IPGUI05 Guidance on The Management of Mpox Infections for Sexual Health Services v3 by Provide Community

Guidance on The Management of Mpox Infections for Sexual Health Services

Version: V3

Ratified by:

Infection Prevention and Control Group

Date ratified: 23/03/2026

Job Title of author:

Reviewed by Committee or Expert Group

1. Background Information on Mpox virus (MPXV)

• There are two known clades of Mpox: Clade I and Clade II

• Transmission of Mpox to humans can be due to zoonotic transmission or personto-person spread

• Clade I Mpox was associated with zoonotic transmission and known to circulate in 5 African countries; Cameroon, Central African Republic, the DRC, Gabon and the Republic of Congo

• Clade I mpox virus (MPXV) and Clade 11 are no longer classified as a High Consequence Infectious Disease (HCID) in the UK, meaning all mpox is now managed as a non-HCID in UK healthcare settings, reflecting lower fatality rates and milder illness for the types seen in recent years, though it remains a significant public health concern

• Infection with Clade I Mpox has been reported to cause more severe mpox disease with a higher case fatality rate

• Clade I mpox virus (MPXV) has historically only been reported in five countries in Central Africa. There is now increasing transmission of clade I mpox in the Democratic Republic of Congo (DRC), and cases are also being reported from other surrounding countries in Central and East Africa

• Between 25 July and 5 August 2024, confirmed Clade I MPXV cases have been reported from Burundi, Kenya, Rwanda and Uganda for the first time, which has expanded the geographical footprint. Since August 2024, clade I MPXV has also been reported from multiple countries outside of the African region that had not previously reported it, including cases in the UK. This is mostly caused by clade Ib MPXV, and is spread mostly through close physical contact (including both sexual and non-sexual contact).

• Clade II cases have been reported from Benin, Cameroon, Cote D’Ivoire, Ghana, Liberia, Nigeria and South Africa in 2024

• There is evidence of sustained sexual transmission of clade I MPXV in the DRC.

• Sexual transmission should not be used to infer whether an mpox case is likely to be clade I or II

2. Mpox: Case Definition

This guidance has been developed to support Provide Sexual Health Services in the event of a suspected case of Mpox being identified within the sexual health clinic

When assessing patients for mpox, always take a travel history. Be alert to the possibility Mpox (Clade I) in all patients with suspected mpox including cases in the UK and where linked to a travel history to the Democratic Republic of the Congo or other specified countries in the African region https://www.gov.uk/guidance/clade-i-mpox-affectedcountries

For all suspected mpox cases

For patients being assessed for suspected mpox, infection prevention and control (IPC) measures should be undertaken per the NHS national infection prevention and control manual for England.

Clinicians should be aware that mpox is a notifiable disease

Clinicians treating patients with suspected mpox should discuss the case with local infection specialists. Infection specialists may wish to discuss possible mpox cases with the UKHSA Imported Fever Service (IFS) on 0844 778 8990 for clinical advice, for example in patients who are severely immunocompromised or pregnant, paediatric patients, or patients from a high risk setting such as shared accommodation.

Test for MPXV, the causative agent of mpox, using an appropriate testing pathway. See also Mpox diagnostic testing guidance

Undertake testing for other diagnoses if clinically appropriate and if not done already.

Possible Case

A possible case is defined as anyone who fits one or more of the following criteria:

• A febrile prodrome (fever >38 degrees C, chills, headache, exhaustion, muscle ache, joint pain, backache and swollen lymph nodes) compatible with mpox infection, where there is a known prior contact with a confirmed case in the 21 days before symptom onset

• An illness, where the clinician had a suspicion of mpox, such as unexplained lesions, including but not limited to

➢ Genital, ano-genital or oral lesion(s)- e.g. ulcers, nodules

➢ Proctitis- e.g. anorectal pain, bleeding

Probable Case

A probable case is defined as anyone with an unexplained rash or lesion(s) on any part of the body (including genital/perianal, oral) or protitis (anorectal pain, bleeding) who:

• Has an epidemiological case to a confirmed, probable or highly probable case of mpox in the 21 days before symptom onset OR

• Identifies as gay, bisexual or other man who has sex with men OR

• Has had one or more sexual partners in the 21 days before symptom onset

Actions for a possible or probable case:

• Have a low threshold for testing for mpox in patients with clinically compatible presentations with a travel history irrespective of sexual history, using designated testing pathways.

• Undertake additional contemporaneous tests to rule out alternative diagnoses if clinically appropriate and if not already done

• Be alert to the possibility of clade I mpox in all patients with suspected mpox if there is a link to the specified countries in the African region (as listed above). Patients with a travel or exposure history indicating possible Clade 1 mpox should be discussed with the Rare and Imported Pathogens Laboratory (RIPL) on 01980 612348 (available 9am to 5pm, Monday to Friday) and the clinical team as soon as possible via the 24/7 Imported Fever Service helpline (0844 778 8990).

• Isolate patients meeting the following criteria as a high consequence infectious disease and contact the Imported Fever Service to discuss urgent testing and typing:

➢ Confirmed or clinically suspected mpox cases but clade not yet known

➢ travel history to the DRC or specified countries where there may be

a risk of clade I exposure including the UK https://www.gov.uk/guidance/clade-i-mpox-affected-countries

➢ link to a suspected case from those countries (listed above), within 21 days of symptom onset and/or there is an epidemiological link to a case of Clade I mpox within 21 days of symptom onset.

Actions required by Clinicians:

Isolate patients meeting the following criteria- (All suspected Mpox cases)

Contact the Imported Fever Service (IFS) (0844 778 8990): - to discuss urgent testing and typing of:-

• Confirmed or clinically suspected mpox cases but clade not yet known and there is a travel history to the DRC or specified countries where there may be a risk of clade I exposure, or a link to a suspected case from those countries (listed above or on updated UKHSA list) https://www.gov.uk/guidance/clade-impox-affected-countries, within 21 days of symptom onset and/or there is an epidemiological link to a case of Clade I mpox within 21 days of symptom onset

• Discuss any patient with suspected mpox and severe or disseminated disease with Imported Fever Service (IFS) (0844 778 8990), even if no travel history is identified.

• Notify the local Health Protection teams on suspicion of Clade I mpox Cases where the clade is unknown, but who have a travel or contact history as above, should be discussed with the Imported Fever Service (0844 778 8990) as soon as possible to ensure appropriate testing and escalation.

Operational case definition of Clade I and Clade II

Clade I - Clade II -

Confirmed mpox case where clade I has been confirmed

Confirmed or clinically suspected mpox case but clade not yet known

TravelhistorytotheDRCorspecifiedcountries where there may be a risk of clade I exposure, or a link to a suspected case from those countries (listed above), within 21 days of symptom onset and/or there is an epidemiological link to a case of Clade I mpox within 21 days of symptom onset

GiventherapidspreadofCladeIintheAfrican region, check the UKHSA mpox pages regularly for any updates to the countries included

Confirmed as Clade II MPXV

Confirmed or clinically suspected mpox but clade not known, and all of the following conditions apply: -

There is no history of travel to the DRC or specified surrounding countries (as above) within 21 days of symptom onset

There is no link to a suspected case from the DRC or specified surrounding countries within 21 days of symptom onset

3. Triage by the Navigation Hub

All patients must be screened for Mpox (MPV) at their point of telephone booking.

Please use this flowchart to triage any questions on Mpox.

the21days before symptomsstarted, have

partner in the last 21days?

*CountrieswhereMpoxiscommon https://www.gov.uk/guidance/clade-i-mpox-affected-countries

4. Management of suspected MPV cases in the Sexual Health Department

The clinical assessing the patient for possible MPV should contact UKHSA East of England Health Protection Team on 0300 303 8537 option 1 for advice. For advice out of hours for health professionals only: 01603 481 221. All patients that require testing will also need discussion with the Imported Fever Service on 0844 7788990

Clade II mpox has been circulating in the UK and globally since 2022 predominantly in gay, bisexual or other men who have sex with men, but remains uncommon. Since 2022, it is no longer classified as a high consequence infectious disease (HCID).

Clade I mpox includes clade Ia, present in central Africa, and clade Ib, which in 2024 to 2025 has caused an outbreak in multiple countries (see the affected country list). Clade I mpox was classified as an HCID until early 2025. Following advice from the Advisory Committee on Dangerous Pathogens (ACDP), it is no longer classified as an HCID.

PPE Requirements

All Mpox is currently classified as having airborne infectious disease (HCID) status with respiratory protection of FFP3 or hood to be worn for any AGPs or where respiratory symptoms or extensive exposed lesions are present When treating any patient with suspected MPV, all staff should ensure they are wearing appropriate PPE and as a minimum FFP3 mask, gown, gloves and eye protection. They should be isolated in a separate clinic room and appropriate decontamination should take place once the room is vacated. Please see the section Decontamination for further advice. In the event of identification of suspected case in clinic, either rash or symptoms or informed as a contact.

Patients presenting to healthcare settings with symptoms suggestive of mpox should be isolated in a single room as soon as mpox is suspected. They should also be provided with a fluid-resistant surgical mask (FRSM) to wear, unless contraindicated and all lesions covered.

➢ Arrange attendance at end of clinic.

➢ Ensure suspected case is isolated in room (Closed door) or removed from waiting/communal area.

➢ Where significant exposure to staff worker has occurred, they should remove themselves and must isolate away from other staff in a designated room and contact local health protection team.

➢ Any staff that have direct contact with case must wear full PPE- FFP3 mask, single use visor/eye protection, full sleeve gown, gloves, (All staff wearing FFP3 masks MUST be fit tested).

➢ For staff who have failed Fit Testing they should use supplied Respirator hoods or exempt from attending to client.

➢ Exclude pregnant staff/ clinically vulnerable (immunosuppressed) staff from contact with patient and exposed staff.

➢ Contact and liaise with the local health protection team and inform infection prevention in working hours via mobile contact or Quality and Safety team 0300 303 2642 Out of hours contact the manager on call 0300 003 0683

➢ For all patients that require testing, discuss with the imported Fever Service 08447788990

➢ Once case transferred to other facility or hospital or area vacated, ensure area closed until terminal clean has been completed and instruction from health protection team for any further cleaning and waste removal

5. MPV Testing with Sexual Health Services

Please remember appropriate PPE when dealing with any suspected MPV case (see Appendix 1)

Frequently Asked Questions (FAQ’s):

What sample types are suitable for Monkey Pox PCR testing?

➢ Viral swab in viral culture medium or Viral Transport Medium from an open sore or from the surface of a vesicle. These can be sourced from Pathology Stores as per normal ordering process.

➢ If all the lesions are crusted, scrape scab material into a dry plain universal container and label as above.

It is advised that no other samples are taken from the patient if they are being tested for MPV. The patient should be followed up by a clinician at least 21 days after exposure and offered appropriate assessment, testing and treatment of their symptoms.

N.B Any screening for other STIs at clinician discretion, must be considered on the availability and turnaround times for Mpox results. Screening for other STI’s must be only as soon as clinically feasible or as soon as negative result received with the consideration that this could be done by home testing methods. Further advice should be sought from the local health protection or imported fever service.

6. How do we request MPV PCR testing

➢ Currently no Electronic requesting available; this is under development.

➢ Temporarily all service users are asked to complete the request form using the hyperlink below, and send with the sample:

➢ Please save and add to the patient notes in the attachments section. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/file/721847/P1_Rare_and_Imported_Pathogens.pdf

Please DO NOT complete the SENDERS INFORMATION SECTION but include Clinic/surgery details within the PATIENT/SOURCE INFORMATION section.

7. What specific packaging and transport is required?

➢ All MPV PCR samples should be labelled with a biohazard sticker.

➢ All MPV PCR samples MUST be double bagged at source.

➢ All MPV PCR samples MUST be packaged independently of routine samples

➢ All MPV PCR samples must be sent using UN3373 transport packaging.

➢ Please ensure transport boxes are clearly labelled with biohazard sticker.

It is advised that no other samples are taken from the patient if they are being test for MPV. The patient should be followed up by a clinician at least 21 days after exposure and offered appropriate assessment, testing and treatment of their symptoms.

Swabs, sample bags and biohazard stickers are available in the clinics. Please contact the team lead for any queries with sample labelling and packing

8. Coding of MPV cases and Consent

Each suspected or confirmed case should be coded within Inform. This can be found on the current sexual health codes. A snapshot of the codes can be seen below.

Consent

In order to triage care with other services that maybe required such as UKHSA for contact tracing or vaccination it is important that consent to share results with GP be obtained and this recorded in clinical notes.

9. Decontamination

Please follow guidance for cleaning and decontamination of the room as per terminal clean within National standards of healthcare cleanliness in healthcare facilities This request should be made via Estates and facilities. Any infectious healthcare waste and other disposable items disposable curtains should be bagged before removal from the room.

10.Summary Process Flowchart

13:00 Suffolk Sexual Health Service Contact no. 0300 303 9982

09:00 - 17.00 Tues 08:00 - 16.00

11.30 - 20.00

09:00 - 17.00

09:00 - 13.00

09:00 - 17:00 Tue 09:00 - 20:00

08:00 - 16:00

09:00 - 20:00

09:00 - 13:00 Mon 09:00 - 17.30 Tues 09:00 - 19.30 Wed 09:00 - 17.30 Thurs 09:00 - 19.30

CLOSED Sat 09:00 - 13.30

11.Further Guidance

https://www.gov.uk/guidance/operational-mpox-monkeypox-hcid-case-definition

References/ Sources of information

1. https://www.gov.uk/guidance/hcid-status-of-monkeypox

2. https://www.gov.uk/guidance/monkeypox-diagnostic-testing

3. https://www.gov.uk/guidance/imported-fever-service-ifs

4. Eurosurveillance | Ongoing mpox outbreak in Kamituga, South Kivu province, 5. associated with monkeypox virus of a novel Clade I sub-lineage, Democratic Republic of the Congo, 2024

Find your local health protection team in England - GOV.UK (www.gov.uk)

https://www.gov.uk/guidance/clade-1-mpox-virus-infection

12.Additional Information

• Mpox (monkeypox): diagnostic testing

• Imported fever service

• NHS England » Management of mpox following removal of HCID status

Appendix 1:

In March 2025, the Advisory Committee on Dangerous Pathogens (ACDP) reclassified clade I Mpox as no longer meeting the criteria for a high consequence infectious disease (HCID). This was based on evidence that clade I Mpox has a low case fatality rate with a similar clinical severity to that of clade II cases, no evidence of community or healthcare transmission from imported cases, and that a safe and effective vaccine is available and being deployed to eligible individuals. Guidance on the management for cases and contacts for both clade I and clade II has been revised into a single approach for all Mpox

Examples of PPE recommendations for the management of patients presenting with mpox-compatible symptoms

These examples and recommendations should be used to inform the risk assessment for PPE use in conjunction with local policies and procedures.

PPE Requirements for Mpox Scenarios - likely sexual health will present without respiratory symptoms and lesions only to genital area, all suspected cases mut be risk assessed.

Scenario 1: Patient with mpox-compatible symptoms who:

• does not have respiratory symptoms, and

• is not severely unwell, and

• does not have extensive lesions

Minimum PPE required:

o single pair of disposable gloves

o disposable, fluid-resistant apron or disposable, long-sleeved, fluidresistant gown where extensive manual handling or unavoidable skin-to-skin contact is anticipated

o fluid-resistant surgical mask (Type IIR)

o eye/face protection if there is a risk of spraying or splashing

Scenario 2: Patient with mpox-compatible symptoms who also has respiratory symptoms

Minimum PPE required:

o single pair of disposable gloves

o disposable, fluid-resistant apron or disposable, long-sleeved, fluidresistant gown where extensive manual handling or unavoidable skin-to-skin contact is anticipated

o fit-tested and fit-checked FFP3 respirator or equivalent e.g., powered air-purifying respirator (PAPR) with appropriate decontamination protocols

o full face visor for eye/face protection

Scenario 3: Patient with suspected or confirmed mpox who requires close clinical care in an inpatient setting and:

o is severely clinically unwell, or

o has extensive lesions

Or patient with suspected or confirmed mpox undergoing an aerosol-generating procedure (AGP)

Minimum PPE required:

o single pair of disposable gloves

o disposable, long-sleeved, fluid-resistant gown or equivalent e.g. coveralls in ambulance settings

o fit-tested and fit-checked FFP3 respirator or equivalent e.g., powered air-purifying respirator (PAPR) with appropriate decontamination protocols

o full face visor for eye/face protection

NHS England Management of Mpox following removal of HCID status. Date last updated: 7 July, 2025.