Management of monkeypox, RHC Glasgow

Case definition: as of the 24th May 2022 the case definition includes:

All possible/probable/confirmed cases should be discussed with on-call Health Protection Team (HPT) consultant (via RHC switchboard).

At time of writing this guideline NO Paediatric cases of monkeypox have been identified in Scotland. Clinicians should familiarise themselves with the most up to date case definition and be aware of current prevalence of monkeypox in children in Scotland.

If a senior clinician assess the child and is confident the diagnosis is not monkeypox, the child can follow the existing red and green pathways.

Here is a link to aid clinicians in the diagnosis of monkeypox: Monkeypox: background information - GOV.UK (www.gov.uk)

Clinicians should be aware of the risk of other infections presenting in children with fever who have recently returned from travel abroad, including viral haemorrhagic fever.

• Disease specific – UKHSA guidance – sampling and related communication will be managed by Paediatric Infectious Disease Consultant (see below)
• Non-specific – please follow the Lab sample management guidance section – please see below
• Advice for patient on discharge – please discuss with the PID consultant

In the UK, the Rare and Imported Pathogens Laboratory (RIPL) at the UK Health Security Agency (UKHSA) Porton Down is currently the designated diagnostic laboratory. Clinicians should discuss individuals in whom monkeypox is suspected with their local Paediatric Infectious Disease clinicians.

The local PID clinician can discuss further with the Imported Fever Service (IFS) (24 hours telephone service: 0844 778 8990, dedicated monkeypox line 0344 2250602) who can also advise on whether laboratory testing is indicated and what samples should be obtained. Preferred sample in swab of vesicular lesions in viral transport medium.

Rare and Imported Pathogens Laboratory (RIPL): Specimen referral guidelines and service user manual version 26 (publishing.service.gov.uk)

How to sample a vesicle for PCR

See details in - Infection Prevention and Control advice for healthcare settings: (scot.nhs.uk)

If patient presents saying they are worried about monkeypox then ask the following:

“Has the patient had contact with a known Monkeypox case in the last 21 days?” 

For all other patients presenting to ED in addition to standard RED / GREEN PATHWAY

Questions to be asked by the Greeter:

All possible, probable or confirmed cases should be provided with a Fluid Resistant Surgical Mask (FRSM) to wear where this can be tolerated and does not compromise their clinical care.  e.g. when receiving oxygen therapy.

African Countries reporting confirmed human cases of monkeypox 1970 – 2021

ED Doctor Role:

Attend patient at front door and from distance clarify if patient fulfills case definition as below:

Case Definition - as of the 24th May 2022 the case definition includes:

If patient fulfils the above criteria then the following to occur:

1. ED Nurse in charge to arrange clearing of all patients in GREEN waiting area in CDU to OPD 3. If this area is not available, patients should be moved into the far end of the corridor in CDU (next to rooms 19 and 20).  

2. ED nurse to don PPE as per infection control measures table below and accompany patient and family to patient to CDU negative pressure room (Rm 18) and triage patient

3. ED medical staff to don PPE as per above and assess patient then contact Paediatric Infectious Diseases consultant to discuss the case and agree on the most appropriate management plan for the patient.

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.

In line with the hierarchy of controls, efforts should be made to perform telephone triage/assessment to help establish symptoms present and risk associated with potential Monkeypox in advance of any face to face contact where possible.

All children with recent travel to west and central Africa with fever will need to attend for clinical assessment.
This is to rule out travel associated infections such as malaria and typhoid which are much more common (and more immediately life threatening) than monkey pox.

The GP triage clinician should establish whether the GP or referring professional has seen the patient. If the patient has been seen by another healthcare professional and is felt to be a possible or probable case then the child only needs to attend for assessment if this is felt to be clinically warranted. If the child is well and does not require acute assessment then then the HPT consultant on call should be contacted to see if the child requires testing and if so whether there is capacity for this to be undertaken in the community. If the child needs to attend RHC for acute assessment or for testing the GP triage clinician should input details into Trakcare ED expects as per flow chart above, should contact ED coordinator and medical registrar in CDU to inform them that the patient will attend.

If patient meets case definition and is asked to attend then the following to occur:

1. ED Nurse in charge to arrange clearing of all patients in GREEN waiting area in CDU to OPD 3. If this area is not available, patients should be moved into the far end of the corridor in CDU (next to rooms 19 and 20).
2. ED nurse to don PPE as per infection control measures table below and accompany patient and family to patient to CDU negative pressure room (Rm 18) and triage patient.
3. RHC medical staff to don PPE as per above and assess patient then contact Paediatric Infectious Diseases consultant to discuss the case and agree on the most appropriate management plan for the patient.

Donning and doffing SOP when caring for monkeypox patients

Best Practice: Appendix 6 - Putting on and removing PPE (scot.nhs.uk)

Requirements are a minimum

Ensure footwear is enclosed.
Hydrate prior to putting on PPE

As monkey pox is a HG3 pathogen it has been agreed that the laboratory medicine position is to follow the VHF protocol for handling of potential monkey pox samples.

1. Laboratory staff should be notified prior to receipt of all specimens from patients with suspected or confirmed Monkey Pox (all laboratories, including biochemistry, haematology, microbiology, virology)
    
   1. During working hours calls may be communicated through specimen reception
   2. Out with routine hours call will be via the on call consultants
      
      
2. Specimens will be transported to the laboratory using appropriate precaution i.e. specimens should be carried in CAT B container/carrier
   
   
   1. Samples MUST NOT be sent via POD system, CAT B boxes must be used and delivered in person
   2. All samples to have clinical details recorded with note on request form – possible Monkey Pox
      
      
3. All non-Microbiology Laboratory samples being processed out with a CL3 facility should be processed as per the High Risk VHF policy
   
   
4. For Microbiology & Virology ALL samples MUST be transferred to the CL3 laboratory and processed within a Class 1 Safety Cabinet

Blood sciences raised concerns over the number of samples that could arrive as this will put a substantial risk on the service out of hours due to working in an MSC with a buddy system. This is to be further discussed by senior management to review what if any help other disciplines could offer.

Work is being undertaken to compile a Laboratory Medicine High Consequence Infectious Disease protocol, this will mostly reflect the VHF policy in relation to communication and sample testing that can be offered out of hours etc.

It was agreed that out with core hours if samples are not urgent they should remain with the patient if the need to be taken, for Blood sciences these should only be taken when they are going to be sent for testing.

Images of individual monkeypox lesions

Ref: Monkeypox: background information - GOV.UK (www.gov.uk)

Monkeypox clinical features (WHO)

Ref: Monkeypox: Introductory course for African outbreak contexts | OpenWHO

Principles for monkeypox control in the UK: 4 nations consensus statement

Published 30 May 2022 - Principles for monkeypox control in the UK: 4 nations consensus statement - GOV.UK (www.gov.uk)

Infection Prevention and Control advice for healthcare settings: Monkeypox: Management of possible, probable and confirmed cases.  Publication date: 1 June 2022 – ARHAI Scotland - Infection Prevention and Control advice for healthcare settings: (scot.nhs.uk)