Health Care News, Health Center News, Social Determinants of Health, Uncategorized

Strong Triage and Planning Necessary to Support Patients with Monkeypox 

Man treated by nurse

Written in partnership with Julia Skapik, MD, MPH, Chief Medical Information Officer, NACHC, Pedro Carneiro, MPH, Clinical Data Scientist, NACHC, and Anthony Fortenberry, MSN, RN, NEA-BC, Chief Nursing Officer, Callen-Lorde Community Health Center.

By the end of September, approximately 26,000 people had received a Monkeypox (MPX) diagnosis in the United States. Though the number of daily cases is starting to decline (CDC Outbreak Cases and Data), this painful virus is still straining many health centers. “Hot spots” are in California, New York, Florida, Texas, Georgia, Illinois, and other areas with large cities.  

The people most impacted by MPX have been gay, bisexual, or men who have sex with men, though anyone in close, prolonged physical contact with someone who has MPX is at risk.  

“Younger LGBT+ people born after 1970 are the ones getting Monkeypox. They didn’t get the smallpox vaccine when they were young, so one of the best things we can do is talk to them about prevention – and encourage them to get the monkeypox vaccine now.” Julia Skapik, MD, MPH, CMIO, NACHC. 

Staff in Community Health Centers (also called federally qualified health centers/FQHCs) are often the first line of defense to protect people from an outbreak. They also must be prepared to manage patients with symptoms. Protection, of course, starts with a strong triage system and a workplan to speed access to treatment.  

Improve triage and protect health center care teams 

It’s critical to gather information on the sexual health of all patients as a primary part of triage. Taking a sexual health history includes asking important questions like: 

  • What is your gender identity?  
  • When were you most recently sexually active? 
  • What body parts do you use when you have sex? 
  • Are you sexually active with one or more partners?  

Considering the current MPX outbreak, it also helps to add questions about rash along with typical COVID-19 questions. An unexplained rash in genital areas may not be from a standard sexually transmitted infection, as in the past. With high-risk encounters, plan to rule-out MPX first. 

If someone is suspected of having MPX during triage, providers can be alerted with a tickler in the EHR so they can grab the proper PPE. This would include a gown in addition to typical PPE for COVID. 

Speed access to monkeypox treatment  

Access to TPOXX, the treatment for patients with severe symptoms, is arduous. Care team members are essentially enrolling a patient in a clinical trial, so patients must complete an informed consent and the care team must complete about an hour of administrative paperwork. It helps to figure-out the workflow and assign staff to complete this work before patients with severe symptoms show up at a health center for care.  

Information to register a patient and get TPOXX for them can be found here: 

“One of our keys to success was establishing a very close relationship with the NYC Dept. of Health. Early in the outbreak we were texting our local health department to learn how much vaccine and treatment we could access, and to keep us informed about rapidly changing guidelines. We created a text chain with the Dept. of Health, other FQHCs and Chief Nursing Officers.  –This was incredibly helpful because we learned from each other about how to manage changes.” Anthony Fortenberry, Chief Nursing Officer, Callen-Lorde Community Health Center 

Treatment requires more than just a prescription  

While the protocol for Monkeypox care instructs patients to quarantine for 2-4 weeks, we know that’s not always possible. Some patients who must quarantine have paid leave, but many don’t. Sometimes they need access to resources like a local food bank or case management services.  

Stigma is a real concern for patients with MPX. To create less stigma in the clinical environment, staff should learn how MPX is transmitted (through sustained contact with a symptomatic patient’s lesions) and how it’s not (elevator buttons, shared pens). Patients should not be made to feel ashamed and rushed to an isolation room.  

“Health center staff have an opportunity to provide culturally competent care to their LGBTQ+ patients. If someone’s not sure what to do, the Infectious Diseases Society of America and NACHC offer training materials that help care teams learn how to be sensitive to issues like these.” 

Julia Skapik, MD, CMIO, NACHC 

Monkeypox resources

To support care teams, NACHC pulled together some useful information for quick access: 

NACHC works closely with Infectious Diseases Society of America, HRSA, CDC, the National Coalition of STD Directors, ASTHO, the White House, and advocacy stakeholders on the Monkeypox response. Information about NACHC’s upcoming webinar on this topic is coming soon. 

PHOTO CREDIT: William J. Nazareth, Jr.