Monkeypox: Take standard, airborne and droplet precautions

by A.J. Plunkett (aplunkett@decisionhealth.com)

If a patient presents with a fever and vesicular/pustular rash, hospitals and other healthcare providers should be prepared to take a combination of standard, airborne, and droplet infection control precaution in case it is monkeypox, according to the CDC.

The CDC recently updated its online monkeypox information page for hospitals in response to recent reports of the disease in Europe, Australia, Canada, and the United States.

While the primary risk is from close contact with bodily fluids, including contaminated linens, “because of the theoretical risk of airborne transmission of monkeypox virus, airborne precautions should be applied whenever possible,” said the CDC. “If a patient presenting for care at a hospital or other health care facility is suspected of having monkeypox, infection control personnel should be notified immediately.”

“For environmental infection control and decontamination guidance, please refer to guidance developed for smallpox, another orthopoxvirus. Some details in this guidance may be applicable to the 2022 monkeypox cases,” said the CDC, with a link to the guidance for environmental control of smallpox virus.

Smallpox, like monkeypox, is from the orthopox genus of viruses.

As of Monday afternoon, there were five confirmed cases of monkeypox in the United States, according to experts during a CDC media briefing. That included a man in Massachusetts who recently traveled to Canada, a patient in New York City, another in Florida and two in Utah.

Newspapers and other media have reported on the patient from Massachusetts, but the CDC refused to talk about the details of his or the other patients, citing confidentiality. However, all the patients’ exposure was consistent with the globally reported cases, said John Brooks, MD, Medical Epidemiologist with the CDC’s Division of HIV/AIDS Prevention.

According to NPR, the cases have been limited to patients had traveled recently to “affected countries or had close contact with those showing symptoms.”

Brooks did note that infection control officials were investigating 200 close contacts with the Massachusetts patient, which he said were mostly healthcare workers.

However, “this is not COVID,” said Capt. Jennifer McQuiston, DVM, MS, Deputy Director of the CDC’s Division of High Consequence Pathogens and Pathology, noting that the risk of airborne transmission remained low.

She also said the information gathered from the last outbreak of monkeypox in the U.S. in 2003 did not show a jump from humans to animals, and did not become endemic.  

Brooks noted that many of the patients in this latest outbreak presented with symptoms that were first suspected to be sexually transmitted. He advised healthcare providers to consider anything with a rash to be investigated as monkeypox.

CDC guidance

The following information about precautions is from the CDC’s hospital monkeypox page:

Isolation

Isolate patients suspected of having monkeypox in a negative air pressure room as soon as possible. If a negative air pressure room is unavailable, place patients in a private examination room. If neither option is feasible, then precautions should be taken to minimize exposure to surrounding persons. These precautions may include placing a surgical mask over the patient’s nose and mouth—if tolerable to the patient—and covering any of the patient’s exposed skin lesions with a sheet or gown.

Personal Protective Equipment (PPE)

Personal protective equipment should be donned before entering the patient’s room and used for all patient contact. All PPE should be disposed of prior to leaving the isolation room where the patient is admitted.

Optimal personal protective measures include:

  • Use of disposable gown and gloves for patient contact.
  • Use of NIOSH-certified N95 (or comparable) filtering disposable respirator that has been fit-tested for the healthcare worker using it, especially for extended contact in the inpatient setting.
  • Visit The National Personal Protective Technology Laboratory (NPPTL) website for frequently asked questions and answers about wearing respirators versus surgical masks.
  • Use of eye protection (e.g., face shields or goggles), as recommended under standard precautions, if medical procedures may lead to splashing or spraying of a patient’s body fluids.

Additional Precautions

In addition to isolating infectious patients and use of PPE when caring for patients, other standard precautions can limit the transmission of monkeypox virus.

These include:

  • Proper hand hygiene after all contact with an infected patient and/or their environment during care.
  • Correct containment and disposal of contaminated waste (e.g., dressings) in accordance with facility-specific guidelines for infectious waste or local regulations pertaining to household waste.
  • Care when handling soiled laundry (e.g., bedding, towels, personal clothing) to avoid contact with lesion material. Soiled laundry should never be shaken or handled in manner that may disperse infectious particles.
  • Care when handling used patient-care equipment in a manner that prevents contamination of skin and clothing. Ensure that used equipment has been cleaned and reprocessed appropriately.
  • Ensure procedures are in place for cleaning and disinfecting environmental surfaces in the patient care environment. Any EPA-registered hospital disinfectant currently used by healthcare facilities for environmental sanitation may be used.  Follow the manufacturer’s recommendations for concentration, contact time, and care in handling.

The CDC also notes that more detailed respirator information has been published by NIOSH and OSHA.