Preparedness guidance: managing possible mpox cases in primary eye care settings

Guidance from the College of Optometrists

The World Health Organisation (WHO) has determined the recent increase in mpox virus (MPXV) cases in a growing number of countries as a public health emergency of international concern. This is in light of a particular clade of mpox, known as Clade I MPXV, demonstrating increased rates of severe illness and mortality, resulting in its classification as a high consequence infectious disease (HCID) and its recent expansion into Central and East African countries.

While there have been reports of a single Clade I MPXV case in Europe, there are currently no known cases in the UK and the overall risk level for the UK population has been assessed as low. However, there is potential for imported cases from affected countries. As such, national public health authorities have issued guidance to support healthcare settings to manage a potential Clade I mpox outbreak.

It is important to stress that the current recommendation from each UK Nation’s public health authorities is a state of preparedness rather than an action stage at this time. However, clinicians must be aware of the signs and symptoms of mpox infection, differentiate between HCID and non-HCID case definitions and understand how to manage any suspected cases.

We have previously issued guidance on managing patients who contact practices with symptoms of respiratory infection, which is relevant to potential mpox outbreaks. Mpox has specific symptoms and is spread via contact (including fomite) and droplet routes. Although mpox does not spread easily between people, specific transmission based precautions (TBPs) are required when providing face-to-face care. Mpox is also a notifiable disease, meaning any suspected or confirmed cases (where clade is unknown) must be reported to your local health protection team.

The advice below sets out how practices can prepare to safely manage patients with suspected or confirmed mpox infection should an outbreak occur. This includes what steps practices that are able to or required to provide face-to-face eye care can take to protect staff and other patients. This guidance is applicable to primary care optometry settings and optical practices.

Frequently Asked Questions 

What is mpox virus and what are the signs and symptoms of infection?

Mpox virus (MPXV) is a virus from the same family as smallpox. Although it does not spread easily, it is usually transmitted through contact with infected skin, mucous membranes (direct contact) and contaminated surfaces (fomite). It can also transmit by breathing in contaminated droplets. The incubation period is between 5 and 21 days (the period between exposure to the virus and the development of symptoms); average 6-16 days. It usually causes a self-limiting infection and most people recover within a few weeks.

There is no known cure for mpox infection so treatment is generally supportive.  However, it can cause severe illness and even death in some individuals. Antiviral drugs can help treat those with severe disease or those at high risk of severe disease. Immunisation via smallpox vaccine are available to help control outbreaks and help protect high risk individuals.

There are two distinct clades of MPXV, Clade I and Clade II. Clade II was responsible for the global outbreak in 2022. Clade Ib, a new strain of the virus, is largely responsible for the current outbreak that originated in the Democratic Republic of Congo. As Clade I MPXV is more likely to cause more severe illness and has a higher mortality rate (approximately 10% of cases), it is classified as a high consequence infectious disease (HCID mpox). Clade II MPXV is generally milder and is less likely to cause severe illness and mortality. Thus, Clade II MPXV is not considered an HCID (non-HCID mpox).

Initial symptoms of mpox infection include:

  • Fever (temperature ≥ 38ºC)
  • Chills
  • Headache
  • Exhaustion
  • Muscle aches (myalgia)
  • Back ache
  • Joint pain (arthralgia)
  • Swollen lymph nodes (lymphadenopathy)

Within 1-5 days of the onset of the above symptoms, a rash develops, often beginning on the face and genital area and can spread to other parts of the body. The rash changes appearance as it goes through different stages before forming into a scab which eventually falls away.

The case definitions of suspected (possible, probable, highly probable) and confirmed mpox infection can be found here.

How can I determine whether an mpox infection is considered a possible high consequence disease (HCID)?

The UK public health authorities have provided an operational case definition to determine a suspected or confirmed case of HCID mpox infection. The following patients should be managed as an HCID case:

  • Confirmed mpox infection where Clade I MPXV has been identified

 

  • Suspected or confirmed mpox infection where clade is not yet known and:

o   There is travel history to the Democratic Republic of Congo (DRC) or specified countries (listed below) where there may be a risk of Clade I mpox infection exposure, or a link to a suspected case from those countries, within 21 days of symptom onset

AND/OR

o   There is an epidemiological link to a case of Clade I mpox infection within 21 days of symptom onset.

The countries where Clade I mpox cases have been reported, including countries bordering those with ongoing Clade I mpox transmission are currently the DRC, Republic of Congo, Central African Republic, Burundi, Rwanda, Uganda, Kenya, Cameroon, Gabon, Angola, South Sudan, Tanzania, Zambia and Sweden. Given the risk of spread to neighbouring countries, an up-to-date list can be found here.

The following patients with mpox infection are not considered as an HCID case:

  • Confirmed mpox infection where Clade II MPXV has been identified

OR

  • Suspected or confirmed mpox infection of unknown clade and none of the epidemiological characteristics listed above in the operational HCID case definition apply.

This means it is important to obtain a comprehensive history, including travel, from patients with symptoms of mpox to determine HCID status and whether they can be seen in practice for urgent/emergency care.

A patient has contacted the practice for an appointment, but they have symptoms of mpox infection. What should I do?

Where patients have a single initial symptom, other than high temperature or fever, you should use your professional judgement to determine infection risk and not unnecessarily defer appointments or refer to other pathways as these symptoms may be due to non-infectious causes.

If patients report symptoms of suspected (possible, probable, highly probable) or confirmed mpox infection, irrespective of HCID status, they should not attend the practice for routine care until:

  • They have been tested for mpox clade (if not already awaiting result)

AND

  • All scabs have fallen away with underlying skin healed or until they are well, whichever is later.

If clinically necessary and in the patient’s best interest, you may offer a remote consultation to address their needs.

If these patients require face-to-face care that cannot be postponed (i.e. the patient has symptoms of an urgent or emergency eye condition), deciding whether this is appropriate in primary care settings is dependent on the HCID status. This means you should take a comprehensive history, including travel, to help determine possible HCID status, which will also inform the notification route.

For suspected or confirmed non-HCID mpox cases, you may offer face-to-face care provided you are able to apply the relevant transmission based precautions (TBPs) according to the 4 Nations consensus statement on the principles of control of non-HCID mpox, your nation’s National Infection Prevention and Control Manual (NIPCM) and any local guidance (see also FAQ below). If this is not possible, the patient should be referred to an appropriate local service that is able to apply these measures (prior agreement should be arranged for such situations), or you should contact your local hospital eye department for advice.

For suspected or confirmed HCID mpox cases, they should not attend the practice but you should refer to an appropriate local service that is able to implement enhanced infection prevention and control measures for managing HCIDs or contact your local hospital eye department for advice.

Do I need to report cases of suspected mpox infection?

Mpox infection is a legally notifiable disease. If you suspect mpox infection, you should contact your local health protection team (HPT) urgently by telephone and advise the patient to contact their GP. You can find your local HPT here:

You should also contact the Imported Fever Service (0844 778 8990) urgently to expedite testing (England, Northern Ireland, Scotland).

If my practice is able to or required to provide face-to-face care for patients with non-HCID mpox infection who present with an urgent/emergency eye condition, what steps should we take to prepare?

A patient screening and triaging protocol should be in place to identify those with suspected or confirmed mpox infection, HCID status and history of urgent or emergency visual or ocular symptoms. Staff involved in the administration of patient appointments should be appropriately trained in this.

Staff who may be at high risk of mpox infection or complications associated with mpox infection should undergo an individual risk assessment to ensure they can continue in their current role safely, or for consideration of redeployment in line with normal business practices. The UK public health authorities advise that staff who are pregnant or immunocompromised (as defined in the Green Book) should not provide clinical care for suspected or confirmed mpox infection.

Staff who are able to provide care should wear an FFP3 mask or equivalent respiratory protective equipment (RPE) where clinically indicated (see below) when providing direct care for these patients, in line with UK public health authority recommendations. This legally requires fit testing to ensure safe and effective use.

Practices should ensure all staff are trained in appropriate infection prevention and control measures, including when to wear personal protective equipment (PPE), RPE and the correct donning, doffing and disposal of PPE.

Practices should ensure they have sufficient levels of PPE and RPE available for staff and patients who attend the practice with symptoms of mpox infection to enable your practice to continue to provide eye care safely.

What specific transmission based precautions are required for managing cases of suspected or confirmed non-HCID mpox infection with an urgent or emergency eye condition?

Practices providing face-to-face care should undertake a practice-based risk assessment by appropriately qualified individuals in order to determine the relevant contact and droplet transmission risk mitigation measures for non-HCID mpox infection in the following areas:

  • Attending the practice

o    Appointments should be scheduled at quieter times of the day and the patient advised to attend the practice alone where possible

o    Patients should be advised to cover skin lesions wherever possible

o    Patients and those accompanying them should be asked to wear a fluid resistant surgical mask (FRSM) for source control

  • Placement in the practice

o    Patients should be isolated at the time of arrival (e.g. in a separate waiting area or room or straight into the consulting room).

  • In the consulting room

o    Staff providing direct care should wear the following PPE and RPE:

  • Fit tested FFP3 mask or equivalent (RPE)
  • Single use disposable gloves
  • Single use disposable long sleeve gown
  • Eye/face protection (goggles or visor)

o    Ensure adequate levels of ventilation

  • Decontaminating (cleaning and disinfecting) the practice

o    All equipment and surfaces that have made contact with the patient should be cleaned and disinfected appropriately in line with standard protocols after the care episode

Am I considered exposed to MPXV if I have provided care to a suspected or confirmed non-HCID mpox infection case?

Staff are not considered exposed to MPXV (low risk, category 1) if:

  • appropriate PPE and RPE is worn while providing direct care or undertaking decontamination procedures, or
  • staff enter the patient room without PPE/RPE AND there is no direct contact with patient (or their bodily fluids) AND they maintain 1m distance from the patient,

Staff are considered exposed to MPXV (medium risk, category 2) if they are not wearing appropriate PPE/RPE and:

  • they provide direct care for any length, or
  • are within 1m of the patient for at least 15 minutes

There is greater risk of infection (high risk, category 3) where there is direct skin-skin contact or contact with bodily fluids to mucous membranes (eyes, nose, mouth).

I have been exposed to non-HCID mpox infection in my practice, am I able to continue to attend work?

If you have been exposed to mpox infection in practice, you are considered a non-household contact and you should inform your employer as soon as possible and contact your local Health Protection Team (HPT) or GP urgently for advice. They may advise testing to determine whether you have been infected, arrange contact tracing and should advise whether or not you should isolate at home.

In general, those with medium risk (category 2) and high risk (category 3) exposure do not have to isolate but your employer or occupational health team should undertake an individual risk assessment prior to returning to work. However, those with high risk exposure should not provide care to children under 5 and individuals who are pregnant or immunocompromised for 21 days from the last exposure.

If you are considered a medium or high risk contact, you should also avoid any activity that involves skin-skin contact for 21 days from the last exposure.

If you subsequently develop symptoms of mpox infection, you should notify your employer as soon as possible and contact your GP urgently. You should not attend work until advised by your medical team or local HPT. In general, this is until all scabs have fallen away and the underlying skin has healed or you feel well, whichever is later.

Further information

September 2024