Dr H GOPAL Surgeon

19/09/2026

At Johns Hopkins, our AI initiatives are helping doctors identify health problems sooner and treat them smarter. We also understand that patients and their caregivers may have questions and concerns about AI technology and how we protect your health privacy.  

11/09/2026

A joint position statement from the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), American Association for the Study of Liver Diseases (AASLD), Crohn’s & Colitis Foundation, ImproveCareNow, and The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), united in their commitment to protecting patients with digestive and liver diseases from vaccine-preventable illness.

Introduction and purpose
The endorsing gastrointestinal and hepatology societies strongly recommend annual influenza vaccination and COVID-19 vaccination for all eligible patients, with particular emphasis on populations at increased risk for severe disease and complications, across the lifespan.

Gastroenterologists, hepatologists, pediatric gastroenterologists, and advanced practice providers (nurse practitioners and physician assistants) are trusted providers for patients with gastrointestinal and liver conditions across the lifespan. It is important that these physicians and providers know the morbidity and consequences of influenza and COVID-19, and the safety of influenza and COVID-19 vaccines.

Key Recommendations
Annual influenza vaccination and up-to-date COVID-19 vaccination are recommended for all eligible patients with gastrointestinal and liver disease, in both adults and children.
Adults: patients 65 years and older, those receiving anti-TNF monotherapy, and liver transplant recipients should receive an enhanced (high-dose, recombinant, or adjuvanted) influenza vaccine.
Children: give the age-appropriate standard-dose inactivated influenza vaccine. Children 6 months through 8 years may require two doses. Enhanced adult formulations are not licensed for children.
The live attenuated (intranasal) influenza vaccine should be avoided in patients receiving immune-modifying therapy and in their household contacts.
Complete indicated vaccinations before transplantation whenever possible; live vaccines are not recommended after transplant.
Household contacts of immunocompromised patients should remain up to date with both vaccines.
A clear recommendation from the gastroenterologist, hepatologist, or advanced practice provider is among the strongest predictors of vaccine uptake.

COVID-19: Morbidity and long-term consequences across the lifespan
COVID-19 poses significant risks for both acute illness and long-term health consequences. According to Centers for Disease Control and Prevention (CDC) data, 1 in 5 COVID-19 survivors aged 18-64 years and 1 in 4 survivors aged ≥65 years experience post-COVID conditions that may persist for months or years after the initial infection.1 These post-COVID conditions affect multiple organ systems, including the cardiovascular, pulmonary, gastrointestinal, and neurological systems. The highest risk ratios were observed for acute pulmonary embolism. Recent surveillance data from the CDC’s COVID-NET surveillance team found that adults aged ≥65 years accounted for 70% of all adult COVID-19 hospitalizations from October 2023 to April 2024. Regretfully, many of these adults had not received an updated COVID-19 booster.2 COVID-19 also continues to cause hospitalization and death in children and adolescents, and vaccination protects against both post-acute sequelae of SARS-CoV-2 infection (PASC) and multisystem inflammatory syndrome in children (MIS-C). Infants and children 6-23 months of age are recognized as a distinct high-risk age group for severe COVID-19, a category with no adult a**log that overlaps substantially with young pediatric liver transplant and biliary atresia patients under gastroenterology and hepatology care.3

Influenza: Morbidity and the importance of vaccination across the lifespan
Influenza causes substantial annual morbidity and mortality and remains one of the most common vaccine-preventable causes of serious infection among patients with gastrointestinal and liver disease. Patients with inflammatory bowel disease (IBD) are at increased risk of influenza and of influenza-related complications, including hospitalization and pneumonia, particularly those receiving corticosteroids or anti-tumor necrosis factor (anti-TNF) therapy.4 Older adults, patients with chronic liver disease or cirrhosis, and solid organ (including liver) transplant recipients are likewise at heightened risk of severe influenza and its complications. Influenza in liver transplant recipients is associated not only with increased morbidity and mortality but also with an increased risk of organ rejection.5 Children are not exempt from this burden; pediatric patients with IBD, chronic liver disease, and liver transplant recipients face similarly increased risks of influenza-related complications.6 In children, influenza can also cause direct hepatic injury: A 2026 study of children hospitalized with acute respiratory infections found that severe transaminase elevations occurred exclusively in those infected with influenza.7

Accordingly, all eligible patients with digestive and liver diseases should receive an annual inactivated influenza vaccine. The AASLD guidelines recommend annual influenza vaccination for patients with chronic liver disease and for solid organ transplant recipients, including liver transplant recipients,8 and the ACG Preventive Care Guidelines in IBD and AGA Clinical Practice Update on vaccinations in patients with IBD provide the same recommendation for patients with IBD.9,10 Vaccination should be offered each fall, ideally in September or October. It may be given throughout the influenza season and can be co-administered with COVID-19, pneumococcal, and respiratory syncytial virus vaccines to improve uptake. The Infectious Diseases Society of America (IDSA) 2025 rapid guidelines likewise strongly recommend age-appropriate annual influenza vaccination for all immunocompromised individuals aged 6 months and older.11,12

Several influenza vaccines are available in the U.S.: a standard-dose inactivated vaccine and three enhanced formulations: high-dose, recombinant, and adjuvanted. Several considerations are specific to immunocompromised patients. Adults 65 years and older should receive one of the enhanced vaccines preferentially recommended for older adults (high-dose, recombinant, or adjuvanted influenza vaccine). Patients receiving anti-TNF monotherapy, as well as liver transplant recipients regardless of age, may have a blunted response to a standard-dose vaccine and should receive a high-dose influenza vaccine when available.5,13 The live attenuated (intranasal) influenza vaccine is not recommended for patients on immune-modifying therapy or for their household contacts, who should instead receive an inactivated influenza vaccine.14 The high-dose, recombinant, and adjuvanted formulations are licensed for adults only and are not appropriate substitutes in children, including children receiving anti-TNF therapy or those who have undergone transplantation.6 In children, the age-appropriate standard-dose inactivated influenza vaccine should be used; children 6 months through 8 years may require two doses given at least four weeks apart if they have not previously received the recommended lifetime number of doses.6

Influenza vaccination is safe and well tolerated in patients with IBD and liver diseases and is not associated with worsening disease activity or transplant rejection. There is no evidence that influenza vaccination induces an IBD flare.15 As with COVID-19, a clear recommendation from the gastroenterologist, hepatologist, pediatric gastroenterologist, or advanced practice provider is among the strongest predictors of vaccine uptake.

COVID-19 vaccines
The endorsing gastrointestinal and hepatology societies strongly recommend COVID-19 vaccination for all eligible patients, with particular emphasis on high-risk populations such as older adults (65 years of age and older) or those with pre-existing conditions who are commonly seen in gastroenterology and hepatology clinics.

Three COVID-19 vaccines are currently available in the U.S.: two mRNA vaccines (Pfizer-BioNTech and Moderna) and one adjuvanted protein subunit vaccine (Novavax). The protein subunit vaccine has demonstrated lower reactogenicity than the mRNA vaccines and may be preferred by patients concerned about side effects.5 Updated COVID-19 vaccines continue to provide meaningful protection in the current epidemiologic era, even as contemporary SARS-CoV-2 variants cause milder illness. In a national cohort of 295,971 U.S. veterans who had previously received the 2023–2024 vaccine, receipt of the 2024–2025 COVID-19 vaccine (given the same day as influenza vaccine) was associated with lower 6-month risks of COVID-19–associated emergency department visits (vaccine effectiveness, 29.3%), hospitalizations (39.2%), and death (64.0%) compared with influenza vaccine alone.16 Protection was consistent across age groups (75 years), among patients with and without major coexisting conditions, and among both immunocompetent and immunocompromised adults—the populations most relevant to gastroenterology and hepatology practice. These contemporary data reinforce the continued value of COVID-19 vaccination for high-risk patients. Consistent findings were reported in a CDC-funded test-negative study of U.S. adults, in which 2024–2025 COVID-19 vaccination was associated with reduced COVID-19-associated emergency department and urgent care encounters and hospitalizations.17

High-risk populations
These organizations recommend vaccination for all eligible individuals across the lifespan, including children and adolescents, in the following groups.

Patients with IBD: COVID-19 vaccination is strongly recommended for all individuals with Crohn’s disease and ulcerative colitis, consistent with the ACG Preventive Care Guidelines and AGA CPU on vaccinations in patients with IBD.9,10 Annual influenza vaccination is likewise strongly recommended for all patients with IBD. The American College of Obstetricians and Gynecologists (ACOG) recommends COVID-19 vaccination in pregnant women, including those with IBD. In children and adolescents with IBD, NASPGHAN Health Supervision recommendations likewise advise annual influenza immunization for patients on immunosuppressive therapy and advise against use of the live attenuated (intranasal) influenza vaccine.18

Liver transplant recipients: Post-transplant patients on immunosuppressive regimens should receive COVID-19 and annual influenza vaccination as part of comprehensive preventive care, with timing coordinated with their transplant team.19 Because vaccines administered during post-transplant immunosuppression are less effective, immunity should be assessed and indicated vaccines—including COVID-19 and influenza—administered before transplantation whenever possible; live vaccines are not recommended after transplant and should be completed prior to listing when needed.8 For the 2024-2025 season, liver transplant recipients were recommended to receive an additional COVID-19 vaccine dose, as for adults 65 years and older.5 For pediatric candidates and recipients, the 2026 AASLD/American Society of Transplantation (AST)/NASPGHAN Practice Guidelines on Pediatric Liver Transplantation provide age-specific recommendations, including administration of all age-appropriate inactivated vaccines to candidates and household contacts before transplantation using an accelerated schedule when needed, and annual influenza immunization for recipients and household contacts after transplantation.20,21

Chronic liver disease: Patients with cirrhosis, chronic hepatitis, metabolic dysfunction–associated steatotic liver disease (MASLD), metabolic dysfunction–associated steatohepatitis (MASH), metabolic dysfunction and alcohol-associated liver disease (MetALD), and other forms of chronic liver disease should receive COVID-19 and annual influenza vaccination because of their increased vulnerability to severe complications and post-COVID sequelae.19 COVID-19-related mortality in patients with chronic liver disease has been reported at approximately twice that of patients without chronic liver disease, underscoring the importance of vaccination in this group.5

Additional high-risk populations: Older adults aged 65 and older and individuals with other pre-existing gastrointestinal conditions or comorbidities should be counseled about vaccination benefits. Given that 80% of COVID-19 hospitalizations occur in patients with multiple underlying conditions, this population requires special attention.

Household contacts: Household members and close contacts of patients with digestive and liver disease who are immunocompromised should remain up to date with influenza and COVID-19 vaccination. Household contacts of patients receiving immune-modifying therapy should receive an inactivated influenza vaccine rather than the live attenuated (intranasal) vaccine.6,11,12

Vaccine safety profile
Extensive clinical data and real-world evidence demonstrate that COVID-19 vaccines are safe and well tolerated in immunocompromised populations, including patients with IBD, liver transplant recipients, and those with chronic liver disease. COVID-19 vaccines are not associated with worsening of underlying gastrointestinal conditions or increased disease activity in patients with IBD.22 Population-based surveillance in the U.S., including the CDC’s Vaccine Safety Datalink and Vaccine Adverse Event Reporting System (VAERS), has not identified any unexpected safety signals for mRNA vaccines after >298 million doses. The rate of serious outcomes (e.g., myocarditis, thrombosis, and anaphylaxis) is very low, and the risk of non-COVID-19 mortality does not increase among vaccine recipients.23-25 Myocarditis is a rare adverse event, but the risk is substantially higher after SARS-CoV-2 infection than after vaccination. The magnitude of this relationship varies by age, s*x, and vaccine product.26 In children and adolescents, COVID-19 vaccines have likewise been shown to be safe; myocarditis after mRNA vaccination is rare, occurs disproportionately in adolescent and young adult males after the second dose, and is typically mild and self-limited, while the risk following SARS-CoV-2 infection is higher.3

These data would suggest that the substantial benefits of vaccination in preventing severe COVID-19 and long-term post-COVID complications significantly outweigh any potential risks in vulnerable populations.

Pediatric considerations
COVID-19 vaccine products for children. Product eligibility is age-stratified. Moderna (Spikevax) is the only vaccine approved for children 6 months and older and is the sole option for children 6–23 months; Pfizer-BioNTech (Comirnaty) is approved for ages 5 years and older; Moderna (mNexspike) and Novavax (Nuvaxovid) are approved for ages 12 years and older, with Nuvaxovid additionally requiring an underlying high-risk condition for ages 12–64 years.27

Guidance from the American Academy of Pediatrics (AAP). The AAP recommends COVID-19 vaccination for all children 6–23 months of age and for children 2–18 years in defined risk groups, under its own independently published immunization schedule.3,28 The endorsing societies concur with this guidance and recommend that pediatric gastroenterologists, hepatologists, and advanced practice providers offer COVID-19 and influenza vaccination to all eligible pediatric patients, particularly those with IBD, chronic liver disease, and liver transplant recipients.

Role of gastroenterology and hepatology providers
Gastroenterologists, hepatologists, pediatric gastroenterologists and hepatologists, and advanced practice providers are trusted by their patients as reliable healthcare advisors. When a provider recommends vaccination, patients are more likely to get vaccinated. Therefore, physicians and advanced practice providers should proactively discuss influenza and COVID-19 vaccination with all eligible patients and address vaccine hesitancy with current evidence-based information about both influenza and COVID-19 risks and vaccine safety.

Additional resources
For more detailed guidance on vaccinating patients with IBD, readers are referred to the ACG Clinical Guideline Update on Preventive Care in IBD and AGA CPU on vaccinations in patients with IBD.9,10 For guidance on vaccinating patients with chronic liver disease or those undergoing liver transplantation, readers are referred to the AASLD/AST Practice Guideline on adult liver transplantation and the ACG Monograph on Geriatrics and GI in a gastroenterology and hepatology practice.5,8 For childhood and adolescent immunization, including for pediatric patients with IBD, the AAP Recommended Child and Adolescent Immunization Schedule provides current guidance.28 For pediatric liver transplantation, readers are referred to the 2026 AASLD/AST/NASPGHAN Practice Guidelines on Pediatric Liver Transplantation covering candidate evaluation and post-transplant management,20,21 and for immunocompromised children more broadly to the AAP clinical report on influenza, COVID-19, and respiratory syncytial virus (RSV) vaccination for immunocompromised children and household contacts6 and the IDSA 2025 rapid guidelines.11,12

1. Bull-Otterson L, Baca S, Saydah S, et al. Post-COVID Conditions Among Adult COVID-19 Survivors Aged 18-64 and ≥65 Years — United States, March 2020-November 2021. MMWR Morb Mortal Wkly Rep. 2022;71(21):713-717.
2. Taylor CA, Patel K, Pham H, et al. COVID-19-Associated Hospitalizations Among U.S. Adults Aged ≥18 Years - COVID-NET, 12 States, October 2023-April 2024. MMWR Morb Mortal Wkly Rep. 2024;73(39):869-875.
3. American Academy of Pediatrics, Committee on Infectious Diseases. Recommendations for COVID-19 Vaccines in Infants, Children, and Adolescents: Policy Statement. Pediatrics. 2025;156(5): e2025073924.
4. Tinsley A, Navabi S, Williams ED, et al. Increased Risk of Influenza and Influenza-Related Complications Among 140,480 Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis. 2019;25(2):369-376.
5. Lutz MK, Caldera F. Vaccination Outcomes and Recommendations Among Older Adults in a Gastroenterology and Hepatology Practice. Am J Gastroenterol. 2025;120: S67-S75.
6. Kao CM, Bahakel H, Heald-Sargent TA, et al. Influenza, COVID-19, and RSV Vaccinations for Immunocompromised Children and Household Contacts. Pediatrics. 2026;158(2): e2026075971.
7. Kalaycik Sengul O, Akyuz SZ, Aktas I, et al. Influenza as the Predominant Cause of Severe Hepatic Involvement in Children Hospitalized with Acute Respiratory Infections: A Post-COVID-19 Era Analysis. Viruses. 2026;18(7):691.
8. Dove L, Chadha RM, Lai JC, et al. AASLD AST Practice Guideline on adult liver transplantation: Candidate evaluation. Hepatology. 2026; 83:1609-1645.
9. Farraye FA, Melmed GY, Lichtenstein GR, et al. ACG Clinical Guideline Update: Preventive Care in Inflammatory Bowel Disease. Am J Gastroenterol. 2025;120(7):1447-1473.
10. Caldera F, Kane S, Long M, et al. AGA clinical practice update on Noncolorectal Cancer Screening and Vaccinations in Patients With Inflammatory Bowel Disease: Expert Review. Clin Gastroenterol Hepatol. 2025;23(5):695-706.
11. Nellore A, Goepfert P, Tan CS, et al. IDSA 2025 Guidelines on the use of vaccines for the prevention of seasonal COVID-19, Influenza, and RSV infections in immunocompromised patients. Clin Infect Dis. 2026; ciag114.
12. Goepfert P, Katz MJ, Kaul D, et al. IDSA 2025 Guidelines on the use of vaccines for the prevention of seasonal Influenza infections in immunocompromised patients. Clin Infect Dis. 2026; ciag116.
13. Caldera F, Hillman L, Saha S, et al. Immunogenicity of High Dose Influenza Vaccine for Patients With Inflammatory Bowel Disease on Anti-TNF Monotherapy: A Randomized Clinical Trial. Inflamm Bowel Dis. 2020;26(4):593-602.
14. Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza With Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2022-23 Influenza Season. MMWR Recomm Rep. 2022;71(1):1-28.
15. Kucharzik T, Ellul P, Greuter T, et al. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J Crohns Colitis. 2021;15(6):879-913.
16. Cai M, Xie Y, Al-Aly Z. Association of 2024-2025 Covid-19 Vaccine with Covid-19 Outcomes in U.S. Veterans. N Engl J Med. 2025;393(16):1612-1623.
17. Wiegand RE, Payne AB, Mak J, et al. Estimated Effectiveness of 2024-2025 COVID-19 Vaccines in Adults. JAMA Intern Med. 2026;186(8):976-986.
18. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Health Supervision in the Management of Children and Adolescents With IBD: NASPGHAN Recommendations. J Pediatr Gastroenterol Nutr. 2012;55(1).
19. Fix OK, Hameed B, Fontana RJ, et al. Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Hepatology. 2020;72(1):287-304.
20. Martinez M, Adeyemi A, Chu J, et al. AASLD AST NASPGHAN Practice Guideline on pediatric liver transplantation: Candidate evaluation. Hepatology. Published online June 22, 2026. doi:10.1097/HEP.0000000000001805.
21. AASLD AST NASPGHAN Practice Guideline on pediatric liver transplantation: post-transplant management. Liver Transpl. Published online June 22, 2026. doi:10.1097/LVT.0000000000000939.
22. Weaver KN, Zhang X, Dai X, et al. Impact of SARS-CoV-2 Vaccination on Inflammatory Bowel Disease Activity and Development of Vaccine-Related Adverse Events: Results From PREVENT-COVID. Inflamm Bowel Dis. 2022;28(10):1497-1505.
23. Panagiotakopoulos L, Moulia DL, Godfrey M, et al. Use of COVID-19 Vaccines for Persons Aged ≥6 Months: Recommendations of the Advisory Committee on Immunization Practices - United States, 2024-2025. MMWR Morb Mortal Wkly Rep. 2024;73(37):819-824.
24. Markowitz LE, Hopkins RH, Jr., Broder KR, et al. COVID-19 Vaccine Safety Technical (VaST) Work Group: Enhancing vaccine safety monitoring during the pandemic. Vaccine. 2024;42 Suppl 3(Suppl 3):125549.
25. Rosenblum HG, Gee J, Liu R, et al. Safety of mRNA vaccines administered during the initial 6 months of the US COVID-19 vaccination programme: an observational study of reports to the Vaccine Adverse Event Reporting System and v-safe. Lancet Infect Dis. 2022;22(6):802-812.
26. Patone M, Mei XW, Handunnetthi L, et al. Risk of Myocarditis After Sequential Doses of COVID-19 Vaccine and SARS-CoV-2 Infection by Age and S*x. Circulation. 2022;146(10):743-754.
27. Centers for Disease Control and Prevention. 2025–2026 COVID-19 Vaccination Guidance. Atlanta, GA: US Department of Health and Human Services, CDC.
28. O’Leary ST; Committee on Infectious Diseases. Recommended Childhood and Adolescent Immunization Schedule: United States, 2026: Policy Statement. Pediatrics. 2026;157.

26/08/2026

26/08/2026

https://youtube.com/shorts/3duwQPpE4HY?si=y_E1TOmSi5D39pPG

08/06/2026

08/06/2026

Surgical Robots market is likely to hit US$ 27.77 billion by 2034, growing at a CAGR of 14.8%. Learn about share, trends & opportunities.

07/06/2026

WHAT DOCTORS MUST KNOW ABOUT MPOX

MPOX — Comprehensive Clinical Reference (June 2026)

1. THE VIRUS & CURRENT EPIDEMIOLOGICAL LANDSCAPE

Mpox (MPXV) comprises two primary clades: Clade I (subclades Ia/Ib), historically the ‘Congo Basin’ strain, endemic to Central Africa with higher virulence (case fatality rate 1–10%); and Clade II (subclades IIa/IIb), the ‘West African’ strain, less virulent (survival >99.9%). Clade IIb caused the 2022 global outbreak. 

The 2022 global outbreak was declared a WHO Public Health Emergency of International Concern, affecting 122 countries — 115 of which had never reported mpox cases — with over 87,000 cases. It significantly differed from prior outbreaks, with a large majority of cases among men who have s*x with men (MSM), and s*xual in*******se being the main route of transmission. 

In August 2024, WHO declared a second PHEIC due to the emergence of MPXV clade Ib in the DRC and spread to neighbouring African countries and sporadically beyond Africa. The WHO PHEIC was lifted in September 2025 as cases declined, but clade IIb continues to circulate globally at low levels. 

Key point for a travel medicine/international practice: You can see either clade depending on your patients’ travel history.

2. TRANSMISSION — HOW IT SPREADS

MPXV is usually transmitted from person to person through close, sustained physical contact. In the clade I outbreak, transmission has occurred through s*xual contact, day-to-day household contact, and in healthcare settings when PPE was not available. In the ongoing clade II outbreak, transmission has been almost exclusively associated with s*xual contact. 

In the DRC clade I outbreak, MPXV is primarily thought to spread through respiratory droplets via coughs, sneezes, or talking that facilitate virus transfer to nearby individuals. Previous outbreaks, particularly among children in West and Central Africa, have demonstrated this mode of transmission. 

Other routes include:

• Direct contact with lesion fluid, scabs, or contaminated materials (bedding, clothing)
• Zoonotic transmission from infected animals (rodents, primates)
• Needlestick injuries (documented in healthcare workers)
• Mother-to-child (vertical transmission possible)

3. CLINICAL PRESENTATION

Incubation Period

The incubation period is roughly 1–2 weeks, though clinicians are currently recommended to monitor patients up to 21 days. A person is not contagious during this period. 

Prodrome

People with mpox may develop an early set of symptoms (prodrome) including fever, malaise, headache, sore throat, or cough, and — in many cases — swollen lymph nodes. 

Lymphadenopathy is a distinguishing feature from smallpox and chickenpox.

The Rash — Four Progressive Stages

Within three days of experiencing initial symptoms, the rash can spread quickly and eventually turns into small fluid-filled sacs known as vesicles. The rash progresses through stages: macules → papules → vesicles → pustules → scabs/crusts. 

Lesions typically develop at the same time and evolve together on any given part of the body. For both clade I and clade II infection, lesions often occur in the ge***al and anorectal areas or in the mouth. 

Sores can occur on the mucosa — in the mouth, nose, throat, or digestive tract. 

The patient is contagious from onset of symptoms until all lesions have fully healed and scabs have fallen off.

Clade Differences in Severity

Clade I tends to cause more serious illness and is linked to more deaths. It may spread more easily than clade II. Clade II causes less severe disease and is less likely to cause death. 

4. COMPLICATIONS

Recognised complications include secondary bacterial infections, pneumonia, sepsis, encephalitis, and loss of vision with severe eye infection. 

Additional significant complications include:

• Proctitis — particularly painful, common in a**l transmission (clade II)
• Pharyngitis/tonsillitis — can cause difficulty swallowing
• Urethritis/balanitis
• Corneal ulceration — can cause permanent visual impairment
• Secondary bacterial superinfection of lesions (most common complication)
• Respiratory compromise — particularly clade I

High-Risk Groups for Severe Disease

• Immunocompromised patients (especially advanced HIV/AIDS)
• Pregnancy
• Children under 5 (clade I: CFR >10% in this group)
• Patients with eczema or atopic dermatitis (disseminated disease risk)

Long Mpox

A study published in the Annals of Internal Medicine assessed 154 people infected with clade IIb mpox 1–18 months after diagnosis and found scarring plus bowel, urinary, and s*xual problems more than a year after infection. While this focused on clade IIb, the findings offer valuable insights into the types of lasting physical and psychosocial effects the virus can cause. 

5. DIAGNOSIS

Consider mpox as the cause of a diffuse or localized rash, particularly if there is recent travel to an outbreak area. Evaluate any individual presenting with certain ulcers or rash for HIV and STIs simultaneously. Conduct a thorough patient history, including detailed travel and s*xual histories, to assess possible exposure. 

Gold standard testing: PCR for MPXV DNA from lesion swabs (roof of lesion, lesion base, or exudate). Throat/rectal swabs also useful.

Differential diagnosis: Chickenpox (varicella), syphilis (secondary), herpes simplex, molluscum contagiosum, hand-foot-mouth disease, scabies, bacterial skin infection.

6. PRECAUTIONS FOR YOU AS A PRACTITIONER

Personal Protective Equipment (PPE) — Non-Negotiable

Healthcare providers should practice effective hand hygiene and don personal protective equipment — gown, gloves, eyewear, and an N-95 or comparable respirator mask — before evaluating or collecting a specimen from a patient with suspected mpox. 

PPE required includes: gown, gloves, eye protection (goggles or face shield covering the front and sides of the face), and a NIOSH-approved particulate respirator with N-95 filters or higher. 

Sharps Safety — Critical

Because of the risk for sharps injuries, CDC advises against unroofing, opening, or aspirating mpox lesions with sharp instruments, and against recapping used needles. There have been documented mpox infections through needlestick injuries, including a nurse infected through a needlestick while sampling a lesion. 

Waste Management

Waste contaminated with clade I or clade II MPXV is designated as Category B infectious substance. Handle, store, treat, and dispose of soiled PPE, patient dressings, and clinical waste in accordance with hazardous materials regulations. 

Environmental Infection Control

Hand hygiene, dedicated personal items, appropriate handling of linens and laundry, cleaning and disinfection of the environment, and waste management should be followed for persons with mpox until all lesions are healed. 

Isolate Suspected Cases

Place patients with suspected mpox in a single-occupancy room with the door closed. If a dedicated room is unavailable, spatial separation and full PPE are essential.

Your Own Vaccination

As a healthcare worker with occupational exposure risk, JYNNEOS vaccination is indicated for you. Both ACAM2000 and JYNNEOS continue to be available for people at occupational risk for exposure.  JYNNEOS is preferred given its superior safety profile.

7. TREATMENT — EVIDENCE-BASED (2025 UPDATE)

Cornerstone: Supportive Care

Supportive measures for pain and other symptom control, as well as treatment of complications such as bacterial superinfection, are the mainstays of therapy. Fortunately, the prognosis in the context of clade IIb mpox is excellent, and the majority of affected individuals recover fully whether they receive medical attention or not. 

Pain management:
Many patients experience significant pain from skin lesions or mucosal involvement, including proctitis or pharyngitis. Pain can often be controlled with over-the-counter a**lgesics such as acetaminophen or NSAIDs. Some individuals may require gabapentin or opioid medications for severe pain. 

Antivirals — Updated Evidence

Tecovirimat (TPOXX):
Results from randomized placebo-controlled clinical trials have now demonstrated that tecovirimat is not effective as monotherapy for mpox. In the NIH-sponsored STOMP study, tecovirimat did not reduce time to clinical resolution, pain score, or rates of MPXV detection compared with placebo among participants with clade II mpox without advanced immunocompromise. The PALM007 trial found a similar lack of efficacy for clade I mpox in the DRC. Clinicians should not use tecovirimat as monotherapy for mpox. 

Use of tecovirimat as part of combination therapy with another antiviral agent can be considered for individuals with advanced immunocompromise, but should only be pursued in consultation with local/state health departments or the CDC. For combination use with brincidofovir, tecovirimat must be accessed via the CDC Expanded Access IND protocol. 

Brincidofovir / Cidofovir:
Brincidofovir is an oral prodrug of cidofovir and is FDA-approved for smallpox treatment. Cidofovir is available IV. Either can be added to tecovirimat in patients with or at high risk of severe mpox, typically given once weekly for 2 weeks. They should never be used concurrently with each other. 

IV cidofovir or oral brincidofovir can be used as adjunctive therapy in people with or at risk for severe disease, or in people who experience clinically significant progression while receiving tecovirimat, develop disease recrudescence, or are ineligible for tecovirimat. Brincidofovir is associated with less nephrotoxicity than cidofovir. 

Vaccinia Immune Globulin IV (VIGIV): Can be considered for severe or life-threatening disease in immunocompromised patients, in combination with antivirals.

Summary of current antiviral approach:

|Patient
Approach
MILD Supportive care only

MODERATE
| Consult CDC/ID; consider tecovirimat + brincidofovir ± VIGIV

Severe / immunocompromised |Consult CDC/ID; consider tecovirimat + brincidofovir ± VIGIV|

|HIV with low CD4 / advanced AIDS|Early antiviral combination + ART optimisation |

8. VACCINATION — PRE- AND POST-EXPOSURE

JYNNEOS (Imvanex/Imvamune): The preferred vaccine.

The standard regimen is two doses administered subcutaneously 28 days apart. Peak immunity is expected two weeks after the second dose. Estimated vaccine effectiveness for preventing mpox disease has ranged from 66–89% for the two-dose series. 

Post-Exposure Prophylaxis (PEP):
Postexposure prophylaxis using JYNNEOS is recommended within 4 days after exposure.  Vaccination within five to 14 days of exposure may reduce symptoms for those who go on to develop mpox illness. Close contacts of a confirmed case, particularly those who are immunocompromised, should receive two doses as PEP. 

Pre-exposure recommendations (for patients you counsel):
Pre-exposure vaccination is recommended for persons with occupational risk, those with planned travel to a country with a clade I mpox outbreak plus an additional risk factor (such as s*x with a new partner or attendance at large public events), and those with multiple s*xual partners, recent STI diagnosis, or s*x at commercial s*x venues where mpox is circulating. 

9. SPECIAL CONSIDERATIONS FOR YOUR INTERNATIONAL TOURIST PRACTICE

• Always take a travel history — ask specifically about recent travel to DRC, Central/Eastern Africa, or any current outbreak region
• Detailed s*xual history is essential — non-judgmental, routine inquiry
• Co-test for HIV and STIs in all mpox cases — co-infection is common and influences management
• HIV-positive patients with low CD4 counts are at very high risk of severe disease — low threshold for antiviral therapy consultation
• Consider clade I in travellers returning from Central Africa — more severe disease, broader transmission routes including respiratory droplets and household contact
• Notify public health authorities — mpox is a notifiable disease in most jurisdictions; reporting is mandatory
• Counsel patients on isolation — remain isolated until all lesions are fully crusted and healed
• Counsel on partner notification — s*xual and household contacts should be traced and offered PEP vaccination

10. YOUR PERSONAL PROTECTION CHECKLIST

• ✅ Ensure you are vaccinated with 2-dose JYNNEOS series
• ✅ Don full PPE (N-95, gown, gloves, eye protection) before any suspected mpox contact
• ✅ Never unroof or aspirate lesions with sharp instruments
• ✅ Triage suspected cases to isolated rooms promptly
• ✅ Know your local/national reporting pathway
• ✅ Know how to access tecovirimat combination therapy via expanded access if needed for severe/immunocompromised patients
• ✅ If you have a needlestick or unprotected exposure, seek PEP vaccination within 4 days and report to occupational health

Key reference sources: WHO Living Clinical Guideline (May 2025), CDC Clinical Overview (December 2025), NIH/NYSDOH Treatment Guidelines (July 2025), STOMP and PALM007 trial data (2025).