New Delhi: Amid the increase in cases of monkeypox being reported in non-endemic countries, the Central government issued guidelines on Tuesday directing district surveillance units to consider even one such case as an outbreak and initiating a detailed investigation through the Integrated Disease Surveillance Programme.
In the ‘Guidelines on Management of Monkeypox Disease’ issued to states and union territories, the health ministry stressed on surveillance and rapid identification of new cases as the key public health measures for outbreak containment, mandating the need to reduce the risk of human-to-human transmission. It stated that India needs to be prepared in view of the increasing reports of cases in non-endemic countries even as no case of monkeypox virus has been reported in the country till date.
The guidelines proposed a surveillance strategy to rapidly identify cases and clusters of infections and the sources of infections as soon as possible in order to isolate cases to prevent further transmission, provide optimal clinical care, identify and manage contacts and protect frontline health workers and effective control and preventive measures based on the identified routes of transmission.
According to the guidelines, a confirmed case is laboratory confirmed for monkeypox virus by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing. All the clinical specimens should be transported to the apex laboratory of ICMR-NIV (Pune) routed through the Integrated Disease Surveillance Programme (IDSP) network of the respective district or state.
Monkeypox has been reported as endemic in several other central and western African countries such as Cameroon, Central African Republic, Cote d’Ivoire, Democratic Republic of the Congo, Gabon, Liberia, Nigeria, Republic of the Congo, and Sierra Leone. However, cases have been also reported in certain non-endemic countries like the US, the UK, Belgium, France, Germany, Italy, Netherlands, Portugal, Spain, Sweden, Australia, Canada, Austria, Israel and Switzerland. The health ministry said it continues to maintain a close watch over the evolving situation.
The document mentions that human-to-human transmission occurs primarily through large respiratory droplets generally requiring a prolonged close contact. It can also be transmitted through direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens of an infected person. Animal-to-human transmission may occur by bite or scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) or through bush meat preparation.
The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days, the document stated. The case fatality ratio of monkeypox has historically ranged from 0 – 11% in the general population and has been higher among young children. In recent times, the case fatality ratio has been around 3-6%, the document stated.
According to the guidelines, a person of any age having a history of travel to the affected countries within the last 21 days presenting with an unexplained acute rash and symptoms like swollen lymph nodes, fever, headaches, body aches and profound weakness is to be considered to be a ‘suspected case’. A ‘probable case’ has to be a person meeting the case definition for a suspected case, clinically compatible illness and has an epidemiological link like face-to-face exposure, including health care workers without appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact etc.
A case is considered laboratory confirmed for monkeypox virus (by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing). The surveillance strategy outlines using standard case definitions by all district surveillance units (DSUs) under IDSP. ‘Even one case of monkey pox is to be considered as an outbreak. A detailed investigation by the Rapid Response Teams need to be initiated through IDSP. “Report any suspected case immediately to the DSU/State Surveillance Units (SSUs) and CSU (Central Surveillance Unit), which shall report the same to Directorate General of Health Services and send the samples as per the guidelines to the designated laboratories’, the document said.
The salient features include targeted surveillance for probable cases or clusters, initiating contact tracing and testing of the symptomatic after the detection of the probable/confirmed case. The guidelines direct hospital based surveillance and testing such in Dermatology clinics, STD clinics, medicine, paediatrics OPDs etc and targeted Surveillance which can be achieved by measles surveillance by Immunization division and targeted intervention sites identified by NACO for MSM, FSW population. The symptoms include lesions which usually begins within 1-3 days of fever onset, lasting for around 2-4 weeks and are often described as painful until the healing phase when they become itchy (in the crust stage). A notable predilection for palm and soles is characteristic of monkey pox, the guidelines stated. According to the guidelines, PPE to be donned before collecting the specimens should include- coveralls/gowns, N-95 mask, head cap, booties/shoe-cover, face shield/safety goggles, double pair of gloves.
On the management front, a patient should be isolated in an isolation room of the hospital/at home in a separate room with separate ventilation and he or she should wear a triple layer mask while the skin lesions should be covered to the best extent possible (long sleeves, long pants) to minimize risk of contact with others. Besides, patients managed at home should not leave the home except for medical care and no visitors should be allowed at home. Healthy household members should limit contact with the patient. Patients should wear a surgical mask, especially those who have respiratory symptoms (e.g., cough, shortness of breath, sore throat). If this is not feasible, other household members should consider wearing a surgical mask when in the presence of the patient. All this is to be continued until all lesions have resolved and scabs have completely fallen off, the guidelines recommended.
The guidelines recommend supportive management of Monkeypox like taking Paracetamol for fever, applying topical Calamine lotion or taking antihistaminics for itching, warm saline gargles/ oral topical anti-inflammatory gel for oral ulcers and taking a nutritious diet. For skin rash, the guidelines advise cleaning with simple antiseptic, applying Mupirocin Acid/Fucidin, for the skin rash and covering it with light dressing if extensive lesions are present and not touching/ scratching them.