36 | Nursing in Practice | Autumn 2022
with monkeypox also has respiratory symptoms , such as sneezing or coughing , then transmission may also occur through this route .
Most cases so far have been associated with men who have sex with men . This includes bisexual men and their partners who share close physical contact . It is important that these groups are offered information about awareness of symptoms or infection presentation , so they can seek help if needed and prevent onward infection to both men and women , whether partners or other household contacts .
For nurses , the greatest risks are through handling bed linen or clothing of an infected person , or through direct contact with their lesions , scabs or respiratory droplets . Risks may be lower in non-hospital settings , and use of PPE should be informed by the employer ’ s risk assessments if a person presents with suspected monkeypox . Be mindful that a person remains infectious until all lesions have dried and scabs have fallen off .
What are the main signs and symptoms of infection ? Typical symptoms include fever , headache , backache and muscle aches , swollen lymph nodes , chills and tiredness . A rash may appear one to five days after onset of fever , with lesions progressing through various stages until scab development and falling off , as with chickenpox . Note that lesions of different appearances and stages may be seen together .
Importantly , studies have indicated that people infected in the current monkeypox outbreak are presenting with different symptoms to those in previous outbreaks . 1 , 5 , 6 In particular , a high proportion have lesions in the anal or genital regions , consistent with transmission through close contact during sexual activity , whereas previously lesions were mainly seen on the limbs , face and neck . Affected people may also be less likely to report fever or fatigue than in earlier outbreaks .
The UK Health Security Agency ( UKHSA ) now provides the following definition of probable cases 7 :
• Anyone who has an unexplained rash or lesions on any part of their body ( including genital , perianal , oral ), or proctitis ( for example anorectal pain , bleeding ), and – who has an epidemiological link to a confirmed , probable or highly probable case of monkeypox in the 21 days before symptom onset , or
– who identifies as a gay , bisexual or other man who has sex with men , or – has had one or more new sexual partners in the 21 days before symptom onset .
Further information on clinical features , including examples of lesions at different stages , are available on the UKHSA website . 8
How should nurses in primary care deal with a suspected case of monkeypox ? Any nurse coming into direct contact with a potential case should follow their employer ’ s policies on the management of people with monkeypox . Any concerns or questions should be shared immediately with their local IPC advisers or on-call consultant microbiologist . The UKHSA ’ s Imported fever service also offers 24-hour access to telephone support and advice . 9
What PPE should nurses use if in direct contact with a potential case ? Relevant guidance can be found in the consensus statement from UKHSA , Public Health Scotland , Public Health Wales and Public Health Agency Northern Ireland . 10 Note that with possible and probable cases of monkeypox , this advises healthcare workers to wear a surgical facemask , or FFP3 mask and eye protection if the patient has symptoms of a lower respiratory tract infection . Gloves and an apron should also be worn , as well as eye protection if there is a risk of eye splash , for example from doing diagnostic tests .
How are cases managed ? Most cases are mild and the illness is viewed as self-limiting . Treatment is mostly supportive , with those infected recovering within two to four weeks . Crucially , patients with possible , probable or confirmed monkeypox are advised to avoid close contact with others until all lesions have healed and scabs dried off . This means they should stay at home and self-isolate , unless they require medical care or have other urgent health or wellbeing issues . The latest advice is that they should also avoid contact with household members , including sleeping and eating in a different room and using a separate bathroom , where possible . Some people may struggle with the experience of isolation .
References 1 WHO . Multicountry monkeypox outbreak : situation update . 4 June 2022 bit . ly / 3Rchwj0 2 WHO . 2022 Monkeypox outbreak : global trends . 1 September 2022 . bit . ly / 3cMLCdP 3 UKHSA . Monkeypox outbreak : epidemiological overview . 30 August 2022 . bit . ly / 3cEqOFA 4 WHO warns of WHO warns of ‘ real ’ risk as monkeypox outbreak tops 1,000 cases . South China Morning Post . 9 June 2022 . bit . ly / 3CSt8Di 5 Thornhill J et al . Monkeypox virus infection across 16 countries – April-June 2022 . N Engl J Med 2022 ; 387:679-691 . bit . ly / 3AIwdDn 6 Girometti N et al . Demographic and cinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London , UK : an observational analysis . Lancet Infect Dis 2022 ; 22 ( 9 ): 1321-8 . bit . ly / 3cJdK1A 7 UKHSA . Monkeypox : case definitions . 9 August 2022 . bit . ly / 3Rhcamz 8 UKHSA . Monkeypox : background information – clinical features . bit . ly / 3KDM3Ut 9 UKHSA Imported fever service . bit . ly / 3TAylps 10 UKHSA . Principles for monkeypox control in the UK : 4 nations consensus statement . bit . ly / 3cGuRRz 11 UKHSA . Monkeypox outbreak : vaccination strategy . bit . ly / 3TDiEO3
Further reading and resources
• UKHSA . Monkeypox : guidance . bit . ly / 3Q5h4le
• British Association for Sexual Health and HIV . Monkeypox resources . bit . ly / 3q45BaT
What measures are being taken to prevent transmission ? The UKHSA is tracing contacts of monkeypox cases to advise them to isolate . The closest contacts , who are deemed high risk , are asked to self-isolate for 21 days from exposure . 10 They should particularly avoid contact with the immunosuppressed , pregnant women and children aged under 12 where possible .
Some contacts are being offered post-exposure prophylactic treatment with the smallpox vaccine , to help prevent spread of the infection . 11 Pre-exposure vaccination is being offered to people at high risk due to a large number of contacts , such as gay , bisexual and other men who have sex with men . 11 The smallpox vaccine is expected to provide some cross-protection – previous data suggest it may be up to 85 % effective in preventing monkeypox infection .
Shortages of the vaccine mean post-exposure treatment is being prioritised for the immunosuppressed , children under the age of 10 to 11 ( school year 6 in England and Wales ) and pregnant women . Smaller doses are being used for pre-exposure vaccination to maximise coverage .
More information will become available as the outbreak progresses , so advice may change .
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