Management of monkeypox, RHC Glasgow

In line with the UK Health Security Agency guidance on Monkeypox case definitions:

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

Minimum PPE requirements for possible, probable and confirmed MPX cases

¹ A full face visor is required in addition to a FFP3 respirator where the respirator is not fluid resistant. HCWs must be fit tested prior to donning a respirator and perform a fit check each time it is donned.

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

Donning and doffing SOP when caring for monkeypox patients

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

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 assesses 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.

Clinicians should discuss individuals in whom monkeypox is suspected with the local Paediatric Infectious Diseases team.

Sampling:

Monkeypox is diagnosed by PCR test on a viral swab taken from one or more vesicles or ulcers. Swabs should be sent in viral transport media.  Tests should be ordered through Trakcare (monkeypox PCR).

For full details on how to correctly obtain sample then see ‘Sampling for diagnostic testing’ section in https://www.gov.uk/guidance/monkeypox-diagnostic-testing.

Important points about sample-labelling, packaging and request forms:

• Ensure that all stoppers and lids are firmly attached. Samples that have leaked in transit cannot be processed if there is insufficient material left.
• Each sample must be labelled with ID, date of birth and type of sample.
• Paperwork (request forms) should NOT be placed in the primary container for Cat B transport.

Samples from possible/probable cases should MUST NOT be sent via POD system. They should be packaged and transported in accordance with Category B transportation regulations. UN 3373 packaging must be used for sample transport. Contact ED coordinator (84585) for Cat B containers.

Transport may be through DX or by Category B courier. Samples should be couriered directly from the clinical area.

Samples from confirmed cases should be packaged and transported in accordance with Category A transportation regulations. UN 2814 packaging must be used for sample transport. Samples from confirmed cases should not be sent for follow up testing unless there is a clearly defined clinical need.

Samples should be sent to the West of Scotland Virology Centre Glasgow. Testing is offered seven days a week with one run performed daily (not as an on-call service/assay). Clinical laboratories should be informed in advance of samples being submitted for monkeypox testing, so that the appropriate precautions can be taken to minimise risk to laboratory workers. Email west.ssvc2@nhs.scot to inform, include contact details for the referrer.

Further details on sample requirements / transport & Packaging of samples / notification of results are detailed here - PHS laboratory information note for monkeypox testing in Scotland (publichealthscotland.scot)

Local testing for other pathogens should proceed as indicated, to prevent potential delays in diagnosis of other illnesses that may require urgent treatment. ALL samples should be clearly labelled identifying the patient as a suspected monkeypox case and packaged in the same way. Similarly they MUST NOT be sent via the POD system.

This includes samples to be sent for monkeypox testing, and samples to be sent for local testing for other investigations, also samples sent to the haematology or biochemistry laboratories. In patients with rash and fever consider swabbing the lesions for HSV/VZV PCR and enterovirus PCR. In returning travellers consider the RHC guidance Fever in the returning paediatric traveller.

See details in - Infection Prevention and Control advice for healthcare settings: Monkeypox (Monkeypox (Clade IIb) only): Management of possible, probable, and confirmed casesInfection 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 above.

If patient fulfils the above criteria then:

1. ED coordinator should clear pathway for patient to go from outside the hospital directly to CDU Rm 18.  A 2 metre path should be maintained for the duration of the patient journey. Any bodily fluids should be cleaned as per the section - Decontamination / Waste / Linen management & Safe management of blood and body fluids (above) 

2. ED nurse to don PPE as per Minimum PPE requirements section above, and accompany patient and family to patient to CDU negative pressure room (Rm 18) and triage patent. Patient lesions to be covered with clothing where possible. Patient to be provided with a Fluid Resistant Surgical Mask and lesions to be covered with clothing where possible

3. ED medical staff to don PPE as per Minimum PPE requirements section above, and assess patient then contact Paediatric Infectious Diseases consultant if ongoing concerns re: monkeypox to discuss the case and agree on the most appropriate management plan for the patient.

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. There is currently no community based testing for monkeypox. 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 the GP feels there is a risk of monkeypox, but has not seen the patient and thus is unsure if they meet current case definition, the patient should be advised to attend ED and will be seen as per the ED pathway above. The GP triage clinician should enter details onto ED expects, but make it clear in the notes that no medical triage has taken place and thus the patient should be assessed for risk at the front door. The GP triage clinician should contact the ED coordinator to inform them of approximate arrival time.

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