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Overview

This Guidelines summary provides information and advice for healthcare professionals on monkeypox. It includes updated vaccination recommendations and a useful contact tracing table. For a complete set of recommendations, refer to the original guidance.

View this summary online at guidelines.co.uk/457008.article

Monkeypox information for primary care

Background

  • 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.

Transmission

  • Monkeypox does not spread easily between people. Spread of monkeypox may 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), an infected human, or materials contaminated with the virus
  • The virus enters the body through broken skin (even if breaks are not visible), the respiratory tract, or the mucous membranes (eyes, nose, or mouth)
  • Person-to-person spread is very uncommon, but may occur through:
    • contact with clothing or linens (such as bedding or towels) used by an infected person
    • direct contact with monkeypox skin lesions or scabs
    • close exposure to the coughs or sneezes of an individual with a monkeypox rash.

Clinical features

  • The incubation period is 5–21 days, but typically 6–16 days following exposure. The initial phase of typical clinical illness usually lasts 1–5 days; patients may experience a combination of fever and/or chills, lymphadenopathy, headache, myalgia, backache, and exhaustion
  • Fever is present in most, but not all, patients. This is followed by a second phase where a rash appears, during which time some existing signs and symptoms—including fever—may diminish or disappear. The distribution of the rash and the appearance of individual skin eruptions typically change over time
  • The rash may be maculopapular initially, typically starting on the face before spreading peripherally, particularly to the palms of the hands and the soles of the feet. The initial rash classically evolves into vesicles and then pustules, often with umbilication, which eventually crust and then desquamate during the next 2–3 weeks. These characteristic pox lesions are typically 0.5–1 cm in diameter and may number from a few to several thousand. Involvement of the oral mucous membranes occurs in many cases; lesions may also occur on the genitals, conjunctivae, and cornea in some patients
  • Localised rashes are seen occasionally, relating to the site of the initial exposure
  • Most patients experience a mild, self-limiting illness, with spontaneous and complete recovery seen within 3 weeks of onset. However, severe illness can occur and sometimes results in death.

Patient assessment

  • As part of an investigation into confirmed monkeypox cases in the UK, individuals that are identified as potential contacts of the case are contacted. These individuals are then asked to contact a Health Protection Team (HPT) if they develop compatible symptoms. However, if a patient who has been identified as a contact of a monkeypox case presents to you, please contact the local HPT for advice. It is unlikely that other patients presenting to primary care will have monkeypox
  • For persons who have travelled to/from Africa, fever is more likely to be caused by common tropical infections such as malaria or typhoid, which should be diagnosed and treated promptly
  • Specialist assessment and laboratory investigation is essential. Patients of concern should be discussed with your local infection specialist in the first instance, who may then discuss the patient with the Imported Fever Service (IFS; telephone number: 0844 7788990). If it is agreed that monkeypox is a possible diagnosis, the HPT must be informed and the patient will need to be referred to a hospital with appropriate isolation facilities, ideally a local infectious diseases centre. The details of this process and any further assessment for the patient will be provided by the IFS
  • Patients can be advised that specialist assessment will be free at the point of care, whatever their nationality.

Infection prevention and control in the case of suspected monkeypox

  • The main risk for transmission would be from direct contact with skin lesions or through contact with a patient’s clothing or linens that have been in contact with the lesions
  • Therefore, practitioners should avoid touching skin lesions with bare hands, wear disposable gloves, and observe strict hand hygiene
  • It is likely that patients would present in the early stages of the illness and, as such, there should be a low risk of environmental contamination during their initial presentation to primary care or during the patient examination
  • If monkeypox is considered likely and the patient is referred to hospital, the room should not be used following transfer and the nearest HPT should be contacted for advice about cleaning and decontamination.

Recommendations for the use of pre- and post-exposure vaccination during a monkeypox incident

Pre-exposure vaccination for occupational exposure

  • The majority of those at risk of occupational monkeypox exposure in the UK are likely to be naïve to smallpox. In line with current policy in the Green Book: Immunisation against Infectious Disease, for naïve individuals at risk of exposure on the basis of an occupational health assessment, pre-exposure vaccination with two doses of modified vaccinia Ankara (MVA-BN) with a minimum interval of 28 days is recommended. This would include those health care workers (HCW) due to care for a patient with confirmed monkeypox, for example staff in high consequence infectious disease centres and those individuals undertaking environmental decontamination, even if they will be wearing full personal protective equipment
  • If vaccine cannot be given before commencing work with potential exposure to monkeypox, post-exposure use of vaccine is likely to be advised.

Post-exposure vaccination

  • Individuals should be risk assessed and offered post-exposure vaccination with a single dose of MVA-BN according to the Contact Management Matrix and Standard Operating Procedure, available in the duty doctors’ pack and Table 1
  • Vaccination should be administered as soon as possible and within 4 days after an identified exposure to prevent or attenuate infection
  • Post-exposure vaccine may be extended up to 14 days for those at high risk of ongoing exposure, and some HCWs where the dose will act as their first pre-exposure dose, as well as those at risk of more severe disease such as children (school year 6 [aged 10–11] and under), pregnant women, and immunosuppressed individuals. If exposure has been intermittent or continuous, post-exposure vaccination should ideally be given within 4 days of the last exposure
  • For individuals with a history of receiving a single dose of a live smallpox vaccine, a single dose of MVA-BN is recommended
  • For individuals who have received a single dose of MVA-BN previously (regardless of timing), completion of the primary course is recommended. There is no need to restart the course
  • For individuals who have received a previous live smallpox vaccine and one MVA-BN vaccine, no further doses are recommended
  • For individuals who have received two doses of MVA-BN within the last 2 years, no further doses are recommended
  • For individuals who have received two doses of MVA-BN more than 2 years ago, a single booster dose of MVA-BN is recommended.

Community exposure

  • Individuals with a community exposure should be offered post-exposure vaccination if they are in risk categories 2 and 3. Individuals with a category 1A or 1B exposure do not usually require vaccination (see Table 1).

Occupational exposure

  • Individuals with an occupational exposure (for example, HCWs or those undertaking environmental decontamination) should be offered post-exposure vaccination if they are in risk categories 2 and 3. Individuals with a category 1A or 1B exposure do not usually require vaccination (see Table 1)
  • Completion of the course with a second dose at least 28 days later should be considered on assessment of a foreseeable future risk through work beyond the current episode.

Individuals with underlying conditions, including immunosuppression and HIV

  • Individuals with atopic dermatitis are known to have developed more site-associated reactions and generalised symptoms following MVA-BN vaccination. Individuals in this group therefore need to have a risk assessment before being offered vaccination to balance the risk from exposure and the risk of side effects from vaccination
  • MVA-BN is a replication defective virus and should pose no risk to those who are immunosuppressed. MVA-BN vaccine has been demonstrated to be safe in people with HIV, and so they should be offered vaccine according to recommendations.

Completing the primary vaccine course

  • The licensed primary course of MVA-BN comprises two doses, given at least 28 days apart
  • If there is a foreseeable risk of subsequent occupational exposure to monkeypox, HCWs, laboratory workers, and individuals undertaking environmental decontamination in exposure categories 1B, 2, and 3, who have received one dose of MVA-BN either as pre- or post-exposure prophylaxis, should be offered a second dose at least 28 days after the first to complete the manufacturer-recommended schedule. This should be undertaken regardless of whether the incident is ongoing
  • For those staff at occupational risk who have received a single dose of MVA-BN or a different smallpox vaccine at any time in the past, only one further dose of MVA-BN is required to complete the recommended schedule, with a minimum interval of 28 days between doses
  • There is no requirement to restart the two-dose schedule. Individuals are considered protected 7 days after completing their second dose of MVA-BN
  • Individuals who received a single dose of vaccine as a result of community exposure (regardless of exposure category) do not need to be offered a second dose as they do not have a foreseeable risk of further exposure to monkeypox and will be past the incubation period from the exposure that warranted post exposure vaccination.

Reinforcing (booster) doses

  • There are limited data to determine the need and timing of a booster dose after a two-dose primary course of MVA-BN for those at ongoing occupational risk of monkeypox
  • Given the evidence of immunological memory from two priming doses and the incubation period of monkeypox, it is likely that adequately primed individuals will make a good response to natural exposure that will protect or reduce the severity of any breakthrough infection. As the response to a booster is good and leads to better persistence, however, a single booster dose at 2 years may be considered for pre-exposure use in individuals who have received two doses of MVA-BN and are at ongoing high risk of occupational exposure, or for post-exposure use amongst contacts who have had a significant exposure (category 2 or 3)
  • Long-term immunogenicity studies are in progress. If a booster dose is considered necessary, then a single dose of 0.5 ml should be administered.

Monkeypox contact tracing guidance

  • Table 1 provides principles for risk assessment and follow up of contacts of confirmed monkeypox cases. It is intended to support risk assessment and categorisation of contacts to ensure they are offered appropriate isolation advice and vaccination
  • Clinicians should also take into account the severity or extent of disease at the time of exposure, as the risk will be higher if there are widespread lesions including hands and face compared with a small number of localised genital lesions.

Table 1: Monkeypox contact tracing guidance: classification of contacts and advice for vaccination and follow up

Exposure risk categoryDescriptionRiskSurveillanceRecommendation for PEPExample scenariosInformation sheets

3

Unprotected direct contact or high-risk environmental contact

Direct exposure of broken skin or mucous membranes to a confirmed, symptomatic monkeypox case, their body fluids or potentially infectious material (including clothing or bedding) without wearing appropriate PPE

 

Penetrating sharps injury (including to cleaning or laboratory staff)

 

High

Active monitoring

 

Provide information and contact number

 

Daily communication with contact for 21 days after last exposure

 

Self-isolation for 21 days, including exclusion from work

 

Avoid contact with immunosuppressed people, pregnant women, and children (school year 6 and under) where possible

 

Offer MVA-BN vaccine (Imvanex®), ideally within 4 days from last exposure (up to a maximum 14 days if high risk of ongoing exposure or severe disease)

 

Body fluid in contact with eyes, nose, or mouth

 

Penetrating sharps injury from used needle

 

Contact in room during aerosol-generating procedure without appropriate respiratory PPE

 

Changing a patient’s bedding without appropriate PPE

 

Sexual or intimate contact

 

Household contact: sharing a residence with a person who has been diagnosed with monkeypox and spending at least one night in the residence during the period when the case is infectious

See ‘Active follow up: category 3’ information sheet

 

If symptoms develop, see ‘Monkeypox isolation for symptomatic contacts’ information sheet

 

2

Unprotected exposure to infectious materials, including droplet or airborne potential route

Not category 3 but:

 

Intact skin-only contact with a symptomatic monkeypox case, their body fluids, or potentially infectious material or contaminated fomite

 

or

 

Passengers seated directly next to case on plane

or

 

No direct contact but within 1 m of symptomatic monkeypox case without wearing appropriate PPE

 

Medium

Active monitoring

 

Provide information and number to contact

 

Daily communication with contact for 21 days after last exposure

 

Avoid contact with immunosuppressed people, pregnant women, and children (school year 6 and under) where possible

 

Exclude from work for 21 days if work involves contact with immunosuppressed people, pregnant women, or children school year 6 and under (not limited to HCWs)

 

International travel is not advisable

Offer PEP with MVA-BN vaccine (Imvanex®), ideally within 4 days from last exposure (up to a maximum 14 days if high risk of ongoing exposure or severe disease)

Clinical examination of patient before diagnosis without appropriate PPE

 

Entering patient’s room without wearing appropriate PPE and within 1 m of case

 

Driver and passengers in shared car or taxi with case, or sitting next to case on plane

 

Subsequent patients in consulting room after a confirmed case was seen and prior to room cleaning

 

Spillage or leakage of laboratory specimen onto intact skin

 

 

See ‘Active follow up: category 2’ information sheet

 

If symptoms develop, see ‘Monkeypox isolation for symptomatic contacts’ information sheet

 

1-B

 

Protected physical or droplet exposure

Not category 3 or 2 but:

 

Contact with confirmed monkeypox case or environment contaminated with monkeypox while wearing appropriate PPE (with no known breaches)

Low

Passive monitoring

 

Provide information sheet and number to contact

 

Can continue with routine activities and travel as long as asymptomatic

PEP not usually required

Healthcare staff working in HCID specialist unit wearing appropriate PPE

 

Person undertaking decontamination of rooms where a confirmed case has stayed, while wearing appropriate PPE

See ‘Passive follow up’ information sheet

If symptoms develop, see ‘Monkeypox isolation for symptomatic contacts’ information sheet

 

1-A

 

No physical contact, unlikely droplet exposure

Not category 3, 2, or 1B but:

 

Community contact 1–3 m from a symptomatic case

 

or

 

HCW involved in care of monkeypox case not wearing appropriate PPE for contact at 1–3 m and has had no direct contact with contaminated objects

 

or

 

Passengers seated within three rows from case on plane

Low

Passive monitoring

 

Provide information sheet and number to contact

 

Can continue with routine activities and travel as long as asymptomatic

PEP not usually required

Staff entering patient room without PPE and:

 

a. without direct contact with patient or their body fluids and

b. maintaining a distance of more than 1 m from patient

 

Passengers who have been seated within three rows, but not directly next to, a case on plane

 

See ‘Passive follow up’ information sheet

 

If symptoms develop, see ‘Monkeypox isolation for symptomatic contacts’ information sheet

 

0

 

No contact

Not category 3, 2, 1A, or 1B:

No known contact with symptomatic monkeypox case in last 21 days

 

or

 

Passengers seated more than three rows away from case on plane

 

or

Laboratory staff operating at minimum containment level 2 handling specimens relating to a monkeypox case with no breaches in standard laboratory PPE, spillages, or leaks

None

None

PEP not required

Passengers seated away from case on plane (that is, more than three rows away)

Staff handling specimens in a UK clinical laboratory at minimum containment level 2 with no breaches in standard laboratory PPE

See general information sheet

HCID=high consequence infectious diseases; HCW=health care worker; PEP=post-exposure prophylaxis; PPE= personal protective equipment

 

Full guidelines:

UK Health Security Agency. Monkeypox: information for primary care. UKHSA, 2018. Available from: gov.uk/guidance/monkeypox-information-for-primary-care.

Published date: 11 September 2018.

UK Health Security Agency. Monkeypox vaccination. UKHSA, 2022. Available from: gov.uk/government/publications/monkeypox-vaccination.

Published date: 20 May 2022.

Last updated: 6 June 2022.

UK Health Security Agency. Monkeypox: contact tracing. UKHSA, 2022. Available from: gov.uk/government/publications/monkeypox-contact-tracing.

Published date: 20 May 2022.

Last updated: 6 June 2022.

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