Latest NHSE letter, 5 Sept 2024.

This letter updates organisations on the current NHS response to the outbreak of Clade I mpox in Eastern and Central Africa. The situation continues to evolve, and all organisations need to be prepared to manage someone who has travelled in this area presenting with clinical signs and symptoms of being a possible or probable case: NHS-response-to-outbreak-of-Clade-I-Mpox-in-Eastern-and-Central-Africa-letter-5-Sept-24.pdf

Current position:

On 14 August 2024, the WHO declared MPXV Clade 1 as a public health emergency of international concern, this has been prompted by what has been happening in the Republic of Congo for some months where they have seen a rapidly increasing number of MPX cases, with a relatively high case mortality rate.  However what has happened in the last few weeks is a spill over from the DRC into other countries (Burundi, Uganda, Kenya and Rwanda) and increasing concern about other countries that border the DRC.

The main concern around Clade 1, which is different to Clade 2, is that it is thought to be more virulent and possibly more infectious and could be transmitting through a heterosexual route.  There has been a high mortality rate with a larger proportion of deaths in children under 15 years.

As of 23 August, there are no reported cases of MPXV Clade I in the United Kingdom however this may change.  We still have a small number of Clade 2 cases in the country principally transmitting in the GBMSM community though these are very small numbers a week.

Currently the risk for the UK has been set as low however extensive planning is underway at a national and regional level focused on several areas:

• The recognition of cases – being alert to the symptoms in returning travelers from infected countries and also ensuring that the appropriate testing is in place
• The management of cases – high consequence infectious disease and any identified case will be managed through the HCID network
• From a health protection teams will be investigating the case looking at the potential source and any contacts through isolation and vaccination
• Border control are providing information to returning travelers and surveillance of anyone who is potentially unwell.  There is particular advice being developed for people returning from countries of concern who work in the health and social care sector – this is expected imminently
• There is national work going on about vaccination, but the position has not changed and the advice remains the same as previously. We are expecting something from JCVI as some point.  The only vaccination that is being advised now is the pre-exposure vaccination for GBMSM and their contacts.

See: Clade I mpox virus infection – GOV.UK (www.gov.uk)

1. Providers to ensure that relevant clinical services – including primary care, urgent care, sexual health services, paediatrics, obstetrics and emergency departments – are aware of the information in this public health message and that a differential diagnosis of Clade I mpox virus (MPXV) infection is considered in any patient who meets the operational case definition below.
2. Providers to ensure that they have adequate stocks of appropriate personal protective equipment (PPE) and relevant staff are trained in its use for the assessment and treatment of patients presenting with suspected Clade I MPXV infection.
3. Providers to ensure there is a clinical pathway for isolation and management of suspected Clade I MPXV cases within their setting. This should include isolation of the patient, liaison with local infection prevention and control (IPC) teams, and arrangements for discussion of the case with local infectious disease, microbiology or virology consultants if a diagnosis of Clade I MPXV is being considered so that appropriate clinical management, including testing and infection control measures, can be implemented.
4. All samples from all individuals testing positive for mpox must be sent to the UKHSA Rare and Imported Pathogens Laboratory (RIPL) for clade differentiating tests.

Healthcare professionals should remain vigilant for Clade I MPXV, including in sexually acquired mpox cases, and should obtain comprehensive travel histories

Mpox is a viral disease with flu-like symptoms with a localised or generalised rash.  Person-to-person spread is mainly through skin-to-skin contact and breathing in virus through the respiratory tract or contact with mucous membranes.

Therefore, contact and respiratory precautions are needed to prevent spread when staff attend a suspected or confirmed case.

Infection is usually self-limiting but severe illness can occur with case fatality rates of 10% reported in non-vaccinated individuals (although more research is needed to understand differing mortality rates).

Clinical features

The incubation period for mpox is between 5 and 21 days.

Symptoms include fever, headache, muscle aches, backache, swollen lymph nodes, chills, lethargy, joint pain. Not all cases experience all of these symptoms.

The patient develops a rash within 1-5 days.

The rash is formed of blisters/vesicles, scabs or ulcers and patients can present with a localised or more widespread rash.  Lesions are infectious until all the scabs have fallen off and the skin underneath is intact.

People with mpox are considered infectious until all the rash has scabbed and healed and there is an absence of febrile symptoms such as headache, muscle aches, back pain, low energy and swollen lymph nodes. People can be re-infected with the disease.

Patients who report a recent travel history to affected countries[1] and have some or all of the symptoms associated with mpox infection should be offered a telephone consultation in the first instance.

If the patient attends the surgery, the patient must be isolated in a room and the door kept shut.  Attending staff should wear the following personal protective clothing:

• FFP3 mask; long sleeved gown; gloves; protective eyewear.
• Staff who wear FFP3 masks should be fit tested on the type of being worn.

[1] Democratic Republic of Congo; Republic of Congo; Central African Republic; Burundi; Rwanda; Uganda; Kenya; Gabon; Angola; South Sudan; Tanzania; Zambia

Clinical diagnosis is difficult and can be confused with other viral infections such as chicken pox. Patients with confirmed Clade 1 mpox infection or symptomatic patient with travel history to affected areas or link with a suspected case from endemic area within 21 days of symptom onset should be discussed with the clinical team as soon as possible via the 24/7 Imported Fever Service helpline (0844 778 8990).

SEL ICB will ensure that all practices have a small supply of FP3 masks and gowns delivered within the next 7-10 days (from 23 August).  We are also working with GSTT to be able to provide local fit testing training for practices to access.  Further details will follow.

Please see attached document: Mpox clade 1 infection decision flow chart

Please see attached pdf:  Suspected Mpox virus pathway for patient self-presenting in General Practice

South London HPT

UK Health Security Agency
5th Floor, 10 South Colonnade
London
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Email london.region@ukhsa.gov.uk

Telephone 0300 303 0450

Urgent out of hours advice for health professionals: 0300 303 0450

Email phe.london.region@nhs.net for notification and enquiries of infectious diseases that contain Patient Identifiable Information.