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Fortuitous diagnosis of monkeypox in a patient hospitalized for several days: risk assessment and follow-up for exposed healthcare workers

Published:November 11, 2022DOI:https://doi.org/10.1016/j.jhin.2022.11.002
      Sir,
      The current monkeypox (MKP) outbreak affects countries where the disease is non-endemic. Atypical presentations, with few skin lesions, have been described [
      • Thornhill J.P.
      • Barkati S.
      • Walmsley S.
      • Rockstroh J.
      • Antinori A.
      • Harrison L.B.
      • et al.
      Monkeypox virus infection in humans across 16 countries – April–June 2022.
      ]. This may lead to delayed diagnosis of the disease, increasing the risk of healthcare worker (HCW) exposure. A recent review identified a single case of transmission to a HCW among 12 publications in high-income countries [
      • Zachary K.C.
      • Shenoy E.S.
      Monkeypox transmission following exposure in healthcare facilities in nonendemic settings: low risk but limited literature.
      ].
      We report the outcomes in a cohort of HCWs who were exposed, without appropriate personal protective equipment (PPE), to an inpatient who had a late diagnosis of MKP.
      A 41-year-old man was admitted to the emergency room (ER) with keratoconjunctivitis. He remained in the ER for 10 h before being transferred to a single room on a general surgery ward. He stayed on this ward for 48 h before an infectious disease consult was requested. MKP infection was then suspected based on the patient's sexual orientation, and vesicular skin lesions on his forearms, forehead, scalp, neck and eyelids. The skin lesions had appeared on the day of ER admission. The patient was transferred to the infectious disease unit with appropriate MKP precautions. From this point, it was assumed that there was no HCW exposure without appropriate PPE. The diagnosis of MKP was confirmed by polymerase chain reaction from a skin lesion swab sampled 1 day later. This triggered contact tracing 4 days after the patient was admitted to the ER.
      All HCWs involved in the initial care of the patient were tracked through hospital software, and face-to-face interviews were conducted by the infection control and prevention team and an occupational physician. Interactions with the patient were categorized.
      Risk exposure was assessed with a tool adapted from the US Centers for Disease Control and Prevention exposure risk assessment [
      Centers for Disease Control and Prevention
      Monkeypox – monitoring and risk assessment for persons exposed in the community.
      ], and UK Health Security Agency contact tracing guidance for classification of contacts [
      UK Health Security Agency
      Monkeypox contact tracing guidance: classification of contacts and advice for vaccination and follow-up. Version 12.
      ]. It was considered that hand hygiene with hydro-alcoholic products was performed on <100% of occasions, and multiple unprotected skin contacts (not involving lesions) was categorized as medium-risk exposure.
      For each contact, we assessed the appropriate use of PPE. Universal masking has been mandatory in our hospital since April 2020, and the patient had donned a surgical mask every time a HCW entered his room.
      Data regarding age, pregnancy, immunodepression and type of exposure were collected. Information on MKP, including modes of transmission, symptoms and instructions for self-surveillance (including daily temperature), was provided. Follow-up calls were made on days 10 and 21 post exposure.
      A total of 44 HCWs were identified who had potentially provided care to the index patient. Seventeen of them were excluded from follow-up because they had no direct contact with the patient or fomites, and had worn a facemask. Another HCW was on holiday and could not be contacted.
      Twenty-six HCWs were assessed for vaccine eligibility. None of them were at risk of severe MKP. Eleven of these HCWs were offered vaccination (four high-risk and seven medium-risk) because of close patient contact without adequate PPE; two of the medium-risk HCWs declined vaccination. Type of care, number of care events, and characteristics of HCWs involved are summarized in Table I.
      Table ICharacteristics of healthcare workers (HCWs) and type of care provided to patient with undetected monkeypox (MKP)
      HCWAge (years)WardProfessionNumber of care eventsType of carePPERisk categoryVaccination
      1>42GSNurse2Eye drops, helped with undressingNoneMediumYes
      2<42GSNurse3Infusion, eye dropsGloves for eye dropsMediumYes
      3<42GSNurse6Infusion, eye dropsGloves for eye dropsMediumYes
      4>42GSAs nurseSeveralUndressing, making bed, temperature, blood pressure, local eye careGloves for eye careMediumYes
      5<42ScannerRT1Contact with skinNoneWeakNA
      652ScannerRT1Contact with skinNoneWeakNA
      730ERNurse5–6Eye drops, delivery of medicationsNoneWeakNA
      851ERAs nurse2–3Blood pressure, temperatureNoneMediumRefused
      936ERNurse3–4Blood pressure, temperature, infusionNoneMediumYes
      10<30ERResident4–5Clinical examination, fluorescein dye testGloves for eye testHighYes
      1121ERMS2–3Clinical examination, fluorescein dye testGloves for eye testHighYes
      12UnknownTransportParamedic2Skin contactGlovesVery weakNA
      13UnknownTransportParamedic1Skin contactGlovesVery weakNA
      1440TransportSB1Linen contactNoneWeakNA
      15UnknownTransportParamedic1Transport as MKP suspectGown, gloves, glasses, FFP2Very weakNA
      16UnknownTransportParamedic1Linen contactNoneWeakNA
      17UnknownTransportSB1Linen contactNoneWeakNA
      18UnknownTransportSB1Skin contactNoneWeakNA
      19>42GSMD1Eye examinationNoneHighYes
      20UnknownGSResident4Eye examinationGlovesVery weakNA
      21UnknownGSResident1Eye examinationGlovesVery weakNA
      22<42GSAs nurse1Blood pressureNoneMediumRefused
      23<42GSNurse4Eye drops, eye cleaningNoneHighYes
      2441GSNurse3–4Infusion, no contact with skinNoneWeakNA
      2536GSAs nurse1Talking to the patient, no contactNoneVery weakNA
      2631GSAs nurse student2–3Bringing water, food, contact with linenNoneWeakNA
      PPE, personal protective equipment; GS, general surgery; ER, emergency room; As nurse, assistant nurse; RT, radiological technician; MS, medical student; SB, stretcher bearer; NA, not applicable.
      Vaccination was administered within a median of 5 days after first contact with the index case.
      At the end of the 21-day follow-up period, none of the 26 HCWs had developed the disease. This report confirms that exposed HCWs are at low risk of contracting MKP in healthcare settings, even without adequate contact and airborne precautions [
      • Zachary K.C.
      • Shenoy E.S.
      Monkeypox transmission following exposure in healthcare facilities in nonendemic settings: low risk but limited literature.
      ].
      The index patient was young and self-caring, and required nursing care for administration of intravenous antibiotics and eye care alone. He is probably representative of many of the inpatients with MKP during the current outbreak. Whilst this probably reduced the risk of transmission, it can also add to difficulty in tracing all HCWs who have had contact (because the contact is likely to have been trivial). The current global outbreak has shown that MKP is spread through close contact. Nevertheless, standard precautions and early suspicion of MKP are paramount to limit HCW exposure, and organizations must be prepared to respond to HCW exposure incidents.
      It remains uncertain whether medium-risk contacts in healthcare settings should be vaccinated. Neither of the two vaccine refusers in this report developed MKP. Indeed, there is only one report of MKP transmission to an exposed HCW, and this was a high-risk contact who had received a single dose of smallpox vaccine 6 days after exposure [
      • Vaughan A.
      • Aarons E.
      • Astbury J.
      • Brooks T.
      • Chand M.
      • Flegg P.
      • et al.
      Human-to-human transmission of monkeypox virus, United Kingdom, October 2018.
      ]. The effectiveness of post-exposure prophylaxis (PEP) probably decreases if delayed [
      • Keckler M.S.
      • Reynolds M.G.
      • Damon I.K.
      • Karem K.L.
      The effects of post-exposure smallpox vaccination on clinical disease presentation: addressing the data gaps between historical epidemiology and modern surrogate model data.
      ], so risk assessment and PEP should be conducted promptly.
      In the context of a healthcare facility with high hygiene standards, HCWs are probably at low risk of contracting MKP. Risk assessment tools for HCWs should be developed or improved based on accumulated experience of the 2022 global outbreak.

      Conflict of interest statement

      None declared.

      Funding sources

      None.

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        Monkeypox transmission following exposure in healthcare facilities in nonendemic settings: low risk but limited literature.
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