Health Ministry releases Guidelines for Monkeypox Treatment, Details

New Delhi: As the country recently reported its first case of Monkey pox in Kerala, the Ministry of Health and Family Welfare has released the guidelines for the Management of Monkeypox Disease.

The guidelines detail out the various aspects of management of the disease including the epidemiology, case definition, differential diagnosis, diagnostic criteria as well as the management strategies other disease. Following is the brief reproduction of the same

• Human-to-human transmission is known to occur primarily through large respiratory droplets generally requiring a prolonged close contact. It can also be transmitted through direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens of an infected person.
• Animal-to-human transmission: may occur by bite or scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) or through bush meat preparation.

• Swollen lymph nodes
• Fever
• Headache
• Body aches
• profound weakness

• Prodrome (0-5 days)

• Skin involvement (rash)

** A clear lesion images should be sent along with the case record form (preferably on the email ID mentioned below)

6.3 Diagnostic modalities for Monkeypox with ICMR NIV Pune

For the confirmation of Monkeypox on the suspected clinical specimens:

a) PCR for Orthopoxvirus genus [Cowpox, Buffalopox, Camelpox, Monkeypox] will be done

b) If specimen will show positivity for the Orthopoxvirus, it would be further confirmed by Monkeypox specific conventional PCR or real time PCR for Monkeypox DNA

c) Additionally, virus isolation and the Next Generation Sequencing of clinical samples (Miniseq and Nextseq) will be used for characterization of the positive clinical specimens

All the clinical specimens should be transported to the Apex laboratory of ICMR-NIV Pune routed through the Integrated Disease Surveillance Programme network of the respective district/state

6.4 Contact Persons from ICMR-National Institute of Virology Pune Maharashtra, India for further queries related to collection and transportation of the clinical specimens

Primary contact person Secondary contact person

Dr. Pragya D. Yadav, Dr. Rima R. Sahay,

Scientist-'F' & Group Leader, Scientist 'C',

Maximum Containment Facility, Maximum Containment Facility

ICMR-NIV, Microbial Containment Complex, ICMR-NIV, Microbial Containment Complex,

130/1, Sus Road, Pashan, Pune 411021 130/1, Sus Road, Pashan, Pune-411021.

Tel: Office: 020-26006111; Tel: Office: 020-26006160;

Email id: hellopragya22@gmail.com Email id: dr.rima.sahay@gmail.com

7. Management

7.1 Principles of Management

• Patient isolation
• Protection of compromised skin and mucous membranes
• Rehydration therapy and Nutritional support
• Symptom alleviation
• Monitoring and treatment of complications

7.2 Patient Isolation

• Isolation of the patient in an isolation room of the hospital/ at home in a separate room with separate ventilation
• Patient to wear a triple-layer mask
• Skin lesions should be covered to the best extent possible (e.g. long sleeves, long pants) to minimize risk of contact with others
• Isolation to be continued until all lesions have resolved and scabs have completely fallen off

Table 2: Supportive management of Monkeypox

7.3 Monitoring and treatment of complications

The patient should closely monitor for the appearance of any of the following symptoms during the period of isolation:

• Pain in eye or blurring of vision
• Shortness of breath, chest pain, difficulty in breathing
• Altered consciousness, seizure
• Decrease in urine output
• Poor oral intake
• Lethargy

In case any of the above symptoms appear, the patient should immediately contact nearby healthcare facility/ specialist.

8. Contact tracing

8.1 Definition of a contact

A contact is defined as a person who, in the period beginning with the onset of the source case's first symptoms, and ending when all scabs have fallen off, has had one or more of the following exposures with a probable or confirmed case of monkey pox:

• face-to-face exposure (including health care workers without appropriate PPE)
• direct physical contact, including sexual contact
• contact with contaminated materials such as clothing or bedding

8.2 Contact identification

Cases can be prompted to identify contacts across household, workplace, school/nursery, sexual contacts, healthcare, houses of worship, transportation, sports, social gatherings, and any other recalled interactions.

8.3Contact monitoring

a) Contacts should be monitored at least daily for the onset of signs/symptoms for a period of 21 days (as per case definition above) from the last contact with a patient or their contaminated materials during the infectious period. In case of occurrence of fever clinical/lab evaluation is warranted.

b) Asymptomatic contacts should not donate blood, cells, tissue, organs or semen while they are under surveillance.

c) Pre-school children may be excluded from day care, nursery, or other group settings.

d) Health workers who have unprotected exposures to patients with monkeypox or possibly contaminated materials do not need to be excluded from work duty if asymptomatic, but should undergo active surveillance for symptoms for 21 days.

Advisory for International Passengers and surveillance at Airports and Role of APHOs/PHOs is also elaborated in Annexure 4.

9. Risk Communication and Preventive Measures

Raising awareness of risk factors and educating people about the measures they can take to reduce exposure to the virus is the main prevention strategy for monkeypox. There are number of measures that can be taken to prevent infection with monkeypox virus:

• Avoid contact with any materials, such as bedding, that has been in contact with a sick person.
• Isolate infected patients from others.
• Practice good hand hygiene after contact with infected animals or humans. For example, washing your hands with soap and water or using an alcohol-based hand sanitizer.
• Use appropriate personal protective equipment (PPE) when caring for patients.

9.1 Reducing the risk of human-to-human transmission

Surveillance and rapid identification of new cases is critical for outbreak containment. During human monkeypox outbreaks, close contact with infected persons is the most significant risk factor for monkeypox virus infection. Health workers and household members are at a greater risk of infection. Health workers caring for patients with suspected or confirmed monkeypox virus infection, or handling specimens from them, should implement standard infection control precautions. Samples taken from people and animals with suspected monkeypox virus infection should be handled by trained staff working in suitably equipped laboratories. Patient specimens must be safely prepared for transport with triple packaging in accordance with WHO guidance for transport of infectious substances.

9.2 Infection Prevention and Control (IPC)

A combination of standard, contact, and droplet precautions should be applied in all healthcare settings when a patient presents with fever and vesicular/pustular rash. In addition, because of the theoretical risk of airborne transmission of monkeypox virus, airborne precautions should be applied as per risk assessment.

Clinical triage includes early recognition and immediate placement of patient in separate area from other patients (source control). All individuals, including family members, visitors and HCWs should apply standard, contact and droplet precautions.

9.2.1 Patient isolation

Patient should be managed in isolation, precautions should be taken to minimize exposure to surrounding persons, which include placing a surgical mask over the patient's nose and mouth—if tolerable to the patient—and covering any of the patient's exposed skin lesions with a sheet or gown.

9.2.2 Ambulance Transfer

• When a case has to be transported, the personnel accompanying the patient should wear PPE (long sleeved gown, N95 mask, gloves, and goggles).
• Give prior information to the hospital of the admission/transfer of a potentially infectious person.
• Request patient to wear a mask (if tolerated) and advise on Respiratory Hygiene and Cough Etiquette.
• If lesions are present, cover them with long sleeved clothing/pant or a clean sheet to minimize contact with others. In the ambulance use disposable linen if available.
• The ambulance should be cleaned and disinfected before using for the other patients. After wearing PPE, surfaces (stretcher, chair, door handles etc.) should be cleaned with a freshly prepared 1% hypochlorite solution or equivalent. Carefully place reusable blankets in a bag without shaking or fluffing them, then put into a laundry bag and send for laundering clearly labelling it so that person in the laundry wears appropriate PPE before handling or autoclaves it before opening. Follow manufacturer's instructions for cleaning/disinfecting reusable equipment in the ambulance. All masks and any waste contaminated with crusts, secretions, serum or body fluids should be disposed of as infectious waste in yellow bag. In the ambulance, if the driver's chamber is not separate, driver should also use PPE.

9.2.3 Additional Precautions

• PPE (Disposable gown, gloves, N95 mask, Eye goggles) should be donned before entering the patient's room and used for all patient contact. All PPE should be disposed of prior to leaving the isolation room where the patient is admitted.

• Hand hygiene (following standard steps of hand hygiene) after all contact with an infected patient and/or their environment during care.

• Correct containment and disposal of contaminated waste (e.g., dressings) in accordance with Biomedical Waste Management guidelines (2016 & subsequent amendments) for infectious waste.
• Care when handling soiled laundry (e.g., bedding, towels, personal clothing) to avoid contact with lesion material.
• Soiled laundry should never be shaken or handled in manner that may disperse infectious particles.

• Care when handling used patient-care equipment in a manner that prevents contamination of skin and clothing.
• Ensure that used equipment has been cleaned and reprocessed appropriately.
• Ensure provisions are in place for cleaning and disinfecting environmental surfaces in the patient care environment.
• Hospital disinfectant currently used for environmental sanitation may be used as per recommendations for concentration, contact time, and care in handling.

9.2.4 IPC at home

Patients who do not require hospitalization may be managed at home taking following preventive measures:

• Patients should be isolated in a room or area separate from other family members. Healthy household members should limit contact with the patient.
• Patients should not leave the home except for medical care.
• No visitors should be allowed at home.
• Patients, especially those who have respiratory symptoms (e.g., cough, shortness of breath, sore throat) should wear a surgical mask. If this is not feasible, other household members should consider wearing a surgical mask when in the presence of the patient.
• Disposable gloves should be worn for direct contact with lesions and disposed of after use.
• Skin lesions should be covered to the best extent possible (e.g., long sleeves, long pants) to minimize risk of contact with others.
• Contain and dispose of contaminated waste (such as dressings and bandages) in the Biomedical waste disposable bag Do not dispose of waste in landfills or dumps.
• Proper hand washing with soap and water (or use of an alcohol-based hand rub) should be performed by the patient and other household members after touching lesion material, clothing, linens, or environmental surfaces that may have had contact with lesion material.
• Laundry (e.g., bedding, towels, clothing) may be washed with warm water and detergent;

 Care should be used when handling soiled laundry to avoid direct contact with contaminated material.

 Soiled laundry should not be shaken or otherwise handled in a manner that may disperse infectious particles.

• Dishes and other eating utensils should not be shared. Soiled dishes and eating utensils should be washed with warm water and dish washing soap.
• Contaminated surfaces should be cleaned and disinfected. Standard household cleaning/disinfectants may be used in accordance with the manufacturer's instructions.
• Pets and domestic animals should be excluded from the patient's environment.

9.2.5 Duration of Isolation Procedures

Affected individuals should avoid close contact with immunocompromised persons and pregnant women until all crusts are gone. Isolation precautions should be continued until all lesions have resolved and a fresh layer of skin has formed.

10. Risk communication

This includes providing public health advice through the channels that target audiences use on how the disease transmits, its symptoms, preventive measures and what to do in case of suspect or confirmed infection. This should be combined with targeting community engagement to the population groups who are most at risk, working closely with health care providers, including STD clinics, and civil society organizations.

Risk communication should be informed by insights from social listening detecting public sentiment and should timely address possible rumours and misinformation. Health information and advice should be provided avoiding any form of stigmatization of certain groups such as men who have sex with men (MSM).

The key measures that can be taken to prevent infection with monkeypox virus:

• Isolate infected patients from others who could be at risk for infection.
• Avoid contact with any materials, such as bedding, that has been in contact with a patient of Monkeypox.
• Practice good hand hygiene after contact with infected persons. For example, washing your hands with soap and water or using an alcohol-based hand sanitizer.
• Use masks and gloves when caring for patients.

The guideline also details out the filing the Case Reporting Format, Procedures for the clinical specimen collection, INSTRUCTIONS ON SAMPLE PACKAGING AND TRANSPORT as well as instructions for international passengers

To read the full guideline click on the following link