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EMS response to the current outbreak of monkeypox

Infectious disease expert Dr. Alexander P. Isakov shares tips for encountering monkeypox


File photo/CDC/AP

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In light of the recent monkeypox outbreak, both the CDC and the National Emerging Special Pathogens Training and Education Center (NETEC) have issued specialist guidance to both EMS and healthcare.

To discuss this emerging issue, Rob Lawrence is joined by Alexander P. Isakov, MD, MPH, professor of emergency medicine at Emory University. He is also the director for Emory’s Section of Prehospital and Disaster Medicine, whose faculty and staff provide medical oversight for 911 communications centers, first responders, and air and ground ambulance services in the metropolitan Atlanta area.

Additionally, Dr. Isakov founded and directs the Emory-Grady EMS Bio-Safety Transport Program, which supports the Emory University Hospital Serious Communicable Diseases Unit and the CDC for the transport and management of persons confirmed or suspected to have a high consequence infectious disease.

Discussed in the podcast are the signs and symptoms of monkeypox, methods of transmission, precautions for providers and notification requirements. The conversation also includes COVID-19, and the current upward trend in cases.

NETEC has released the following information about the history of and infection control methods for monkeypox.

History of monkeypox

Monkeypox is a rare, pox-like viral disease. It was first discovered in 1958 in monkeys kept for research. The first human case of monkeypox was recorded in 1970 in the Democratic Republic of Congo during a period of intensified effort to eliminate smallpox. Human cases of monkeypox have since been reported in other central and western African countries. In the past several years, cases of Monkeypox have been detected outside of Africa, typically linked to international travel or imported animals.

On May 18, the Massachusetts Department of Public Health (DPH) confirmed a single case of monkeypox in an adult male who had recently travel to Canada. The CDC has been tracking multiple clusters of Monkeypox reported in countries that typically do not see Monkeypox cases, including Portugal, Spain, Sweden, Italy and the United Kingdom. 

The CDC is urging healthcare providers in the U.S. to be alert for patients who have rash illnesses consistent with monkeypox, regardless of whether they have travel or specific risk factors for monkeypox and regardless of gender or sexual orientation.

EMS Strategies for preventing the spread of monkeypox

It is very unlikely that EMS clinicians will encounter a person infected with Monkeypox during routine operations. However, EMS professionals should follow an identify, isolate and inform strategy to stop the spread of illness. In suspected cases, state health departments should be immediately contacted for the possible initiation of special pathogen transport protocols.

Identifying the signs, symptoms, and risk factors for monkeypox

The signs and symptoms of monkeypox include flu-like symptoms (fever, headache, muscle aches) and swollen lymph nodes. One to three days after the onset of viral symptoms, the patient will develop a rash that becomes vesicular/pustular starting on the face and covering the whole body.

Monkeypox infection may be possible in those who have recently traveled to a country where Monkeypox is endemic, including Central and Western African countries such as Nigeria or the Democratic Republic of Congo, parts of Europe where monkeypox has been reported, other areas reporting monkeypox, cases or had close contact with a person sick with monkeypox in the last 5-21 days.

How to prevent person-to-person transmission of monkeypox

A patient is considered infectious 5 days prior to rash onset until crusting of skin lesions. Person-to-person transmission occurs through exposure to large respiratory droplets, which can be projected as far as 6 feet. It can also be transmitted by way of exposure to mucous membranes (eyes, nose, mouth), direct contact with body fluids or lesions, and indirect contact with lesions, such as through contaminated clothing or linens.

PPE for EMS personnel managing patients suspected of infection with monkeypox

To guard against the possibility of airborne transmission, EMS personnel should strictly adhere to standard, contact and airborne precautions. This includes a NIOSH-approved, fit-tested N-95 respirator, gown, gloves and eye protection with face shield or goggles.

Implementing a hierarchy of controls in EMS care

  • Separate the driver compartment from the patient compartment.
  • Turn the exhaust fan on high in the patient compartment, if so equipped.
  • Adjust air handling to introduce fresh air in both compartments if possible.
  • Driver should wear an N-95 respirator if isolation of driver compartment cannot be verified.
  • Limit the number of personnel making patient contact.
  • Use PPE checklists for donning and doffing, ideally with a trained observer. See NETEC’s guide on the role of the trained observer.
  • 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.
  • Clean and disinfect all surfaces of the ambulance and equipment with an EPA-registered hospital grade disinfectant. Look for disinfectants with a label claim against vaccinia.

Infection prevention and waste management when caring for a patient with monkeypox

Apply a surgical mask to the patient if tolerated and consider covering the patient with an impervious sheet if rash is present.

Monitor personnel for signs and symptoms of illness for 21 days after transport if the patient is confirmed to have monkeypox.

Monkeypox contaminated waste must be managed as a Category A waste pathogen, requiring specific waste handling, transporting and final disposal protocols. To determine if this waste may be exempt from category A Infectious Substance Regulations, contact the local public health authorities for further guidance.

Informing healthcare personnel and public health authorities of a suspected case of monkeypox

If you suspect a case of monkeypox, contact your state health department for possible initiation of special pathogen transport protocols, or the CDC’s monkeypox call center through the CDC Emergency Operations Center (770-488-7100).

Inform other responding personnel if a risk of monkeypox is suspected and prevent unprotected exposure to the patient.

Inform supervisory personnel – some communities may have dedicated transport teams and/or designated facilities for transport and management of patients suspected or confirmed to be infected with special pathogens.

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.

Additional resources for EMS management of monkeypox

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.