Mpox Training for Healthcare Workers

GROWING KWAZULU-NATAL TOGETHER

1
 GROWING KWAZULU-NATAL TOGETHER

Table of contents
• Background
• Epidemiology
• Transmission
• Pathogenesis
• Clinical presentation
• Diagnosis
• Case definition
• Treatment
• Complications and severe Mpox
• Guidance from the SOP for Infection Prevention & Control
(IPC) – healthcare management of the Mpox patient
• Mpox prevention measures
2
2
 GROWING KWAZULU-NATAL TOGETHER

Background
• Mpox is a viral zoonotic disease caused by
the ‘monkeypox’ virus (MPXV).
• The MPXV virus is a double-stranded DNA
virus that belongs to the orthopoxvirus
genus of the poxviridae family.
• There are more than 80 known poxviruses
and they affect different species of
mammals, birds, reptiles and insects. Two
poxviruses are known to cause only human
disease – smallpox and molluscum
contagiosum. The former has been
eradicated through mass-vaccination
programmes.
Weyer, NICD; Frey SE & Belshe RB, NEJM
2004; Lum, et al., 2022

3
3
 GROWING KWAZULU-NATAL TOGETHER

Genetic clades of the virus

4
4
 GROWING KWAZULU-NATAL TOGETHER

Background (continued)

• Mpox virus was discovered in 1958, when two outbreaks of a

pox-like disease occurred in colonies of monkeys kept for
research. Despite being named ‘monkeypox’ originally, the
source of the disease remains unknown. Scientists suspect
that African rodents and non-human primates (like monkeys)
might harbour the virus and infect people.

• In November 2022, WHO introduced the term ‘Mpox’ to

reduce the stigma associated with the term ‘monkeypox’.

5
5
 GROWING KWAZULU-NATAL TOGETHER

History of Mpox

6
6
 GROWING KWAZULU-NATAL TOGETHER

History of Mpox (continued)

• Since early May 2022, cases of Mpox have been reported from
countries where the disease is not endemic, and continue to be
reported in several endemic countries. Most confirmed cases with
travel history reported travel to countries in Europe and North
America, rather than West or Central Africa where the Mpox virus is
endemic. This is the first time that many Mpox cases and clusters
have been reported concurrently in non-endemic and endemic
countries in widely disparate geographical areas
(https://www.who.int/emergencies/situations/monkeypox-oubreak-
2022)

• The outbreak was declared a Public Health Emergency of

International Concern (PHEIC) by WHO on 23 July 2022.

7
7
 GROWING KWAZULU-NATAL TOGETHER

Epidemiology

• The WHO declared Mpox as a global public health threat based on

recent multiregional epidemiological investigations of the MPX.
• MPX was an ignored zoonotic infection endemic to tropical rainforest
regions of Western and Central African rural communities. In May
2022, the potential threat of Mpox virus (MPXV) being spread across
the contemporary world via transnational tourism and animal
movements was identified.
• From 2018 to 2022, various cases of MPX were diagnosed among
Nigerian travellers and have been documented in Israel, the UK,
Singapore, and the US. More recently, in 2022, MPX cases have been
confirmed in more than 100 non-endemic countries.
• Particular disease-associated risk factors fluctuate among different
epidemics. The unpredicted appearance of MPX in non-endemic
regions suggests some invisible transmission dynamic (Ullah, 2023).

8
8
 GROWING KWAZULU-NATAL TOGETHER

Confirmed Mpox cases reported by WHO from

1 January 2022 to 30 April 2024

9
9
 GROWING KWAZULU-NATAL TOGETHER

10
10
 GROWING KWAZULU-NATAL TOGETHER

South African statistics: 2024

Two* of the above cases have died (Health Policy Watch, 2024).

Five cases of Mpox were reported in South Africa during 2022.

11
11
 GROWING KWAZULU-NATAL TOGETHER

Mpox transmission cycle

12
12
 GROWING KWAZULU-NATAL TOGETHER

Mpox transmission
A person with Mpox is infectious from the time that symptoms start until
the rash has fully healed and a fresh layer of skin has formed.

1. Human-to-human transmission through direct contact with

infectious skin or mucosa lesions (in the mouth or genitals of a
person with Mpox):
• Face-to-face (while talking or breathing)
• mouth-to mouth (kissing)
• skin-to-skin contact (touching, hugging and vaginal or anal sex) – but
the role of sexual transmission through semen is not yet clear
• mouth-to-skin contact (oral sex or kissing the skin)
• respiratory secretions through droplet spread

13
13
 GROWING KWAZULU-NATAL TOGETHER

Mpox transmission (continued)

2. Indirect contact through:

• contaminated clothing, bedding, linen or other objects
(fomite transmission)
• contaminated sharps (medical needles and tattoos)
• in healthcare, home or community settings

3. Vertical transmission:
• during pregnancy
• via the placenta
• during or after delivery
14
14
 GROWING KWAZULU-NATAL TOGETHER

Mpox transmission (continued)

4. Animal to human spread:

• Mpox can spread to humans when they come into physical contact
with an infected animal such as some species of monkeys or a
terrestrial rodent (such as the tree squirrel).
• ‘Physical contact’ includes bites or scratches from the infected
animal, or during activities such as hunting, skinning, trapping, or
cooking.
• The virus can also be transmitted through eating infected animals if
the meat is not cooked thoroughly.
• The risk of catching Mpox from animals can be reduced by avoiding
unprotected contact with wild animals, especially those that are sick
or dead (including their meat and blood). In countries where animals
carry the virus, any foods containing animal parts or meat should be
cooked thoroughly before eating.
15 (https://www.who.int/health-topics/monkeypox#tab=tab_1) 15
 GROWING KWAZULU-NATAL TOGETHER

Mpox transmission (continued)

16
16
 GROWING KWAZULU-NATAL TOGETHER

Mode of transmission for Mpox virus

17
17
 GROWING KWAZULU-NATAL TOGETHER

Clinical features
Incubation period: 5 to 21 days (usually 7 to 14 days)
The classical description of Mpox comprises two phases of illness:
• Prodromal phase – fever, lymphadenopathy, headache, myalgia, sore
throat, back pain, asthenia, chills and malaise, followed by
development.
• Rash starting on face then extremities (number of lesions varies) – rash
can evolve from macules → papules → vesicles → pustules → crusts.
• For some people, the first symptom of Mpox is a rash, while others may
have different symptoms first.
• Mpox virus can cause severe disease in certain population groups =
young children, pregnant women, and immunosuppressed persons.
• Complications can include secondary bacterial skin/soft tissue
infections, sepsis, pneumonia, encephalitis, and ophthalmic disease.

18
18
 GROWING KWAZULU-NATAL TOGETHER

Symptomatic progression of Mpox

19
19
 GROWING KWAZULU-NATAL TOGETHER

Systems affected by Mpox

20
20
 GROWING KWAZULU-NATAL TOGETHER

Mpox rash progression

Stage one: Macules
• Macules appear like flat, round pink spots with no bump, lasting for one to two
days.
Stage two: Papules
• Papules go from a flat, pink spot to a raised bump that typically lasts one to
two days.
Stage three: Vesicles
• In this stage, the bumps go from raised to filled with a clear fluid for another
one to two days.
Stage four: Pustules
• Vesicles progress from a clear fluid-filled bump to an opaque pus bump. The
pus bump enlarges, gets firmer, and can develop a small divot in the center.
The bump may begin forming a small, crusted scab in the center. This stage
takes about a week or so.
Stage five: Scabs
• Over a week or two, the pus bumps will crust and scab over. Scabs will
21 remain for about a week before beginning to fall off. 21
 GROWING KWAZULU-NATAL TOGETHER

Mpox rash at each stage

22
22
 GROWING KWAZULU-NATAL TOGETHER

23
23
 GROWING KWAZULU-NATAL TOGETHER

Clinical images – penile lesions

24
24
 GROWING KWAZULU-NATAL TOGETHER

Clinical images – oral/perioral lesions

25
25
 GROWING KWAZULU-NATAL TOGETHER

Perianal, anal and rectal lesions

26
26
 GROWING KWAZULU-NATAL TOGETHER

Differential diagnosis

The rash which develops in MPX may resemble other

infectious diseases or other conditions, including varicella
zoster virus (VZV, chickenpox), herpes simplex virus (HSV),
primary or secondary syphilis, disseminated gonococcal
infection (DGI), foot and mouth disease, chancroid,
lymphogranuloma venereum (LGV), granuloma inguinale,
molluscum contagiosum, measles, scabies, rickettsia pox,
chikungunya, Zika virus, dengue fever, vasculitis and other
bacterial skin and soft tissue infections
(WHO, 2022: Clinical management and infection
prevention and control of Mpox)

27
27
 GROWING KWAZULU-NATAL TOGETHER

WHO suggested outbreak case definition

Suspected case
A person of any age presenting with an unexplained acute rash
AND
One or more of the following signs or symptoms: headache, acute onset of fever
(>38.5°C), lymphadenopathy, myalgia, back pain, asthenia
AND
For which the following common causes of acute rash or skin lesions do not fully
explain the clinical picture: varicella zoster, herpes zoster, measles, herpes
simplex, bacterial skin infections, disseminated gonococcus infection, primary or
secondary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale,
molluscum contagiosum, allergic reaction (e.g. to plants); and any other locally
relevant common causes of papular or vesicular rash.
NB: It is not necessary to obtain negative laboratory results for listed
common causes of rash illness in order to classify a case as suspected.

28
28
 GROWING KWAZULU-NATAL TOGETHER

Probable case
• A person presenting with an unexplained acute skin rash, mucosal lesions
or lymphadenopathy (swollen lymph nodes). The skin rash may include
single or multiple lesions in the ano-genital region or elsewhere on the
body. Mucosal lesions may include single or multiple oral, conjunctival,
urethral, penile, vaginal, or anorectal lesions. Ano-rectal lesions can also
manifest as ano-rectal inflammation (proctitis), pain and/or bleeding.
AND
one or more of the following:
• an epidemiological link to a probable or confirmed case of mpox in the 21
days before symptom onset;
• multiple and/or casual sexual partners in the 21 days before symptom
onset;
• a positive test result for orthopoxviral infection (e.g. OPXV-specific PCR
without MPXV-specific PCR or sequencing).

29
29
 GROWING KWAZULU-NATAL TOGETHER

Confirmed case

A person with laboratory confirmed MPXV infection by

detection of unique sequences of viral DNA by real-time
polymerase chain reaction (PCR)c and/or sequencing.

30
30
 GROWING KWAZULU-NATAL TOGETHER

Diagnoses
• Identifying Mpox can be difficult, as other infections and conditions can look
similar. It is important to distinguish Mpox from chickenpox, measles, bacterial
skin infections, scabies, herpes, syphilis, other sexually transmissible
infections, and medication-associated allergies.
• Someone with Mpox may also have another sexually transmissible infection
such as herpes. Alternatively, a child with suspected Mpox may also have
chickenpox. For these reasons, testing is key for people to get treatment as
early as possible and prevent further spread.
• Detection of viral DNA by PCR is the preferred laboratory test for Mpox. The
best diagnostic specimens are taken directly from the rash – skin, fluid or
crusts – collected by vigorous swabbing. In the absence of skin lesions,
testing can be done on oropharyngeal, anal or rectal swabs. Testing blood is
not recommended. Antibody detection methods may not be useful as they do
not distinguish between different orthopoxviruses.

(https://www.who.int/news-room/fact-sheets/detail/monkeypox )

31
31
Laboratory investigation
• First line test: Mpox or orthopoxvirus PCR All info available from: www.nicd.ac.za
• Electron microscopy can be useful
• WHO is not recommending use of rapid tests (yet)
• Sequencing of positive cases is important
• In RSA, several laboratories including NICD and several private laboratories
• Samples:

Dry swabs or
swabs in VTM
Ship as cat A (UN2814) (in accordance with IATA regs),
preferably on ice (cold chain)
 GROWING KWAZULU-NATAL TOGETHER

Clinical management

Clinical management in most cases is largely

supportive:
• Antipyretics for fever
• Analgesia for pain
• Antihistamines for pruritis
• Oral salt water rinse/antiseptic for oral lesions
• Warm baths and topical local anaesthetic for genital and
anorectal lesions
• Antibiotics for secondary bacterial skin/soft tissue
infection (not for uncomplicated lesions)
• Good hydration and nutrition
33
33
 GROWING KWAZULU-NATAL TOGETHER

Antiviral therapy

Antivirals
• No treatment is approved specifically for Mpox.
• Most people recover fully within 2 to 4 weeks without the need for
medical treatment.
• Antivirals are mostly reserved for SEVERE cases (including
individuals requiring hospitalization, children <8 years, pregnant and
breastfeeding women, PLHIV, and those with complications, aberrant
infection, etc.).
• South Africa received Tecovirimat (also known as TPOXX or ST-246)
for treatment of patients who experience severe health complications
as a result of mpox disease. The process to secure more treatment
including vaccine is underway in case the need arises (NDoH, Media
Statement Thursday, 20 June 2024)

34
34
 GROWING KWAZULU-NATAL TOGETHER

Infection Prevention & Control (IPC)

SOP FOR HEALTHCARE MANAGEMENT OF MPOX
PATIENT
PURPOSE
This Standard Operating Procedure (SOP) aims to guide personnel in
adhering to infection prevention and control (IPC) standards during
healthcare or while providing care to the suspected, probable, or
confirmed Mpox case.

OBJECTIVE
To give guidance and identify IPC principles to reduce all avoidable risks
during care and monitoring of Mpox cases to ensure that appropriate
public health measures are instituted to contain the spread.

35
35
 Cleaning and disinfection of surfaces
• PPE such as gloves, gown, respirator, e.g. N95, FFP2, and eye protection
should be worn by health workers while cleaning and disinfecting patient
care equipment and patient care areas.
• Use dedicated footwear that can be decontaminated. Disposable shoe
covers are not recommended.
• Wet cleaning methods are preferred. Use dedicated cleaning material.
• Disinfect using 70% alcohol or hypochlorite solution, a concentration of
1000 ppm, usually 2 sachets to 4.5L of water.
• To prevent cross-contamination, cleaning must always be carried out from
the cleanest area first, finishing in the dirtiest area last, and always clean
from top to bottom.
• Particular attention should be paid to toilets and frequently touched
surfaces.
• Use disposable or dedicated patient care equipment and clean and disinfect
equipment before use on other patients.
• Dishes can be washed with detergent in hot water (>55°C) while wearing
domestic gloves.

36
 Safe handling of linen
• Do not shake linen or laundry, as this may disperse
infectious particles.

• Place linen carefully into a designated container or bag for

transport to laundry services.

• Wash with hot water at >60°C with laundry detergent, and

dry according to routine procedures, preferably at high heat.

• Workers in the laundry area should follow standard

transmission-based precautions.

37
 Waste management

• Waste should be segregated into general waste,

infectious waste and sharps placed in appropriate bins at
the point of use (fill to ¾ full).

• Waste management and disposal (including PPE) should

be done according to local regulations for infectious
waste.

• Ensure that health workers wear appropriate PPE during

the handling of waste.

• Transport waste to designated areas. Storing of waste

should be done in a controlled access area.
38
 Management of deceased patients
• Handling of the deceased should be kept to a minimum.

• Perform hand hygiene and wear PPE according to contact and droplet
precautions, as patients with rashes that have not healed may still be
infectious.

• Ensure that any leakage of body fluids is contained.

• The body should be wrapped in a cloth or shroud and transferred to the

mortuary as soon as possible.

• The dignity of the dead, their cultural and religious traditions, and their
families should be respected and protected. Family and friends may view
the body after it has been prepared for burial, in accordance with local
customs. They should not touch or kiss the body, and should clean their
hands with soap and water or alcohol-based hand sanitiser after the
viewing. 39
 Management of exposed healthcare workers

• Health workers should notify infection control and

occupational health teams to receive a medical evaluation
and instruction on follow-up.

• Health workers who have had occupational exposure do not

have to be excluded from work if they are asymptomatic, but
should undergo active surveillance for symptoms for 21 days
post-exposure. They should not work with vulnerable patients.

• Health workers who have had exposure to a person with

confirmed Mpox should undergo medical evaluation and
consideration for possible interventions.

40
 GROWING KWAZULU-NATAL TOGETHER

Prevention when managing Mpox patients

• Health workers should perform hand hygiene according to the WHO
‘Your 5 moments for hand hygiene’, including prior to donning and
after removing PPE.
• Place the patient in a well-ventilated, single patient room with a
dedicated bathroom or toilet.
• If single patient rooms are not available, consider cohorting confirmed
cases, maintaining a distance of at least one metre between patients.
• The isolation room/area should have signage posted at the entrance
indicating contact/droplet precautions.
• Wear PPE, including gloves, gown, a respirator (e.g. N95, FFP2) and
eye protection.
• Use dedicated footwear that can be decontaminated.
• Health workers should be trained on procedures for safe donning and
doffing of PPE.

41
41
 GROWING KWAZULU-NATAL TOGETHER

Self-care and prevention

If you have Mpox:
• Stay home and in your own room if possible.
• Wash hands often with soap and water or hand sanitiser, especially
before or after touching sores.
• Wear a mask and cover lesions when around other people until your
rash heals.
• Keep skin dry and uncovered (unless in a room with someone else).
• Avoid touching items in shared spaces, and disinfect shared spaces
frequently.
• Use saltwater rinses for sores in the mouth.
• Take warm baths with baking soda or Epsom salts for body sores.
• Take over-the-counter medications for pain, like paracetamol.
• Using condoms during sex will help reduce the risk getting Mpox, but
will not prevent its spread from skin-to-skin or mouth-to-skin contact.
42
42
 GROWING KWAZULU-NATAL TOGETHER

References
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10196482/pdf/fmicb-14-1160984.pdf
• Titanji BK, Tegomoh B, Nematollahi S, Konomos M, Kulkarni PA. Monkeypox: A
Contemporary Review for Healthcare Professionals. Open Forum Infect Dis, 2022; 9:7,
ofac310. DOI: 10.1093/ofid/ofac310.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9307103/pdf/ofac310.pdf
• https://www.who.int/news-room/fact-sheets/detail/monkeypox
• Lu J, Xing H, Wang C, et al. Mpox (formerly monkeypox): pathogenesis, prevention, and
treatment. Sig Transduct Target Ther, 2023; 8, 458.
DOI: https://doi.org/10.1038/s41392-023-01675-2
• Shubham Upadhayay, Richmond Arthur, Divya Soni, Poonam Yadav, UmaShanker
Navik, Randhir Singh, Thakur Gurjeet Singh, Puneet Kumar. Monkeypox infection: The
past, present, and future.
DOI: https://www.sciencedirect.com/science/article/pii/S1567576922008669?via%3Dihub
• https://www.who.int/emergencies/outbreak-toolkit/disease-outbreak-toolboxes/mpox-
outbreaktoolbox#:~:text=WHO%20suggested%20outbreak%20case%20definition&text=
i)%20A%20person%20who%20is,pain%2C%20profound%20weakness%2C%20or%20f
atigue

43
43
 GROWING KWAZULU-NATAL TOGETHER

References
• World Health Organization, 2022. Clinical management and infection prevention and
control of monkeypox. https://iris.who.int/bitstream/handle/10665/355798/WHO-MPX-
Clinical_and_IPC-2022.1-eng.pdf?sequence=1
• National Department of Health. Infection prevention and control (IPC) standard
operating procedures (SOP) for healthcare workers management of monkeypox patient.
https://www.nicd.ac.za/wp-content/uploads/2022/06/IPC-SOP-For-monkeypox-
management.pdf
• Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al.
Monkeypox Virus Infection in Humans across 16 Countries — April to June 2022.
Clinical N Engl J Med, 2022; 387:679-691.
• USAID. 2023. Mpox Training for Clinical Providers.

44
44
 THANK YOU
Questions?
Caleb Wang, 084 774 8580, caleb.wang@kznhealth.gov.za