Reviewed on : 19 Jul 2022

Reviewed by : GP Gateway Editor

Expires : 19 Jul 2024

Midlands Monkeypox Update August 2022

Across the region, we have seen a number of patients who have been diagnosed with monkeypox following atypical presentation.

These patients have presented with what was initially diagnosed as tonsilitis. In both cases where the patients were inpatients, it was noted that there were a number of pus-filled lesions present on the tonsils.

Whilst we know that there are a number of possible reasons why patients may present with symptoms of tonsilitis, we are asking all practitioners to consider monkeypox as a differential diagnosis and take an appropriate history for these patients.

In addition, when we are discussing sexual contacts with patients and taking sexual history, please can we ensure we are considering that patients may not have directly had contact with another person during sexual contact but may have shared sex toys (or alternatives) which could also be a source of transmission.

Also to note that the case definition for monkeypox has been updated recently (https://www.gov.uk/guidance/monkeypox-case-definitions):

Possible case

A possible case is defined as anyone who fits one or more of the following criteria:

• A febrile prodrome^† compatible with monkeypox infection where there is known prior contact with a confirmed case in the 21 days before symptom onset
• An illness where the clinician has a suspicion of monkeypox – this could include unexplained genital, ano-genital or oral lesion(s) (for example, ulcers, nodules) or proctitis (for example anorectal pain, bleeding)

Febrile prodrome consists of fever ≥ 38°C, chills, headache, exhaustion, muscle aches (myalgia), joint pain (arthralgia), backache, and swollen lymph nodes (lymphadenopathy).

Probable case

A probable case is defined as anyone with an unexplained rash or lesion(s) on any part of their body (including genital/perianal, oral), or proctitis (for example anorectal pain, bleeding) and who:

• has an epidemiological link to a confirmed, probable or highly probable case of monkeypox in the 21 days before symptom onset
• Or, identifies as a gay, bisexual or other man who has sex with men (GBMSM)
• Or, has had one or more new sexual partners in the 21 days before symptom onset
• Or, reports a travel history to West or Central Africa in the 21 days before symptom onset

Actions on a possible or probable case

Test for monkeypox (using designated testing pathway).

Undertake additional contemporaneous tests to rule out alternative diagnoses if clinically appropriate and if not done already.

If admission of patient required for clinical reasons, admit to single room isolation at negative or neutral pressure at local hospital site with RPE PPE (with appropriate IPC arrangements).

Or, if patient not requiring admission for clinical reasons: self-isolation at home (based on assessment by the clinician and following UKHSA guidance).

Or, if patient not requiring admission for clinical reasons but self-isolation at home is not possible for social or medical reasons following clinician assessment: isolation in single room at negative or neutral pressure at local hospital site with RPE PPE pending test result (prioritise probable cases).

Highly probable case

A highly probable case is defined as a person with an orthopox virus positive result since 15 March 2022 and where monkeypox remains the most likely diagnosis.

Confirmed case

A confirmed case is defined as a person with a laboratory confirmed monkeypox infection (monkeypox PCR positive).

Action on a confirmed or highly probable case

All confirmed or highly probable cases should be assessed for the need for admission based on either clinical or self-isolation requirements. The NHS provides guidance on management of patients with confirmed monkeypox.

All confirmed or highly probable cases should be notified to the local health protection team by the clinician.

Midlands Regional Operations Centre SPOC

0114 324 0465

For latest information on Covid-19 visit for:

NHS: https://www.england.nhs.uk/ourwork/eprr/coronavirus/

About Monkeypox

Monkeypox is a viral zoonotic disease that until May 2022, was primarily identified in Central and West Africa. There are 2 historical clades of monkeypox :

• Central African clade with a reported mortality of 10%
• West African clade with a reported mortality of 1% from epidemiological cluster and outbreak reports from Africa.

Prior to 2022, it was occasionally identified in other countries related to travel from endemic areas in Central and West Africa.

Within the UK, monkeypox has previously been classified as a High Consequence Infectious Disease (HCID). This is not a legal classification but agreed by UKHSA and the NHS to enable a consistent approach to public health and clinical or NHS management.

The rationale for classifying monkeypox as an HCID was that there were infrequent importations, limited information about the disease course and outcome, no confirmed availability of vaccine and unclear approaches to treatment. Therefore, it was reasonable to have a highly precautionary approach designed for complete containment around single cases. This recognised that the initial clinical assessment cannot determine the particular clade of monkeypox, and would reduce spread in healthcare environments and the community by enabling early identification of imported cases.

Since 13 May 2022, cases of monkeypox have been reported in multiple countries that do not have endemic monkeypox virus in animal or human populations, including countries in Europe, North America and Australasia. Epidemiological investigations are ongoing; however reported cases thus far have no established travel links to an endemic area. This suggests significant community transmission in multiple non-endemic countries in recent weeks. In the UK, all reported cases have been identified as the West African clade through rapid molecular testing.

The situation in the UK has now changed. There are now many cases and it is clear that community transmission is occurring with multiple generations of spread. Illness appears to be generally mild, though some individuals will require hospital admissions to manage secondary infections or complications from the illness. Pre and post exposure prophylaxis using Imvanex is now available. Due to this changed context, the clade of monkeypox currently circulating in the UK is no longer classified as an HCID.

However, future importations of monkeypox from West Africa and/or monkeypox caused by the Central African clade should remain classified as an HCID as the severity of the original clades remains unknown.

Monkeypox is a hazard group 3 organism (ACDP/HSE). Other organisms in this category include Salmonella typhi, HIV, Hepatitis B and C, and Mycobacterium tuberculosis that are managed routinely in the community. From July 2022, the international agreed approach for managing clinical waste and diagnostic samples is that they are now managed as Category B, similar to the other organisms in Hazard Group 3.

These principles are to ensure a proportionate response to deliver on achievable strategic outcomes. These principles do not replace the need for local dynamic risk assessments which remain key.

Strategic aims

The strategic aims of the public health response are:

• Suppress the transmission of monkeypox in the community and aim for eradication (decreasing Rt below 1) by targeting public health measures to the highest risks for transmission
• Protect against spread of infection in hospitals and healthcare settings and to healthcare workers assessing and managing patients
• Enable safe functioning of NHS services, including those services which can diagnose and manage cases, in the context of community transmission of monkeypox

Assumptions about transmission and biology

These assumptions are based on the available data and expert opinion and are aligned with the World Health Organization (WHO). They will be regularly reviewed using the evidence generated in the incident response.

1. For individuals with infection who are well, ambulatory, and have either prodrome or rash, the highest risk transmission routes are direct contact, droplet or fomite. Transmission seen so far in this outbreak is consistent with close direct contact.
2. There is currently no evidence that individuals are infectious before the onset of the prodromal illness.
3. For individuals with infection who have evidence of lower respiratory tract involvement or severe systemic illness requiring hospitalisation, the possibility of airborne transmission has not been excluded.
4. It remains important to reduce the risk of fomite transmission. The risk can be substantially reduced by following agreed cleaning methods based on standard cleaning and disinfection, or by washing clothes or domestic equipment with standard detergents and cleaning products. Within healthcare, please refer to local country national infection prevention and control manual or guidance for decontamination.
5. Waste management and decontamination practice should follow best practice and be based on all the available evidence on safe handling of all waste in accordance with country specific legislation and regulations (clinical waste is now managed as Category B).
6. The highest risk period for onwards infection is from the onset of the prodrome until the lesions have scabbed over and the scabs have fallen off.
7. Deroofing procedures and throat swabs are not considered to be aerosol generating procedures (AGPs) but may cause droplets. The list of AGPs is available in the national infection prevention and control manual.
8. There is little available evidence on monkeypox in genital excretions and a precautionary approach for the use of condoms for 12 weeks after infection is recommended, (this will be updated as evidence emerges), in addition to abstaining from sex while symptomatic including during the prodromal phase and while lesions are present.
9. The disease in healthy adults is primarily self-limiting and with a relatively low mortality. There is remaining uncertainty over potentially increased severity in children and in individuals who are highly immunocompromised or pregnant.

Implications PPE

Risk assessment and consideration of the hierarchy of controls will help determine the level of personal protective equipment (PPE) to use.

For possible/probable cases, the minimum PPE is:

• Gloves
• Fluid repellent surgical facemask (FRSM) (an FRSM should be replaced with an FFP3 respirator and eye protection if the case presents with a lower respiratory tract infection with a cough and/or changes on their chest x-ray indicating lower respiratory tract infection)
• Apron
• Eye protection is required if there is a risk of splash to the face and eyes (for example when taking diagnostic tests)

For confirmed cases requiring ongoing clinical management (for example inpatient care or repeated assessment of an individual who is clinically unwell or deteriorating), the minimum recommended PPE for healthcare workers is:

• fit-tested FFP3 respirator
• eye protection
• long sleeved, fluid repellent, disposable gown
• gloves

The above PPE will be used as the basis for contact classification.

Community and domestic

1. Home isolation may be used for clinically well ambulatory possible, probable or confirmed cases for whom it is judged by the primary clinician and the HCID network as safe and clinically appropriate, with ongoing clinical and public health support for clinical management and isolation.
2. For ambulatory well possible, probable or confirmed cases with limited lesions, covering lesions and wearing a face covering or mask reduces the risk of onwards transmission.
3. Individuals with possible, probable or confirmed monkeypox should avoid close contact with others until all lesions have healed, and scabs dried off. This should include staying at home unless requiring medical assessment or care, or other urgent health and wellbeing issues.
4. Close household and non-household contacts of confirmed cases should be risk assessed. Medium risk contacts (category 2) do not need to isolate, but should avoid close contact with young children or individuals who are pregnant or severely immunocompromised. High risk (category 3) contacts should be advised to self-isolate for 21 days.
5. Cleaning to reduce risk from the environment in the community settings can be effectively achieved without using specialist services or equipment.
6. The risk of transmission in the home environment for possible, probable or confirmed cases can be reduced by the case performing regular domestic cleans and washing their own clothing and bed linen in a domestic washing machine.
7. Transport from the community to healthcare facilities for possible, probable or confirmed cases should be via private transport where possible. Where private transport is not available, public transport can be used but busy periods should be avoided. Any lesions should be covered by cloth (for example scarves or bandages) and a face covering must be worn.

Ambulatory care

1. For possible, probable or confirmed cases, attending ambulatory healthcare (for example outpatients, EDs, urgent care centres, general practice, sexual health clinics), patients should be placed in a single room for assessment. The case should be provided with a Fluid Repellant Face Mask FRSM to wear as appropriate.
2. Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.
3. Medium risk contacts (category 2) do not need to isolate, but should avoid activities involving close contact with young children or individuals who are pregnant or severely immunocompromised. High risk (category 3) contacts should be advised to self-isolate for 21 days.

Inpatient healthcare

1. For cleaning and decontamination of the room within healthcare settings, healthcare facilities should refer to the relevant country national infection prevention and control manual.
2. Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.
3. Medium risk contacts (category 2) do not need to isolate, but should avoid activities involving close contact with young children, or individuals who are pregnant or severely immunocompromised. High risk (category 3) contacts should be advised to self-isolate for 21 days.

Other residential settings

1. Within non-domestic residential settings (for example adult social care, prisons, homeless shelters, refuges), individuals who are clinically well should be managed in a single room with separate toilet facilities where possible.
2. In domestic and non-domestic settings where healthcare is being provided, waste generated is classified as healthcare waste and should be managed appropriately.
3. Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.
4. Close contacts of confirmed cases in these settings should be assessed for vaccine, following the contact recommendations.

Coventry & Warwickshire Actions

If patient presents to primary care setting and has any of the following symptoms suggestive of Monkeypox , please isolate in an examination room immediately: rash on any part of body, fever, new lump/s on neck, groin or under arm (as per BASHH guidance)

Undertake assessment of patient, maintaining where possible safe distance and wearing routine PPE (fluid resistant surgical mask, apron, gloves, and eye protection if risk of splashing)

If patient is undergoing telephone consultation, the following guidance should also be followed:

Assess patient against case definitions for possible and probable cases of monkey pox.

Any possible/probable cases who are likely to have acquired through sexual contact, or if they have genital lesions, refer to sexual health services (Coventry: 0300 020 0027, Warwickshire: 0300 123 6644) who will pick up clinical responsibility for the pathway at that point. Most cases currently are linked with sexual contact.

Ask the patients to isolate at home and ring the above numbers 9am to 5pm Monday to Friday. GUM/Sexual health on-call can also be contacted in and out of hours via GEH switchboard (Warwickshire service): 02476 351351 (9-5pm weekdays, 9-12pm weekends/bank holidays), or UHCW switchboard (Coventry service): 02476 964000 (24/7)

If the case definition is met but not appropriate for sexual health services/unable to access timely advice, please contact Virology on 02476 965471, or the on-call microbiologist (if out of hours) via UHCW switchboard: 02476 964000.

Please note that if individuals are triaged by sexual health and they do not have genital lesions/not contracted through sexual contact, they will be asked to contact their GP for onward management (necessary to pick up clinical responsibility)

Following risk assessment between GP & Virology/Microbiologist, or having referred individual appropriately to sexual health services, patient will either return home (and isolate), or need to be transferred to sexual health service/hospital (this should be in private transport, as long as not exposing anyone vulnerable/individuals not already exposed).

Until another solution is locally found, and only as a last resort should suspected cases (who are well) travel by public transport, with lesions covered and a face mask on (avoiding busy times and advising to distance from others on the transport). The latter is consistent with national guidance, but not the preferred option.

The Primary Care Clinician should notify UK Health Security Agency (UKHSA) at the point the decision to swab is made: 0344 225 3560 Option 0 Option 2.

Swabs not undertaken in sexual health services will be undertaken by home testing service (co-ordinated through Virology/Microbiology). Note that these are viral swabs of lesions. Home swabbing service only operational during core working hours (Monday-Friday 9am-5pm). Out of hours assessment to be made through Virology/Microbiology to determine if the testing can wait until the next working day or if testing at sexual health service or hospital is needed immediately.

Only results from home swabbing will be conveyed to primary care, who will then need to notify the individuals of results, and notify UKHSA, who will advise on further action. For the first few cases, an incident management team meeting would be called to discuss responsibilities for onward follow up of the individuals.

NB Anyone who is clinically unwell and cannot be managed in community should be referred and conveyed to hospital via ambulance (ensuring ambulance team aware of monkeypox status), via usual procedures.

• NB: If the patient had presented to the primary care setting the room in which they have been seen will need to be decontaminated in line with the National IPC manual