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

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:

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:

Health care worker - Personal Protective Equipment (PPE):

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

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)

Containment and Disposal of Contaminated Waste

Discharge environmental cleaning and disinfection

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.

References

Alakunle, E., et al. (2020). “Monkeypox Virus in Nigeria: Infection Biology, Epidemiology, and Evolution.” Viruses vol. 12, 11 1257. 5 Nov.

British HIV Association. (2022). BHIVA rapid statement on monkeypox virus. Tuesday 17 May. BHIVA rapid statement on monkeypox virus. Accessed May 19, 2022.

Bunge, E.M., Hoet, B., Chen, L., Lienert, F., Weidenthaler, H., Baer LR, et al. (2022) The changing epidemiology of human monkeypox—A potential threat? A systematic review. PLoS Negl Trop Dis 16(2): e0010141. https://doi.org/10.1371/ journal.pntd.0010141

Butcher, W., Ulaeto, D. (2005). Contact inactivation of orthopoxvirues by household disinfectants. Journal of Applied Microbiology, 99(2): 279-284.

Centers for Disease Control and Prevention (CDC). Guide D - Specimen Collection and Transport Guidelines.

Centers for Disease Control and Prevention (CDC). (2003). Multistate outbreak of monkeypox-- Illinois, Indiana, and Wisconsin, 2003. MMWR. Morbidity and mortality weekly report vol. 52, 23: 537-40.

Centres for Disease Control and Prevention (CDC). Monkeypox. (2022). https://www.cdc.gov/poxvirus/monkeypox/index.html. Accessed May 20, 2022.

Erez, Noam et al. (2019). Diagnosis of Imported Monkeypox, Israel, 2018. Emerging infectious diseases vol. 25,5: 980-983.

Formenty, Pierre et al. (2010). Human monkeypox outbreak caused by novel virus belonging to Congo Basin clade, Sudan, 2005.” Emerging infectious diseases vol. 16,10: 1539-45.

Gelfand, H.M., Posch, J. (1971). The recent outbreak of smallpox in Meschede, West Germany, Am J Epidemiol; 93:234-7.

Government of UK. (2022). Monkeypox cases confirmed in England – latest updates. Monkeypox cases confirmed in England – latest updates - GOV.UK (www.gov.uk). Accessed May 20, 2022.

Heymann, D.L., Simpson, K. (2021). The Evolving Epidemiology of Human Monkeypox: Questions Still to Be Answered. J Infect Dis.; 223(11):1839-1841.

Hobson, Gemma et al. (2021). Family cluster of three cases of monkeypox imported from Nigeria to the United Kingdom, May 2021. Euro surveillance : bulletin Europeen sur les maladies transmissibles - European communicable disease bulletin vol. 26,32: 2100745.

Ihekweazu, Chikwe et al. (2020). Importance of epidemiological research of monkeypox: is incidence increasing? Expert review of anti-infective therapy vol. 18, 5: 389-392.

Jezek, Z et al. (1988). Human monkeypox: disease pattern, incidence and attack rates in a rural area of northern Zaire. Tropical and geographical medicine vol. 40, 2: 73-83.

Jezek, Z et al. (1987). Human monkeypox: clinical features of 282 patients. The Journal of infectious diseases vol. 156, 2: 293-8.

Likos, Anna M et al. (2005). A tale of two clades: monkeypox viruses. The Journal of general virology vol. 86,Pt 10: 2661-2672.

Mary, G., et al. (2019). Monkeypox re-emergence in Africa: a call to expand the concept and practice of One Health. Expert review of anti-infective therapy vol. 17,2: 129-139.

Nakazawa, Yoshinori et al. (2013). Phylogenetic and ecologic perspectives of a monkeypox outbreak, southern Sudan, 2005. Emerging infectious diseases vol. 19,2: 237-45.

Nolen, Leisha Diane et al. (2016). Extended Human-to-Human Transmission during a Monkeypox Outbreak in the Democratic Republic of the Congo. Emerging infectious diseases vol. 22,6: 1014-21.

Public Health Agency of Canada. (2016 revised). Infection control guidelines: Routine practices and additional precautions for preventing the transmission of infection in health care. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases- conditions/routine-practices-precautions-healthcare-associated-infections/routine-practices - precautions-healthcare-associated-infections-2016-FINAL-eng.pdf

Public Health Agency of Canada. (2022). Public Health Agency of Canada Confirms 2 cases of Monkeypox. May 19, 2022. https://www.canada.ca/en/public-health/news/2022/05/public- health-agency-of-canada-confirms-2-cases-of-monkeypox.html Accessed: May 20, 2022.

Reed, Kurt D et al. (2004). The detection of monkeypox in humans in the Western Hemisphere. The New England journal of medicine vol. 350, 4: 342-50.

Rimoin, Anne W et al. (2010). Major increase in human monkeypox incidence 30 years after smallpox vaccination campaigns cease in the Democratic Republic of Congo. Proceedings of the National Academy of Sciences of the United States of America vol. 107, 37: 16262-7.

Simpson K, Heymann D, Brown CS, et al. (2020). Human monkeypox - After 40 years, an unintended consequence of smallpox eradication. Vaccine; 38(33):5077-5081.

Vaughan, Aisling et al. (2018). Two cases of monkeypox imported to the United Kingdom, September 2018. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin vol. 23,38: 1800509.

Wehrle PF, Posch J, Richter KH, et al. (1970). An airborne outbreak of smallpox in a German hospital and its significance with respect to other recent outbreaks in Europe. Bull World Health Org 1970; 43:669-79.

Yinka-Ogunleye, Adesola et al. (2018). Reemergence of Human Monkeypox in Nigeria, 2017. Emerging infectious diseases vol. 24, 6.

Yong, Sarah Ee Fang et al. (2020). Imported Monkeypox, Singapore. Emerging infectious diseases vol. 26, 8: 1826-1830.

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