NATIONAL INSTITUTE OF CHILD HEALTH

GOVERNMENT OF SINDH

M POX MANAGEMENT GUIDELINES

Dr. Wajid Hussain, Assistant Professor Pediatric Infectious Disease, JSMU/ NICH

M pox is a viral zoonotic infection caused by the monkey pox virus (MPVX) Actions for a confirmed or probable case:
resulting fever bodyach and a characteristic Rash
MPVX is Double-stranded DNA virus orthopoxvirus genus family poxviridae  ISOLATION: As the main differential condition – varicella zoster
and has two phylogenetically distinct clades: Central African (Congo Basin) (“chickenpox”) - is highly contagious, a precautionary approach
clade and the West African clade. should be adopted initially:
CASE DEFINATIONS
Suspect Case  Place the patient in a negative pressure ventilation room (if
available) and apply the appropriate signage on the door.
 New characteristic rash OR  DO NOT allow visitors
 Meets one of the epidemiologic criteria and has a high clinical
suspicion† for M pox The risk of environmental contamination and transmission increases with the
increasing development and spread of skin lesions.
Probable Case
No suspicion of other recent Orthopoxvirus exposure (e.g., Vaccinia  COMMUNICATION::
virus in ACAM200 vaccination) AND demonstration of the presence of  ID consultant & Infection Prevention & Control team
 Following assessment by the ID, if case still considered
o Orthopoxvirus DNA by polymerase chain reaction of a probable the local Health team should be informed.
clinical specimen OR
 STAFFING:
o Orthopoxvirus using immunohistochemical or electron
 Avoid unnecessary staff contact
microscopy testing methods OR
o Demonstration of detectable levels of anti-orthopoxvirus  Only staff with a clear, documented history of having had
IgM antibody during the period of 4 to 56 days after rash varicella/measles OR who are fully vaccinated against
varicella/measles should care for the patient
Confirmed Case  Immunocompromised or pregnant staff should not care for
Demonstration of the presence of Monkeypox virus DNA by polymerase the patient.
chain reaction testing or Next-Generation sequencing of a clinical
specimen OR  PERSONAL PROTECTIVE EQUIPMENT:
Isolation of Monkeypox virus in culture from a clinical specimen
PPE for healthcare workers caring for suspected or confirmed
Exclusion Criteria patients should include:
A case may be excluded as a suspect, probable, or confirmed case if:  A fluid-repellent, disposable gown
 Disposable gloves
 An alternative diagnosis* can fully explain the illness OR  N 95
 An individual with symptoms consistent with monkeypox does not  Eye protection (face shield or goggles) for all interactions
develop a rash within 5 days of illness onset OR that may involve contact with the patient or potentially
 A case where high-quality specimens do not demonstrate the contaminated areas in the patient’s environment.
presence of Orthopoxvirus or Monkeypox virus or antibodies to Diagnosis
orthopoxvirus Confirmation of MPXV infection is based on nucleic acid amplification testing
(NAAT), using real-time or conventional polymerase chain reaction (PCR),
Epidemiologic Criteria (Within 21 days of illness onset any one of following) Specimen Collection and Storage
1- Contact with a person with a similar appearing rash or confirmed or
probable monkeypox OR  Swabs of lesion surface and/or exudate,
 Roofs from more than one lesion, or
2- Close in-person contact with individuals in a social network experiencing  Lesion crusts
monkeypox activity, men having sex with men (MSM), or social event (e.g., Specimen Type Collection Storage Collection
a bar or party) OR Materials Temperature purpose
Skin lesion Dacron or Refrigerate (2-8 Recommended for
3- Traveled to a country with endemic /confirmed cases of monkeypox OR material, polyester °C) or freeze (- diagnosis
including: • Swabs flocked swabs 20°C or lower)
4- Contact with animal or exotic pet African endemic species or used of lesion exudate with VTM or within 1 hour of
product of such animal (game meat, creams, lotions, powders, etc.) • Lesion roofs • dry swab collection; -20°C
Lesion crusts or lower after 7
days *
Clinical Manifestations:
Oropharyngeal Dacron or Refrigerate (2-8 Recommended for
The incubation period of monkeypox virus infection is roughly 1 to 2 weeks swab polyester °C) or freeze (- diagnosis if
but can range from 4 to 21 days flocked swabs 20°C or lower) feasible, in
with VTM or within 1 hour of addition to skin
 Febrile prodromal, headache, mylagia, and lymphadenopathy dry swab collection; -20°C lesion material
or lower after 7
 Classic Rash is deep-seated and well-circumscribed lesions, often days
with central umbilication; and lesion progression through specific
sequential stages—macules, papules, vesicles, pustules, and scabs.
 Starting on the head or face and progressing to the limbs and trunk.
 Lymphadenopathy differentiating it from chicken pox

Symptoms typically last two to three weeks and usually go away on their
own or with supportive care.
People remain infectious until all of the lesions have crusted over, the scabs
fallen off and a new layer of skin has formed underneath.
 MODE OF TRANSMISSION INFECTION PREVENTION AND CONTROL

Transmission of monkeypox virus occurs when a person comes into The identify, isolate, inform framework is key to reduce the risk of
contact with the virus from an animal, human, or materials contaminated transmission in health care settings. Once identified, isolate apply
with the virus. The virus enters the body through broken skin (even if not CONTACT AND STANDARD PRECAUTIONS
visible), respiratory tract, or the mucous membranes (eyes, nose, or Patient placement A patient with suspected or confirmed monkey pox
infection should be placed in a single room with dedicated toileting
mouth).
facilities.
Special air handling is generally not required. However, an airborne
infection isolation room (negative pressure) should be used for any
procedures that are likely to spread oral secretions
Animal-to-Human (Zoonotic) Transmission Personal Protective Equipment
All HCP should use a gown, gloves, eye protection (goggles or face shield),
It may occur through bite or scratch, direct contact or indirect contact
and a N95. While there is no epidemiologic evidence to date that
with body fluids or cutaneous or mucosal lesion material of infected monkeypox is spread by the airborne route, at this time the CDC
animals such as rope squirrels, tree squirrels, Gambian poached rats, recommends respiratory.
dormice, and monkeys
Monkeys and humans are incidental hosts All HCP determined to have had an exposure to monkeypox should be
monitored for symptoms for 21 days from the day of last interaction.

Patient transport – Patient transport outside the room should be limited

Human-to-Human Transmission to those essential, the patient should wear a medical mask during
transport and any exposed skin lesions should be covered with a clean
Primarily through droplet respiratory particles and contact
sheet or gown.
Droplet Direct Care of the environment – Standard cleaning and disinfection procedures
Indirect
contact Vertical should be performed.
contact transmission When handing soiled laundry (eg, bedding, towels, personal clothing),
through contact with lesion material that may be present on the laundry should
Thought to
Respiratory fomites be avoided..
occur primarily
particles after Activities such as dry dusting, sweeping, or vacuuming should be avoided.
through direct Infected
prolonged Wet cleaning methods are preferred
contact with material,
face-to-face such as Captive animals infected with monkeypox should be isolated from other
infectious
contact clothing or animals and placed into immediate quarantine. animals come into
sores, scabs, or
linens contact should be quarantined, and observed for symptoms for 30 days.
body fluids
POST-EXPOSURE MANAGEMENT
Exposure definition and risk stratification and management
Supportive care High-Risk Low/Uncertain
Intermediate-
 Symptoms normally resolve on their own without the need for Risk Risk
treatment. Unprotected contact Being within six feet Being within six feet
 Analgesics and Antipyretics can be used to relieve some between a person's skin for three hours or of an unmasked
symptoms or mucous membranes more of an unmasked person with
 Good Hydration and the skin, lesions, or person with monkeypox for less
 Avoid scratching skin and take care of their rash by cleaning their bodily fluids from a monkeypox without than three hours
person with monkeypox wearing, at a without wearing, at
hands before and after touching lesions and keeping skin dry and
(eg, sexual contact, minimum, a surgical minimum, a surgical
uncovered unless they are unavoidably in a room with someone inadvertent splashes of mask mask
else patient saliva to the eyes
Antiviral therapy or oral cavity of a person,
INDICATION ungloved contact with
 Those with severe disease and those at risk for severe disease patient) or contaminated
materials (eg, linens,
(eg, those younger than eight years of age)
clothing).
 patients with complications of the infection,
For individuals who have case-by-case basis Post-exposure
 immunocompromised patients) had a high-risk exposure evaluating the vaccination is not
Tecovirimat is the treatment of choice to monkeypox, we likelihood of indicated for those
Cidofovir/brincidofovir suggest post-exposure transmission from the with a low-
Triflourodine (and vidarabine) eye drops or ointments vaccination with the MVA specific exposure /uncertain-risk
vaccine exposure.

Types of vaccines —
There are two available vaccines that can reduce the risk of developing monkeypox. The modified vaccinia Ankara (MVA) vaccine) and ACAM2000
vaccine.
●MVA vaccine – The MVA vaccine is made from a highly attenuated, nonreplicating vaccinia virus and has an excellent safety profile, even in
immunocompromised people and those with skin disorders. The MVA vaccine is administered as two doses subcutaneously four weeks apart.
●ACAM2000 – ACAM2000 is a replication-competent smallpox vaccine that can only be used in select patients and is associated with more
adverse events

1 https://www.cdc.gov/poxvirus/monkeypox/clinicians/index.html.
2. "Monkeypox," World Health Organization, 19 May 2022. [Online]. Available: https://www.who.int/news-room/fact-sheets/detail/monkeypox.
3. "Epidemiological update: Monkeypox outbreak," European Centre for Disease Prevention and Control, 20 May 2022. [Online].
4. "Monkeypox," UK Health Security Agency, 18 May 2022. [Online]. Available: https://www.gov.uk/guidance/monkeypox#transmission.

For Further Details contact Dr. Wajid Hussain, Assistant Professor, Pediatric Infectious Disease NICH /JSMU