Fourth case of monkeypox identified in Scotland

On 30 May 2022, Public Health Scotland (PHS) confirmed the fourth case of monkeypox in the country. As of 29 May 2022, the UK Health Security Agency (UKHSA) identified 172 cases of monkeypox in England, while on 26 May 2022, Public Health Wales (PHW) and the Public Health Agency (PHA) confirmed the first cases of monkeypox in Wales and Northern Ireland respectively, though the UKHSA have reported a second case in Northern Ireland. Further, the European Centre for Disease Prevention and Control (ECDC) reported an additional 118 cases from 12 EU and EEA member states, as of 25 May 2022. 

The risk to the UK population remains low, but people are advised to be alert to any new rashes or lesions, which would appear like spots, ulcers or blisters, on any part of their body. Although this advice applies to everyone, the majority of cases identified to date have been among men who are gay, bisexual and men who have sex with men (MSM), so people in these groups in particular, are advised to be aware of the symptoms, particularly if they have recently had a new sexual partner. Anyone with unusual rashes or lesions is advised to contact NHS 24 (Scotland), NHS 111 (England or Wales) or a sexual health service, contacting clinics ahead of visiting and avoiding close contact with others until seen by a clinician. 

Monkeypox is a viral infection usually associated with travel to West Africa and has only rarely been reported out with this region. Monkeypox can be transmitted through close contact with a person who already has the infection, including direct contact during sex, and can also be passed on by contact with clothing or linens used by a person who has the disease. Initial symptoms of monkeypox include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body, including the genitals. The rash changes and goes through different stages before finally forming a scab, which later falls off. 

PHS and the UKHSA are working closely with the NHS and other stakeholders, in order to urgently investigate where and how recent confirmed monkeypox cases were acquired, including how they may be linked to each other. Clinicians should be alert to individuals presenting with rashes without a clear alternative diagnosis and should contact local specialist services for advice, if monkeypox infection is suspected. 

Additionally, on 30 May 2022, PHS, the UKHSA, PHW and the PHA have agreed new guidance in helping healthcare professionals and the public respond and manage the monkeypox outbreak, and to help prevent further transmission now that community transmission is occurring in the UK and other countries. 

People who have possible, probable or confirmed monkeypox can now isolate at home, if they remain well enough, whilst following measures in the new guidance to reduce further spread and while being monitored by local health protection teams. In addition, the UKHSA has purchased over 20,000 doses of a safe smallpox vaccine called Imvanex and this is being offered to identified close contacts of those diagnosed with monkeypox to reduce the risk of symptomatic infection and severe illness. 

The guidance offers the following recommendations:

• People with possible, probable or confirmed monkeypox should avoid contact with other people until their lesions have healed and the scabs have dried off. Cases can reduce the risk of transmission by following standard cleaning and disinfection methods and washing their own clothing and bed linen with standard detergents in a washing machine.
• Cases should also abstain from sex while symptomatic, including the period of early symptom onset, and while lesions are present. Whilst there is currently no available evidence of monkeypox in genital excretions, as a precaution, cases are advised to use condoms for eight weeks after infection and this guidance will be updated as evidence emerges.
• If people with possible, probable or confirmed monkeypox infection need to travel to seek healthcare, they should ensure any lesions are covered by cloth and wear a face covering and avoid public transport where possible.
• Contacts of someone with monkeypox will also be risk assessed and told to isolate for 21 days if necessary.
• Where possible, pregnant healthcare workers and severely immunosuppressed individuals, as outlined in the Green Book, should not assess or clinically care for individuals with suspected or confirmed monkeypox. This guidance will be reassessed as evidence emerges.
• The minimum recommended personal protective equipment (PPE) for staff working with confirmed cases includes fit tested FFP3 respirators, aprons, eye protection and gloves. For possible or probable cases minimum recommended PPE for staff includes fluid repellent surgical facemasks (FRSM), gowns, gloves and eye protection.
• Within non-domestic residential settings, such as adult social care, prisons, homeless shelters and refuges, individuals who are clinically well should be managed in a single room with separate toilet facilities where possible. Close contacts of confirmed cases should be assessed for vaccination. 

Separately, a risk assessment has been carried by the Human Animal Infections and Risk Surveillance group (HAIRS) looking at household pets and the risk of transmission.

Sources: PHS, 30 May 2022 and UKHSA, 30 May 2022