Interim guidance on infection prevention and control for suspect, probable or confirmed monkeypox within Healthcare settings – 27 May 2022

Monkeypox is a rare infectious disease caused by the monkeypox virus (genus orthopox). Monkeypox virus is related to, but distinct from, the viruses that cause smallpox (variola virus) and cowpox. Cases of monkeypox are usually found in central and western Africa and it is rare to find cases outside of that geographic area. There are two genetically distinct clades of monkeypox virus: West African clade monkeypox manifests with limited human-to-human transmission, and a case fatality of 1%, whereas the Congo Basin clade is associated with human-to-human transmission and case fatalities historically reported of 10%.

On 13 May 2022, WHO was notified of laboratory-confirmed human cases of monkeypox in the United Kingdom (UK). The UK has confirmed the West African clade of the monkeypox virus. It is unknown at this time if the virus has mutated, which may lead to a change in the modes of transmission, clinical presentation or severity of disease. Transmission risk to healthcare workers is considered low at this time.

On May 19, the Public Health Agency of Canada confirmed the first two human cases of monkeypox in Canada. Both cases were detected in Quebec and other suspected cases are under investigation. Confirmed and probable monkeypox cases have now been reported in many countries outside of Africa.

Person-to-person spread of monkeypox is uncommon. However, when spread does occur between people, the mode is through close contact with an infected person such as through direct contact with their body fluids, respiratory droplets, and/or monkeypox sores, or by sharing clothing, bedding or common items that have been contaminated with the infected person's body fluids or sores. Sexual transmission has not been previously identified as a mode of transmission, though sexual partners also have close direct contact. It is not known whether airborne transmission of monkeypox occurs, although it does not appear to be the primary mode of transmission.  However, given evidence of airborne transmission with smallpox, there is a concern that monkeypox can also be transmitted by the airborne route. At this time, as more information is gathered, healthcare settings should implement droplet and contact precautions, in addition to airborne precautions until more information about the potential for aerosol transmission is known.

At this time, it is not known if a person can transmit the infection just before they develop fever or develop a rash.

If a case is suspected, immediately notify local public health authorities.

Transmission

A person can contract monkeypox when they come into close contact with an infected animal, infected person, or materials contaminated with the virus. The virus can enter the body through broken skin, the respiratory tract, or through mucous membranes. Transmission can occur via direct contact with monkeypox skin lesions, non-intact skin or scabs, indirect contact with clothing or linens used by an infected person, or close contact with the respiratory tract secretions of an individual with monkeypox.

Clinical Progression and Incubation Period

• Incubation period is typically 6-13 days from time of exposure, with a range of 5-21 days.
• In previous clinical descriptions, the febrile stage lasts 1 to 4 days prior to the first eruption of skin lesions.
• In some recent cases it appears that the initial lesions may precede the development of the febrile stage.
• Lesions progress from macule, to papule, to vesicle, to pustule, which will then crust.
• The rash/skin lesion stage can last 2-4 weeks.
• The patient is contagious until the scab crusts have fallen off (about 3-4 weeks) and new skin has formed.
• Most infections last 2-to-4 weeks and self-resolve.

Infection Prevention and Control

Airborne, droplet, and contact precautions should be used for all suspect, probable, and confirmed cases of monkeypox. Precautions should be used when a patient presents with fever and vesicular/pustular rash (suspected case). Any lesions or respiratory secretions should be considered infectious material.

Routine Practices

Continue to follow routine practices including:

• Point of Care Risk Assessment (PCRA)
• Hand Hygiene
• Patient Placement
• Respiratory hygiene
• Personal Protective Equipment (PPE)
• Injection and Medication Safety
• Cleaning and Disinfection Procedures
• Waste Management

Hand Hygiene

Alcohol-based hand sanitizers and soap and water are acceptable methods for hand hygiene. When hands are visibly soiled, soap and water is the preferred method. Hand hygiene should always be performed after the removal of gloves.

Additional Precautions

As the modes of transmission in this current outbreak are not well understood, airborne, droplet and contact precautions are recommended.

Patient:

• Patient should perform hand hygiene
• Patient should wear a medical mask
• Suspect, probable and confirmed cases should be immediately placed into an Airborne Infection Isolation Room (AIIR) or single room with the door closed, for assessment upon entry to the healthcare setting.
• If the patient must leave the room, a medical mask should be worn, if medically able to tolerate or clinical condition allows.
• Skin lesions should be kept covered with a gown, clothes, sheet or bandage, except during examination.
• Room should be cleaned and disinfected after use (as per directions below).

Health care worker - Personal Protective Equipment (PPE):

• Fit-tested and seal-checked N95 respirator
• Gown (cuffed, long sleeve)
• Gloves
• Eye protection (e.g., face shield or goggles)

All PPE (including respirators) must be discarded after each contact with the patient and hand hygiene performed. All PPE should be donned before entering the patient’s room. All PPE should be disposed of prior to leaving the isolation room except for the respirator, which should be removed, outside of the room once the door is closed, and hands should again be cleaned.

Room Selection/Patient Placement

Patient should be placed in an AIIR, when available.

If an AIIR is not available, the patient should be placed in a single room with the door closed. For inpatients, a dedicated patient bathroom is required and commode can be used if dedicated bathroom not available

Visitors should be restricted to those necessary for care or compassionate grounds.

Cleaning and Disinfection

Equipment

• Use standard housekeeping cleaning and disinfection protocols.
• Dedicate patient care equipment to a single patient.
• Clean and disinfect all reusable equipment with hospital-approved disinfectants (with Drug Identification Numbers (DIN)), as per manufacturers’ recommendations immediately after use. 

Environmental surfaces

All patient contact surfaces should be cleaned and disinfected with hospital-approved disinfectants (with Drug Identification Numbers (DIN)), as per manufacturers’ recommendations.)

Hospital-grade cleaning and disinfecting agents (with Drug Identification Numbers (DIN)), are sufficient for environmental cleaning for monkeypox.

Clean and disinfect all surfaces that could have been touched including chairs in the area and public bathrooms. Attention should be paid to frequently touched surfaces, such as doorknobs, call bell pulls, faucet handles and wall surfaces that may have been frequently touched by the patient.

Use standard housekeeping cleaning and disinfection protocols.

Laundry (such as linens, towels, clothing, bedding)

• Wear appropriate PPE (gloves, gown, fit-tested and seal-checked N95 respirator and eye protection) during collection and bagging of all linens at the point of use.
• The laundry materials should carefully be placed in a leak-proof bag, sealed or tied and placed inside an impermeable bag for transport to laundry area.
• In ambulatory care settings, standard medical laundry facilities should be used.  If not available, the items may be washed in a standard washing machine using hot water (70 degrees Celsius) with detergent and must be completely dried in a commercial dryer.
• When handling soiled laundry (clothing, towels, bedding), care should be taken to avoid contact with the worker’s skin and clothing.
• Do not shake laundry, as it disperses contaminated infectious particles into the air and onto the surrounding surfaces.

Containment and Disposal of Contaminated Waste

• Biomedical waste should be contained in impervious waste-holding bags or double bagged according to municipal/regional regulations.
•   Contaminated disposable items should be discarded according to jurisdictional protocols.

Discharge environmental cleaning and disinfection

• For discharge environmental cleaning and disinfection:
  • HCW must wear a gown, gloves, fit-tested and seal-checked N95 respirator and eye protection during cleaning and disinfection.
  • Use standard housekeeping discharge cleaning and disinfection protocols.
  • All disposable items in the patient’s room should be discarded.
  • Privacy curtains must be changed.
  • Equipment/supplies that cannot be disinfected must be discarded.

Transportation of suspected monkeypox patients

If a patient with suspect, probable, or confirmed monkeypox requires transportation, the patient should not use public transportation. The patient should be masked and lesions covered during transport. If used, patient transport services should be informed that the patient has suspect, probable, or confirmed monkeypox. The receiving healthcare setting should be informed before the patient’s arrival of the diagnosis and need for airborne, droplet and contact precautions.

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