Principles for monkeypox control in the UK: a 4-nation agreement

This statement was agreed by the UK Public Health Agency:UKHSA), Public Health Scotland, Public Health Wales and Public Health Agency Northern Ireland.

Reason for change

Monkeypox is a viral zoonotic disease that occurs mainly in Central and West Africa. There are 2 clades of monkeypox – a Central African clade with a reported mortality of 10% and a West African clade with a reported mortality of 1% from an epidemiological cluster and outbreaks from Africa. Previously it was sometimes exported to other regions. Within the UK it is classified as a high-consequence infectious disease (HCID) for NHS management, in particular to enable early identification and prevention of spread within the healthcare environment for imported cases and to recognize the initial clinic cannot determine the particular clade of smallpox.

Given the infrequent imports and limited spread, and the limited information available on the disease course and outcome, the UK clinical and public health response to monkeypox was initially based on the High Consequence Infectious Disease management system. This was very precautionary and designed for complete retention around single cases. It was also designed prior to the confirmed availability of vaccine and therapy.

The context has now shifted to that of multiple cases in the UK and reports of community outbreaks within younger age groups and severity are accumulating rapidly. Pre- and post-exposure prophylaxis using Imvanex is available for deployment.

Since 13 May 2022, cases of monkeypox have been reported in multiple countries that do not have an endemic monkeypox virus in animal or human populations, including countries in Europe, North America and Australasia. Epidemiological research continues; however, reported cases to date have not established established travel links to an endemic area. This suggests a significant community distribution in several non-endemic countries in recent weeks. In the UK, all reported cases have been identified as the West African clade by rapid molecular testing.

Community distribution takes place in the UK with multiple generations of spread. Disease appears to be generally mild, consistent with other information on the West African clade.

Too cautious a response poses a risk to public health. The exclusion of health workers affects clinical services, especially sexual health clinics and emergency departments (EDs). It is important that health care management promotes engagement with health care providers as well as preventing stigma and controlling spread.

Monkeypox is a dangerous group of 3 organisms (ACDP / HSE). Other organisms in this category include Salmonella typhi, HIV, Hepatitis B and C, and Mycobacterium tuberculosis which are routinely administered in the community. High Consequential Infectious Disease is not a legal classification but is instead agreed upon by a UKHSA and an NHS program to enable consistent access to infections that meet agreed criteria.

This proposal is to ensure a proportionate response to deliver achievable strategic results. These principles do not replace the need for local dynamic risk assessments that remain key.

Strategic goals

  • suppress the distribution of monkeypox in the community and aim at extermination (decreasing Rt below 1) targeting public health initiatives to the highest risks for transmission.
  • protect against the spread of infection in hospitals and health settings and to health workers evaluating and managing patients
  • enable the safe operation of NHS services, including those services that can diagnose and manage cases, in the context of community distribution of monkeypox.

Audience

Professionals – to report on the development of operational leadership in UKHSANHS and other organizations.

Assumptions about transmission and biology

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

  1. For individuals with an infection who are healthy, walking, and have either a prodrome or a rash, the highest risk transmission pathways are direct contact, drip, or fomite. Distribution seen so far in this explosion matches close direct contact.

  2. There is currently no evidence that individuals are infected prior to the onset of prodromal disease.

  3. For individuals with an infection who have signs of lower respiratory tract involvement or severe ubiquitous disease requiring hospitalization, the possibility of airborne transmission has not been ruled out.

  4. It remains important to reduce the risk of foamed delivery. The risk can be greatly reduced by following agreed-upon cleaning methods based on standard cleaning and disinfection, or by washing clothes or household equipment with standard detergents and cleaning products. Within healthcare, please refer to local national infection prevention and control manual / guide for pollution.

  5. Waste management and pollution-free practice should follow best practice and be based on all available evidence of safe handling of all waste in accordance with country-specific laws and regulations.

  6. The highest risk period for further infection is from the onset of the prodromal until the lesions have crumbled and the crusts have fallen off.

  7. Skinless procedures and sore throats are not considered aerosol generating procedures (AGPs) but can cause drips. The list of AGPs is available in the national handbook on infection prevention and control.

  8. There is no available evidence of monkeypox in genital excretions and preventive access for condom use for 8 weeks after infection is recommended, (this will be updated when evidence appears), other than abstinence from sex during symptomatic including during the prodromal phase. and while injuries are present.

  9. The disease in healthy adults is primarily self-limiting and with relatively low mortality. There is remaining uncertainty about possibly increased severity in children and in individuals who are highly immunocompromised or pregnant.

Implications

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

For possible / probable cases, the minimum PPE is:

  • gloves
  • fluid repellent surgical face mask (FRSM) (an FRSM should be replaced with FFP3 spiral and eye protection if the case presents lower respiratory tract infection with 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 splashing to the face and eyes (eg when performing diagnostic tests)

For confirmed cases requiring ongoing clinical administration (e.g., inpatient care or repeated assessment of an individual who is clinically ill or deteriorating), for the recommended minimum PPE for health workers are:

  • properly tested FFP3 spiral
  • eye protection
  • long-sleeved, fluid repellent, one-use dress
  • gloves

The top PPE will be used as a basis for contact classification.

  1. Home isolation can be used for clinically well-traveled possible, probable, or confirmed cases for which it is judged by the primary care physician and the HCID network as secure and clinically appropriate, with ongoing clinical and public health support for clinical management and isolation.

  2. For ambulatory good possible, probable or confirmed cases with limited injuries, covering injuries and wearing a face mask / mask reduces the risk of further transmission.

  3. Individuals with possible, probable, or confirmed monkeypox should avoid close contact with others until all lesions have healed, and crusts have dried. This should include staying at home unless medical evaluation or care is needed, or other urgent health and well-being issues.

  4. Close domestic and non-domestic contacts of confirmed cases should be risked. Medium risk contacts (category 2) do not require exclusions or isolation provided they perform active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High-risk (category 3) contacts should be advised to isolate themselves for 21 days.

  5. Cleaning to reduce environmental risk in the community settings can be effectively achieved without the use of special services or equipment.

  6. The risk of transmission in the home environment for possible, probable or confirmed cases can be reduced by the case by performing regular household cleanings and washing their own clothes and sheets in a home washing machine.

  7. Transportation from the community to health facilities for possible, probable, or confirmed cases should be by private transportation where possible. Where private transportation is not available, public transportation may be used but busy periods should be avoided. Any injury should be covered with cloth (such as scarves or bandages) and a face covering should be worn.

Outpatient care

  1. For possible, probable, or confirmed cases, attending outpatient health care (e.g., outpatients, emergency departments, emergency care centers, general practice, sex clinics), patients should be placed in a single room for evaluation. The case must be equipped with a Fluid Surgical Mask to wear as appropriate.

  2. Where possible, pregnant women and severely immunocompromised individuals (as outlined in the Green Book) should not evaluate or clinically care for individuals with suspected or confirmed monkeypox. This will be re-evaluated as index appears.

  3. Medium risk contacts (category 2) do not require exclusions or isolation provided they perform active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High-risk (category 3) contacts should be advised to isolate themselves for 21 days.

Inpatient treatment

  1. For cleaning and decontamination of the room within health settings, health facilities must refer to the relevant country manual for infection prevention and control.

  2. Where possible, pregnant women and severely immunocompromised individuals (as outlined in the Green Book) should not evaluate or clinically care for individuals with suspected or confirmed monkeypox. This will be re-evaluated as index appears.

  3. Medium risk contacts (category 2) do not require exclusions or isolation provided they perform active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High-risk (category 3) contacts should be advised to isolate themselves for 21 days.

Other residential settings

  1. Within non-domestic living conditions (e.g. adult social care, prisons, homeless shelters, shelters), individuals who are clinically well should be managed in a single room with separate toilet facilities when possible.

  2. In domestic and non-domestic contexts where treatment is provided, waste generated is classified as waste and should be managed appropriately.

  3. Where possible, pregnant women and severely immunocompromised individuals (as outlined in the Green Book) should not evaluate or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed when an index appears.

  4. Close contacts of confirmed cases in these settings should be evaluated for vaccine, following the contact recommendations.

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