Infection Prevention and Control in Healthcare Settings

Overview

Infection prevention and control (IPC) recommendations for healthcare settings are provided in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). These recommendations and practices are intended to be used when providing care for any patient in a healthcare setting, including those with monkeypox virus (MPXV) infection.

If a patient seeking care is suspected to have MPXV infection, use Standard Precautions and implement additional infection control measures including patient placement, patient management, waste management, and environmental infection controls. Additionally, notify infection prevention and control personnel immediately. If healthcare personnel are exposed, CDC's risk assessment and monitoring guidelines can help determine a course of action, including whether post-exposure prophylaxis is recommended.

Proper PPE use

Monkeypox infections among healthcare providers (HCPs) have been rare in the United States even during the height of the clade II monkeypox outbreak. A study of 313 HCPs exposed to monkeypox patients in Colorado found no infections. However, there have been a few infections that occurred through sharps injuries reported to CDC, including a Florida nurse infected through a needlestick while sampling an monkeypox lesion. There have also been a handful of cases where improper personal protective equipment (PPE) was worn, and a few where the exposure route was unclear.

To avoid monkeypox infection, CDC recommends healthcare personnel use appropriate PPE when caring for patients with suspected monkeypox. PPE includes:

• Gown
• Gloves
• Eye protection (i.e., goggles or a face shield that covers the front and sides of the face)
• NIOSH-approved particulate respirator equipped with N95 filters or higher

Patient placement

• Place a patient with suspected or confirmed MPXV infection in a single-person room with a dedicated bathroom; special air handling is not required.
• Keep the door closed if safe to do so.
• Limit transport and movement of the patient outside of the room to medically essential purposes. If the patient is transported outside of their room, they should use well-fitting source control (e.g., medical mask) and cover exposed skin lesions with a sheet or gown.
• Perform intubation, extubation, and any procedures likely to spread oral secretions in an airborne infection isolation room.

Waste management

• Perform waste management (i.e., handling, storage, treatment, and disposal of soiled PPE, patient dressings, etc.) in accordance with U.S. Department of Transportation (DOT) Hazardous Materials Regulations (HMR; 49 CFR parts 171-180.)
• Waste contaminated with clade I or clade II MPXV is designated as Category B infectious substances except when they contain or are contaminated with laboratory cultures of clade I MPXV.
• Follow state and local regulations for handling, storage, treatment, and disposal of waste, including Regulated Medical Waste.

Environmental infection control

Perform standard cleaning and disinfection procedures using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim.

• Handle soiled laundry (e.g., bedding, towels, personal clothing) in accordance with recommended standard practices, avoiding contact with lesion material that may be present on the laundry.
• Gently and promptly contain soiled laundry in an appropriate laundry bag; never shake or handle laundry in a manner that may disperse infectious material.
• Avoid activities such as dry dusting, sweeping, or vacuuming. Wet cleaning methods are preferred.
• Manage food service items in accordance with routine procedures.

Managing patients with MPXV exposure

In general, patients in healthcare facilities who have had an MPXV exposure and are asymptomatic do not need to be isolated, but they should be monitored.

• Assess the patient for signs and symptoms of monkeypox, including a thorough skin exam, at least daily, for 21 days after their last exposure.
• If you suspect monkeypox: maintain recommended patient isolation precautions for monkeypox until MPXV infection is ruled out.
• If you confirm monkeypox: maintain recommended patient isolation precautions for monkeypox until all lesions have crusted, those crusts have separated, and a fresh layer of healthy skin has formed underneath.
• Adapt post-exposure risk assessment and management for patients from community guidance or healthcare guidance, depending on the nature and location of a patient's exposure.

Depending on the jurisdiction, you may need to make decisions regarding discontinuation of isolation precautions in a healthcare facility in consultation with the local or state health department.

During the 21-day monitoring period

If a rash occurs

Place patients on empiric isolation precautions for monkeypox until:

1. Rash is evaluated,
2. Testing is performed, if indicated, and
3. Results of testing are available and are negative

If symptoms of monkeypox are present, but there is no rash

• Place patients on empiric isolation precautions for monkeypox for 5 days after the development of any new symptom, even if this 5-day period extends beyond the original 21-day monitoring period.
• If 5 days have passed without the development of any new symptom and a thorough skin and oral examination reveals no new rashes or lesions, discontinue isolation precautions.
• You may discontinue isolation precautions prior to 5 days if monkeypox has been ruled out.
• If a new symptom develops again at any point during the 21-day monitoring period, again place the patient on empiric isolation precautions for monkeypox; begin a new 5-day isolation period.

Patients unable to communicate onset of symptoms

Some patients like newborns, those with delirium, etc., may not be able to communicate about their potential monkeypox symptoms.

• For such outpatients, consider use of isolation precautions for monkeypox for their healthcare visits until they are able to communicate about onset of symptoms (e.g. following delirium resolution) or for up to 21 days after their last exposure.
• For such inpatients, consider use of isolation precautions for monkeypox and monitoring for signs of infection until they are able to communicate about onset of symptoms (e.g. following delirium resolution) or for up to 21 days after their last exposure.

Consider the risk of their exposure incident (how likely they are to develop MPXV infection), the risk that transmission would pose to other patients on their unit (e.g., immunocompromised patients), and other factors when deciding whether to isolate exposed patients who are unable to communicate about onset of symptoms.

Blood transfusion and organ transplantation clinical considerations

To date, there have been no confirmed reports of MPXV transmission from medical products of human origin including blood transfusion, organ transplantation, or implantation, transplantation, infusion, or transfer of human cells, tissues, or cellular or tissue-based products. As a precaution, people who have a high- or intermediate-risk exposure from either healthcare or community settings should not donate blood, cells, tissue, breast milk, or semen while they are being monitored for symptoms.

Given the morbidity and mortality among individuals awaiting organ transplantation, potential deceased donors who have been exposed and have no evidence of MPXV infection as determined by a physical examination could be considered for organ donation following appropriate risk-benefit considerations. Potential living donors who have been exposed to MPXV could consider deferring donation until 21 days following their last exposure. The risk of such wait time should be weighed against the morbidity and mortality risk for individuals awaiting organ transplantation. All decisions should be based on appropriate risk-benefit considerations, recognizing that MPXV has been detected in some samples taken from people who reported no symptoms. CDC will continue to monitor case data and available science for new or changing information about transmission.

The Organ Procurement and Transplantation Network (OPTN) Disease Transmission Advisory Committee, a public-private partnership that links all professionals involved in the U.S. donation, procurement, and transplantation system, is evaluating the implications for organ transplantation.

Visitation

• Limit visitors to patients with monkeypox to people essential for the patient's care and wellbeing (e.g., parents of a child, spouse).
• Make decisions about who might visit, including whether the visitor stays or sleeps in the room with the patient, by taking into consideration patient age, patient ability to self-advocate, visitor ability of to adhere to infection prevention and control recommendations, whether the visitor already had higher risk exposure to the patient, and other relevant aspects.
• In general, visitors with contagious diseases should not be visiting patients in healthcare settings to minimize the risk of transmission to others.

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