Management of mpox, RHC Glasgow

Clade I cases are anticipated to have similar presentations as encountered in Clade II cases. Common symptoms of mpox include a skin rash or pus-filled lesions which can last two to four weeks. It also can cause fever, headaches, muscle aches, back pain, low energy and swollen lymph nodes. A further description of common presentations is available at Mpox | NHS inform

When to suspect mpox

Consider mpox where a case presents with:

1. a prodrome (fever, chills, headache, exhaustion, myalgia, arthralgia, backache, lymphadenopathy), and where there is known prior contact with a confirmed or suspected case of mpox in the 21 days before symptom onset

Or:

2. an mpox-compatible rash anywhere on the skin (face, limbs, extremities, torso), mucosae (including oral, genital, anal), or symptoms of proctitis, and at least one of the following in the 21 days before symptom onset:

• recent new sexual partner
• contact with known or suspected case of mpox
• a travel history to a country where mpox is currently common - this does not include people transiting through the affected country where they do not leave the airport
• link to an infected animal or meat

If the rash is highly clinically suggestive of mpox, but you cannot identify a risk factor, discuss with local infection services whether to consider mpox testing alongside the more common differential diagnosis.

Consider common infections such as chickenpox or shingles, herpes simplex virus, and enterovirus in the differential diagnosis; these circulate widely and are more common than mpox; exclude as appropriate.

When to consider clade I mpox, a high consequence infectious disease (HCID operational case definition)

In a person with clinically suspected mpox, they should be managed as HCID if they meet one or more of the following criteria:

• has a travel history to specified countries where there may be a risk of clade I exposure in the 21 days before symptom onset (this does not include people transiting through the affected country where they do not leave the airport)
• has an epidemiological link to a confirmed or suspected case of clade I mpox in the 21 days before symptom onset
• has a relevant zoonotic link, including contact with a wild or captive mammal that is an African native species (this includes contact with derived products, for example, game meat)

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 Mpox. This will be reassessed as evidence emerges.

** If there are significant workforce pressures in CDU that may delay assessment of the patient or 1^st assessment of other patients, then an early discussion between ED consultant in charge and Medical Paediatric on-call consultant shuld occur to identify the best placed clinical team to conduct the assessment.

Monday – Friday between 0900-1700, the Infectious diseases (ID) registrar can be contacted to see if they are able to offer any support.

If between the hours of 16:00-midnight the senior medical registrar based in ED can be moved into CDU to offer support.

Donning and doffing video link - High Consequence Infectious Diseases (HCID) | Turas | Learn (nhs.scot)

PPE - There has been no change to the existing Scottish VHF ensemble. When caring for patient with suspected or confirmed Clade I mpox cases current Scottish VHF PPE guidance should be followed:

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

If a senior clinician assesses the child and is confident the diagnosis is not mpox, the child can follow the existing pathways.

Here is a link to aid clinicians in the diagnosis of mpox: Mpox: 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.

The roles of acute medical personnel are detailed in appendix 3.

Clinicians should discuss individuals in whom mpox is suspected with the local Paediatric Infectious Diseases team, PH on call consultant and the Imported Fever Service (IFS). Contact details below

After discussion with IFS, samples should be sent to West of Scotland Virology lab. Samples should be packaged and transported in accordance with Category B transportation regulations (Appendix 4).

Prior to sending any samples please contact the lab via email west.ssvc2@nhs.scot Use email both in and out of hours (which will be picked up in the following morning including at weekends). Please include contact details in email for results to be returned to.

Mpox is diagnosed by PCR test on a viral swab taken from one or more vesicles or ulcers. Swabs should be sent in MSS (red topped bottles also used for COVID testing). If there are no skin lesions then a throat swab should be sent in MSS. Testing can be ordered in TrakCare in ‘New request’ tab by searching for ‘monkeypox virus PCR’.

PHS laboratory information note for mpox testing in Scotland:
2024-09-23-phs-laboratory-information-note-monkeypox-cases-in-the-uk-v8.pdf (publichealthscotland.scot)

Clinical laboratories should be informed in advance of samples being submitted for mpox testing, so that the appropriate precautions can be taken to minimise risk to laboratory workers.

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 Mpox case and packaged in the same way. They MUST NOT be sent via the POD system.

Blood sample packaging: the blood bottles must be packaged in Category B transport boxes to prevent any accidental spillage. These containers should be available at each A&E department. If not, these are available from Virology at GRI by taxi during office hours (38721) and QEUH A&E out of hours. One container is required for each laboratory, i.e. haematology, biochemistry microbiology. Please minimise the samples sent to routine labs.

Currently the CL3 hood is non-functional at QEUH microbiology and microbiology samples will be processed at GRI if needed. Haematology and Biochemistry tests for patients fulfilling the case definition at QEUH are currently processed in Haematology.

• Blood is drawn from the patient, wearing full protective equipment as above. The packaging materials and boxes must not enter the patient’s room. Take only the labelled bottles and venepuncture equipment into the patients room
• After filling the bottles, the doctor should wipe his/her hands with an alcohol soaked wipe, then wipe each bottle individually.
• An assistant, wearing gloves, should come to the door of the room, but not enter the room. The assistant should hold open specimen bags. The doctor from the patient’s room should drop a single blood bottle into each bag using a no touch technique.
• Away from the patient room, the assistant should seal each bag, then wrap each specimen + bag in the container provided. The request form and specimens are then put in the cardboard box and sealed with the sticker provided prior to delivery to the lab.

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.

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.

National Services Scotland. Mpox IPC advice for healthcare settings (v18, 06/09/2024)

UK Imported Fever Service (IFS) on 08 44 77 88 99 0 (Doctor on Call: 07789 031 672)

Public Health Protection Team (0141 201 4917 Mon-Fri 9-5pm, 0141 211 3600 and ask for the NHS GG&C Public Health Protection Team on call out of hours) including overnight

Paed Infections diseases registrar (Monday – Friday 0900-1700.  Page 18083).

Paed infectious diseases consultant: working hours through Dect 84939, OOH: ask for oncall paed ID consultant through switchboard.

Figure 1. African Region countries reporting laboratory confirmed clade I mpox (historic or current)

The situation may change rapidly in different countries. It is possible for mpox cases to be reported in countries who have not reported clade I mpox to date. Mpox of an unknown clade has been reported in Gabon but is presumed to be clade I (due to case travel history).

07/02/25 The United Arab Emirates has now been added to the list of countries with ongoing Clade 1 mpox transmission - see UKSA guidance referenced below for up to date list of countries

Source: UK Health Security Agency. 2024. Clade I mpox - affected countries. Given the continuing spread of clade I mpox, please check the link regularly for any updates to the countries included.

Images of individual mpox lesions

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

Mpox clinical features (WHO)

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

ED Nurse triage & co-ordinator role:

Attend patient at ambulance door entrance and from distance clarify if patient fulfils case definition as per above.

If patient fulfils the case definition for Mpox:

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  
2. ED nurse to don HCID PPE and accompany patient and family 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 coordinator alerts hospital coordinator to facilitate nursing support from ward nursing teams to support acute service function of ED and CDU.

Medical team roles:

1. Following triage relevant medical / ED staff to don HCID PPE to assess patient and then contact Paediatric Infectious Diseases consultant if ongoing concerns re: Mpox to discuss the case and agree on the most appropriate management plan for the patient.
2. As part of medical assessment ‘fever in in returning traveller’ should be considered. Fever in the returning paediatric traveller.

Role of GP triage Clinician

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 Mpox in advance of any face-to-face contact where possible. Advice should be sought from the ID Consultant on call if there is any dubiety, prior to the child attending RHCG.

All children with recent travel to 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 and whether the patient fulfils the case definition. There is currently no community-based testing for Mpox. 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 Mpox, 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.