

As included in the legend, the orange circles indicate areas of reported cases of Mpox that historically had not had cases in prior outbreaks. The blue circles indicate areas that had. For more information and specific numbers, visit the CDC here.


Mpox spreads from person to person through direct contact (CDC, 2022c). The transmission mechanisms are respiratory droplets with close and prolonged contact, contact with body fluids, contaminated patient's environment or items, and the rash or scabs of the skin lesion of an infected person. As mentioned above, Mpox can spread from when symptoms start until the rash has fully healed with new skin formed over it (CDC, 2022c). Mpox can also be spread through sexual contact. While it is not, by definition, a sexually transmitted infection (STI), it can be more accurately described as a “sexually transmissible” infection, meaning the contact does not have to be exclusively intimate or sexual to be transmitted, as close personal contact can spread the virus (CDC, 2022c).

Animal-to-human transmission (zoonotic) occurs due to direct contact with the consumption of infected animals or the blood, body fluids, and lesions of infected animals (The Lancet, 2018). Animals found to transmit Mpox are rodents, rabbits, squirrels, monkeys, porcupines, and gazelles (Singh et al., 2021).

According to the United States case data, as of July 25th, 2022, the median age of patients with confirmed Mpox cases is 35. The male sex is the most highly impacted by this outbreak. Of the male patients who provided information on their sexual activity, 99% reported male-to-male sexual contact (CDC, 2022h). According to the Morbidity and Mortality Weekly Report (MMWR) by the CDC, because the report cases seem to be primarily affecting gay, bisexual, and other men who have sex with men, public health programs must continue to deliver respectful, harm-reducing, tailored educational and informative messages of strategies of generalized protection that do not create or perpetuate stigma to diverse communities of men who have sex with men (CDC, 2022i). It is important to emphasize that anyone can contract Mpox as it is a public health concern.

Signs & Symptoms

Mpox is usually a self-limiting disease lasting 2 to 4 weeks (World Health Organization [WHO], 2022). The incubation period of Mpox is generally 17 days (CDC, 2022c). The invasion stage lasts up to 5 days. In this stage, symptoms are fever, intense headache, lymphadenopathy, back pain, myalgia, and intense asthenia (lack of energy).

The rash evolves in a set sequence from (WHO, 2022a):

Flat macules → Slightly raised papules → Clear fluid-filled vesicles → Yellow fluid pustules → Crusted wounds

Directly from the CDC’s Mpox clinical recognition site, the following collection of pictures includes characteristics of the Mpox rash that are being seen (CDC, 2022d):

Image 2:Mpox Rash

Centers for Disease Control and Prevention (August 23, 2022)

photos of key characteristics of mpox rash

For additional photos of the Mpox rash, visit the CDC’s clinical recognition site here.

See below in the following chart for a breakdown of what is being seen with the rash, from enanthem to scabbing (CDC, 2022d):

Table 1: Mpox Rash: From Enanthem to Scab Stages Centers for Disease Control and Prevention (August 23rd, 2022)
StageStage DurationCharacteristics
  • Sometimes, lesions first form on the tongue and in the mouth.
Macules1-2 days
  • Macular lesions appear.
Papules1-2 days
  • Lesions typically progress from macular (flat) to papular (raised).
Vesicles1-2 days
  • Lesions typically become vesicular (raised and filled with clear fluid).
Pustules5-7 days
  • Lesions typically become pustular (filled with opaque fluid)- sharply raised, usually round, and firm to the touch (deep-seated).
  • Finally, lesions typically develop and depressions in the center (umbilication).
  • The pustules will remain for approximately 5 to 7 days before beginning to crust.
Scabs7-14 days
  • By the end of the second week, pustules have crusted and scabbed over.
  • Scabs will remain for about a week before beginning to fall off.

Commonly, areas of lighter or darker skin and/or pitted scars can remain after the rash scabs have healed and fallen off (CDC, 2022d). Once all of the scabs are gone and new skin has covered those spots, the person is no longer contagious (CDC, 2022d).

The number of lesions varies from a few to several thousand (WHO, 2022). The rash is more concentrated on the face and extremities than on the trunk. The rash affects the (WHO, 2022):

  • Face (95% of cases)
  • Palms of hands and soles of feet (75% of cases)
  • Oral mucous membranes (70% of cases)
  • Genitalia (30% of cases)
  • Conjunctivae (20% of cases)

Additional characteristics to note when identifying Mpox (CDC, 2022d):

  • The lesions are often described as painful until the scabs become itchy when they crust over in the healing process.
  • The rash could be confined to only a few or a single lesion.
  • They are typically scattered or localized to a body site rather than diffuse all over the body.
  • The lesions are typically firm or almost rubbery as well as well-circumscribed.
  • The lesions are often deep-seated with umbilication (a dot on the top of the lesion).
  • Rectal symptoms are being reported (bloody or purulent stools, pain in the rectum, rectal bleeding).

Differential Diagnoses

Lymphadenopathy is a distinctive feature of Mpox compared to other rash-presenting differential diagnoses that may initially appear similar (Grant et al., 2020; WHO, 2022):

  • Chickenpox
  • Measles
  • Smallpox
  • Bacterial skin infections
  • Scabies
  • Syphilis
  • Medication-associated allergies

VZV skin eruptions usually evolve over 24 hours instead of days, as seen with Mpox, and are seen on the trunk more frequently than in Mpox (Singh et al., 2021). Mpox has lesser eruptions than VZV or smallpox. Smallpox is five times more transmissible, has more nausea and vomiting, a less febrile stage before eruptions, more lesions, and a more profound systemic illness (Beer & Rao, 2019).


At this time (January 2023), testing is only recommended if the patient has a rash consistent with Mpox (CDC, 2022e).

The polymerase chain reaction (PCR) laboratory test is recommended for accuracy and sensitivity. PCR can be used alone or in combination with sequencing. The recommended specimen type is skin lesion material, including swabs of lesion surface or exudate, roofs from more than one lesion, or lesion crusts. A biopsy is an option, but samples must be stored in a dry, sterile tube with no viral transport media and kept cold. PCR blood tests are usually inconclusive because of the short duration of viremia relative to the timing of specimen collection after symptoms begin and should not be routinely collected from patients (WHO, 2022).


Complications of Mpox can include (WHO, 2022):

  • Secondary infections
  • Bronchopneumonia
  • Sepsis
  • Encephalitis
  • Infection of the cornea with possible loss of vision 

Bronchopneumonia is poorly understood, considered a secondary infection, and uncommon (Reynolds et al., 2017).

Hypoalbuminemia and low hematocrit, suggesting malnutrition, were found in patients hospitalized with Mpox during the 2003 outbreak in the United States (Reynolds et al., 2017). This finding may be due to oral lesions and cervical lymphadenopathy. Malnutrition is a common problem contributing to the severity of Mpox patients in rural Africa (Reynolds et al., 2017).

Mpox lesions on the cornea can lead to conjunctivitis, keratitis (inflammation of the cornea), or loss of vision (CDC, 2022l). The CDC calls this "ocular Mpox" (CDC, 2022l). Although it is fortunately rare, this serious ocular complication requires that healthcare professionals are aware of this sight-threatening condition (CDC, 2022l). If necessary, patients showing the signs and symptoms of ocular Mpox must be considered for emergency ophthalmologic evaluation and treatment (CDC, 2022l). For patients with active Mpox infection, it is essential to decrease the risk of Mpox transfer to the eye (CDC, 2022l). Patients should be advised to practice good hand hygiene and avoid touching their eyes (CDC, 2022l). When a patient typically wears contact lenses, the CDC recommends that patients refrain from using contact lenses during active infection (CDC, 2022l).

It is also important to note that children eight years and younger are at a higher risk for Mpox complications (Zimmerman & Curtis, 2022). Children with Mpox are reported to have an increased hospitalization rate and an increased risk for complications, including bacterial superinfections, cellulitis, pneumonia, abscesses, and sepsis (Zimmerman & Curtis, 2022).


There are no standard guidelines for the treatment of Mpox at this time. Reynolds et al. (2017) recommend symptomatic support, fever, pain management, measures to prevent secondary skin infection, adequate hydration and nutrition, protecting vulnerable anatomical locations such as the eyes, and managing complications. The skin and mucosal lesions require care. A serious rash can lead to dehydration, protein loss, and secondary infection. Focal inflammation of the lymphatic system and lung congestion can affect oxygenation and decrease food and fluid ingestion.

The following drugs are currently stockpiled for use from the Strategic National Stockpile (SNS) as options for treatment (CDC, 2022f; WHO, 2022; Zimmerman & Curtis, 2022):

  • Cidofovir (Vistide) is an antiviral that has been proposed as a treatment in serious, dangerous cases. Cidofovir is a nucleotide analog that inhibits the production of herpes viruses.
  • Tecovirimat (TPOXX or ST-246) is an antiviral approved by the United States Food and Drug Administration (FDA) for treating smallpox in adults and children. Clinical trials have found it to be safe with minor side effects. It is available in pill or injection forms. It is only recommended for those with severe Mpox disease or those at an increased risk of severe disease. High-risk populations for Mpox include children under the age of eight years, children with underlying skin conditions, immunocompromised individuals, and pregnant women.
  • Brincidofovir (CMX001 or Tembexa) is an antiviral approved by the FDA for treating human smallpox in adults and children, including neonates. This drug is currently not available from the SNS.

Smallpox vaccination is about 85% effective in preventing Mpox or resulting in a milder illness if it is not prevented (WHO, 2022). The Centers for Disease Control and Prevention (CDC) suggests a smallpox vaccine be administered within fourteen days of exposure, though preferably within four days, for healthcare workers and others exposed to Mpox cases. Vaccinia immune globulin (VIG) has not shown adequacy in treatment or prophylaxis.

ACAM2000 and JYNNEOS (Imvamune or Imvanex) are the two currently available and licensed vaccines in the United States to prevent smallpox infection (CDC, 2022g). ACAM2000 is a live virus inoculated into the skin by pricking the skin surface (CDC, 2022g). After it has been inoculated, a lesion is meant to develop at that site. Because the virus is growing and can spread from that site, individuals who receive this vaccine must take precautions to prevent the spread of the vaccine virus until they are considered fully vaccinated in 28 days (CDC, 2022g). JYNNEOS is a live virus that is non-replicating that is administered via two subcutaneous injections four weeks apart (CDC, 2022g). This vaccine bears no concern for possible spread. Individuals who receive this vaccination are not considered vaccinated until two weeks after the second dose (CDC, 2022g).

Prevention of Spread

The WHO recommends contact and droplet precautions for Mpox. The CDC's (2007) most recent recommendations for Mpox are contact and airborne precautions. To serve as a reminder (CDC, 2007):

  1. Contact Precautions are used for patients with known or suspected infections or colonized with epidemiologically essential microorganisms that can be transmitted by direct or indirect contact. The patient should be in a private room.
  2. Standard Precautions should be used, and a gown and gloves should be worn if there is likely to be contact with the patient or environmental surfaces.
  3. Airborne Precautions are implemented for diseases transmitted by microorganisms carried by airborne droplet nuclei. Possibly infectious patients should be separated from others and asked to wear a surgical mask before airborne precautions can be provided. A surgical N95 respirator is recommended for Airborne Precautions. The N95 is a single-use, disposable item that must be fit-tested to be effective. Airborne Precautions also require using an airborne infection isolation room (AIIR) with specially engineered airflow and ventilation systems. The door to the room must be kept closed, and the negative air pressure should be monitored. When the patient in airborne precautions has to be moved or transported, they should wear a surgical mask from when they leave the isolation room until they return.

Regarding environmental infection control in inpatient hospital settings, the following recommendations have been made by the CDC (CDC, 2022j):

  • Soiled patient laundry should be removed from patient rooms while avoiding contact with any lesion material left on them
  • Soiled laundry should be promptly contained in a laundry bag and never be shaken (not to disperse infectious material)
  • Cleaning activities such as dry dusting, sweeping, or vacuuming should be avoided and wet cleaning methods used instead (so as not to disperse infectious material in the air)
  • No portable fans should be allowed in patient rooms

Anyone diagnosed with Mpox, or suspects that they might have it, should avoid close contact with others. Once the rash sores scab over completely and fall off, the infected person is considered no longer contagious (CDC, 2022a). Because many cases have included sores in the genital and rectal areas among men who have sex with men, abstinence from sex when Mpox is suspected is encouraged.

Case Study

Scenario/Situation/Patient Description

A 35-year-old female presents with a five-day history of fever, intense headache, lymphadenopathy, and lack of energy. She has clear fluid-filled vesicles on her face, palms, and soles. Vital signs are within normal limits except for a pulse of 110. She reports that her significant other has been sick for about two weeks and has sores on his face. She does not know if she had chicken pox as a child and has not started any new medications. She has been taking Tylenol. She reports not eating for days and that she has also not been drinking very much. She is pale, and her skin turgor is poor. Her physical examination is otherwise normal.


The patient is given a surgical mask and put in an ER room with the door closed. A CBC, metabolic profile, urinalysis, and swab of her lesions are sent for PCR. The patient is hospitalized on contact and airborne precautions for hydration and symptom management.

Discussion of Outcomes

The patient's symptoms are significantly better the next day. Her PCR was positive for Mpox. These results are reported to the Health Department, which has initiated contact tracing. She is discharged with symptom management instructions and contact management education to be followed until her lesions heal.

Strengths & Weaknesses

Hopefully, the ER staff is conscious of the potential for Mpox and notices the lymphadenopathy. Given the differential diagnoses and the sanitation and nutrition status of the average American, Mpox may not be considered. Contact isolation and blood and urine tests would have been done with open lesions. Swabbing for a PCR would not be a normal test. In the worst case scenario, she is treated for her symptoms and discharged.


Mpox has been raising concern worldwide. Symptom management is the best treatment at this point. Smallpox vaccination is recommended for exposure to Mpox. Healthcare professionals need to know the potential for Mpox and how to identify it from differential diagnoses.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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