Audit, Compliance and Risk Blog

California issues guidance on protecting workers against workplace monkeypox

Posted by Jon Elliott on Fri, Oct 14, 2022


As public and occupational health agencies around the word continuously reevaluate their responses to the spread of monkeypox (also called MPX), California has issued the first regulation-oriented guidance I’ve seen. On September 13, the Division of Occupational Safety and Health (DOSH, but universally called Cal/OSHA) issued “Protecting Workers from Monkeypox (MPX) for Employers and workers Covered by the Aerosol Transmissible Diseases Standard (Title 8 section 5199).” Depending whether MPX comes to be considered an epidemic, this Cal/OSHA effort may be the first of many – I’ve written about public health and OSH agency responses to the COVID-19 epidemic many times since 2020 – or an outlier reflecting California’s aggressive approach to potential hazards. The remainder of this note discusses the new guidance, which is targeted at health and public service workplaces but has relevance for other employers as well.

What is monkeypox (MPX) and how is it transmitted?

The US Centers for Disease Control and Prevention (CDC) describe monkeypox as a:

“…rare disease caused by infection with the monkeypox virus. Monkeypox virus is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox symptoms are similar to smallpox symptoms, but milder, and monkeypox is rarely fatal. Monkeypox is not related to chickenpox.

Monkeypox was discovered in 1958 [and the] first human case of monkeypox was recorded in 1970. Prior to the 2022 outbreak, monkeypox had been reported in people in several central and western African countries. Previously, almost all monkeypox cases in people outside of Africa were linked to international travel to countries where the disease commonly occurs or through imported animals. These cases occurred on multiple continents.”

CDC describes possible monkeypox symptoms to include:

  • Fever

  • Headache

  • Muscle aches and backache

  • Swollen lymph nodes

  • Chills

  • Respiratory symptoms (e.g., sore throat, nasal congestion, or cough)

  • A rash that can look like pimples or blisters that appears on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus.

The rash goes through different stages before healing completely. The illness typically lasts 2-4 weeks. Some patients get a rash first followed by other symptoms; others only experience a rash.

Cal/OSHA’s new guidance notes that that “MPX spreads primarily by close or direct contact with infectious rashes, lesions, scabs, or body fluids. It can also spread through touching materials used by a person with MPX that haven’t been cleaned, such as clothing, towels, and bedding. The virus can become airborne during changing or handling of contaminated linen. In addition to lesions on the skin, lesions may be located in the mouth or throat, and research is underway to further understand the role of respiratory fluids, droplets, and particles in the transmission of MPX.”

Although most public health and OSH agencies have focused their concerns on transmission via direct contact, Cal/OSHA’s guidance considers monkeypox to be an “aerosol transmissible disease” covered by Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard (8 CCR 5199).

Who is targeted by the new guidance?

Cal/OSHA’s monkeypox guidance is directed at employers subject to the state’s ATD Standard, consisting of the following types of public health and safety workplaces: 

  • Hospitals

  • Skilled nursing facilities

  • Clinics, medical offices, and other outpatient medical facilities

  • Home health care

  • Long term health care facilities and hospices

  • Medical outreach services

  • Paramedic and emergency medical services

  • Medical transport

  • Police services, provided during transport or detention of persons reasonably anticipated to be cases or suspected cases of aerosol transmissible diseases

  • Police services provided with health care or public health operations

  • Public health services that are reasonably anticipated to be provided to cases or suspected cases of aerosol transmissible diseases

  • Public health services rendered in health care facilities or in connection with the provision of health care

  • Correctional facilities and other facilities that house inmates or detainees

  • Homeless shelters (includes migrant shelters)

  • Drug treatment programs

  • Facilities, services, or operations that perform aerosol-generating procedures on cadavers

  • Laboratories that perform procedures with materials that contain or are reasonably anticipated to contain aerosol transmissible pathogens

The ATD Standard has differing requirements for three different types of employers, which are reflected in Cal/OSHA’s new MPX Guidance:

  • referring employers (such as outpatient clinics)

  • laboratories that may handle materials containing the MPX virus

  • hospitals and all other employers (including homeless shelters, drug treatment programs and correctional/detention facilities) that may have MPX exposures

What must employers do?

Cal/OSHA’s new MPX Guidance focuses targeted categories of employers on ATD Standard requirements triggered by the presence of MPX exposure hazards, including detailed discussion of the following:

  • ATD Exposure Plan (including MPX) – including evaluation, training, procedures, engineering and work practice controls, equipment and personal protective equipment (PPE), access to appropriate medical services following an exposure, and record keeping

  • Respiratory protection

  • PPE

  • Responding to MPX exposure incidents

What’s next?

Cal/OSHA’s MPX Guidance became effective when issued on September 13. In California, Cal/OSHA and the state Department of Public Health continue to monitor and plan ongoing responses. Nationally and globally, public health and OSH agencies are doing the same; responses and further development depend on the course of monkeypox’s spread..

Self-Assessment Checklist

If the organization has employees in California, are any of its operations subject to the state’s Aerosol Transmissible Diseases Standard?

  • If so, does each ATD Exposure Plan and compliance program address monkeypox?

If the organization has no employees in California, has it evaluated the hazards of monkeypox exposures, and implemented appropriate prevention and response procedures?

Where Can I Go For More Information?

 - “Monkeypox” webpage 

 - “Infection Prevention and Control of Monkeypox in Healthcare Settings” webpage

 - “Considerations for Reducing Monkeypox Transmission in Congregate Living Settings” webpage


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About the Author

Jon Elliott is President of Touchstone Environmental and has been a major contributor to STP’s product range for over 30 years. 

Mr. Elliott has a diverse educational background. In addition to his Juris Doctor (University of California, Boalt Hall School of Law, 1981), he holds a Master of Public Policy (Goldman School of Public Policy [GSPP], UC Berkeley, 1980), and a Bachelor of Science in Mechanical Engineering (Princeton University, 1977).

Mr. Elliott is active in professional and community organizations. In addition, he is a past chairman of the Board of Directors of the GSPP Alumni Association, and past member of the Executive Committee of the State Bar of California's Environmental Law Section (including past chair of its Legislative Committee).

You may contact Mr. Elliott directly at:

Tags: Health & Safety, CDC, Safety and Health at Work, Cal/OSHA, Monkeypox