Managing Patients with Monkeypox

Dear Team,

Earlier this week, Governor Hochul issued an executive order declaring a state disaster emergency citing a rise in cases of the monkeypox virus across the state. Likewise, New York City Mayor Adams declared monkeypox a public health emergency as the city finds itself at the center of the state's current outbreak.

These precautionary measures by the Governor and NYC Mayor expand the number of people eligible to administer monkeypox vaccines, require providers to send vaccine data to the state's health department, and will boost ongoing response efforts including efforts to get more vaccines and expand testing capacity. The declarations also allow officials to issue emergency orders and implement health code amendments to help slow the spread of the virus. The World Health Organization (WHO) has declared the monkeypox outbreak a public health emergency of international concern.

As pre-hospital care providers, it is important that you familiarize yourself with the below information as it is quite possible that you will receive a call for monkeypox over the next several weeks.

What is monkeypox?

Monkeypox is a rare disease of the orthopoxvirus family that is caused by infection with the monkeypox virus.

What are the symptoms of monkeypox?

Symptoms of monkeypox can include an influenza-like prodrome followed by a rash. In some cases, the rash might start first followed by other symptoms, while others only experience a rash. These rashes can appear like pimples or blisters often in mucosal areas such as the mouth and anogenital or rectal areas which may remain limited to these areas or even spread to the face, torso, or extremities. Refer to the CDC’s Case Definitions for use in the 2022 Monkeypox Response for additional information.

There can be a significant amount of pain associated with symptoms. Pain may interfere with basic functions such as eating, urination, and defecation which can cause distress and compound problems for the patient. Co-infections with sexually transmitted infections, group A streptococcal infection, and other viruses have also been reported.

How long does the virus typically last?

Lesions go through different stages of healing and typically last 2-4 weeks. The progression of these lesions can be seen here.

How does monkeypox spread?

Monkeypox can be spread in a variety of ways. This virus is historically zoonotic in nature from infected animals that either scratch/bite an individual or by eating meat/products that are infected. The most common way individuals spread monkeypox is through direct contact with the infectious rash, scabs, and/or body fluids. It is possible to also contract monkeypox through respiratory secretions during face-to-face contact, or during intimate physical contact. Spread can also happen by touching clothing or linens that have been contaminated with infectious rash or body fluids.

Although this is not considered a sexually transmitted infection, as described above, monkeypox can spread during intimate physical contact between individuals. People who can get pregnant are also at risk since this virus can spread to their fetus through the placenta.

What PPE should we use with a patient with suspected/confirmed monkeypox?

PPE used by healthcare personnel should include a gown, gloves, eye protection (i.e., goggles), and a NIOSH-approved particulate respirator equipped with N95 filters or higher. A surgical mask alone will not suffice.

What additional precautions or controls should we implement on these calls? Please read each point fully.

  1. Inform other responding personnel if a risk of monkeypox is suspected, limit the number of personnel making patient contact, and prevent unprotected exposure to the patient. Attendants, Junior Corp, and Ride-Alongs should not enter the residence of a monkeypox patient and should remain at headquarters if possible.

  2. Avoid activities that could resuspend dried material from lesions (e.g., use of portable fans, dry dusting, sweeping, or vacuuming).

  3. Apply a well-fitting source control (e.g., medical mask) to the patient and cover exposed skin lesions with a sheet or gown prior to initiating transport.

  4. Separate the driver compartment from the patient compartment. If isolation of the driver compartment cannot be completed, the driver of the ambulance should wear an N95 or higher-rated respirator.

  5. Turn the ambulance exhaust fan on high in the patient compartment.

  6. Adjust air handling to introduce fresh air in both compartments if possible.

  7. Exercise caution when performing aerosol-producing procedures (e.g., endotracheal intubation, airway suctioning, CPAP/BiPAP, CPR). Only perform these procedures if medically necessary and cannot be postponed.

  8. Inform the receiving facility as soon as possible, that you suspect a patient may be infected with monkeypox so that space is made available to properly isolate the patient on arrival (airborne isolation room if available) and that receiving healthcare personnel are in appropriate PPE.

  9. Healthcare providers must immediately report suspect cases of monkeypox to their LHD.

How do we clean up after a monkeypox call?

Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant on all surfaces. Soiled linens should be discarded only at the hospital. Avoid dusting or sweeping the ambulance, use the hose as "wet" cleaning is preferred with this virus.

What should I do as a provider after this type of call?

Healthcare personnel who have had exposure to monkeypox should be monitored and must receive postexposure management. Any volunteer who has cared for a patient with suspected or confirmed monkeypox should be alert to the development of symptoms that could suggest monkeypox infection, especially within the 21-day period after the last date of care. The volunteer should then contact their physician immediately to discuss vaccine eligibility.

As always, stay safe, and please let me know if you have any additional questions.

Teddy J. O'Rourke

First Lieutenant


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