UKHSA Mpox Toolkit for Stakeholders

 

 

 

Monkeypox Information

Across the Midlands, 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  (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/

Epidemiology

Mpox is an infectious disease that is caused by infection with monkeypox virus (MPXV).

Mpox was first discovered in 1958 when outbreaks of a pox-like disease occurred in monkeys kept for research. The first human case was recorded in 1970 in the Democratic Republic of the Congo (DRC), and since then the infection has been reported in a number of African countries. Prior to 2022 most cases were reported from the DRC and Nigeria.

In 2003, mpox was recorded in the US when an outbreak occurred following the importation of rodents from Africa. Cases were reported in both humans and pet prairie dogs. All the human infections followed contact with an infected pet exposed to an imported animal and all patients recovered.

There are 2 major genetic groups (clades) of MPXV, Clade I (formerly known as Central African or Congo basin clade) and Clade II (formerly known as West African clade). Clade I is split into Clade Ia and Clade Ib. Clade II is split into Clade IIb and Clade IIa, with subgroup clusters called lineages. The majority of the cases seen in the outbreak in 2022 were from Clade IIb, lineage B.1.

Since May 2022, cases of human mpox have been reported in multiple countries that have not previously had MPXV in animal or human populations, including the UK. The majority of these cases are from Clade IIb, lineage B.1.

Since January 2023, Clade II mpox is no longer considered a high consequence infectious disease (HCID) within the UK. Clade I mpox remains an HCID. There is further information on the HCID status of mpox available. Further information on the epidemiology of mpox is available in the mpox epidemiological overview.

Mpox 2024

Historically, Clade I mpox was known to circulate in 5 Central African Region countries:

• Cameroon
• Central African Republic (CAR)
• Democratic Republic of the Congo (DRC)
• Gabon
• Republic of the Congo

In 2024, Clade I mpox cases were reported from countries in Africa beyond these 5 Central African Region countries. This is likely to be because of multiple factors including waning population immunity from the discontinued smallpox vaccine and changing environmental and social factors, but the full aetiology remains unclear.

Clade I MPXV has previously been intermittently transmitted from animals to humans, with small mammals and primates acting as hosts. Clade I MPXV can also spread via human-to-human transmission and had previously been associated with close contact. However, in March 2023, infections linked to sexual contact and international travel were reported in the DRC for the first time.

As of August 2024, no cases of Clade I mpox have ever been detected in the UK.

Transmission

Mpox does not spread easily between people unless there is very close contact.

The virus is transmitted through skin-to-skin contact, breathing in virus through the respiratory tract, or contact with mucous membranes (eyes, nose, mouth, genitals).

Person-to-person spread may occur through:

• direct contact with skin lesions or scabs (including during sexual contact, kissing, cuddling or other skin-to-skin contact)
• coughing or sneezing of someone who has mpox when they’re close to you
• contact with clothing or linens (such as bedding or towels) used by someone with mpox

Spread of mpox may also occur when a person comes into close contact with an infected animal (rodents are believed to be the primary animal reservoir for transmission to humans), human, or materials contaminated with the virus. Mpox has not been detected in animals in the UK.

Clinical features

The incubation period is the duration/time between contact with the person with mpox and the time that the first symptoms appear. The incubation period for mpox is between 5 and 21 days.

Mpox infection is usually a self-limiting illness and most people recover within several weeks. However, severe illness can occur in some individuals. HCID mpox is known to cause more severe disease than non-HCID mpox clades with case fatality rates of 10% reported in non-vaccinated individuals previously.

The illness begins with:

• fever
• headache
• muscle aches
• backache
• swollen lymph nodes
• chills
• exhaustion
• joint pain

However, not all people who have mpox experience all of these symptoms. Within 1 to 5 days after the appearance of fever, a rash develops, often beginning on the face then spreading to other parts of the body including the soles of the feet and palms of the hands. Lesions can also affect the mouth, genitals and anus. The rash changes and goes through different stages before finally forming scabs which eventually fall off.

Some individuals may not have a widespread rash, and in some cases only genital lesions are present. These may be blisters/vesicles, scabs or ulcers.

An individual is contagious until all the scabs have fallen off and there is intact skin underneath. The scabs may also contain infectious virus material.

Images of individual mpox lesions

Notes

Areas of erythema and/or skin hyperpigmentation are often seen around discrete lesions.

Lesions can vary in size and may be larger than those shown.

Lesions of different appearances and stages may be seen at the same point in time.

Detached scabs may be considerably smaller than the original lesion.

Diagnosis

Clinical diagnosis of mpox can be difficult, and it is often confused with other infections such as chickenpox. A definite diagnosis of mpox requires assessment by a health professional and specific testing in a specialist laboratory.

In the UK, testing is provided by many NHS laboratories, and is also available at the Rare and imported pathogens laboratory (RIPL) at the UK Health Security Agency (UKHSA) Porton Down.

Patients with a travel or exposure history indicating possible HCID mpox should be discussed with the RIPL clinical team as soon as possible via the 24/7 Imported Fever Service helpline (0844 778 8990).

All samples from all individuals testing positive for mpox must be sent to the UKHSA Rare and Imported Pathogens Laboratory (RIPL) for clade differentiating tests. Samples from suspected and confirmed cases of mpox should be shipped as Category B diagnostic samples. See guidance on diagnostic testing for information on how to submit samples for testing.

Treatment

Treatment for mpox is mainly supportive. Non-HCID mpox is usually mild and most of those infected will recover within a few weeks without treatment.

Antiviral drugs such as cidofovir and tecovirimat can be used to treat mpox patients with severe disease or those who are at high risk of severe disease.

Smallpox vaccine can be used to support the control of outbreaks of mpox. People vaccinated against smallpox in childhood may experience a milder disease. Vaccines have been used to protect high risk individuals during outbreaks.

Infection prevention and control

Prevention of transmission by respiratory and contact routes is required. Appropriate precautions are essential for suspected and confirmed cases. Scabs are also infectious and care must be taken to avoid infection through handling bedding and clothing. Information on infection prevention and control measures are available in the National infection prevention and control manual for England.

Mpox virus is classified as an ACDP Hazard Group 3 pathogen and all laboratory work with live virus must be conducted at full Containment level 3 (CL3), in accordance with the Control of Substances Hazardous to Health Regulations 2002 (as amended). See the guidance on diagnostic testing for further information on handling specific sample types.

Laboratories must ensure that appropriate controls commensurate to CL3 are in place to minimise risk to laboratory workers so that they can safely perform laboratory tests that are essential to clinical care.

Further information

See WHO factsheet.

Additional mpox resources are also available on GOV.UK, including information on case definitions, contact tracing and vaccination.

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

Further information