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This publication is available at https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement

This statement has been agreed by the UK public health agencies: UK Health Security Agency, Public Health Scotland, Public Health Wales and Public Health Agency Northern Ireland.

Monkeypox is a viral zoonotic disease that occurs primarily in Central and West Africa. There are 2 clades of monkeypox – a Central African clade with a reported mortality of 10% and a West African clade with a reported mortality of 1% from epidemiological cluster and outbreak reports from Africa. Previously it was occasionally exported to other regions. Within the UK it is classified as a high consequence infectious disease (HCID) for NHS management, particularly to enable early identification and prevention of spread within the healthcare environment for imported cases and recognising the initial clinical cannot determine the particular clade of monkeypox.

Given the infrequent importations and limited spread, and the limited information available about the disease course and outcome, the UK clinical and public health response to monkeypox was initially based on the High Consequence Infectious Disease management system. This was highly precautionary and designed for complete containment around single cases. It was also designed prior to the confirmed availability of vaccine and treatment.

The context has now changed to that of multiple cases in the UK and information on community spread within younger age groups and severity is accumulating rapidly. Pre and post exposure prophylaxis using Imvanex is available for deployment.

Since 13 May 2022, cases of monkeypox have been reported in multiple countries that do not have endemic monkeypox virus in animal or human populations, including countries in Europe, North America and Australasia. Epidemiological investigations are ongoing; however reported cases thus far have no established travel links to an endemic area. This suggests significant community transmission in multiple non-endemic countries in recent weeks. In the UK, all reported cases have been identified as the West African clade through rapid molecular testing.

Community transmission is occurring in the UK with multiple generations of spread. Illness appears to be generally mild, consistent with other information about the West African clade.

An overly precautionary response creates public health risk. The exclusion of healthcare workers impacts clinical services, especially sexual health clinics and emergency departments (ED). It is important that health management promotes engagement with health services as well as preventing stigma and controlling spread.

Monkeypox is a hazard group 3 organism (ACDP/HSE). Other organisms in this category include Salmonella typhi, HIV, Hepatitis B and C, and Mycobacterium tuberculosis that are managed routinely in the community. High Consequence Infectious Disease is not a legal classification but is instead agreed by a UKHSA and NHS programme to enable a consistent approach to infections that meet agreed criteria.

This proposal is to ensure a proportionate response to deliver on achievable strategic outcomes. These principles do not replace the need for local dynamic risk assessments which remain key.

Professionals – to inform development of operational guidance in UKHSA, NHS and other organisations.

These assumptions are based on the available data and expert opinion and are aligned with the World Health Organization. They will be regularly reviewed using the evidence generated in the incident response.

For individuals with infection who are well, ambulatory, and have either prodrome or rash, the highest risk transmission routes are direct contact, droplet or fomite. Transmission seen so far in this outbreak is consistent with close direct contact.

There is currently no evidence that individuals are infectious before the onset of the prodromal illness.

For individuals with infection who have evidence of lower respiratory tract involvement or severe systemic illness requiring hospitalisation, the possibility of airborne transmission has not been excluded.

It remains important to reduce the risk of fomite transmission. The risk can be substantially reduced by following agreed cleaning methods based on standard cleaning and disinfection, or by washing clothes or domestic equipment with standard detergents and cleaning products. Within healthcare, please refer to local country national infection prevention and control manual / guidance for decontamination.

Waste management and decontamination practice should follow best practice and be based on all the available evidence on safe handling of all waste in accordance with country specific legislation and regulations.

The highest risk period for onwards infection is from the onset of the prodrome until the lesions have scabbed over and the scabs have fallen off.

Deroofing procedures and throat swabs are not considered to be aerosol generating procedures (AGPs) but may cause droplets. The list of AGPs is available in the national infection prevention and control manual.

There is no available evidence on monkeypox in genital excretions and a precautionary approach for the use of condoms for 8 weeks after infection is recommended, (this will be updated as evidence emerges), in addition to abstaining from sex while symptomatic including during the prodromal phase and while lesions are present.

The disease in healthy adults is primarily self-limiting and with a relatively low mortality. There is remaining uncertainty over potentially increased severity in children and in individuals who are highly immunocompromised or pregnant.

Risk assessment and consideration of the hierarchy of controls will help determine the level of personal protective equipment (PPE) to use.

For possible/probable cases, the minimum PPE is:

For confirmed cases requiring ongoing clinical management (for example inpatient care or repeated assessment of an individual who is clinically unwell or deteriorating), for the minimum recommended PPE for healthcare workers is:

The above PPE will be used as the basis for contact classification.

Home isolation may be used for clinically well ambulatory possible, probable or confirmed cases for whom it is judged by the primary clinician and the HCID network as safe and clinically appropriate, with ongoing clinical and public health support for clinical management and isolation.

For ambulatory well possible, probable or confirmed cases with limited lesions, covering lesions and wearing a face covering/mask reduces the risk of onwards transmission.

Individuals with possible, probable or confirmed monkeypox should avoid close contact with others until all lesions have healed, and scabs dried off. This should include staying at home unless requiring medical assessment or care, or other urgent health and wellbeing issues.

Close household and non-household contacts of confirmed cases should be risk assessed. Medium risk contacts (category 2) do not need exclusions or isolation provided they comply with active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High risk (category 3) contacts should be advised to self-isolate for 21 days.

Cleaning to reduce risk from the environment in the community settings can be effectively achieved without using specialist services or equipment.

The risk of transmission in the home environment for possible, probable or confirmed cases can be reduced by the case performing regular domestic cleans and washing their own clothing and bed linen in a domestic washing machine.

Transport from the community to healthcare facilities for possible, probable or confirmed cases should be via private transport where possible. Where private transport is not available, public transport can be used but busy periods should be avoided. Any lesions should be covered by cloth (for example scarves or bandages) and a face covering must be worn.

For possible, probable or confirmed cases, attending ambulatory healthcare (for example outpatients, emergency departments, urgent care centres, general practice, sexual health clinics), patients should be placed in a single room for assessment. The case should be provided with a Fluid Resistant Surgical Mask to wear as appropriate.

Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.

Medium risk contacts (category 2) do not need exclusions or isolation provided they comply with active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High risk (category 3) contacts should be advised to self-isolate for 21 days.

For cleaning and decontamination of the room within healthcare settings, healthcare facilities should refer to the relevant country national infection prevention and control manual.

Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.

Medium risk contacts (category 2) do not need exclusions or isolation provided they comply with active monitoring, but should be excluded from activities involving close contact with children, severely immunocompromised, or pregnant women. High risk (category 3) contacts should be advised to self-isolate for 21 days.

Within non-domestic residential settings (for example adult social care, prisons, homeless shelters, refuges), individuals who are clinically well should be managed in a single room with separate toilet facilities where possible.

In domestic and non-domestic settings where healthcare is being provided, waste generated is classified as healthcare waste and should be managed appropriately

Where possible, pregnant women and severely immunosuppressed individuals (as outlined in the Green Book) should not assess or clinically care for individuals with suspected or confirmed monkeypox. This will be reassessed as evidence emerges.

Close contacts of confirmed cases in these settings should be assessed for vaccine, following the contact recommendations.

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