Monkeypox is a rare zoonotic infection, causing a human disease similar to, but usually milder than, smallpox. According to the Centers for Disease Control and Prevention (CDC) (2015), in Africa, monkeypox has been shown to cause death in as many as one in 10 persons who contract the disease.
Symptoms typically begin with fever, headache, muscle ache and swollen lymph nodes. Within one to three days of the fever a rash appears, often beginning on the face and then spreading to other parts of the body. Lesions progress through different stages—namely macules, papules, vesicles, pustules and scabs—before falling off. The illness typically lasts between two and four weeks and the incubation period ranges from five to 21 days. The virus is known to be spread via respiratory droplets and through contact with fluid from the vesicles or pustules.
In September 2018, an adult male who had recently travelled to Nigeria was admitted to Blackpool Victoria Hospital with groin lesions and a fever. Cases of monkeypox outside of Africa are extremely rare. Indeed, the only other cases to be reported occurred in the USA in 2003 and were linked to exposure to infected animals that had been imported from west Africa as pets (Bernard et al, 2006).
This factor, combined with an atypical presentation of the virus, led to an initial delay in diagnosis and it was not until Public Health England (PHE) reported that another unrelated traveller from Nigeria had tested positive for monkeypox in Cornwall that comparisons were made between the two cases (subsequently known as case 1 and case 2). The Blackpool patient was transferred to the High Consequence Infectious Diseases (HCID) unit in Liverpool on 10 September 2018 and the diagnosis was confirmed the next day.
Owing to the theoretical risk of airborne transmission, the CDC (2015) recommends the use of FFP3 respirators, disposable long-sleeved gowns, gloves and eye protection when caring for patients with monkeypox. The delay in diagnosis meant that staff caring for the patient wore only standard personal protective equipment (PPE) comprising a plastic apron and gloves and therefore had been unwittingly exposed to the virus.
In response to the two cases, Public Health England (PHE) convened a national Incident Management Team (IMT) and a number of immediate actions were agreed to limit the risk of further transmission. This included a contact-tracing exercise to identify all staff or patients who might have been exposed to the virus. This was such an unprecedented situation that the IMT felt it necessary to share a rapid communication about the two cases via the Eurosurveillance journal (Vaughan et al, 2018).
As nurse consultant for infection prevention at Blackpool Teaching Hospitals and a key member of the IMT, I was responsible for ensuring that all necessary actions were taken locally to protect patients and staff in Blackpool. One of the first tasks was to ensure that the rooms that had been occupied by the monkeypox-positive patient were decontaminated effectively.
At the time of this incident, and due to the rarity of the virus outside Africa, no specific guidance documents were available to help assist in this exercise. Monkeypox virus is classed as a ‘category A’ infectious substance, which is transported in a form that, when exposure to it occurs, is capable of causing permanent disability, life-threatening or fatal disease in otherwise healthy humans or animals (World Health Organization, 2007). To add some context, the Ebola virus falls within the same category. Therefore, special precautions were required when disposing of any waste that had been contaminated with the monkeypox virus.
During the Ebola virus outbreak in 2014, I was the Trust lead for Ebola virus preparedness and oversaw the development of the Trust's Viral Haemorrhagic Fever Plan. I was therefore asked by Public Health England (PHE) to contribute towards a new monkeypox guidance document, which aimed to set out what cleaning methods should be used, how soiled linen should be processed and how the clinical waste should be disposed of. This guidance is now available on the PHE website (PHE, 2018).
The initial contact-tracing exercise determined that a total of 77 hospital staff and three patients had been exposed to the virus and therefore would require either active or passive follow-up by PHE during the 21-day incubation period. A number of community contacts, including friends and relatives of the patient, were also identified. My team were tasked with determining whether or not these contacts were classed as high, intermediate or low risk, as defined by PHE based on the type of interaction or contact they had with the monkeypox-positive patient.
Those who were classed as a high or intermediate risk needed active daily follow-up by PHE, which consisted of a text message to which they were expected to reply if they developed symptoms indicative of monkeypox. This cohort was also offered post-exposure prophylaxis, which consisted of a third-generation smallpox vaccine (IMVANEX®).
Two weeks later, a secondary case (case 3) was diagnosed in a healthcare worker, despite having received the vaccine, who was consequently transferred to a HCID unit in Newcastle. This staff member had been identified as one of only three contacts who had handled contaminated bed-linen without wearing adequate PPE, which placed them in the high-risk category. This was the first ever case of person to person transmission recorded outside of Africa and, subsequently, the two remaining high-risk contacts were excluded from work until the incubation period had passed.
Investigations determined that the healthcare worker became unwell after working a long day shift and therefore all patients and staff with whom they had come into contact were also considered to be at risk. This totalled a further 54 staff and eight patients, all of whom required the same assessment by the infection prevention team to determine which risk category they fell into; what type of follow-up they required by PHE and whether or not they required the vaccine. The healthcare worker had also visited family members and attended an appointment at their GP surgery while unwell.
This meant that in the North West alone, over 200 hospital, primary care and community contacts had been identified and could present in the emergency department (ED), or be referred to the isolation unit for an assessment at the request of the PHE Imported Fever Service at any time. It was therefore vital to ensure that the Trust was fully prepared for all such eventualities.
I and the team used ICNet Infection Prevention surveillance software to electronically tag all patient and community contacts so that a daily track of who was coming in and out of the hospital could be maintained. During that time a number of contacts were admitted to hospital for health reasons unrelated to monkeypox so the team had to make sure that the ward staff knew what symptoms to look out for during the incubation period. The team then provided PHE with daily reports on each of these inpatients so that the regional contact-tracing database was kept up to date.
I also developed a number of local guidance documents to assist staff in the recognition and management of monkeypox. One such document was an algorithm for the ED, which was designed to identify any patient contacts quickly so that they would be immediately triaged into an isolation area.
The infection prevention nursing team visited the ED and isolation unit daily to provide specific education and training about monkeypox to all frontline staff. During the surveillance period, several of the contacts developed clinical illness indicative of monkeypox, which required either telephone assessment by the Imported Fever Service or face-to-face clinical assessment in the hospital. The infection prevention team were on constant standby to ensure that the clinicians involved in the assessment of these cases were fully prepared and competent in the use of enhanced PPE, including FFP3 respirators; that the domestic staff were adhering to the new PHE decontamination guidance; and that all category A waste was handled and disposed of appropriately.
Cases 1 and 2 made a full recovery and were discharged from their respective hospitals after two consecutive clearance samples were obtained. Case 3, the healthcare worker, continued to test positive after 6 weeks in isolation in the HCID unit in Newcastle and was eventually discharged to their own home under strict instructions to self-isolate. I worked closely with the North West Ambulance Service to arrange for the healthcare worker to attend the isolation unit for twice-weekly screening. This, too, was a logistical challenge and took a great deal of planning to ensure that no one else was exposed to the virus during these hospital visits. Eventually, case 3 also tested negative and the incident was officially closed by PHE on 27 November 2018. The hospital subsequently received a letter from the Chief Medical Officer, thanking them for their management of this incident. This is indicative of the high-profile nature of the incident and the successful way in which the infection prevention team responded.
The threat of imported pathogens is ever present but this incident demonstrated that monkeypox can present anywhere in the UK. Clinicians, therefore, need to remain alert to its salient clinical features. Despite receiving the vaccine, one healthcare worker developed monkeypox following an exposure that was subsequently categorised as ‘high risk’, emphasising the importance of using enhanced PPE and isolation precautions when dealing with any potential HCIDs. I and the infection prevention team have gone on to share our learning at numerous local and national events in the hope that other infection prevention teams will benefit from our experience.