MSDH Monkeypox Oral TPOXX Request Form

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MSDH Monkeypox Oral TPOXX Request Form

Oral tecovirimat for treatment of mpox is primarily available through the National Institutes of Health's Study of Tecovirimat for Mpox (STOMP). Healthcare providers should either contact the STOMP call center (1-855-876-9997).

If your patient is not eligible for STOMP or not willing to participate in the trial, Please fill out this form to the best of your ability and MSDH will reach out to you regarding next steps.

Note: TPOXX treatment is only shipped on business days. If you are a hospital or other healthcare provider who has questions or a need to request more urgent delivery or request IV TPOXX rather than oral, please contact the MSDH Office of Epidemiology at 601-576-7725 (or after hours 601-576-7400).

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Date

M-D-Y

Facility Information

Facility Name:

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Facility Type:

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Facility Address:

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Facility City:

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Facility State:

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Facility Zipcode:

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Requesting Clinician Name:

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Clinician Direct Phone Number:

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Clinician Email:

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Administrative Contact Name (if different than clinician):

Administrative Contact Phone Number:

Administrative Contact Email:

Patient Information

First Name:

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Last Name:

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Date of Birth:

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M-D-Y

Age:

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Street Address:

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City:

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State:

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Zipcode:

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Phone Number:

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Sex at Birth:

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Male

Female

Unknown

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Gender:

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Female

Male

Transgender/female-to-male (FTM)

Transgender/male-to-female (MTF)

Genderqueer/gender nonconforming

Other gender category

Unknown

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Other gender category:

Ethnicity:

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Hispanic

Non-Hispanic

Unknown

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Race:

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American Indian or Alaskan Native

Asian

Black

Native Hawaiian/Pacific Islander

White

Other

Unknown

Other race:

Weight

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Date of Onset:

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M-D-Y

Is the patient currently an inpatient or an outpatient?

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Inpatient

Outpatient

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Has the patient been tested for monkeypox?

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Treatment Indications

Treatment indications: Select all that apply

Encephalitis

Lesions affecting ≥ 25% of body surface that may be confluent, necrotic, and/or hemorrhagic in appearance or cause sepsis

Lesions near or directly involving the eye

HIV with CD4 < 200 cells/mm3

Hematologic malignancy

History of solid organ transplantation

Hematopoietic stem cell transplant < 24 months post-transplant or ≥ 24 months but with graft-versus-host disease or malignant disease relapse

A condition actively requiring chemotherapy, radiation, or continuous or high-dose systemic corticosteroids

Other severe immunocompromising condition. (Persons with severe immunocompromise are known to be at high risk for protracted or life[1]threatening manifestations of mpox regardless of disease severity at presentation.)

Children (< 18 years), regardless of illness severity or underlying comorbidities at presentation

Pregnant or lactating individuals, regardless of illness severity or underlying comorbidities at presentation

Persons with active skin conditions placing the person at higher risk for disseminated infection defined as: atopic dermatitis; active exfoliative skin condition(s) such as eczema, burns, impetigo, active varicella zoster virus infection, psoriasis, or Darier disease (keratosis follicularis)

Disease resulting in airway compromise or affecting the nervous system

Cardiac (e.g., myocarditis) and/or neurologic disease (e.g., encephalitis) which might occur in a small number of patients with mpox

Generalized malignancy

Therapy with alkylating agents within 180 days prior to mpox illness onset

Antimetabolites within 180 days prior to mpox illness onset

Radiation therapy within 180 days prior to mpox illness onset

Does the patient have any contradindications to oral medication?

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Yes

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MSDH Follow-up

Treatment approved?

Yes

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Reason Not Approved:

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Who approved/disapproved?

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MSDH comments:

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