Monkeypox Healthcare Worker Advisory
Monkeypox is a rare viral zoonotic infectious disease (i.e. an infection transmitted from animals to humans) that occurs sporadically, primarily in remote villages of Central and West Africa, near tropical rainforests. It is caused by the monkeypox virus which belongs to the Orthopoxvirus genus in the family Poxviridae. The Orthopoxvirus genus also includes variola virus (the cause of smallpox), vaccinia virus (used in the vaccine for smallpox eradication), and cowpox virus (used in earlier smallpox vaccines). Following the eradication of smallpox, monkeypox virus has emerged as the most important Orthopoxvirus.
Case fatality in outbreaks has been between 1% and 10%, with most deaths occurring in younger age groups and immunocompromised patients. There are two distinct types, Congo Basin and West African clades, with the former being more virulent.
Until the recent outbreak of 2017, the last time that cases of monkeypox were reported in Nigeria was in the 1970s. The 2017 Nigerian outbreak is the largest documented outbreak of the West African clade to date.
This is an advisory to health care workers, to prevent person to person transmission of Monkeypox especially in health care settings.
Monkeypox is spread through:
- contact with an infected animal, human, or contaminated materials.
- From animal to human through bite or scratch from animals and preparation of infected bushmeat.
- Human-to-human transmission occurs through respiratory droplets, contact with infected persons or contaminated materials.
- Anybody can be infected.
Health workers including
- Doctors, nurses and other health workers providing direct patient care without adequate infection prevention and control (IPC) measures.
- Hospital staff who clean and disinfect contaminated surfaces, materials and supplies.
- Laboratory staff who handle blood samples from suspected monkeypox cases.
Signs and symptoms of Monkeypox:
The incubation period of monkeypox is usually between 6 to 16 days but can range from 5 to 21 days. The clinical manifestation of the disease has two phases, with an initial invasive period in the first 5 days, where the main symptoms are fever, lymphadenopathy (swelling of lymph nodes), back pain, intense headache, myalgia (muscle ache) and severe asthenia (lack of energy). A maculopapular rash (skin lesions with flat bases) appears 1-3 days after the onset of fever, developing into small fluid-filled blisters (vesicles), which become pus-filled (pustules) and then crust over in about 10 days.
Complete resolution takes up to three weeks. Nearly all patients have face lesions, three quarters have lesions on the palms of their hands and soles of their feet, and 30% have genital involvement. The eyes are involved in most cases, 20% have lesions on the eyelid, with some on the cornea. There are oral mucosa lesions in 70% of cases. Skin lesions can vary widely from a few to up to many thousands, and the lymph node swelling can precede the rash unlike in other Orthopoxvirus infections.
Monkeypox is usually self-limiting, with symptoms lasting between 2 and 3 weeks. Severe cases occur more commonly among children, who also have greater mortality – the case fatality has ranged from 1% to 10%, higher in Congo Basin cases.
Polymerase chain reaction (PCR) of lesions is the mainstay of monkeypox diagnosis. The Swabs and scabs from skin lesions are sent to the designated reference laboratory in dry containers. Serum samples can also be taken; however, these often yield negative results due to the transient viraemia.
Antibody (ELISA) tests can show past exposure to Orthopoxvirus infections, and certain reference facilities can perform virus isolation by cell culture in high containment. In order to interpret test results, it is critical that patient information is provided with the specimens including:
- a) Approximate date of onset of fever
- b) Date of onset of rash
- c) Date of specimen collection
- d) Current status of the individual (stage of rash)
- e) Age.
– Any person presenting with a history of sudden onset of fever, followed by a vesiculopustular rash occurring mostly on the face, palms and soles of feet.
– Any suspected case with laboratory confirmation (Positive IgM Antibody, PCR or Virus isolation).
– Any person who has no symptoms but who has been in physical contact with or exposed to the body fluids of a confirmed case in the last three weeks (i.e. skin secretions, oral secretions, pre-mastication of food, urine, stools, vomiting, blood, sexual contact)
There are no specific treatments available for monkeypox infection, although various novel antivirals have in-vitro and animal data supportive of effect such as Brincindofovir and Tecovirimat. Vaccination against smallpox has been proven to be 85% effective in preventing monkeypox but is no longer routinely available following global smallpox eradication. Screening and management of co-morbidities and all other secondary infections should be carried out.
Please find below a guide in carrying out supportive treatment for the cases of monkey pox:
|Protection of compromised skin and mucous membranes||Skin rash||I. Keep clean with simple antiseptic
II. Cover with light dressing if extensive
III. Patients are encouraged to not touch and scratch the lesions
|Skin and genital ulcers||I. Antiseptic cleaning
II. Warm saline sitz bath (for vulvo- vagina ulcers)
III. Light Sofra-Tulle dressing
|Oral sores||I. Warm saline gurgle
II. Vitamin C and other multivitamins
|Conjunctivitis||Most cases are self-limiting.
Consult Ophthalmologist if severe or symptoms persist.
|Rehydration Therapy||Dehydration can follow poor appetite, nausea, vomiting and diarrhea.||Give ORS in mild cases, especially in children.
Give intravenous fluids (normal saline or dextrose saline as necessary).
|Loss of skin integrity and exudation from extensive skin lesions may also result in dehydration.||Ensure cleaning and appropriate dressing/covering of skin lesions.|
|Alleviation of distressful symptoms||High grade fever||Tepid sponging
Antipyretics such as Paracetamol
|Chills and rigors were especially common in hospitalised Nigerian patients|
|Itching/Pruritus||Warm bath/warm clothing
Antihistamines- (e.g. Loratadine)
|This symptom was self-limiting in most Nigerian cases|
|Pain||Paracetamol or non-steroidal anti- inflammatory drugs (NSAID)||Most cases improved on Paracetamol alone|
|Nausea and persistent vomiting||Consider anti-emetics such as metoclopramide 10 mg IV/ orally every 8 hours until vomiting stops. For children aged 1-5years, give chlorpheniramine syrup 1mg twice daily.|
|Provision of nutritional support||Headache||Consider Paracetamol if distressful
|Malaise||Ensure adequate hydration, nutrition and treatment of secondary infection|
|Poor appetite (inadequate feeding)||Ensure adequate feeding with diet containing carbohydrates, proteins and vitamins/minerals|
|Psychosocial support||See section on psychosocial support||See section on psychosocial support||
|Treatment of complications||Secondary bacterial infections (boils, abscesses, dermatitis)||Antiseptic cleaning
Empirical treatment with oral/parenteral cephalosporins (Cefuroxime 500mg bd for 5days or Ceftriaxone IV 1g daily for 5days) OR B-lactam antibiotics (Amoxyl/Clavulanic acid 625mg twice daily for atleast 5days)
Moist occlusive dressing are recommended to cover areas of the skin that have experienced epidermal loss
|Bronchopneumonia||Give empiric antibiotics
(Consider B Lactams or Macrolides)
|Sepsis||Full septic work-up
Consider intravenous broad-spectrum antibiotic pending culture results
|Culture may only be possible in biosafety level 2 laboratory|
|Encephalitis||Pay attention to nutrition and hydration if unconscious
Consider nasogastric (NG) tube feeding
Control seizures with anticonvulsants
Consider empirical broad-spectrum antibiotics
|Keratitis/Corneal ulceration||Patients who wear contact lenses should abstain from wearing their contact lenses while ill, to prevent contact with the eyes
|Ocular infections with monkeypox virus can cause permanent corneal scarring ad loss of vision|
|Treatment of comorbidities||Dependent on associated infections/conditions||Manage based on clinical findings and established treatment/management guidelines|
The national guidelines for Monkeypox case management and Infection prevention and control are available on the NCDC website for download.
INFECTION PREVENTION AND CONTROL (IPC)
Measures that can be taken to prevent infection with monkeypox virus include:
- Avoiding contact with animals that could harbor the virus including sick or dead animals in areas where monkeypox cases have occurred.
- Avoiding contact with any material that has been in contact with a sick animal.
- Isolating potentially infected animals from other animals.
- Quarantine of any animals that might have come into contact with an infected animal, handling them with standard precautions and observing for monkeypox symptoms for 30 days and washing with soap and water after contact with infected animals.
- Thoroughly cooking all animal products before eating.
- Isolation of infected patients, including use of personal protective equipment and implementation of standard infection control precautions by health workers.
- Regular hand washing after caring for or visiting sick people.
- Public health education on preventive measures.
If you find any suspected case of monkey pox in your facility, please kindly call the Disease Surveillance and Notification Officers [DSNO] in your LGA [contacts of DSNO attached]. The LGA DSNOs will collect the samples from the patient with the support of the medical officers. Please ensure that two samples are collected as one will be sent to the National Reference Laboratory, NCDC Abuja and the other sent to Lagos State Biobank, Mainland Hospital Yaba.
In case of any other clarifications, please kindly call the State Epidemiologist on 08093054359, 08023169485 or send WhatsApp message to 08023169485. You can also visit NCDC website for more information.
|2||AJEROMI-IFELODUN||ADEBOLA ADEDAYO ENIOLA||08024216487|
|3||ALIMOSHO||ASHOROBI BUNMI MARY||08072710337|
|4||ALIMOSHO||AKINDELE AGBAJE A||08055467578|
|6||APAPA||BADRU MUHAMMED T||08023978044|
|7||BADAGRY||FAGBENLE TUNDE PHILLIP||08035486573|
|8||EPE||AYENI BERNICE B||08033563143|
|9||ETI OSA||SHOBALOJU ADEJOKE O||08134992002|
|10||IBEJU-LEKKI||OMOTESHO S OLUWOLE||08033527600|
|11||IFAKO IJAIYE||LASISI RASHEEDA O||08035545386|
|12||IKEJA||KEHINDE JAMES OLUMIDE||08033869391|
|14||KOSOFE||SALAMI EVELYN E||07033475906|
|20||OSHODI-ISOLO||ADEBAYO-IGE SYDQAT O||08023727203|
|23||SURULERE||MOMOH B AZEEZ||08023329167|
Clinical Photos Showing Vesiculopustular Rashes in Monkeypox Patients
If you find any suspected case of monkey pox in your facility, please kindly call the Disease Surveillance and Notification Officers [DSNO] in your LGA