Guidance for Emergency Medical Services (EMS) Professionals on Suspected Cases of Monkeypox

New York State Health Department

IDENTIFICATION

  1. Monkeypox is a rare disease of the orthopoxvirus family that is caused by infection with the monkeypox virus.
  2. 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 MonkeypoxResponse for additional information.
  3. Lesions go through different stages of healing and typically lasts 2-4 weeks. The progression of these lesions can be seen here: Centers for Disease Control and Prevention (CDC) MonkeypoxClinical Recognition webpage.
  4. 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. With the presentation of symptoms, it is important to evaluate for and treat other potential infections as deemed appropriate.
  5. 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 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.
  6. 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.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

  1. Standard Precautions should be applied for all patient care, including for patients with suspected monkeypox.
  2. PPE used by healthcare personnel should include gown, gloves, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), and a NIOSH-approved particulate respirator equipped with N95 filters or higher.
  3. For more information on infection prevention and control of monkeypox, please visit the CDCwebsite or the monkeypox main information page.

EMS RESPONSE AND TRANSPORT

  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.
  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 driver compartment cannot be verified the driver of the ambulance should wear an N95 or higher-rated respirator.
  5. Turn the exhaust fan on high in the patient compartment (if so equipped).
  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.

ENVIRONMENTAL INFECTION CONTROL

  1. Standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim and follow the manufacturer’s directions for concentration, contact time, and care and handling. Products with Emerging ViralPathogens claims may be found on EPA’s List Q.
  2. Soiled laundry (e.g., bedding, towels, personal clothing) should be handled in accordance with recommended [PDF – 241 pages] standard practices, avoiding contact with lesion material that may be present on the laundry. Soiled laundry should be gently and promptly contained in an appropriate laundry bag and never be shaken or handled in manner that may disperse infectious material.
  3. Activities such as dry dusting, sweeping, or vacuuming should be avoided. Wet cleaning methods are preferred.
  4. Detailed information on environmental infection control in healthcare settings can be found in CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities and Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
  5. Guidance for EMS Professional on Suspected Cases of Monkeypox (June 24, 2022) [section IV.F. Care of the environment] and Infection Prevention and Control of Monkeypox inHealthcare Settings.

MONKEYPOX MEDICAL WASTE

  1. In June 2022, the U.S. Department of Transportation (USDOT) released additional guidance on the handling of regulated medical waste (RMW) from suspected or confirmed cases of monkeypox. Here is the USDOT June 2022 guidance.
  2. The previous position of the USDOT was that facilities should hold untreated RMW generated from suspected cases of monkeypox and wait until testing confirms the diagnosis and identifies the clade before disposing of the waste. However, the USDOT, in conjunction with other Federal partners, has issued new guidance indicating that during the ongoing 2022 multi-national outbreak of West African clade monkeypox, if clinician teams determine that a patient does not have known epidemiological risk for the Congo Basin clade of monkeypox (e.g. history of travel to the Democratic Republic of the Congo, the Republic of Congo, the Central African Republic, Cameroon, Gabon, or South Sudan in the prior 21 days) it is appropriate to manage waste from suspected monkeypox patients as RMW. If the Congo Basin clade of monkeypox is excluded, medical waste does not have to be held pending clade confirmation and medical waste needs to be packaged, transported, and treated as RMW. The waste must be packaged in accordance with 49 CFR § 173.197, labelled as United Nations (UN) 3291, Regulated medical waste (Monkeypox waste), and treated by incineration or by autoclaving at 121°C/250°F for at least 30 minutes.
  3. If epidemiological risk factors indicate a risk for Congo Basin clade, waste should be managed as a Category A infectious substance pending clade confirmation. If testing shows any clades except the West African clade, it needs to be packaged, transported, and treated as Category A waste. The waste must be packaged in accordance with 49 CFR § 173.196, labelled as United Nations (UN) 2814, Infectious substances, affecting humans (Monkeypox waste), and managed as Category A waste.
  4. Additional information can be found on the Centers for Disease Control and Prevention (CDC) website.

HEALTHCARE PERSONNEL EXPOSURE

  1. Healthcare personnel and patients in healthcare facilities who have had an exposure to monkeypox should be monitored and receive postexposure management.
  2. Any healthcare worker 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, and should notify infection control, occupational health, and the local health department (LHD) to be guided about a medical evaluation.
  3. Healthcare workers who have unprotected exposures (i.e., not wearing PPE) to patients with monkeypox do not need to be excluded from work duty, but should undergo active surveillance for symptoms, which includes measurement of temperature at least twice daily for 21 days following the exposure. Prior to reporting for work each day, the healthcare worker should be interviewed regarding evidence of fever or rash.
  4. Healthcare workers who have cared for or otherwise been in direct or indirect contact with patients suspected or confirmed to have monkeypox while adhering to recommended infection control precautions may undergo self-monitoring or active monitoring as determined by the LHD. Additional information about assessing exposure risk and public health recommendations for individuals exposed to a patient can be found on the CDC website.

REPORTING

  1. Healthcare providers must immediately report suspect cases of monkeypox to their LHD.
  2. Reporting should be to the LHD in the county in which the patient resides.
  3. New York City residents suspected of monkeypox infection should be reported to the NYC Health Department Provider Access Line (PAL) at 866-692-3641. Outside of New York City, contact information.
  4. If you are unable to reach the LHD where the patient resides, please contact the NYSDOH Bureau of Communicable Disease Control at: 518-473-4439 during business hours or 866-881-2809 evenings, weekends, and holidays.
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